Hepatic Artery Pseudoaneurysm Masquerading as Malignant Jaundice

Abstract

Introduction: Visceral artery aneurysms and pseudoaneurysms (PSAs) are rare conditions with a reported incidence of 0.1 to 0.2%. The etiology of most PSAs are abdominal trauma, iatrogenic or pancreatico-biliary procedures. Hepatic artery PSAs are often asymptomatic or can present with abdominal pain, nausea, hemobilia, and rarely jaundice. Case Report: A 74-year-old man presented with jaundice, pruritus, and malaise that progressively worsened over a 2 week period. On admission the total bilirubin (TB) levels was 7.6, direct bilirubin (DB) 4.9, aspartate aminotransferase (AST) 39, alanine aminotransferase (ALT) 35, alkaline phosphatase (ALP) 214, Ca 19-9 79.4, and CEA 1.1. A contrast-enhanced computerized tomography (CT) scan was performed which showed significantly distended intrahepatic bile ducts, a common hepatic duct (CHD) stricture and a 2.6 x 3.8 cm contrast-filled lobulated stricture consistent with a PSA of the right hepatic artery (RHA) (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) was attempted, however cannulation was unsuccessful. A percutaneous transhepatic cholangiogram was therefore performed identifying a severe stricture in the common hepatic duct. Bilateral percutaneous transhepatic biliary drains were placed, and brushings of the bile duct were performed. Cytology brushing were unremarkable, and there remained concern for cholangiocarcinoma. Eight days after percutaneous transhepatic cholangiography and drainage (PTCD), the patient presented with bloody drainage in his right hepatic drain. The patient underwent a PTCD which revealed a complex communication between the CHD and the RHA (Figure 2). The PSA was successfully embolized. An ERCP (Figure 2) was then performed with digital cholangioscopy (Figure 3). No tumor was visualized and a CHD stricture was confirmed due to extrinsic compression. The patient was managed conservatively and during outpatient clinic follow-up he was asymptomatic and his liver enzymes had normalized.Figure 1Figure 2Figure 3Discussion: Our case represents a spontaneous hepatic artery psudoaneurysm causing obstructive jaundice. In rare situations PSAs may develop from atherosclerosis. ERCP with digital cholangioscopy was crucial in our case to demonstrate an absence of a tumor and correctly identify extrinsic compression from the PSA.