Unmasking of a missed right hepatic artery pseudoaneurysm by biliary decompression following Roux-en-Y hepaticojejunostomy for Strasberg type E3 bile duct injury.

Bile duct injuries (BDI) after cholecystectomy often coexist with vascular injuries, but hepatic artery pseudoaneurysms may be missed on initial imaging. We report a right hepatic artery (RHA) pseudoaneurysm that manifested as haemobilia only after biliary decompression by Roux-en-Y hepaticojejunostomy for a Strasberg type E3 injury. A 28-year-old man presented 4 weeks after open cholecystectomy with obstructive jaundice. Magnetic resonance imaging confirmed a Strasberg type E3 stricture and identified a missed 8-mm RHA pseudoaneurysm. Following hepaticojejunostomy, haematemesis occurred on postoperative day 3. Computed tomography angiography demonstrated enlargement of the pseudoaneurysm to 12-mm with arteriobiliary communication. Covered stenting was followed by recurrent bleeding requiring glue-lipiodol embolization, complicated by non-target splenic embolization and an abscess requiring percutaneous drainage. The patient recovered and remained asymptomatic at three months. This case suggests that relief of biliary hypertension can unmask contained pseudoaneurysms and reinforces the importance of routine preoperative arterial-phase imaging in complex BDI.