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Background. Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options. Methods. A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords “cystic” and “artery” and “pseudoaneurysm” in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis. Results. Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years. Conclusions. Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.

Objective To acquaint with the presentation and management of the cystic artery aneurysm by enriching the reviewed literature with our own experience. Background Cystic artery pseudoaneurysm is an uncommon entity with varied clinical presentation. Inflammation and trauma are associated with most of the cases. Limited experience with the condition challenges the management of individual cases. Materials and methods We retrieved all the reported cases of cystic artery pseudoaneurysm, published up to December 2019, from the PubMed database and excluded those arising as postoperative complications. A total of 59 cases were analyzed, and we also included our experience of managing a case of cystic artery pseudoaneurysm. Results Abdominal pain (77.9%) was the most common presentation followed by upper GI bleed (64.4%), while 19 patients (32.2%) had presented with classic Quincke's Triad. Most of the cases were diagnosed following the rupture of the pseudoaneurysm (n = 49, 83.05%). Fifteen patients presented with shock. Hyperbilirubinemia (59.3%) and anemia (55.9%) were the commonest laboratory findings. Although CT angiogram remains the investigation of choice, a conventional angiogram is the gold standard and sufficed as the definitive management in 20 cases. Cholecystectomy formed the definitive management in the rest of the cases. We successfully managed a middle-aged female patient of cystic artery aneurysm with xanthogranulomatous cholecystitis by open cholecystectomy. Conclusion Cystic artery pseudoaneurysms are amenable to successful management with careful evaluation and timely cholecystectomy or angioembolization or a combination of both.

Highlights • Hemobilia from pseudoaneurysm rupture after laparoscopic cholecystectomy is rare. • Due to consequent rapid hemodynamic instability, it could be life threatening. • Non-contrast CT and ERCP examinations were performed to confirm hemobilia diagnosis. • Investigations revealed that there was no contrast agent leakage. • Thus, our patient was treated conservatively as opposed to surgically., Introduction Hemobilia due to pseudoaneurysm rupture is a rare, life-threatening complication of laparoscopic cholecystectomy (LC) that can cause rapid hemodynamic instability. Therefore, symptoms of hemobilia must be assessed carefully. Presentation of case An 88-year-old woman underwent LC in our hospital, and blood tests revealed elevation of hepatobiliary enzyme levels on postoperative day (POD) 12. Computed tomography (CT) showed a high absorption area in the common bile duct (CBD), and a diagnosis of hemobilia and a pseudoaneurysm without active bleeding into the abdominal cavity was made. There was no leakage of contrast medium outside the CBD during endoscopic retrograde cholangiography; thus, an endoscopic nasobiliary drainage (ENBD) tube was inserted on POD 12 and an endoscopic retrograde biliary drainage (ERBD) stent was placed in the CBD on POD 13. Thereafter, hepatobiliary enzyme levels gradually normalized and the ENBD tube and ERBD stent were removed on POD 27 and POD 54, respectively. The patient was discharged on POD 66. Discussion Hemostasis establishment using surgery or intervention radiology is often required for the treatment of hemobilia due to pseudoaneurysms; however, conservative treatment was effective in our case and we were able to pursue a minimally invasive approach. Erosion due to clip penetration or incomplete clipping of the cystic artery or its branches during surgery may have caused the cystic artery pseudoaneurysm. Conclusion Hemobilia could be life threatening and cause acute hemodynamic instability; therefore, prompt diagnosis is required. Although the frequency of complication is low, the possibility of hemobilia after LC should be considered.

Patient: Male, 66-year-old Final Diagnosis: Cholecystocolic fistula • cystic artery pseudoaneurysm • gastrointestinal bleed Symptoms: Hematochezia • right upper quadrant Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Acute lower gastrointestinal bleeding (GIB) is often associated with favorable outcomes. It is readily diagnosed and managed with colonoscopy, or may resolve spontaneously. Rarely, extra-colonic sources of bleeding may masquerade as lower GIB, posing a diagnostic challenge and potentially lead to harm if there are therapeutic delays. An example is cystic artery pseudoaneurysm, a rare complication of acute cholecystitis and laparoscopic cholecystectomy, which may bleed through a cholecystocolic fistula presenting as lower GIB. Case Report: A 66-year-old man with multiple comorbidities including coronary artery disease with multiple stents and peripheral arterial disease presented with massive hematochezia. He was on aspirin 81 mg, clopidogrel 75 mg, and rivaroxaban 20 mg daily. The patient was hemodynamically unstable with BP 77/50 mmHg and heart rate 115 beats/min. Pertinent laboratory investigations showed hemoglobin 10.4 g/dL, WBC 17.2×103/uL, platelet 437×103/uL, and INR 1.28. Total bilirubin and liver enzymes were normal. Following prompt volume resuscitation with crystalloids and 2 units of O-negative blood, CT angiogram of the abdomen revealed a ruptured cystic artery pseudoaneurysm bleeding through a cholecystocolic fistula. This developed as a complication of un-diagnosed gangrenous cholecystitis. The patient was sent for transcatheter embolization and the bleeding was controlled. The gangrenous cholecystitis was managed conservatively due to the patient’s high surgical risk. Conclusions: Although extra-intestinal sources of gastrointestinal bleeding are rare, clinicians should maintain a high index of suspicion, especially in elderly patients presenting concomitantly with right upper-quadrant pain. As delayed diagnosis leads to increased fatality rates, a prompt CT angiogram of the abdomen is pertinent in suspected cases.

Cystic artery pseudoaneurysm complicating acute cholecystitis is a rare condition. It may be asymptomatic and incidentally radiologically discovered or presents as right upper abdominal pain, hemobilia, and digestive hemorrhage. We report a case of an incidental preoperative discovery of a pseudoaneurysm of the cystic artery associated with Chilaiditi’s sign in a 54-year-old man admitted for acute cholecystitis. To the best of our knowledge, this is the first report associating these two rare entities.

Highlights • Vascular assessment is important in all complex biliary injury cases. • Perihepatic/peribiliary collaterals provide adequate blood supply to bile ducts. • Balloon dilatation is helpful in biliary-enteric anastomotic strictures. • Delayed biliary enteric repair is better in proper hepatic artery block cases. • Minimum hilar dissection should be done during definitive repair., Introduction Complete proper hepatic arterial [PHA] occlusion due to accidental coil migration during embolization of cystic artery stump pseudoaneurysm resulting from a complex vasculobiliary injurie [CVBI] post laparoscopic cholecystectomy [LC] is an extremely rare complication with less than 15 cases reported. We present a case depicting our strategy to tackle this obstacle in management of CVBI and review the relevant literature. Presentation of case A 35 year old lady presented on sixth postoperative day with an external biliary fistula following Roux-en-y hepaticojejunostomy [RYHJ] for biliary injury during LC. She developed a leaking cystic artery pseudoaneurysm, during angioembolisation of which, one coil accidentally migrated into left hepatic artery resulting in complete PHA occlusion. Fourteen months later, cholangiogram revealed a worsening RYHJ stricture despite repeated percutaneous balloon dilatations. Multiple collaterals had developed. Revision RYHJ was fashioned to the anterior wall of biliary confluence with an extension into left duct. Minimum hilar dissection ensured preservation of collateral supply to the biliary enteric anastomosis. Postoperative recovery was uneventful. The patient is doing well at 1 year follow up. Discussion Definitive biliary enteric repair should be delayed till collateral circulation is established within the hilar plate, hepatoduodenal ligament and perihepatic/peribiliary collaterals to provide an adequate arterial blood supply to biliary confluence and extrahepatic portion of the bile duct. Conclusion Assessment of hepatic arteries should be part of investigation of all complex biliary injuries. Delayed definitive biliary enteric repair ensures a well-perfused anastomosis. Minimum hilar dissection is the key to preserve biliary and hepatic neovasculature.

Cystic artery pseudoaneurysm (CAP) is a rare disease, with small number of previous reports related to CAP. Besides, it is frequently prone to critical condition due to arterial bleeding. Here, we presented a case of ruptured CAP with acute calculus cholecystitis and its subsequent successful management with temporary endoscopic biliary drainage for obstructive jaundice and embolization for the culprit artery without cholecystectomy. Since CAP is at high risk of bleeding, intravascular treatment, which is only one currently available therapeutic option, is urgently required in the clinical sites.

Hemorrhagic cholecystitis is a potentially deadly and difficult to recognize entity. It is associated with cystic artery pseudoaneurysm and is usually seen in the setting of acute calculous cholecystitis. We report two cases of hemorrhagic cholecystitis with arteriographic findings of cystic artery pseudoaneurysms that were successfully embolized using microcoils, facilitating subsequent cholecystectomy. Both cases had unusual presentations of gallbladder rupture with hemoperitoneum, the latter of which was atypical occurring in the absence of gallstones. We believe when hemorrhagic cholecystitis is suspected, a two-step therapeutic approach should be employed with embolization of the bleeding cystic artery followed by cholecystectomy. A comprehensive literature review and discussion of hemorrhagic cholecystitis will be provided.

Introduction: The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare. Case Report: Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition. Conclusion: Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels’ injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.

Cystic artery pseudoaneurysm (CAP) is a rare entity most often resulting from inflammatory conditions (acute cholecystitis or pancreatitis) or iatrogenic trauma (cholecystectomy). We report the case of a 73-year-old female who presented with abdominal pain and gastrointestinal bleeding after an episode of acute cholecystitis and endoscopic retrograde cholangiopancreatography for choledocolithiasis removal. Computed tomography and angiography revealed a CAP measuring 5 cm. A right hepatic artery transcatheter embolization was performed with glue, excluding the pseudoaneurysm. The next day, the patient underwent open cholecystectomy with ligation of the cystic artery. Later, ischemic hepatitis and abscess developed. publishersversion published

Pseudoaneurysms of the cystic artery and cholecystoduodenal fistula formation are rare complications of cholecystitis and either may result from an inflammatory process in the abdomen. A 68-year-old man admitted with acute cholecystitis subsequently developed massive upper gastrointestinal (GI) bleeding. Abdominal computed tomography showed acute calculous cholecystitis and hemobilia secondary to bleeding from the cystic artery. Angiography suggested a ruptured pseudoaneurysm of the cystic artery. Upper GI endoscopy showed a deep active ulcer with an opening that was suspected to be that of a fistula at the duodenal bulb. The patient was managed successfully with multimodality treatment that included embolization followed by elective laparoscopic cholecystectomy. Presently, there is no clear consensus regarding the clinical management of this disease. We have been able to confirm various clinical features, diagnoses, and treatments of this disease through a literature review. A multidisciplinary approach through interagency/interdepartmental collaboration is necessary for better management of this disease.

Patient: Male, 90 Final Diagnosis: Ruptured cystic artery pseudoaneurysm Symptoms: Epigastric pain • Fever Medication: — Clinical Procedure: Open cholecystectomy Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases. Case Report: A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudo-aneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm. Conclusions: A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.

Cystic artery pseudoaneurysm is an exceedingly rare complication of biliary interventions, such as cholecystectomy, or cholecystitis [1]. Prompt intervention is often required due to their predisposition to bleeding. Ideal diagnosis and treatment would have the patient go directly to Interventional Radiology for angiography and embolization, followed by a short interval cholecystectomy [2, 3]. However, due to their low incidence patients often undergo several less invasive diagnostic tests prior to diagnosis [4]. Here we describe what we believe is the first reported pediatric case of a cystic artery pseudoaneurysm secondary to cholecystitis.

Background Cystic artery pseudoaneurysms are rare. It usually occurs as a complication of laparoscopic cholecystectomy, but can arise uncommonly as a complication of acute cholecystitis. Ruptured cystic artery aneurysms present with haemobilia, intraperitoneal or upper gastrointestinal bleeding. We present an unusual case of cystic artery aneurysm presenting as a massive lower gastrointestinal bleed. Case presentation A 47-year-old man was admitted with a thoracic abscess and was noted incidentally on CT to have acute cholecystitis. Subsequently the patient then presented with massive fresh PR bleeding. This was found on CT to be the result of a cystic artery pseudoaneurysm with associated gallbladder fistulation to the hepatic flexure, secondary to cholecystitis. The patient was treated with coil embolisation of the cystic artery made a full recovery and was discharged with a view to performing an elective cholecystectomy. Conclusion Cystic artery pseudoaneurysm is a rare complication of cholecystitis which can present as massive lower gastrointestinal haemorrhage secondary to cholecystocolic fistula. Percutaneous embolization is a safe and effective treatment in the acute phase.

The pathogenesis of formation of cystic artery pseudoaneurysms is not well understood, but is thought to result from erosion of the cystic artery wall from the adjacent inflammatory process associated with acute or chronic cholecystitis. The presented case discusses an incident of hemorrhage from a cystic artery pseudoaneurysm resulting in a large perihepatic hematoma as well as hemobilia, which developed after a routine cholecystostomy catheter exchange. This was treated with transcatheter embolization using ethylene-vinyl alcohol copolymer.

Pseudoaneurysm (PA) of the cystic artery is rare. Most of the reported cases are iatrogenic and develop secondary to liver biopsy, laparoscopic cholecystectomy, ERCP, and liver transplant. Other reported causes include trauma, malignancy, arteriovenous malformations, and inflammation in the hepatobiliary and pancreatic system. Cystic artery psuedoaneurysm is usually asymptomatic but may also present as vague abdominal pain, intra-abdominal mass, and hemobilia. In the event of rupture, it may present as a catastrophic intra-peritoneal bleeding with hemorrhagic shock. Doppler ultrasound and contrast-enhanced CT scan are useful tools for the diagnosis of this condition. However, selective visceral angiography is confirmatory and offers the opportunity for therapeutic embolization. We report a case which presented with upper right quadrant abdominal pain, vomiting, and hypotension. Abdominal ultrasonography revealed subhepatic hematoma and pericholecystic fluid collection along with acute calculus cholecystitis and sludge in the bile duct. Subsequent contrast-enhanced CT and CT angiography confirmed the presence of ruptured cystic artery psuedoaneurysm with subhepatic hematoma. The patient after resuscitation underwent selective visceral angiography and successful coil embolization of the cystic artery pseudoaneurysm. During the same admission, ERCP and biliary stenting were also performed followed by laparoscopic cholecystectomy. This case reports a rare entity which was successfully treated using a multimodality strategy.

A patient with a cystic artery pseudoaneurysm (CAP) presented to the emergency department with upper abdominal and back pain. The patient also had clinical signs of sepsis. CT revealed gallstones with acute suppurative cholecystitis with a gallbladder perforation. In addition, a CAP was also suspected and subsequently diagnosed on CT angiography. The pseudoaneurysm was treated with embolisation and a cholecystostomy was performed for the gallbladder perforation. Following her acute admission, the patient underwent an elective cholecystectomy and made a good recovery post surgery.

Hyun Kyo Lee, Tae Jun Song, Jong Wook Choi, So Young Ha, Jung Wook Kim, Jong Soo Shin, Chul Nam Kim, Sun Hee Chang Department of Internal Medicine, Surgery and Pathology, Inje University Ilsan Paik Hospital, Goyang; Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul; Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea

Highlights • Pseudoaneurysm of the cystic artery following acute cholecystitis is rare. • It can be safely managed laparoscopically with simultaneous cholecystectomy. • This avoids multiple invasive procedures and decreases morbidity associated with open surgery., INTRODUCTION Pseudoaneurysm of the cystic artery is very rare. In the majority of cases it has been reported as a post-operative complication of laparoscopic cholecystectomy, however it has also been associated with the presence of acute cholecystitis or pancreatitis. When these pseudoaneurysms rupture they can lead to intraperitoneal bleeding, haemobilia and upper gastrointestinal haemorrhage. Radiological as well as open surgical approaches have been described for control of this rare pathology. PRESENTATION OF CASE We report the laparoscopic surgical management of an incidental, unruptured cystic artery pseudoaneurysm in a patient presenting with acute cholecystitis. DISCUSSION Cystic artery pseudoaneurysm is a rare entity and as such there is no consensus on the clinical management of this condition. A variety of treatment strategies have been reported in the literature including radiological selective embolisation and coiling, open cholecystectomy with ligation of the aneurysm, or a two-step approach involving radiological management of the pseudoaneurysm followed by an elective cholecystectomy. CONCLUSION In this report we have demonstrated that laparoscopic management of a cystic artery pseudoaneurysm with simultaneous laparoscopic cholecystectomy is feasible and safe. This avoids multiple invasive procedures and decreases morbidity associated with open surgery.

Cystic artery pseudoaneurysm is a rare entity most closely associated with trauma to the biliary vasculature (usually iatrogenic) or inflammation from adjacent cholecystitis. Most cases are treated intraoperatively during cholecystectomy. We describe 3 cases of cystic artery pseudoaneurysms secondary to acute cholecystitis, 2 with active hemobilia, treated with transcatheter embolization at our institution.

Cystic artery pseudoaneurysm is a very rare disease in which there is an abnormal, focal dilatation of the artery supplying the gallbladder. The condition may occur as a consequence of a localised inflammatory response, such as in cholecystitis. Here, we present the case of a 56-year-old man who presented with chronic cholecystitis in whom a 1.8 cm × 2 cm cystic artery pseudoaneurysm was found incidentally during laparoscopic cholecystectomy. Prior to the operation, routine investigations such as ultrasound revealed no indication of cystic artery pseudoaneurysm, ruptured or otherwise. This case is reported to emphasise that cystic artery pseudoaneurysm may be caused by chronic or acute cholecystitis and that skilled surgeons may handle them laparoscopically.

Cystic artery pseudoaneurysm is a rare pathology. Of the 20 cases reported so far, chronic cholecystitis and iatrogenic biliary injury form the majority of causes. Currently, there is no published report of such pseudoaneurysms caused secondary to pancreatitis, hence the management in such a scenario is unclear. We hereby present the first such report of cystic artery pseudoaneurysm occurring as a sequel of acute necrotising pancreatitis. A 33-year-old man who recovered from a recent attack of acute pancreatitis was readmitted for melena and fever. Computed tomography of abdomen revealed blood in the gall bladder with pericholecystic blush and resolving pancreatic necrosis. Percutaneous transarterial embolisation of the cystic artery was done. This stabilised the patient but persistent sepsis and clinical deterioration warranted a surgical exploration and cholecystostomy. Hence, transarterial embolisation followed by surgery in selected cases can be an ideal management protocol.

We discuss a patient with late presentation of hemobilia following cholecystectomy, which is unusual because pseudoaneurysm caused by vascular injury during surgery typically presents soon after surgery. Endoscopic retrograde cholangiopancreatography revealed a large blood clot arising from the biliary orifice with subsequent computed tomography angiography diagnosing a large pseudoaneurysm in the region of the cystic artery adjacent to the cholecystectomy clips. Embolization was performed via direct percutaneous puncture of the pseudoaneurysm.

Hemobilia is a rare cause of upper gastrointestinal bleeding (UGIB). It is commonly iatrogenic, and is more rarely caused by tumors, lithiasis, and inflammatory or vascular disease. We describe a case of cystic artery pseudoaneurysm, which caused acute pancreatitis as an unusual complication.

A 45-year-old woman status post laparoscopic cholecystectomy 3years ago presented with upper gastrointestinal bleeding. Endoscopy revealed hemobilia. Computed tomographic abdomen demonstrated a 2-cm aneurysm in the gall bladder fossa, consistent with a pseudoaneurysm. Initially, transcatheter coil embolization was attempted but recanalization of the aneurysm with recurrent bleeding in 2 days ensued. The aneurysm was then accessed percutaneously under ultrasound guidance and thrombin was injected into the aneurysm with subsequent complete thrombosis of the aneurysm and cessation of bleeding.

Pseudoaneurysm of the cystic artery is a rare complication of cholecystitis. 34 cases have been reported from 1976 to 2012, searched on MEDLINE and most of the cases have presented with gastrointestinal bleeding. We report the third case of an unruptured pseudoaneurysm of the cystic artery associated with calculous cholecystitis. An 85-year-old female presented to the emergency unit with epigastric pain and jaundice. Laboratory data and contrast-enhanced computed tomography (CT) revealed calculous cholecystitis and Mirizzi syndrome accompanied by a pseudoaneurysm in the gallbladder. Color Doppler ultrasonography (US) clearly demonstrated the pulsatile pseudoaneurysm. After biliary drainage and antimicrobial therapy, selective hepatic angiography with the aim of providing transcatheter arterial embolization was performed but the pseudoaneurysm had already thrombosed spontaneously. Open cholecystectomy was successfully carried out. Histological specimens demonstrated the pseudoaneurysm with organized thrombus in the epithelial wall of the gallbladder thickened with severe fibrosis. It is suggested that cholecystitis with unusual symptoms such as gastrointestinal bleeding requires immediate enhanced CT and US with Doppler imaging in order not to overlook a rare but life-threatening pseudoaneurysm.