Iatrogenic portobiliary fistula treated with covered stent following percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage (PTBD) is a common interventional radiology (IR) procedure typically used in the treatment of biliary obstruction when an endoscopic approach has failed or is not technically feasible. PTBD has a low overall complication rate with the Society of Interventional Radiology suggesting adverse event thresholds of 10% for major complications, 5.7% for hemorrhage, 2% for hemobilia, and 3.3% for death, with the average reported rates of each of these being significantly lower. However, in rare instances serious complications such as vascular injury occur. The present report describes a case of a 62-year-old woman with Non-Alcoholic Steatohepatitis (NASH) cirrhosis and remote Whipple procedure who developed symptomatic choledocholithiasis with failed Endoscopic Retrograde Cholangiopancreatography (ERCP). Interventional radiology was consulted for PTBD, which was complicated by an iatrogenic portobiliary fistula (PBF). Diagnosis required sequential imaging and procedural evaluation, as initial non-invasive computed tomography (CT) and initial portal venography failed to clearly demonstrate the connection due to catheter occlusion of the fistula. This case report focuses on the management of this complication, which was successfully treated with balloon-expandable covered stent placement in the biliary system and dual-tract coil embolization.