Pseudoaneurysm of the Cystic Artery: A Unique Presentation of a Ruptured Gallbladder

This case report details the atypical presentation and management of a 65-year-old male with a medical history encompassing hypertension, hepatitis C, and alcohol abuse (Model for End-Stage Liver Disease (MELD) score: 6). The patient presented to the emergency department with chest and lower abdominal pain, nausea, and vomiting. Initial imaging, including a contrast-enhanced computed tomography angiogram (CTA), revealed a distended gallbladder, perihepatic fluid, and an intraluminal blush arising from the right cystic artery. Laparoscopic cholecystectomy was performed, revealing a substantial perihepatic blood collection and a ruptured gallbladder with a posteriorly positioned cystic artery that was seen entering the gallbladder lumen through the posterior wall. Bleeding was observed filling into the gallbladder. Owing to significant adhesions and gallbladder friability, a subtotal cholecystectomy was undertaken, with clips applied and electrocautery employed for hemostasis. The cystic artery was clipped at its takeoff and subsequently cauterized. Postoperatively, minimal serosanguineous drainage was observed, and pathological examination of the gallbladder confirmed a benign nature. The case discussion addresses the rarity of gallbladder perforation, especially in the context of acute cholecystitis, and introduces a unique scenario of an abnormally positioned cystic artery causing a pseudoaneurysm, a novel phenomenon not previously documented. The critical presentation precluded cystic artery embolization, necessitating a tailored approach with a subtotal cholecystectomy. This case contributes valuable insights into the understanding and management of complex gallbladder pathologies, emphasizing the importance of adapting surgical strategies to address multifaceted anatomical and clinical considerations.