Use of Amplatzer Vascular Plug to Treat a Biliary Cutaneous Fistula
A 69-year-old female patient with painless obstructive jaundice was referred to the interventional radiology for decompression of biliary obstruction. The cause of obstruction was an intrahepatic tumor, a cholangiocarcinoma. A percutaneous puncture of a peripheral right hepatic duct branch was performed using a 22 G needle for cholangiography. Multisegmental bile duct obstruction was demonstrated, most likely due to the intrahepatic tumor.\nSubsequently, a 18 G Ring Needle (DPLN-40-25-RING Drainage Access Catheter Needle Set, William Cook, Bjaeverskov, Denmark) was used for the puncture of the adequate right bile duct. With this access, the stricture was negotiated with a biliary manipulation catheter (William Cook) and an angled hydrophilic guidewire (Glidewire; Terumo, Tokyo, Japan); an internal-external drainage was deployed. After about one week, indices of biliary stasis were not improved in relation with the multisegmental bile duct obstruction; therefore another drainage was positioned. The cholangiography performed through the first drainage was used for the correct deployment of the second internal-external drainage. The drainage was maintained for 10 days during which the jaundice resolved and bilirubin levels normalized. The patient was submitted to a laparoscopic view that confirmed the impossibility of surgical removal of the tumor. Therefore, a biliary permanent stent was deployed [10 × 80 mm, (Gore-Viabil Endoprosthesis, USA)]. In that same procedure, a biliary cutaneous fistula (BCF) consequent to the first internal-external drainage removal was observed. Moreover, a biliary leak was observed. A conservative approach was used as first line treatment. An external drainage was maintained for the time necessary to ensure that the stent functioned and for the diversion of bile flow away from the BCF and biliary leak. Subsequent cholangiograms revealed the persistence of BCF and of the biliary leakage and the correct functioning of the stent. The biliary leakage was successfully embolized using coils ().\nUsing the percutaneous approach, a fistulography was performed using a 7 Fr sheath (). Through the same approach, a 7 mm AVP IV (AVP-AGA Medical Corp., Plymouth, MN, USA)was deployed. Immediate fistulography and cholangiogram revealed the complete exclusion of the fistula (). External drainage was maintained for a few days to ensure the definitive embolization of the BCF.\nFollowing the procedures, the patient remained well, with resolution of her jaundice and of the leakage and BCF.