Hepatic Artery Pseudoaneurysm Research Articles

Massive Hemobilia: A Diagnostic and Therapeutic Challenge

Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia. Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed. Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1). The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.

Microcatheter looping technique for catheterization of the proper hepatic artery through pancreaticoduodenal arcades and gastroduodenal artery in celiac axis occlusion

Abstract The present report describes a case of successful embolization of the hepatic artery pseudoaneurysm in a 61-year-old female patient with celiac axis occlusion. Because of celiac artery occlusion, the hepatic artery had to be catheterized through the pancreaticoduodenal arcades and the gastroduodenal artery (GDA) from the superior mesenteric artery (SMA). Despite coaxial catheterization using a torque guide wire, the proper hepatic artery (PHA) could not be catheterized because of the acute angle between the GDA and the PHA. The use of the microcatheter looping technique facilitated catheterization of the PHA and subsequent embolization of the right hepatic artery pseudoaneurysm.

Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation

We present a case of a 71-year-old woman with an unusual complication of aortic intramural hematoma and hepatic artery pseudoaneurysm following cardiopulmonary resuscitation and thrombolysis done for sudden cardiopulmonary arrest and pulmonary embolism. Patient was on Warfarin treatment for a prior history of pulmonary embolism and experienced recurrent cardiac arrests, which finally resolved after intravenous administration of thrombolytic agents. However, follow-up computed tomographic angiography revealed descending aortic intramural hematoma with intramural blood pool and concomitant liver laceration with hepatic artery pseudoaneurysm. The patient received transcatheter embolization for the hepatic injury with careful follow-up for the aortic injury and was later discharged in a stable condition. Follow-up with subsequent computed tomographic angiography at a regular interval over 1 month shows near complete resolution of the intramural hematoma. The purpose of this report is to describe the rare complication of cardiopulmonary resuscitation and thrombolysis in the form of concomitant injuries of the aorta and liver. Although the use of thrombolytic agents in patients with pulmonary embolism and cardiac arrest is still a matter of debate, this case report supports the concept that thrombolysis has a role in restoring cardiopulmonary circulation, especially in recurrent cardiac arrests resulting from pulmonary embolism. On the other hand, this case also highlights the increased association of the bleeding-related complication as a result of vigorous efforts of cardiopulmonary resuscitation. Aggressive management with interventional radiology for hepatic pseudoaneurysm and conservative management of the aortic intramural hematoma resulted in favorable outcome for our patient.

Stent Graft in the Treatment of Pseudoaneurysms of the Hepatic Arteries

The purpose of our study was to evaluate the technical feasibility, procedural complications, clinical follow-up, and computed tomography (CT) scan outcomes of hepatic artery pseudoaneurysms (HAPs) treated with stent graft. Between October 2004 and October 2009, we treated 8 patients with HAPs with stent graft. Stent graft deployment was technically successful in all the patients. Complete exclusion of the pseudoaneurysm preserving patency of the hepatic artery was achieved in 6 patients. Total occlusion of the common hepatic artery was observed in 1 patient, and vasospasm of proper hepatic artery and endoleak from distal stent margin were observed in another patient. The 2 patient were controlled through occlusion parent artery with coils. After these procedures, symptoms of bleeding and abdominal pain disappeared. Follow-up enhanced CT scan was performed at an average of 14 months (range, 6-26 months), which showed complete disappearance of the HAP and patency of the stent without intrastent stenosis in 6 patients who had successful deployment of the stent. Endovascular treatment of HAPs using stent graft can maintain the hepatic artery blood flow and could be considered as an alternative to embolization.

Massive upper gastrointestinal bleeding due to right hepatic artery pseudoaneurysm secondary to cholecystitis

Abstract A literature trawl reveals a substantial number of reports on true visceral aneurysms, including the hepatic artery, but only a handful of cases of visceral pseudoaneurysms. The ones in relation to the biliary tree are associated with previous gall bladder surgery and can result in significant gastrointestinal bleeding. There are more than 10 reported cases of cystic artery pseudoaneurysms but a thorough search revealed only two cases in English (1,2) and perhaps one in Japanese literature of right hepatic artery pseudoaneurysm secondary to cholecystitis presenting as massive upper gastrointestinal bleed. We present a probable fourth case in a 52 year old woman with classical clinical/biochemical picture, typical radiological appearance and who underwent successful interventional radiological treatment of this condition.

Reversed Saphenous Bypass for Hepatic Artery Pseudoaneurysm After Liver Transplantation

Hepatic artery pseudoaneurysm (HAP) is found in 1-2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation after orthotopic LT is reported to be as high as 75%. Because of the rarity of complications, particularly when considered individually, much of the direction for the management of complications is anecdotal. This article discusses the presentation, etiology, types, treatment indications, and vascular procedures used to manage complications with LT. Between January 2004 and December 2011, 464 LTs were performed at our institution. Of these, 9 (1.9%) consecutive patients underwent surgical treatment of HAP (8 men and 1 woman; median age, 58.4years [range, 46-67years]). Four patients underwent transarterial chemoembolization before LT for hepatocellular carcinoma. In all cases, revascularization with a reversed autologous saphenous vein bypass was performed. Four patients had ruptured pseudoaneurysms, and the others were diagnosed as having asymptomatic pseudoaneurysms during the follow-up period. The median delay between LT and the diagnosis of HAP was 39.6days (range, 22-92days). All were anatomically extrahepatic. The median diameter was 15.3mm (range, 9-30mm). Four patients had a T-tube. In 6 cases, biliary leakage was associated with the LT and, in the remaining 3, mycosis was recorded. After surgery, 1 patient underwent retransplantation because of ischemic cholangitis. Five years later, 5 patients had normal arterial anatomy, and the other 3 patients had stenosis that was successfully treated by stents. All of the patients had normal liver function at follow-up. One patient died 16months later because of a heart attack. HAP with massive intraperitoneal bleeding is a rare but serious life-threatening complication when it occurs after LT. The majority of HAP cases are associated with bile leakage and mycosis; therefore, surgery must be the treatment of choice. Our conclusions support surgical revascularization with reversed saphenous grafts as a feasible and efficient treatment in cases of HAP.

Total endovascular solution for complex visceral aneurysms

Visceral aneurysms are rare in the general population (<2%), and the most serious complication is represented by aneurysm rupture. The use of stent grafts to exclude visceral aneurysms is described in several reports but is reserved for patients with favorable anatomy. We report here on a hepatic artery pseudoaneurysm in a liver transplant patient and a patient with an aneurysmal vein graft degeneration of a renal bypass, both with no suitable proximal neck for standard stent grafting. Both patients were successfully treated with a custom-made aortic endograft with a single fenestration for the hepatic or renal artery, together with a visceral covered stent. Although initial results are promising, long-term follow-up is required to assess durability.

Hepatic Artery Pseudoaneurysms: A Single-Center Experience

The management of hepatic artery aneurysms has evolved largely because of changes in etiology and presentation, and advances in endovascular therapy. Although many case reports have been published on the condition, few have been from developing countries and few have compared patient outcomes after angioembolization and surgery. This study retrospectively analyzed patients admitted with hepatic artery pseudoaneurysms between 1999 and 2011. The patients were divided into those who presented before 2007 (surgery group) and after 2007 (embolization group), and their demographic characteristics, presentation, and investigations; the technical and clinical success of treatment; and in-hospital mortality were studied. A total of 29 patients were studied, 17 of whom men, with a median age of 42 years. Of these 29 patients, 8 underwent surgery and 21 had embolization (24 total procedures). No mortality was seen in the surgery group, and their hospital stay was longer and transfusion requirement higher than those in the embolization group, in whom technical success was achieved in all procedures and clinical success in 19 of 24 (79%). Clinical failure and complications were seen when common hepatic artery aneurysms were embolized. Three patients (14%) died in the embolization group from ischemic hepatitis and bowel gangrene, coagulopathy, and a leak from a previous pancreaticojejunal anastomosis. Both surgery and angioembolization are equally effective for hepatic artery pseudoaneurysms, but the latter has the advantages of more rapid bleeding control, shorter hospital stay, and lower transfusion requirement.

Percutaneous thrombin injection in an infant to treat hepatic artery pseudoaneurysm after failed embolization

Percutaneous thrombin injection has been described in case reports as an alternative to surgical intervention for the treatment of hepatic artery pseudoaneurysms associated with high-grade liver lacerations in adults. However, there is limited description in the literature of this technique being applied in children, particularly in preadolescents, and no published literature describes its use in infants. The procedure can be performed by pediatric radiologists and pediatric interventional radiologists skilled in ultrasound-guided aspiration techniques. We report successful application of percutaneous thrombin injection in an infant to treat a pseudoaneurysm of a left hepatic arterial branch in an 11-month-old girl with a grade IV liver laceration after superselective transcatheter arterial embolization failed to achieve thrombosis.

Hepatic transplantation: postoperative complications

Advances in surgical techniques and immunosuppression have made orthotopic liver transplantation a first-line treatment for many patients with end-stage liver disease. The early detection and treatment of postoperative complications has contributed significantly to improved graft and patient survival with imaging playing a critical role in detection. Complications that can lead to graft failure or patient mortality include vascular abnormalities, biliary abnormalities, allograft rejection, and recurrent or post-transplant malignancy. Vascular abnormalities include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava, as well as hepatic artery pseudoaneurysm, arteriovenous fistula, and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not used to diagnose allograft rejection, it plays an important role in identifying complications that can mimic rejection. Ultrasound is routinely performed as the initial imaging modality for the detection and follow-up of both early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are used to characterize biliary complications and computed tomography is used to confirm abnormal findings on ultrasound or for the evaluation of postoperative collections. The purpose of this article is to describe and illustrate the imaging appearances and management of complications associated with liver transplantation.

4:18 PM Abstract No. 222 - Onyx as a second-line embolic agent in peripheral applications

Purpose To retrospectively assess the outcomes of using ethylene vinyl alcohol copolymer (Onyx) following failed coil embolization in peripheral applications. Materials and Methods Four cases involving the peripheral use of Onyx at a prior coil embolization site were retrospectively reviewed to determine the source of arterial hemorrhage, the patient’s coagulation status at the time of the procedure, the number of coils deployed, the time between interventions and the amount, cost and concentration of Onyx used. Complications related to use of Onyx and amount of time without recurrent bleeding were also noted. Results Sites of failed peripheral coil embolization included renal and pulmonary arteriovenous malformations, a hepatic artery pseudoaneurysm and a spontaneous bleed from a lumbar artery. The number of coils deployed ranged from 1 to 7, with a range of recurrent bleeding from 3 to 564 days following initial coil embolization. Two patients were coagulopathic at the time of embolization with Onyx. Technical success rate of cessation of hemorrhage was 100%. No complication such as nontarget embolization, end-organ ischemia or DMSO toxicity was noted with the use of Onyx. No evidence of recurrent bleeding has been recorded to date, although one patient died 11 days post-procedure from multiorgan failure related to underlying liver disease. In 3 patients 1.5 mL of Onyx 18 (6% EvOH) was used; in 1 case 1.1 mL of Onyx 34 (12% EvOH) was used, with an average cost to each patient of $5,005. Conclusion Onyx may be an effective embolic agent for recurrent hemorrhage following failed peripheral coil embolization or for embolization in coagulopathic patients, as suggested by this small series, however due to the established primary efficacy of coil embolization and the high cost of Onyx, it may be best suited as a second-line agent. Table 1

Endovascular Embolisation of Hepatic Pseudoaneurysm Causing Massive Hemorrhage in a Blunt Hepatic Trauma Patient

Hepatic artery pseudoaneurysm is an uncommon and a late complication after a blunt hepatic trauma. Although hepatic artery pseudoaneurysms may stay silent, it is usually better to treat them due to the high hemorrhage risk they cause. We are presenting a patient with post traumatic hepatic laceration who had serious bleeding with late onset after percutaneous drainage of the old hematoma. On a multidetector computerised tomography (MDCT) scan, a large hematoma surrounding a pseudoaneurysm was diagnosed which was treated with endovascular cyanoacrylate (glue) embolisation.

Lower gastrointestinal bleeding due to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Pseudoaneurysm of hepatic artery is a rare but known complication of laparoscopic cholecystectomy (LC). Such pseudoaneurysms may bleed in biliary tree, upper gastrointestinal (GI) tract or peritoneal cavity leading to life-threatening internal haemorrhage. It is very rare for them to present as lower GI bleeding. We report an unusual case of Right hepatic artery pseudoaneurysm developed following LC, which ruptured into hepatic flexure of colon resulting in catastrophic lower GI bleeding. This was associated with partial celiac artery occlusion due to thrombosis. Due to failure of therapeutic embolisation, the patient was subjected to exploratory laparotomy to control haemorrhage. Postoperatively, patient recovered well and was discharged on postoperative day 10. A strong index of suspicion is necessary for early diagnosis of such condition and to limit resultant morbidity. Angioembolisation is the first-line treatment and surgery is indicated in selected cases.

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy. Here, we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery (CHA) stump that developed after distal pancreatectomy with en block celiac axis resection (DP-CAR), and was successfully treated through covered stent placement. The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer. She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery, and computed tomography (CT) showed an occluded portal vein due to the spreading inflammation around the abscess. Her general condition improved after CT-guided drainage of the abscess. However, 19 d later, she presented with melena, and CT showed a pseudoaneurysm arising from the CHA stump. Because the CHA had been resected during the DP-CAR, this artery could not be used as the access route for endovascular treatment, and instead, we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery. After stent placement, cessation of bleeding and anterograde hepatic artery flow were confirmed, and the patient recovered well without any further complications. CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow. To our knowledge, this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

A Case of Ruptured Traumatic Hepatic Artery Pseudoaneurysm into the Biliary Tract Cured by Transcatheter Arterial Embolization after Episodes of Gastrointestinal Bleeding

A Case of Ruptured Traumatic Hepatic Artery Pseudoaneurysm into the Biliary Tract Cured by Transcatheter Arterial Embolization after Episodes of Gastrointestinal Bleeding

Hepatic artery pseudoaneurysm as a cause of gastrointestinal system bleeding: A case report with a brief review of the literature

A hepatic artery pseudoaneurysm is, by definition, a pulsatile hematoma due to a leakage of blood through a tear or disruption of the arterial wall, and the blood is contained only by the hepatic parenchyma or surrounding hematoma. It can be a very rare cause of gastrointestinal system bleeding. These pseudoaneurysms are usually very well managed by angiographic intervention. However, in some cases, surgery is inevitable. Herein, we present a 63-year-old female presenting with gastrointestinal system bleeding 45 days after surgery for cholangiocarcinoma. She was found to be bleeding from a pseudoaneurysm of the hepatic artery and underwent surgical intervention.

Autologous Saphenous By-Pass as Treatement of the Hepatic Artery Pseudoaneurym in Liver Transplant Recipients

Background: The incidence of hepatic artery pseudoaneurysm (HAP) is 1 to 2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation following LT been reported to be as high as 69%. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. This article discusses the presentation, etiology, treatment indications, and the vascular procedure used to manage these complications. Patients and methods: From 2003 to 2011, 454 LTs were performed in our institution. Of these, 8 (1,7%) patients underwent vascular procedure to treat HAP after LT, 7 male and 1 female with a median age of 59.5 years (range, 46-68). Three patients underwent TACE before LT for HCC. In all cases a revascularization with autologous saphenous patches was performed. Results: Three patients revealed the pseudoanuryms as a rupture with bleeding, in others 5, the HAP were diagnosed during the normal followup. The diagnosis was made with a CT-scan in all cases, confirmed with a standard angiography in 3 cases. The median delay between the LT and the HAP diagnosis was 36 days (range, 28-125). All were extraepatic located. All patients had a T-Tube. The median diameter of the HAP was 1.2 mm (range, 1.0-1.4). In 6 cases a bile leakage was associated and in the remnants 2 a candidiasis (Candida Glabrata) was founded at the histologic analisys. One patient was re-transplanted due to ischemic cholangitis. At 5-years follow-up 4 patients had a normal arterial anatomy, the others 3 patients had a by-pass stenosis but with a normal liver function. One patients died 3-yrs after LT due to HCC recurrence. Discussion: Limited and debated literature suggests that stenting of HAP during acute hemorrhage can be successfully performed. Surgical intervention near the hepatic vessels at long-term posttransplantation is a major procedure and can be complicated due to the presence of a large number of intraabdominal adhesions related to the previous transplant. The revascularization of the artery also presupposes a brief period of ischemia. Our results suggest a high succeful rate of the surgical procedure as a saphenous by-pass. In conclusion, our experience strongly support the surgical revascularization as treatment of choice in case of extrahepatic HAP at high risk of rupture or ruptured.

Endoscopic extraction of vascular embolization coils that have migrated into the biliary tract in a liver transplant recipient

Hepatic artery pseudoaneurysm (HAA) is a rare vascular complication of liver transplantation. Minimally invasive radiological interventions are generally considered before seeking surgical treatment of HAA. Coil embolization of the aneurysmal sac and or exclusion of pseudoaneurysm by deploying a stent over the aneurysm are effective interventions to control hemobilia arising from the HAA. Migration of coils inside the bile duct is a rarely reported complication in post-hepatic transplantation. Treatment options remain largely unexplored due to the rarity of its occurrence. Endoscopic retrograde cholangiographic removal of migrated vascular coils in the common bile duct following embolization of HAA has not been described in a liver transplant setting. We report a liver transplant recipient who underwent uneventful and successful endoscopic removal of migrated coils into the bile duct.

Miliary Tuberculosis Presenting With GI Bleed From Hepatic Artery Pseudoaneurysm Rupture in an HIV Infected Patient

SESSION TYPE: Infectious Disease Student/Resident Cases

Successful treatment of a common hepatic artery pseudoaneurysm using a coronary covered stent following pancreatoduodenectomy: report of a case

This report presents the case of a common hepatic artery (CHA) pseudoaneurysm secondary to postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD), which was successfully treated using a coronary covered stent. A 70-year-old female underwent subtotal stomach-preserving PD for middle cholangiocarcinoma. POPF was identified on postoperative day (POD) 7, and the patient suddenly lost 500ml of blood via the abdominal drain on POD 19. Urgent celiac arteriography revealed a CHA pseudoaneurysm. A coronary covered stent was placed to prevent rupture of the pseudoaneurysm and to maintain hepatic arterial flow, instead of performing transarterial embolization. No vascular adverse events were encountered during or after the procedure. Computed tomography and angiography showed a patent stent graft and good hepatic arterial flow 9months after placement of the stent. Endovascular stent-graft placement not only treated the pseudoaneurysm, but also preserved the arterial blood flow. This report describes the placement of a covered stent graft for delayed hemorrhage after PD.