Painful pulsatile epigastric mass

Abstract

A 40-year-old woman with obesity and hypertension presented to the emergency department with abdominal pain. Physical examination revealed a tender, pulsatile, epigastric abdominal mass. A 6.5 × 6.5-cm fusiform common hepatic artery aneurysm, extending from the celiac bifurcation to the origin of the gastroduodenal artery, was seen on a computed tomography scan (A, B, C/Cover, D). Pulse examination was normal. She denied a smoking history or a family history of aneurysm. The patient was admitted for blood pressure control, and the following day was taken for urgent aneurysm repair. Proximal control of the celiac artery was obtained. The left gastric and splenic arteries were ligated to mobilize celiac artery for adequate exposure and control. Distally, the proper hepatic artery and gastroduodenal artery were controlled. The aneurysm sac was opened and reconstructed using a saphenous vein interposition extending from the celiac artery to the common origin of the proper hepatic and gastroduodenal arteries. The aneurysm sac was closed over the graft. Postoperatively, the patient developed elevations of the hepatic transaminases, which soon normalized. Aspirin was administered for antiplatelet therapy and the patient was discharged home on postoperative day 6 and was advised to return to normal activity. At 6 months, she had no pain and fully resumed her daily activities. Hepatic artery aneurysm has an incidence of 0.002% in the population.1Abbas M.A. Fowl R.J. Stone W.M. Panneton J.M. Oldenburg W.A. Bower T.C. et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar The causes of hepatic artery aneurysms are unclear, but they are most frequently associated with fibromuscular dysplasia, Takayasu arteritis, vasculitis, Wegner granulomatosis, and connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome.2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar Repair is recommended for aneurysms larger than 2 cm in size or if they are symptomatic or ruptured.1Abbas M.A. Fowl R.J. Stone W.M. Panneton J.M. Oldenburg W.A. Bower T.C. et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar, 2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar, 3Berceli S.A. Hepatic and splenic artery aneurysms.Semin Vasc Surg. 2005; 18: 196-201Crossref PubMed Scopus (159) Google Scholar, 4Lumsden A.B. Mattar S.G. Allen R.C. Bacha E.A. Hepatic artery aneurysms: the management of 22 patients.J Surg Res. 1996; 60: 345-350Abstract Full Text PDF PubMed Scopus (82) Google Scholar Endovascular and open repair are viable options. The hepatic circulation should be maintained and ligation is recommended only if adequate collateral circulation is present.2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar,3Berceli S.A. Hepatic and splenic artery aneurysms.Semin Vasc Surg. 2005; 18: 196-201Crossref PubMed Scopus (159) Google Scholar Although combined left gastric and splenic ligations can lead to proximal gastric ischemia, if the gastroepiploic artery is preserved, ischemic complications are rare. Open repair was chosen in this case owing to an inadequate distal landing zone for stent placement. Publication was discussed with the patient and consent obtained.