Case Of Hepatic Artery Pseudoaneurysm Research Articles

Case Report: When Arteries Betray: Massive Post-transplantation Hemorrhage

Hepatic artery pseudoaneurysm is a rare complication that may occur in the setting of liver transplantation and other traumatic instrumentation of the hepatobiliary system. This condition poses a significant morbidity and mortality risk and must be diagnosed and intervened upon emergently. Herein we present a case of hepatic artery pseudoaneurysm complicated by hemorrhagic shock in the setting of a post-liver transplant biliary leak. In this case, the patient was ultimately diagnosed via hepatic angiogram, treated with hepatic artery embolization, and required subsequent retransplantation. The objective of this case was to demonstrate the importance of maintaining a high clinical suspicion for hepatic artery pseudoaneurysm in the post-transplant setting, emphasize the use of computed tomography angiography as a primary diagnostic tool, and involving interventional radiology early in the treatment course.

A Case Series on Transarterial Embolization in Treatment of Hepatic Artery Pseudoaneurysm (Indian perspective) - our experience in a Single Institute (Centre of Excellence)

ABSTRACT Purpose: To evaluate the role of transarterial embolization in hepatic artery pseudoaneurysm (HAP) in the Indian population with an analysis of cases done in our hospital in 1 year. Materials and Methods: We searched our database on the computer of the School of Digestive and Liver Disease (SDLD) for cases of HAP within the last 1 year (from May 2021 to April 2022) and then reviewed in detail, examining causes, clinical data, laboratory data, treatment given, and any intervention and if yes then its complications and outcome. We then analyzed all the data from the perspective of the Indian population and compared them with those of previous literature. Result: Eight patients of HAP were found during investigations, who were admitted to SDLD. Another two patients were referred from another department to GI Radiology of SDLD. Causes were identified as blunt trauma abdomen, chronic pancreatitis, liver biopsy, and liver abscess, with blunt trauma being the most common cause. We found two HAPs in the extra-hepatic location, whereas in the rest of the cases, it was intra-hepatic. Among them, the left hepatic artery was involved in one patient and the right hepatic artery was involved in two patients. All the patients were evaluated carefully by both ultrasonography (USG) and tri-phasic computed tomography of the liver. We successfully embolized all of the total 10 patients of HAP in the last 1 year; however, one patient died due to sepsis. Each patient was followed up by USG. Conclusion: HAP is a complication related to blunt injury abdomen, pancreatitis, and post-surgical cases, which should be treated promptly. It can be deadly if left untreated. Successful and prompt intervention can provide good outcomes for these patients and prevent rupture-related complications.

A Rare Case of Hepatic Artery Pseudoaneurysm by Penetrating Duodenal Ulcer in an Early Living Donor Liver Recipient

A Rare Case of Hepatic Artery Pseudoaneurysm by Penetrating Duodenal Ulcer in an Early Living Donor Liver Recipient

Kist hidatiğin nadir prezantasyonu: hepatik arter psödoanevrizma kanaması ve senkron duodenal fistül

Aims: Hydatid cyst disease is a rare cause of upper gastrointestinal bleeding. Peculiarly if it's resulted from a ruptured hepatic artery aneurysm in the hydatid cyst cavity which is fistulated into the duodenum. We here present a case of hepatic artery pseudoaneurysm due to a complicated hydatid cyst with synchronous duodenal fistula. 
 
 Case: A 45-year-old male was admitted to the emergency department with hematemesis and hematochezia. The patient had a history of a hydatid cyst of liver and a surgical procedure of lung ecinoccosis. Endoscopy revealed an unusual ulcerated lesion in the duodenum. Yellow membranes were observed in the midst and blood oozing. After unsuccessful endoscopic sclerotherapy, a Computerized Tomography (CT) was performed. CT revealed a ruptured hydatid cyst into the duodenum and bleeding from the formed hepatic artery pseudoaneurysm. Hepatic artery coil embolization was performed urgently and a percutaneous transhepatic drainage catheter was applied to maintain the bile flow. Subsequently, a 10 Fr , 10 cm plastic stent was inserted via Endoscopic Retrograde Cholangiopancreatography (ERCP). The rare complication which was observed after embolization was the hepatic abscess. Although a percutaneous catheter was inserted initially, drainage wasn’t successful. As a last option, surgical debridement was considered.
 
 Conclusion: If a patient who presented with upper gastrointestinal bleeding with a previous history of liver hydatid cyst, cyst complications must be listed as a differential diagnosis. Besides endoscopy, contrast-enhanced CT and ЕRCP are the essential diagnostic and therapeutic approaches.

Role of interventional radiology in management of post-liver transplant anastomotic complications

BackgroundLiver transplantation is considered to be the treatment of choice in cases of end-stage liver disease; however, as a major procedure, the operation is fraught with complications. The etiology, symptoms, and diagnostic methods for arterial, portal, and biliary issues are thoroughly discussed. Interventional procedures such as balloon angioplasty and stent placement in the arterial and portal systems, as well as biliary interventional procedures, are described.ResultsIn our study, we reviewed 25 cases of post-living donor transplanted liver, with anastomotic complications including biliary stenosis 40%, hepatic vein stenosis 20%, portal vein stenosis 16%, biliary leakage 16%, and hepatic artery stenosis or pseudo-aneurysm 16%. We had 10 cases of biliary stenosis, 7 of which were successfully treated with the insertion of an internal/external drain, and one case failed. Two patients died. We had four cases of hepatic venous obstruction with successfully implanted stents and a perfect outcome, efficacy, and patency rate of 100%. We also had two cases of hepatic artery stenosis that were perfectly managed by stent placement, with a patency rate of 100%. We came across two cases of hepatic artery pseudo-aneurysm. One case failed due to large sac size, while the other was successful. Finally, in our study, we had a 100% success rate in 5 cases of portal vein stenosis in the early postoperative period.ConclusionsPercutaneous IR was effective treatment for hepatic vein occlusion, portal vein stenosis, hepatic artery stenosis, and anastomotic biliary stricture after living donor liver transplantation. The interventional radiology team is now an integral part of the multi-disciplinary care of transplant patients. As new interventional instruments are developed and experience is gained, the outcomes of interventional treatments will continue to improve.

Emergency surgery for hemobilia due to hepatic artery pseudoaneurysm rupture complicated by Mirizzi syndrome type II: a case report

BackgroundHemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required.Case presentationA 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks.ConclusionsWe experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required.

The Role of Sonography in a Rare Case of Hepatic Artery Pseudoaneurysm: A Case Study Report

Hepatic artery pseudoaneurysms (HAPs) are rare, life-threatening complications that arise in response to liver trauma or underlying inflammatory processes. The risk of rupture necessitates prompt diagnosis and treatment. Sonography is an important imaging modality used to evaluate and characterize suspected HAPs. In the case described below, sonography played an important role in the diagnosis and successful treatment of a patient with a large, high-risk HAP.

A rare cause of cholangitis

We described a case of hepatic artery pseudoaneurysm occurring as a complication of biliary stent migration, presented as cholangitis. It was managed by endoscopic retrograde cholangiopancreatoraphy and the pseudoaneurysm was treated with coil embolization.

A rare and catastrophic case of hepatic artery pseudoaneurysm causing obstructive jaudice

A rare and catastrophic case of hepatic artery pseudoaneurysm causing obstructive jaudice

Effectiveness of Endovascular Coil Embolization of Ruptured Hepatic Artery Pseudoaneurysm

Purpose: To assess the efficacy of endovascular management for ruptured hepatic artery pseudoaneurysm (HAP). Methods: Six cases of HAP in five patients (four men and one women; mean age, 50; range, 28 - 62) were treated with transcatheter arterial coil embolization using microcoil (Boston Scientific, Watertown, MA, USA) and Tornado Coil (Cook, Bloomington, IN, USA) with or without stent graft between January 2007 and September 2008. They were analyzed with regard to the clinical presentation, radiological findings with procedure, and clinical and radiologic outcomes. Results: All patients presented with epigastric pain or gastrointestinal bleeding. The pseudoaneurysms were ranged from 0.6 to 4.4 cm in size and located in the common hepatic artery (n = 1), junction between proper and right hepatic artery (n = 1), proper hepatic artery (n = 2), the left hepatic artery (n = 1), right hepatic artery (n = 1). Embolization was performed with microcoils in all pseudoaneurysmal sac with or without both afferent and efferent segment. A self-expandable stent (n = 1) was also used. Overall technical success was 100% (6 of 6) and complete occlusions of HAPs were achieved in 5 out of 6 cases, 83.3% of clinical success rate. Re-bleeding occurred in one case of stent graft at proper hepatic artery following coil packing for pseudoaneurysmal sac. Clinical success rate of embolization for both afferent and efferent segment was 100% (3 of 3). Procedure-related minor complications happened in 2 of 5 patients, and they were treated conservatively. Conclusion: Transcatheter coil embolization for ruptured HAP is sufficiently effective and additional embolization in both afferent segment and efferent segment can improve clinical success rate.

Common ultrasound and contrast-enhanced ultrasonography in the diagnosis of hepatic artery pseudoaneurysm after liver transplantation.

The diagnostic value of common ultrasound and contrast-enhanced ultrasonography (CEUS) in hepatic artery pseudoaneurysm (HAP) after liver transplantation was investigated. From January 2005 to November 2015, information was collected on 2,085 cases of orthotopic liver transplantation. The cases included 1,617 men and 468 women. Common ultrasound and CEUS were used to monitor arterial blood flow following surgery, and the complications were assessed. Instruments used included Acuson Sequoia 512 and Mylab Twice, and the contrast agent was SonoVue. The standard of common ultrasound in the diagnosis of HAP was follicular structure, which had arterial blood flow signal present beside the hepatic artery. The diagnostic criteria of HAP using CEUS were abnormal and round contrast enhancement zone and perfusion of the contrast agent in the zone near the hepatic artery. The diagnostic standard of HAP was computed tomographic angiography (CTA) and emergency operation. Eight cases of HAP were diagnosed in 2,085 patients after liver transplantation (0.38%). Three cases of HAP were diagnosed successfully by common ultrasound while 5 cases were missed. Sensitivity, specificity and diagnostic accuracy for common ultrasound was 37.5, 100 and 99.76%, respectively. Six cases of HAP were diagnosed by CEUS and 2 cases were missed. Sensitivity, specificity and diagnostic accuracy for CEUS was 75, 100 and 99.9%, respectively. Collectively, CEUS is a convenient and effective diagnostic method for HAP following liver transplantation, the diagnostic sensitivity was obviously higher than that of the common ultrasound, and it was more convenient than CTA. Nevertheless, the diagnosis of pseudoaneurysm with deep location, and unsatisfactory grayscale images were easily missed.

Amoebic Liver Abscess with Hepatic Artery Pseudoaneurysm: Successful Treatment by Interventional Radiology

Amoebic liver abscess is most common extra-intestinal presentation of amoebiasis. It is rarely complicated with vascular involvement including thrombosis of hepatic vein or IVC and pseudo-aneurysm of hepatic artery. We describe a case of hepatic artery pseudo-aneurysm as a complication of amoebic liver abscess treated with percutaneous embolization.

Hepatic artery pseudoaneurysm caused by acute idiopathic pancreatitis

Hepatic artery pseudoaneurysm (HAP) is a very rare disease but in cases of complication, there is a very high mortality. The most common cause of HAP is iatrogenic trauma such as liver biopsy, transhepatic biliary drainage, cholecystectomy and hepatectomy. HAP may also occur with complications such as infections or inflammation associated with septic emboli. HAP has been reported rarely in patients with acute pancreatitis. As far as we are aware, there is no report of a case caused by acute idiopathic pancreatitis, particularly. We report a case of HAP caused by acute idiopathic pancreatitis which developed in a 61-year-old woman. The woman initially presented with acute pancreatitis due to unknown cause. After conservative management, her symptoms seemed to have improved. But eight days after admission, abdominal pain abruptly became worse again. Abdominal computed tomography (CT) was rechecked and it detected a new HAP that was not seen in a previous abdominal CT. Endoscopic retrograde cholangiopancreatography (ERCP) was performed because of a suspicion of hemobilia as a cause of aggravated abdominal pain. ERCP confirmed hemobilia by observing fresh blood clots at the opening of the ampulla and several filling defects in the distal common bile duct on cholangiogram. Without any particular treatment such as embolization or surgical ligation, HAP thrombosed spontaneously. Three months after discharge, abdominal CT demonstrated that HAP in the left lateral segment had disappeared.

Use of a Multilayered Stent for the Treatment of Hepatic Artery Pseudoaneurysm After Liver Transplantation

To the Editor: We would like to use this opportunity to share with the wider clinical community our experience in managing a hepatic artery pseudoaneurysm (HAP) of a 59-year-old man after liver transplant using a multilayered stent. HAP is a rare but well-recognised complication occurring after orthotopic liver transplantation (OLT). The reported incidence is 0.3% to 2.6% [1, 2]. The majority of cases of HAP occurring after OLT arise in the context of endovascular intervention or secondary to diathermy injury to the artery during surgery [3]. They have also been reported to complicate other hepato-pancreatico-biliary surgical procedures [4]. With time, the natural history of HAP is of enlargement and an associated risk of rupture, which can be fatal [5]. Patients most commonly present with intraperitoneal bleeding or gastrointestinal haemorrhage secondary to haemobilia; however, incidental and asymptomatic HAP may be recognised [6]. Established management options include surgical ligation and endovascular coil embolisation; however, both of these methods are associated with a significant risk of hepatic ischaemia, which often requires retransplantation [5]. Coronary artery stent-grafts have also been used to treat HAP, often after failure of coil embolisation [7]. The introduction of the Multilayer Aneurysm Repair System (MARS) stent (Cardiatis SA, Belgium) is a recent development in endovascular aneurysm repair. This is an uncovered stent comprised of three-dimensional braided tubing that decreases blood flow velocity in the aneurysmal sac whilst improving laminar blood flow in the main artery and surrounding arterial tributaries [8]. Its use for the treatment of HAP occurring after OLT has not previously been reported. Our case involves a 59 year-old man who underwent OLT for alcoholic cirrhosis in January 2011. The patient’s main indication for OLT was recurrent ascites. A transjugular intrahepatic portosystemic shunt was inserted in November 2010 before emergency surgical repair of a ruptured umbilical hernia. He was transplanted in early January 2011. He received a whole liver from a 74-year-old brainstem-dead donor who was involved in a road-traffic accident. His hepatectomy was performed whilst he was on veno-venous bypass and was uncomplicated. The implantation included a cavocavostomy, end-to-end pulmonary vein anastomosis using 5.0 Prolene (Ethicon, UK) suture material, end-to-end arterial anastomosis to the common hepatic artery using 6.0 Prolene (Ethicon, UK) suture material, and duct-to-duct biliary anastomosis using 5.0 polydioxanone (Ethicon, UK) suture material. The cold ischaemic time was 12 h and 40 min. During surgery, he received 4 U of blood, 1 pool of platelets, and 6 U of fresh frozen plasma. His postoperative recovery was complicated by mild acute cellular rejection on day 10, which required augmentation with intravenous methylprednisolone. He was discharged home on day 16. His immunosuppression medication included tacrolimus, azathioprine, and prednisolone. Because he was a cytomegalovirus mismatch, vanganciclovir was given for 100 days. At 3 months after OLT, the patient was admitted to our hospital for investigation of graft dysfunction. Liver histology showed evidence of perivenular haemorrhage and A. M. Elsharkawy (&) G. Sen M. Hudson S. Masson D. M. Manas Liver Unit, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, UK e-mail: ahmede@doctors.org.uk

Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Hepatic artery pseudoaneurysm is a rare and potentially fatal complication of laparoscopic cholecystectomy that often presents with abdominal pain, anemia, hemobilia, and liver function elevations. The authors report a case of hepatic artery pseudoaneurysm diagnosed by abdominal computed topography in a 54-year-old man who had undergone laparoscopic cholecystectomy the previous month. Definitive treatment was angiography with embolization.

Hepatic Artery Pseudoaneurysm: A Unique Cause of Obscure Upper GI Bleeding

Hepatic Artery Pseudoaneurysm (HAP) is a rare clinical entity and is usually associated with iatrogenic or traumatic etiologies, and almost always manifests with hemobilia. We report the first documented case of HAP in a patient with chronic cholecystitis without any underlying history of trauma or surgery, presenting as massive upper gastrointestinal hemorrhage (UGIH) without hemobilia. A 73 year old Caucasian female with past history of NIDDM, hypertension, hyperlipidemia presented to ER with non-radiating epigastric pain, nausea and black melanonic stools for past 24 hours. Pertinent labs on admission showed a Hb of 10.3 g, WBC 12.3, T.B 2.3 mg, AST 525 U, ALT 451 U, ALP 133 U, BUN 35 and S.Cr 1.0. Abdominal ultrasound showed multiple gallstones, and the CT scan showed a large intraluminal echogenic structure consistent with a gallstone, with thickened GB wall. Over the next day, the patients Hb dropped to 6 g and upper GI Endoscopy (UGIE) revealed acute hemorrhage, possibility of a duodenal ulcer was entertained. To investigate the possibility of GB malignancy in view of the above radiological findings and CA 19–9 level of 2801, an ERCP was done which showed no hemobilia or stone, and a CBD stent was placed for patency. Patient continued to have UGIH with falling Hb, and multiple endoscopies failed to achieve adequate hemostasis. Subsequent UGIE study showed an adherent clot on the lateral wall with active oozing. Patient was then taken for selective catherization and angiogram of the celiac trunk and right hepatic arteries, which yielded visualization of large extravasations of contrast from the inferior aspect of the right common hepatic artery and confirmed a pseudoaneurysm, eroding into the duodenal mucosa. Successful embolization and hemostasis was achieved. The patient also had a gall bladder biopsy to rule out malignancy, which revealed chronic active cholecystitis. This case illustrates a extremely rare association of HAP with chronic cholecystitis presenting as UGIH in an unusual form and not as the classical hemobilia. Of the multiple case reports and series submitted for HAP, almost all have shown a preceding interventional procedure involving the hepatobiliary and pancreatic systems or history of trauma. HAP due to biliary inflammation is usually attributed to stone eroding into the artery or due to local weakness of vessel wall. Awareness of this rare presentation and association of HAP may allow early diagnosis and timely intervention.

Hepatic Artery Pseudoaneurysm Associated with Plastic Biliary Stent

The increased use of interventional procedures and laparoscopic cholecystectomy in the management of hepatobiliary disorders is associated with an increased incidence of hemobilia and hepatic artery aneurysm. Here we report a case of hepatic artery pseudoaneurysm associated with a plastic biliary stent. Multiple factors were involved in the formation of the hepatic artery aneurysm (HAA) and it was successfully treated by embolization.

Hepatic Artery Pseudoaneurysm: A Report of Seven Cases and a Review of the Literature

To analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature. We searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature. There were five cases of HAP among 18,015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients. Hepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.