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A true vascular aneurysm of the hepatic artery proper as a rare cause of nonmalignant painless jaundice.

Rare causes of painless jaundice include parasitic infections and lymphoma. To date, two cases of vascular pseudoaneurysm in acute cholecystitis and chronic pancreatitis have been reported [1,2]. An 85-year-old man was diagnosed by contrast-enhancedcomputed tomography scanwith a partially thrombotic aneurysm of the hepatic artery proper, which was compressing the common bile duct (CBD) (●" Fig.1). An initial attempt to place an endoprosthesis via endoscopic retrograde cholangiopancreatography (ERCP) failed, and obstructive cholangitis developed (bilirubin 23.1mg/dL, C-reactive protein 116mg/L, leukocytosis 17800/μL), which required antibiotic treatment, resection, and/or a second problem-focused ERCP. Resection was discussed but was not considered to be feasible due to significant cardiovascular co-morbidity. Therefore, biliary tract decompression by ERCP was planned. ERCP was particularly challenging. At a distance of 35mm from the papilla, below the junction of the cystic duct, the vascular aneurysm caused a moderately severe smooth-walled stenosis (50%–90%), measuring at least 45mm in length. The external compression resulted in a curved CBD with a right-angled kink (●" Fig.2 and ●" Fig.3). After endoscopic papillotomy, widening of the stenosis was achieved by careful use of bougies (5–10Fr). Subsequently, one double-pigtail endoprosthesis was placed in the right hepatic duct (7Fr/16cm) to serve as a splint for the second endoprosthesis, which had to be implanted around and over the aneurysm to finally reach the dilated biliary ducts of the left liver segments (10Fr/12cm; ●" Fig.4 and●" Fig.5). Correct stent placement was confirmed by postinterventional ultrasound (●" Fig.6). Interventional occlusion of the aneurysm was not performed due to the risk of wide-ranging ischemia. Thus, only mechanical biliary drainage evidenced by decreasing cholestasis was able to circumvent the complications of this rare vascular cause of bile duct compression. In contrast to arterial pseudoaneurysms, which are a rare but established complication of ERCP [3,4], this is, to our knowledge, the first case of a true vascular aneurysm leading to progressive cholangitis that required treatment by ERCP. Fig.1 The partially thrombotic aneurysm of the hepatic artery proper (yellow arrows) extended from the junction of the gastroduodenal artery up to the branching of the right and left hepatic artery (diameter 4.3cm).