An exploration of radiological signs in post-intervention liver complications

Full text

An exploration of radiological signs in post-intervention liver complications
Faezeh Khorasanizadeh
a,1
, Narges Azizi
a,1
, Roberto Cannella
b,*
, Giuseppe Brancatelli
b
a
Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
b
Section of Radiology - Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
ARTICLE INFO
Keywords:
Hepatobiliary interventions
Computed tomography
Magnetic resonance imaging
Ultrasound
ABSTRACT
The advent and progression of radiological techniques in the past few decades have revolutionized the diagnostic
and therapeutic landscape for liver diseases. These minimally invasive interventions, ranging from biopsies to
complex therapeutic procedures like transjugular intrahepatic portosystemic shunt placement and transarterial
embolization, offer substantial benets for the treatment of patients with liver diseases. They provide accurate
tissue diagnosis, allow real-time visualization, and render targeted treatment for hepatic lesions with enhanced
precision. Despite their advantages, these procedures are not without risks, with the potential for complications
that can signicantly impact patient outcomes. It is imperative for radiologists to recognize the signs of these
complications promptly to mitigate further health deterioration. Ultrasound, CT, and MRI are widely utilized
examinations for monitoring the complications. This article presents an overarching review of the most
commonly encountered hepatobiliary complications post-radiological interventions, emphasizing their imaging
characteristics to improve patient post-procedure management.
1. Introduction
In recent decades, radiological interventions have played an
increasingly important role in the diagnosis and management of a range
of liver diseases [1]. These interventions with numerous benets, from
enabling accurate tissue diagnosis to providing therapeutic solutions for
hepatic parenchymal diseases and hepatic tumors, have emerged as vital
tools for clinicians [2,3]. Radiological approaches not only offer less
invasive alternatives to traditional surgical methods but also facilitate
real-time visualization, which can enhance precision and optimize out-
comes [4,5]. Each intervention, be it biopsy, open or laparoscopic liver
resection, open or laparoscopic cholecystectomy, percutaneous chol-
ecystostomy, transjugular intrahepatic portosystemic shunt (TIPS),
chemical ablation, thermal ablation, newer ablative techniques such as
irreversible electroporation, transcatheter arterial treatments including
transarterial embolization, chemoembolization (TACE), or radio-
embolization, has brought about its indication and procedural imaging
characteristics [6–11]. However, all these procedures carry a potential
risk of several complications [12–14]. These complications necessitate
close monitoring and a nuanced understanding of radiological results to
ensure optimal patient outcomes. Fig. 1 presents a comprehensive
summary of the most common hepatobiliary complications observed
post-intervention.
Due to the wide variety of complications and their serious effects on
patient outcomes, understanding the imaging signs of these complica-
tions is crucial. Table 1 delineates the most prevalent hepatobiliary
complications associated with common liver interventions, including
their frequencies. Recognizing the radiological features of these post-
intervention complications is essential to improve the management of
such conditions, mitigating further clinical deterioration. Our article
aims to comprehensively review the key radiological features of com-
mon hepatobiliary complications, including infectious, biliary, and
hemorrhagic types. This will provide a detailed visual guide, aiding
radiologists in accurately identifying and addressing these complica-
tions following liver interventions.
2. Abscess formation
Hepatic abscesses, although not common, are complications within-
hospital mortality of 9.6 % [59]. These abscesses manifest post-
intervention, with symptoms ranging from fever, chills, malaise, and
abdominal discomfort to elevated white blood cell [60]. Several risk
* Corresponding author at: Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Via del Vespro 129, Palermo
90127, Italy.
E-mail address: roberto.cannella@unipa.it (R. Cannella).
1
These authors contributed equally.
Contents lists available at ScienceDirect
European Journal of Radiology
journal homepage: www.elsevier.com/locate/ejrad
https://doi.org/10.1016/j.ejrad.2024.111668
Received 9 April 2024; Received in revised form 28 July 2024; Accepted 2 August 2024
European Journal of Radiology 180 (2024 ) 111668
Available online 5 August 2024
0720-048X/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license ( http ://creativecommons.org/licenses/by/4.0/ ).

factors predispose individuals to the formation of hepatic abscesses: pre-
existing biliary-enteric anastomosis, external drainage, malfunctioning
Oddi sphincter, underlying diabetes mellitus, and residual iodized oil
from prior TACE procedures [61]. The compromised function of the
duodenal extensor muscle can heighten the risk, as it predisposes the
bile ducts to bacterial inux from the bowel lumen [62,63].
Imaging has a crucial role in the characterization, differential diag-
nosis, and extension of patients with suspected hepatic abscess. Ultra-
sonography (US) typically reveals these abscesses as hypoechoic,
circumscribed lesions, or larger heterogeneous masses with internal
septa and hyperechoic cellular debris. This method detects lesions over
2 cm with 85–95 % sensitivity [64]. Notably, color Doppler examination
often demonstrates an absence of central vascularization [65]. When
utilizing contrast-enhanced ultrasonography (CEUS), the abscess is dis-
cerned as a lesion with heterogeneous peripheral enhancement, delin-
eated by a hypoechoic center, an echoic rim, and thin vessels tracing the
septa and boundaries [66]. On computed tomography (CT), hepatic
abscesses typically appear as hypodense lesions, which can be either
isolated or conuent. This modality demonstrates a 95 % sensitivity in
identifying abscesses as small as 0.5 cm [64]. Contrast-enhanced CT can
demonstrate a central hypodense uid area encased by a vivid hyper-
dense rim and an outer hypodense halo—known as “double-target”
appearance. The inner rim corresponds to the abscess wall and exhibits
sustained enhancement, while the external one corresponds to the liver
parenchyma, showing delayed phase enhancement [67]. Additionally, a
cluster sign — dened as a concentrated aggregation of numerous small
(<2cm) low-density lesions within the liver — indicates an early stage in
the formation of pyogenic abscesses [68]. Rarely, the sporadic presence
of air microbubbles within the abscess can be observed (Fig. 2) [67].
Magnetic Resonance Imaging (MRI) can demonstrate a T1-hypointense
and T2-hyperintense lesion, with sensitivity of 100 % and specicity
of 96.3 %. High signal intensity in diffusion weighted images (DWI)
combined with low signal intensity on apparent diffusion coefcient
(ADC) can be leveraged to guide precise drainage in instances of mul-
tiple collections [69].
Differentiating hepatic abscesses, tumor necrosis, liver infarction,
and secondary infection after TACE is challenging. Liver infarctions
appear as well-dened, hypodense, wedge-shaped lesions from the
hilum to the capsule, resulting from reduced blood ow or blocked
vessels. Tumor necrosis in the liver manifests as non-enhancing areas in
tumors on contrast-enhanced scans, typically due to insufcient blood
supply, contrasting with infarctions’ usually with irregular boundaries.
Additionally, secondary infection in infarctions showed interval
rounding and sometimes developed internal foci of gas, which is indic-
ative of infection. The internal gas formation appeared focally localized
with a mottled appearance or an air–uid level, different from the linear
branching pattern of pneumobilia [63]. Hemostatic material, used to
stop bleeding during open surgeries, also presents a differential diag-
nosis challenge for abscesses. To distinguish, it’s crucial to know the
patient’s surgical history and consult with the surgeon regarding the use
of hemostatic material. Unlike abscesses, gas pockets in hemostatic
material usually form straight lines without showing gas-uid levels.
While rim enhancement is typically absent, a granulomatous reaction
around the material may induce it after several days surrounded by a
robust peripheral enhancement [60].
Differentiating expected post-ablation ndings from hepatic abscess
formation is also crucial for appropriate patient management. Post-
ablation changes typically include an ablation zone characterized by
hypodensity on CT, which may show rim-like enhancement due to
reactive hyperemia and central hyperdense areas from cellular disrup-
tion [70]. Small air bubbles could be seen immediately post-ablation due
to tissue uid boiling but usually resolve by the rst or second follow-up
[70]. In contrast, hepatic abscess formation is suggested by interval
enlargement of the ablation zone, persistent or new air-uid levels, and
clinical signs of infection [70,71]. Additionally, DWI has demonstrated
its utility in distinguishing between infected and non-infected collec-
tions [72].
3. Cholangitis
Cholangitis after hepatobiliary procedures, as an inammation of the
bile duct, presents a critical risk with a mortality rate between 2 % to 4.5
%, often due to anastomosis stenosis following surgery [73–75]. How-
ever, it might occur following minimal invasive interventions such as
transhepatic biliary drainage, biliary stent placement, or percutaneous
transhepatic cholangiography [76]. The importance of recognizing this
condition lies in its potential to lead to serious complications, including
biliary sepsis, liver abscesses, and in severe cases, multiorgan failure if
not promptly addressed [75,77,78].
The imaging features of post-hepatic intervention cholangitis can be
subtle and require a high index of suspicion [79]. On US, ndings
indicative of cholangitis might include biliary wall thickening and per-
icholedochal echogenicity signaling inammation. While the US shows
sensitivity of 73 % for detecting choledocholithiasis, it has lower
sensitivity for other obstructive pathologies [80,81]. It’s critical to
recognize that a normal US does not rule out cholangitis, prompting the
need for additional imaging modalities [80]. CT imaging without
contrast may reveal nonspecic biliary dilation. However, post-contrast
CT can show enhancement of the bile duct walls, periductal enhance-
ment representing inammation, and may also identify complications
such as abscesses or leaked bile, with both sensitivity and specicity
exceeding 83 %. This modality is also adept at identifying emergent
complications, including abscess formation [82]. MRI, particularly with
MR cholangiopancreatography (MRCP), with sensitivity of 96 % and
specicity of 100 %, is the most sensitive modality for detecting biliary
abnormalities [83]. It can delineate the biliary tree in detail and, with
contrast, can highlight areas of inammation and infection, differenti-
ating from brosis and malignancy. [83].
4. Biloma
Biliary complications such as bile duct injury, bile leakage and
biloma are uncommon after intervention, but any delay in their diag-
nosis and treatment can lead to severe, life-threatening consequences
[84]. Bile leakage can result in the formation of bilomas, which are
dened as any well-circumscribed intra-abdominal bile collections,
either encapsulated or non-encapsulated, external to the biliary tree
[85]. The disruption of the biliary tree, often due to iatrogenic injury or
abdominal trauma, can lead to either intrahepatic or extrahepatic
biloma formation. Bilomas can exacerbate the prognosis of hepatic ab-
scesses and are linked to signicant morbidity and mortality if not
promptly diagnosed and managed appropriately [86]. The clinical pre-
sentation of bilomas can be variable and often subtle, making
Fig. 1. The perspective of post-intervention liver complications.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
2

Table 1
The most common liver interventions, the most prevalent hepatobiliary complications, and their reported frequency.
Procedure The most common hepatic complications Reported frequency (%) Reference
Liver Biopsy
Hemorrhagic complications 0.11–10.9 [15,16]
Bile peritonitis 0.03–0.22 [17]
Hemobilia 0.01–0.20 [16]
Hemoperitoneum 0.03–0.70 [17]
Biopsy of surrounding organs 0.00–0.04 [17]
Arteriovenous stula 5.40 [17,18]
Breakage of the biopsy instrument 0.02–0.06 [17]
Liver Resection
Hemorrhagic complications 1.96–5.96 [19,20]
Bile leakage 1.35–19.61 [19]
Biloma 0.98 [19]
Perihepatic abscess 0.98–3.02 [19,21]
Cholangitis 0.98 [19]
Portal vein thrombosis 1.57–20.00 [22,23]
Liver failure 0.68–2.80 [21]
Cholecystectomy
Hemorrhagic complications 0.59–3.64 [24]
Bile leakage/stula 0.59–21.05 [25]
Biloma 2.50* [26]
Biliary strictures 0.00–0.89 [27]
Retained gallstones 0.40–4.17 [24,28]
Subhepatic collection 7.14–10.53 [25,28]
Pseudoaneurysms N/A
**
Percutaneous Cholecystostomy
Hemorrhagic complications 1.65–3.55 [29,30]
Biloma/Abscess formation 0.41 [29]
Catheter blockage 8.89 [31]
Catheter leakage 4.44 [31]
Catheter dislodgement 0.03–4.54 [29,31]
Ablation
Hemorrhagic complications 0.52–14.51 [32]
Thermal biliary injuries or stenosis
***
0–10.5 [13]
Irreversible electroporation biliary injuries 1.80 [33]
Biloma 0.04–0.20 [32,34]
Biliary stricture 0.04–0.22 [32]
Cholecystitis 0.04–3.23 [32]
Cholangitis 1.46 [35]
Abscess formation 0.26–4.71 [32,33,36]
Tumor Seeding 0.00–0.52 [32,37]
Portobiliary stula/Hemobilia 0.04–0.48 [32]
Arterioportal stula 0.08–0.39 [32,38]
Thrombosis of portal vein 0.53–3.23 [33,36,39]
Liver infarction 0.04–1.61 [32,36]
Liver failure 0.08–3.23 [36,38]
Transcatheter arterial treatments
Catheter dislocation/migration N/A
Hepatic arterial damage 16.02 [40]
Segmental liver infarction 0.17 [41]
Bile leakage and biloma 0.85–0.87 [41,42]
Ischemic biliopathy 5.13 [43]
Cholecystitis 0.30 [41]
Abscess formation 0.22–1.28 [41,44]
Liver failure 0.26–13.38 [41,45]
Transjugular Intrahepatic
Portosystemic Shunt
Hemorrhagic complications 2.06 [46]
Bile duct injury 1.37–5.00 [47,48]
TIPS site infection 3.33–4.39 [46]
Shunt stenosis 31.11–46.66 [49–51]
Shunt occlusion 8.88–12.22 [52]
Hemobilia 1.03–1.37 [46,47]
Segmental liver infarction 0.26 [46]
Liver failure N/A
Endoscopic Retrograde
Cholangiopancreatography
Hemorrhagic complications 1.34–16.98 [53,54]
Infections 1.44–3.77 [53,54]
Stent misplacement 4.14–6.51 [55,56]
Percutaneous Transhepatic
Cholangiography
Hemorrhagic complications 2.50–6.9 [57]
Bile leakage/biloma 0.77–28.70 [57]
Cholangitis 4.61–26.3 [57]
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
3

radiological investigation challenging.
US can identify cystic-like lesions and reveal a range of ndings from
well-circumscribed collections in the liver parenchyma to large locu-
lated uid collections throughout the abdomen. Sensitivity of US in the
detection of intra-abdominal bile collections is estimated to be 70 %
[69,85,87]. CT can offer a precise localization of the biloma and detailed
imaging of the surrounding structures but it may need to be com-
plemented by contrast-enhanced MRI for a denitive diagnosis [88].
Biloma after radiofrequency ablation can present a “mural nodule in
cyst” pattern on contrast-enhanced portal venous phase CT and axial fat-
saturated T2-weighted MRI, typically several months post-treatment
[89]. The mural nodule, which lacks enhancement, represents the
treated tumor and necrotic tissue, while the cyst is lled with bile. This
pattern arises from bile accumulation at the boundary between ablated
and non-ablated tissue, eventually dissecting this interface. US or CT-
guided sampling of the biloma followed by laboratory analysis might
be necessary to conrm the diagnosis when previous imaging and
clinical ndings are inconclusive. MRI, including MRCP, can further
delineate the characteristics of a biloma and bile leaks with sensitivity
ranging from 53–63 % and a specicity between 51–66 %, indicating
moderate diagnostic accuracy [90]. Gadolinium ethoxybenzyl (Gd-EOB-
DTPA)-enhanced MRCP is also used for non-invasive diagnosis (Fig. 3),
improving the accuracy metrics, offering a sensitivity of 76–82 % and a
specicity consistently at 100 % [85,87,90,91]. Invasive imaging tech-
niques such as endoscopic retrograde cholangiopancreatography
(ERCP) and percutaneous transhepatic cholangiography can provide
further guidance on management. They not only point out the location
and severity of the injury but also enable interventions like stent
placement or sphincterotomy [92]. These interventions aid in enhancing
bile ow, draining bilomas, and decompressing the biliary system,
thereby promoting healing [93].
5. Biliary strictures
Benign biliary strictures predominantly stem from iatrogenic causes,
such as cholecystectomy, post-liver transplant, partial hepatectomy,
hepaticojejunostomy, and exposure to chemotherapy or radiation.
Injury to the common bile duct during laparoscopic or open cholecys-
tectomy contributes to the majority of iatrogenic bile duct injuries,
despite the overall incidence of benign biliary strictures post-
cholecystectomy being relatively low (0.2–0.7 %) [94]. These stric-
tures, commonly occurring in the common hepatic or common bile ducts
due to inadvertent ligation, may be identied during surgery or manifest
postoperatively as obstructive jaundice or peritonitis. Distinctly, biliary
strictures following orthotopic liver transplant are characterized by
either proximal stricture at the anastomosis level or peripheral stricture
due to arterial ow impairment, resulting in ischemic cholangiopathy
[95].
US exhibits high sensitivity (approximately 100 %) in detecting
intrahepatic biliary dilation and the obstruction level but is less effective
in identifying strictures or masses [94]. Multiphase contrast-enhanced
CT, a valuable diagnostic tool in the evaluation of biliary strictures,
reveals benign strictures with distinctive features such as smooth con-
tours, regular wall edges, and limited extent of narrowing, offering a
clear differentiation from the complex and irregular characteristics
typical of malignant strictures. [96]. As a highly accurate imaging mo-
dality, MRCP is extensively utilized for evaluating biliary obstructions,
achieving diagnostic sensitivity of 98 % although the accuracy of MRCP
in differentiating various types of biliary strictures can vary from 30 %
to 100 % [94,97–100]. For brotic strictures, MRCP typically shows a
gradual narrowing, regular borders, and involvement of a short section
of the biliary tract [101–103]. By combining both MRI and MRCP for
differentiating benign from malignant strictures, studies have shown
sensitivity values between 82.3 % and 95.6 %, specicity values ranging
from 91.3 % to 93.8 %, and an overall accuracy between 89 % and 94.5
% [104,105].
6. Cholecystitis and gallbladder perforation
During invasive procedures in proximity to the gallbladder fossa,
complications such as cholecystitis or gallbladder perforation may
inadvertently arise. Acute acalculous cholecystitis (AAC) is character-
ized by acute inammation of the gallbladder in the absence of lithiasis.
[106]. A key factor in the development of AAC is the injury caused by
Footnote: N/A: not available, * The provided data is derived from a single case report and a literature review. The actual incidence of this condition may differ based on
variations in patient demographics and the surgical techniques employed. ** Between the years 1991 and 2020, a total of 67 cases were reported [58]. However, a
precise frequency was not identied.*** Especially affecting the peripheral branches of the biliary ducts.
Fig. 2. 42-year-old man with acute pancreatitis who underwent endoscopic retrograde cholangiopancreatography. Contrast-enhanced CT on hepatic arterial (A) and
portal venous (B) phases show a hypodense hepatic abscess with targetoid appearance and inner air microbubbles (arrow). Note the wedge-shaped area of
hyperenhancement in the right hepatic lobe on the hepatic arterial phase (arrowheads in A).
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
4

ischemia–reperfusion. Given that the gallbladder artery is a terminal
artery, inadequate blood ow often results in ischemic necrosis of the
gallbladder wall. The diagnosis of AAC is often made through clinical
symptoms such as pain in the right upper abdomen, a positive Murphy’s
sign, and a raised temperature [107]. Acute cholecystitis can escalate,
leading to dire complications such as gallbladder perforation, a medical
emergency which can lead to a peritoneal infection. Contributing factors
to gallbladder injury and perforation encompass inammation,
decreased gallbladder motility, prior surgical adhesions, or the presence
of a percutaneous cholecystostomy catheter during ablation [96].
The US diagnostic criteria of AAC contain a positive Murphy sign,
where the pain is induced by probe pressure on the gallbladder area,
lack of gallstone, gallbladder enlargement (transverse diameter more
than 5 cm and vertical diameter more than 8 cm), and a thickened
gallbladder wall (more than 3.5 mm), known as a “double-wall” sign. US
can also detect the presence of peritoneal effusion and the occurrence of
echoes in the gallbladder. Sensitivity and specicity of US can range
between 30 % and 100 % [107]. CT scans can be used to conrm AAC
diagnosis when US results are inconclusive. CT diagnostic criteria
involve a lack of gallstones, wall thickening (more than 3 mm), peri-
cholecystic fat stranding, and signs of more severe conditions like
gangrenous cholecystitis or gallbladder perforations. MRCP can visu-
alize the pancreatic-biliary ductal system without contrast agents,
making it non-invasive and safe. While ERCP is another diagnostic op-
tion, its invasive nature combined with a higher risk of pancreatitis
causes MRCP to be often favored, especially in post-intervention or
critical patients [108].
For gallbladder perforation, US manifestations overlap with AAC
with a sensitivity of 31.5 % [109,110]. The ’sonographic-hole’ sign,
dened as the direct visualization of a defect in the gallbladder wall,
serves as a highly specic indicator of gallbladder perforation and is
detectable across US, CT, and MRI imaging modalities [111]. In some
cases of gallbladder perforation, adhesions of the omentum to the
adjacent gallbladder can obscure the gallbladder wall, making it chal-
lenging to assess the location and dimensions of the perforations using
conventional US. CEUS, on the other hand, enhances the visibility of the
gallbladder wall during the early arterial phase, presenting it as a
“hyperechoic line”, showing hyperenhanement compared to the sur-
rounding liver parenchyma [112]. A recent case series demonstrated
that small vessel slow ow perfusion Doppler imaging effectively iden-
ties perforated gallbladders, highlighting features like unclear gall-
bladder walls and perfusion defects [113]. Enhancing this method with
spectral analysis measurements such as Peak Systolic Velocity (PSV) and
Resistive Index (RI) could provide more detailed insights into
gallbladder conditions. This combined approach offers both visual and
quantitative data, potentially improving the diagnosis of gallbladder
perforations, though further clinical validation is needed. CT stands as
the most sensitive diagnostic tool for gallbladder perforation. The
ndings encompass changes in gallbladder, pericholecystic, and other
organs. Gallbladder changes involve enhancement and thickening of the
gallbladder wall except for gangrenous gallbladder, wall defects, and
intramural gas and collections (Fig. 4). Pericholecystic changes include
fat stranding, uid collections, biloma, and extra-luminal stones. Other
organs may show pericholecystic liver enhancement, liver abscesses,
portal vein thrombosis, pneumoperitoneum, intestinal wall thickening,
and ascites [110]. MRI is a rarely used modality for suspected gall-
bladder perforations. There are a few case reports of gallbladder
perforation utilized MRI which showed wall defect and intraluminal
haematoma on post-contrast imaging and a loculated collection in the
Fig. 4. 70-year-old woman with injury of the gallbladder wall after thermal
ablation of hepatic metastasis in the right liver lobe. Coronal contrast-enhanced
CT on portal venous phase demonstrates a distended gallbladder with wall
thickening and irregular wall defects (arrow), suggestive of perforation.
Fig. 3. 74-year-old man with persistent biliary output from subhepatic drainage after cholecystectomy. Axial T2-weighted sequence (A) demonstrates a round, uid
containing observation. Hepatobiliary phase images acquired at 30 min (B) and 35 min (C) after the injection of gadoxetate disodium shows a progressive lling of
the contrast agent (arrows) within the observation, due to a biliary leak from the hepatic hilum, allowing the diagnosis of biloma.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
5

pericholecystic region [114,115].
7. Hemobilia
This condition is characterized by the extravasation of blood into the
bile ducts, often resulting from iatrogenic injuries, including complica-
tions following ERCP [116]. It is particularly prevalent in instances of
interventions on the caudate lobe in deeper regions of the liver, where
there exists a heightened risk of simultaneous damage to vessels and bile
ducts [34]. Patients with hemobilia can exhibit symptoms such as
jaundice, melena, and abdominal pain [13].
On US, clots can be seen as oating hyperechoic material within
anechoic biliary lumen, however detecting clots, especially smaller
ones, within the bile ducts is challenging using US due to the clots’
diminished echogenicity and their tendency to adhere to ductal walls in
case of self-limiting hemobilia. In active hemobilia, the injection of a US
contrast agent can demonstrate contrast agent bubbles lling the gall-
bladder lumen [117]. In emergency situations, CT angiography is the
rst-line modality for detecting hemobilia. It offers accurate identica-
tion and pinpointing of the bleed’s origin, allowing for prompt and
decisive intervention [116]. Scattered hyperdensities can be observed
within bile ducts on a pre-contrast CT scan (Fig. 5). Additionally,
enhancement of the ductal walls post-contrast injection may point to a
cholangitic process, potentially initiated by the persistent hemorrhagic
stimulus on the ductal walls [117]. MRI with MRCP can demonstrate
intrabiliary lling defects with uid–uid level, mass-like, or cast-like
appearance with mixed signal intensity on T2-weighted images consis-
tent with blood products in various stages of breakdown and high signal
intensity on T1-weighted images could be in favor of hemobilia in the
proper clinical setting and history of recent iatrogenic or accidental
trauma. Active extravasation of contrast material into the lumen of the
biliary tract, can be demonstrated by dynamic MRI, with ndings similar
to those with contrast enhanced CT. Subtraction imaging techniques
help distinguish between other hyperintense duct obstructions, such as
gallstones or sediment, and genuine blood ow [116,118].
8. Fistula formation
Fistula can form at various locations depending on the type of he-
patic intervention. Biliocutaneous, enterobiliary, bronchobiliary, bil-
iopleural, arteriovenous, and arterioportal stulae are reported as
complications of hepatic interventions, especially after biopsy, ablation,
and cholecystectomy [17,18,25,32,38]. The clinical presentation of
biliary stulas is usually with abdominal pain, jaundice, and raised in-
ammatory markers in the immediate postoperative period or produc-
tive bilious coughs in bronchobiliary stula [119]. Several factors may
contribute to the formation of stulas, including the size and location of
the ablated liver tumor, the proximity of vital structures, the experience
of the operator, and the technique used during the procedure [119].
Inadequate ablative margins, incomplete coagulation of tissues, or
excessive energy delivery can increase the risk of stula formation
[119].
US has shown high diagnostic accuracy in patients with arteriove-
nous stulae, with a sensitivity of 83.3 % and a specicity of 90.7 %
[120]. On Doppler ultrasound, arteriovenous stulas display a low-
impedance, bidirectional blood ow within the portal vein [121]. US
and contrast-enhanced CT are useful for the diagnosis of associated
biliary dilation, pneumobilia, biloma, and collection or visualization of
the stulous tract [122]. MRI and MRCP, with T2-weighted sequences,
identies hyperintense stulous tracts, while the hepatobiliary phase
with hepatobiliary specic agents including Gadobenate dimeglumine
(Gd-BOPTA), and Gd-EOB-DTPA play role as good substitutions of he-
patic iminodiacetic acid (HIDA) scan to show biliary agent leak into
adjacent organ [123,124]. ERCP and cutaneous cholangiography are
particularly effective for visualizing contrast extravasation from the
biliary system into other organs such as lung, gastrointestinal tract, and
vascular structure the management is conservative for most stula with
an external drainage catheter, endoscopic sphincterotomy and/or stent
placement meanwhile embolization for biliovascular stula is recom-
mended [124,125].
Fig. 5. 74-year-old woman with hemobilia after endoscopic retrograde cholangiopancreatography. Pre-contrast (A) and contrast-enhanced CT on portal venous
phase (B) show dilatation of the main bile duct with hyperdense material in the common bile duct (arrow) and in the gallbladder lumen (arrowhead) consistent with
blood. No evidence of active bleeding is observed.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
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9. Hemorrhagic complications
Intraperitoneal bleeding is one of the most prevalent serious com-
plications following various interventions underscoring the importance
of vigilant monitoring [126]. This complication is often related to direct
mechanical injury, and when lesions situated adjacent to large vessels
are treated. Patients with cirrhosis are at elevated risk, with the main
cause being the coagulopathy brought about by hepatic dysfunction
[34].
US is typically the rst-line diagnostic tool for suspected post-
interventional hemorrhage. Hematomas on US often appear avascular
echogenic in acute phase and will show different levels of internal echo
in the rst month [127]. CEUS excels as a tool for prompt detection and
facilitates the planning of subsequent treatment strategies [128]. The
characteristic feature of active bleeding along the needle track observed
in CEUS is the linear spillage of microbubbles during the vascular phase
into the peritoneal cavities. In instances of hemoperitoneum, CEUS is
distinguished by a jet-like leakage of contrast agents from various
pathological sources into the perihepatic peritoneal space. For subcap-
sular hematomas, CEUS reveals unenhanced areas within the liver pa-
renchyma, which are marked by their convex margins [117]. On CT
scan, the hematoma manifests as a biconvex or enlarging intra-
parenchymal lesion, typically supercial at the device entry point, and
high-density values between 45–70 Hounseld Units (HU) in precon-
trast images without any enhancement on post contrast phases (Fig. 6).
However, in the presence of active bleeding there is extravasation of
contrast material or increased enhancement of hematoma (Fig. 7)
ranging between 85 and 370 HU [129,130]. MRI distinguishes between
active bleeding, hematomas, and other hepatic lesions with sensitivity of
94 % and specicity of 82–89 % [131]. However, MRI’s utility is limited
by its longer scanning times and less accessibility compared to US and
CT in emergent settings. Hematoma appears notably hyperintense on
Fig. 6. 80-year-old man with hepatic hematoma after percutaneous liver biopsy performed in the liver parenchyma for suspected autoimmune hepatitis. CT images
on pre-contrast (A), hepatic arterial (B), portal venous (C), and delayed phases show a large intraparenchymal hematoma (arrow) extended to the liver capsule in the
right hepatic lobe without evidence of active bleeding.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
7

T2-weighted MRI at its onset. It typically presents with regular borders,
adopting shapes such as biconvex, biconcave, or “quarter-moon,” which
varies based on whether it is situated peripherally or more towards the
center of the liver [132]. The active bleeding exhibited isointense signals
on both T1 and T2-weighted images, suggesting the presence of intra-
cellular oxyhemoglobin characteristic of an acute hemorrhage [133].
10. Thromboses
Vascular thrombosis represents a serious complication that can arise
following various medical interventions. This complication may mani-
fest several hours after a procedure. In patients with hepatocellular
carcinoma, it’s essential to differentiate post-interventional thrombosis
from tumor thrombosis or disease progression. Depending on the vessel
involved, thromboses can range from minor to major complications,
with smaller-caliber vessels that exhibit diminished ow due to previous
treatments or existing conditions being more susceptible [13].
Acute arterial thrombosis in US presents as an intraluminal hyper-
echoic spot due to fresh thrombus formation in hepatic arteries close to
100 % sensitivity, devoid of inner ow on color Doppler [134]. Subacute
arterial thrombosis demonstrates reduced echogenicity compared to
acute arterial thrombosis, indicating clot maturation [134]. Contrast-
enhanced CT, as a secondary diagnostic approach, is essential if hepat-
ic Doppler ultrasound indicates abnormalities or encounters technical
challenges. In contrast-enhanced CT, the diagnosis of hepatic artery
thrombosis is suggested by the absence of contrast uptake in the hepatic
artery, which is indicative of impaired or halted arterial blood ow. This
imaging modality demonstrates a sensitivity and specicity of 100 %
and 97 %, respectively, for identifying hepatic artery thrombosis and
stenosis, compared to invasive angiography, which is typically reserved
for therapeutic interventions [135]. In MRI, acute arterial thrombosis
presents as isointense on T1-weighted imaging, with heterogeneity on
T2-weighted imaging. As the clot ages, MRI characteristics transition,
with variable intensity on both T1 and T2-weighted imaging [136].
Acute venous thrombosis detects a distinct, hyperechoic thrombus in
the portal or hepatic vein, absent of inner ow on color doppler, and
subacute venous thrombosis echogenicity diminishes over time, making
it harder to differentiate from surrounding tissue [13]. On CEUS, portal
vein thrombosis is identied by a lack of lling in the portal vein [134].
The thrombus appears less dened with time, but vascular congestion
may persist. Contrast-enhanced CT reveals an intraluminal defect in the
portal vein or hepatic veins (Fig. 8), often accompanied by segmental
enhancement of the nearby liver tissue. This is likely due to a compen-
satory increase in local arterial blood ow. Conversely, hepatic vein
thrombosis is most identiable during the portal or equilibrium phase of
contrast-enhanced CT, commonly linked with a wedge-shaped area of
the liver exhibiting reduced enhancement due to vascular congestion
[13,137]. Acute venous thrombus appears as a clear intraluminal defect
on MRI. Over time, MRI characteristics of the venous thrombus shift,
showing increased heterogeneity [13,134,136,138].
Fig. 7. 50-year-old man with bleeding from a distal branch of the splenic artery occurring after endoscopic retrograde cholangiopancreatography performed for
stenting of inltrating cholangiocarcinoma in the common bile duct. CT images on pre-contrast (A), portal venous (B), and delayed (C) phases demonstrate a
perisplenic hematoma with progressive contrast extravasation (arrow).
Fig. 8. 78-year-old woman with hepatocellular carcinoma treated with percutaneous ablation. Post-interventional contrast-enhanced CT on hepatic arterial (A),
portal venous (B) phase and MinIP reconstruction (C) show a new nontumoral thrombosis of the right hepatic vein (arrow in C) with segmental hypoenhancement in
the drained area better visible on the hepatic arterial phase (arrowheads in A).
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
8

11. Pseudoaneurysms
Pseudoaneurysms after laparoscopic cholecystectomy are clinically
signicant, with 81 % of patients showing symptoms like gastrointes-
tinal bleeding and abdominal pain within the rst eight weeks which
affect 74 % and 61 % of patients, respectively [14]. About 28 % of cases
also present with bile duct damage or bile leakage, and one-third of
pseudoaneurysms occur even after uncomplicated laparoscopic chole-
cystectomy [14]. Therefore, any patient with abdominal pain or
bleeding signs post laparoscopic cholecystectomy should be evaluated
for a pseudoaneurysm. The most commonly implicated arteries include
the right hepatic artery (70 %), the cystic artery (19 %), or a combina-
tion of both (3 %), primarily due to iatrogenic damage to a hepatic ar-
tery branch [14].
The sensitivity of US can vary based on the size of the pseudoa-
neurysm, and it might have limitations in detecting small pseudoa-
neurysms. Upon US examination, a pseudoaneurysm might resemble an
anechoic area, akin to a cyst formation. The diagnostic process is
signicantly facilitated by the use of color Doppler imaging, which re-
veals the characteristic yin-yang sign, indicative of turbulent ow within
the lesion [14]. During the arterial phase of a contrast-enhanced CT
study, pseudoaneurysms are discernible as small, well-delineated
hyperdense nodules within the location area of previous intervention
[139]. CT angiography stands as the most dependable non-invasive
technique for detecting pseudoaneurysms. It can provide the pseudoa-
neurysm’s location and size, thrombosed pseudoaneurysms, abnormal
vessels, and anatomical variations. Traditional angiography, although
invasive and demanding a skilled interventional radiologist, shows a
sensitivity of 90 %, pinpointing the exact location and size of the
pseudoaneurysm, uncovering the bleeding source, and can seamlessly
transition from a diagnostic to a therapeutic procedure. MRI can
distinguish between a blood clot and a gallstone in cases of obstructive
jaundice for instance [14]. On MRI, acute blood clots (less than 1 week
old) typically show as isointense or slightly hypointense on T1-weighted
images and hyperintense on T2-weighted images, while clots aged 1–6
weeks become hyperintense on both T1 and T2 images due to methe-
moglobin [140]. Clots older than 6 weeks appear hypointense on both
T1 and T2 images because of hemosiderin [140]. Gallstones contrast-
ingly exhibit variable signals; on T1-weighted images, cholesterol gall-
stones are typically hypointense and pigment gallstones hyperintense,
whereas on T2-weighted images, gallstones are generally hypointense,
though internal structures like uid-lled clefts can appear hyperintense
[141,142]. Monitoring the progression of the pseudoaneurysm’s diam-
eter is essential for determining the necessity of further interventions
[143].
12. Liver infarction
Liver infarction is rare but signicant complication, often prolonging
hospital stays and limiting further treatments [144]. The liver’s dual
blood supply from the hepatic artery and portal vein typically protects it
from infarction, but compromise can lead to necrosis and secondary
infections, potentially causing abscesses and sepsis. The risk factors
following transcatheter arterial treatments include non-selective in-
jections, large masses, and repeated procedures [145,146,42]. In-
farctions are more common in treatments for liver metastases than
hepatocellular carcinoma, likely due to the absence of cirrhosis formerly
[147]. Patients without cirrhosis face higher risks of locoregional com-
plications, unlike those with cirrhosis who benet from a protective
vascular network against infarction [144,148].
On both conventional and Doppler ultrasound, liver infarctions
Fig. 9. 68-year-old man with hepatic infarction after cholecystectomy for gallbladder carcinoma. Pre-contrast (A), hepatic arterial (B), and portal venous (C) phases
show a large wedge-shaped area of hepatic infarction (arrow) in the left liver lobe associated with thrombosis of the left portal vein (arrowhead) and lack of
opacication of the intrahepatic branches of the left hepatic artery.
Fig. 10. 78-year-old man with cirrhosis and hepatocellular carcinoma proved
at surgical resection. Follow-up contrast enhanced CT demonstrates multiple
enhancing tumor nodules (arrows) due to tumor seeding in the perihepatic
abdominal fat and in the abdominal wall.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
9

manifest as hypoechoic, nonvascular areas. These hypoechoic zones,
located at the periphery of the liver, often exhibit internal echogenic
bands indicating liver infarcts. This distinctive “bright band” sign can be
a valuable diagnostic indicator to distinguish infarctions from abscesses
[149]. On CT, infarcted liver areas typically manifest as hypodense re-
gions that fail to enhance post contrast administration (Fig. 9) [144].
The CT ndings are closely aligned with the gross pathological changes
seen in liver infarction. Typically, liver infarcts can be distinguished as
clear-cut regions, markedly different from the surrounding tissue and
are extended in a wedge shape towards the liver’s edge [150]. On MRI,
liver infarctions demonstrate wedge shape hypointensity on T1-
weighted sequences and hyperintensity on T2-weighted sequences
without signal loss on opposed-phase images excluding focal fatty liver.
Normal vessels coursing through these areas conrm the lack of mass
effect. [144,151].
13. Tumor seeding
Tumor seeding, a rare but serious complication of percutaneous in-
terventions, involves the accidental implantation of tumor cells along
the intervention path, leading to potential metastasis [11]. This
dissemination of cells can initiate new tumor growth at different sites,
complicating the clinical situation and possibly diminishing the benets
of the intervention [60]. The risk of seeding is heightened during biopsy
compared to therapeutic procedures like ablation [152]. In a retro-
spective study, no wall seeding was observed for ablations only, while
the rate was 0.13 % for biopsies only and 2.70 % when both procedures
were conducted [37]. To reduce the probability of needle seeding, the
coaxial biopsy method is reported as a safer method than other ap-
proaches because it allows multiple samples of the lesion to be taken
with just one puncture [153].
Tumor seeding closely mimics the primary tumor’s radiographic
appearance as an enhancing, irregular soft tissue structures along the
track of the device (Fig. 10). However, post-ablation inammatory
changes often serve as a confounding factor, as these too can exhibit
similar imaging features. Biopsy stands as the denitive means of dif-
ferentiation, offering histopathological insights [60].
14. TIPS stenosis or occlusion
TIPS stenosis emerges as a signicant complication, predominantly
resulting from brous tissue inltration into the endograft, thereby
narrowing the lumen [116 154]. Previous studies showed that within
two years post-TIPS creation, between 29–85 % of patients faced TIPS
dysfunction depending the type of stent (bare or covered) [155,156]. In
instances of recurrent thrombotic TIPS occlusion, it is imperative to
exclude hypercoagulopathy, given its prevalence in patients recom-
mended for TIPS, thereby predisposing them to thrombosis. Neverthe-
less, acute shunt thrombosis is noted in less than 5 % of TIPS insertions
[157]. Particularly with bare metal stents, acute TIPS occlusion is
frequently attributed to the formation of biliary-venous stulas,
considering the thrombogenic nature of bile [157]. Though the intro-
duction of covered stents has bolstered patency, stenosis still affects
8–21 % of patients one-year post-TIPS insertion [155,158].
On post-implementation of the TIPS, Doppler imaging visually rep-
resents the blood ow in the stent, portal, and hepatic venous systems
[158]. Detecting sonographic abnormalities necessitates a subsequent
TIPS angiography accompanied by portal pressure measurements [158].
Some studies proposed a one-year post-TIPS angiographic assessment
for patients to ascertain portal decompression and shunt patency [158].
Stent velocities below 90 cm/s in doppler indicate roughly 50 % stent
stenosis, and those under 50–60 cm/s suggest potential failure.
Conversely, exceeding 250 cm/s suggests signicant lumen reduction,
akin to high-grade arterial stenosis. Doppler velocities below 50 cm/s or
above 250 cm/s within the stent have over 90 % sensitivity and speci-
city in pinpointing stent malfunctions [159]. Using color Doppler
ultrasound to detect TIPS dysfunction with covered metal stents showed
a satisfactory sensitivity of 82 %, but its specicity was only 58 % [160].
To enhance diagnostic accuracy, researchers have explored the use of
CT, for evaluating TIPS (Fig. 11). This approach has demonstrated a
sensitivity of 92 % and a specicity of 77 % in identifying hemody-
namically signicant stenosis [161]. MRI is limited for evaluating ste-
nosis in TIPS stents due to artifacts caused by the stent materials [162].
15. Advances in imaging
Emerging imaging technologies, such as dual-energy CT (DECT) and
photon-counting CT (PCCT), have recently shown promise in enhancing
diagnostic capabilities [163,164]. These tools offer higher spatial reso-
lution and improved conspicuity of liver lesions, even at smaller sizes
[165]. The possibilities to perform virtual monoenergetic imaging and
material decomposition reconstructions, signicantly enhance tissue
characterization, improve contrast enhancement, and reduce beam
hardening artifacts [166,167]. These advancements allow for more
precise differentiation of tissue properties by utilizing the unique re-
sponses of different materials at varying energy levels. Despite their
potential, there is a need for further research to establish the specic
applications and accuracy of these advanced imaging modalities in the
management of post-interventional complications.
16. Conclusion
Understanding the radiological ndings associated with post-
intervention complications is crucial for promptly identifying primary
complications that may arise following a procedure. This awareness
facilitates early and targeted intervention, thereby mitigating the risk of
adverse outcomes. The US serves as a valuable diagnostic instrument
during treatment and acts as a surveillance tool, providing real-time
imaging and monitoring of the treated area. This role could be
augmented using color Doppler and CEUS. The CT scan with multiphase
contrast study continues to be the preferred tool in emergency settings,
offering a comprehensive view of the internal structures and aiding in
Fig. 11. 68-year-old man with occluded TIPS. Coronal contrast-enhanced CT
image on portal venous phase demonstrates lack of enhancement within the
TIPS (arrow) consistent with TIPS occlusion. Note the presence of ascites (*) as
complication of portal hypertension.
F. Khorasanizadeh et al.
European Journal of Radiology 180 (2024 ) 111668
10

the immediate diagnosis of complications. Dynamic MRI, MRCP and
specic hepatobiliary contrast agents offering detailed images of the
liver and surrounding tissues, thereby contributing to the nuanced un-
derstanding of the patient’s condition.
Declaration of generative AI and AI-assisted technologies in the
writing process
During the preparation of this work, the authors used ChatGPT/
OpenAI for checking grammar and sentence structure. After using this
tool, the authors reviewed and edited the content and take full re-
sponsibility for the content of the publication.
Funding
Roberto Cannella: co-funding by the European Union - FESR or FSE,
PON Research and Innovation 2014-2020 - DM 1062/2021.
CRediT authorship contribution statement
Faezeh Khorasanizadeh: Writing – review & editing, Writing –
original draft, Visualization, Supervision, Project administration.
Narges Azizi: Writing – original draft, Visualization. Roberto Can-
nella: Writing – review & editing, Writing – original draft, Visualization,
Supervision, Conceptualization. Giuseppe Brancatelli: Writing – re-
view & editing, Supervision.
Declaration of competing interest
The authors declare the following nancial interests/personal re-
lationships which may be considered as potential competing interests:
Roberto Cannella: support for attending meetings from Bracco and
Bayer; research collaboration with Siemens Healthcare.
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