Sonographic diagnosis and follow-up of idiopathic hepatic artery aneurysm, an unusual cause of obstructive jaundice

Hepatic Artery Aneurysm in the Setting of Acute Pancreatitis and Giant Cell Arteritis

Visceral artery aneurysms are rare with an incidence of 0.1%-0.2%. Of these, 20% are hepatic artery aneurysms (HAAs). Despite the potential of remaining asymptomatic for long periods of time, the risk of rupture for HAAs is 20%-80%. Treatment includes operative management with open or endovascular techniques. HAA in the setting of pancreatitis has been reported in two prior cases outside of the United States. However, there have been no cases describing the association of HAA and giant cell arteritis (GCA). We present a rare case of an 80-year-old male with a history of GCA who was found to have developed HAA following an episode of acute pancreatitis that was repaired surgically with an open technique. To our knowledge, the association between HAA with acute pancreatitis and GCA has not been reported before.

Management of a Fulminant Upper Gastrointestinal Bleeding Exteriorized Through Hemobilia Due to Arteriobiliary Fistula Between the Common Bile Duct and a Right Hepatic Artery Aneurysm - A Case Report

Right hepatic artery aneurysms are rare events that might remain asymptomatic for a long period of time. However, in cases presenting large lesions, symptoms might develop especially due to the association of compression of the surrounding elements. Most often these symptoms and signs include diffuse abdominal pain, jaundice or portal vein compression signs. In rare cases life-threatening complications might develop due to the aneurysmal erosion of the biliary duct, portal vein or due to the aneurysmal rupture in the peritoneal cavity. In all these cases emergency surgery is imposed. We present the case of a 66-year-old patient diagnosed with a partially thrombosed right hepatic artery aneurysm compressing the common bile duct who was initially submitted to a percutaneous arterial embolization of the aneurysm in association with an external biliary drainage; three weeks later the patient presented a fulminant upper gastrointestinal bleeding exteriorized through the external biliary drainage, hematemesis and hematochezia. The patient was successfully submitted to surgery, intraoperatively a synchronous rupture of the portal vein being revealed. The right hepatic artery aneurysm was resected en bloc with common bile duct resection and segmental portal vein resection. The continuity of the portal vein was re-established through the interposition of a cadaveric allograft, the common bile duct was anastomosed with en Roux en Y limb while the right hepatic artery aneurysm was ligated and resected, the arterial vascularization of the liver being provided by the left hepatic artery.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm - A Case Report and Literature Review

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary.

Aortic and splanchnic artery aneurysms: Unusual causes of biliary obstruction - A retrospective cohort from literature

Mechanical obstruction of the biliary tree and resultant stasis are the cornerstone of a spectrum of diseases ranging from biliary colic to fulminant cholangitis. Infrequently acquired abnormalities of the abdominal vasculature can lead to biliary obstruction. In 2010, we reported a case of acute cholangitis resulting from compression of extra hepatic bile duct by an abdominal aortic aneurysm (AAA). We subsequently conducted a follow up scoping review of literature to identify other cases of acquired abdominal arterial abnormalities resulting in biliary obstruction looking at their management and outcomes. The articles were independently reviewed by two of the authors and pertinent data was extracted. The data was divided on an anatomic basis into two groups: one with primary aortic pathology and one with splanchnic vessel pathology. We identified 39 cases of biliary obstruction secondary to acquired aortic or splanchnic vessel abnormalities; 16 were caused by AAAs and 23 by splanchnic vessels. The cases were managed via conservative, endoscopic, endovascular or open surgical options based on the available technology and expertise. Although uncommon, recognition of aortic and splanchnic arterial abnormalities as a potential cause of biliary obstruction is important as management entails not only cautious decompression of the biliary tree but also addressing the underlying vascular pathology. We recommend that extrinsic biliary compression by an aneurysm or pseudoaneurysm be considered among the differential diagnosis in patients presenting with biliary obstruction and a known lesion of the abdominal vasculature.

Jaundice as a Rare Indication for Aortic Aneurysm Repair

Compression of adjacent anatomic structures by an abdominal aortic aneurysm (AAA) can result in a variety of symptoms. We describe the case of an 88-year-old Caucasian woman with jaundice, elevated laboratory parameters for extrahepatic and intrahepatic cholestasis, and concomitant juxtarenal AAA compressing the liver hilum. Following exclusion of other common causes for cholestasis, the patient was considered to have a symptomatic AAA. Open abdominal aortic surgery revealed a contained rupture and was repaired. Obstructive jaundice secondary to a compromising AAA is a rare condition and to the best of our knowledge has not been reported to date.

Hepatic artery aneurysm: incidental diagnosis with abdominal ultrasonography and treatment by coil embolization

Hepatic artery aneurysm (HAA) was first reported at autopsy in 1809, represents one fifth of visceral aneurysms and the mortality from spontaneous rupture is high in most of cases. We are reporting a case of an asymptomatic 48-year-old woman with an extrahepatic HAA, diagnosed initially and incidentally with abdominal ultrasonography, confirmed by a three-dimensional contrast-enhanced magnetic resonance imaging and angiography. Endovascular treatment was considered feasible and was successfully treated with coil embolization.

Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Rare spontaneous remission of hepatic artery aneurysm following ABO incompatible living donor liver transplantation: a case report

A 60-year-old male patient with an unknown cause for cirrhosis and a hepatoma underwent an ABO incompatible living donor liver transplantation (LDLT) from his son. The transplanted graft was his son's right lobe. For ABO incompatible transplantation, splenectomy was performed for desensitization. A catheter was inserted into the recipient's right hepatic artery for subsequent local immunosuppression. On the 15th postoperative day, a fusiform 15 × 10 mm aneurysm was observed in the graft right hepatic artery using ultrasonography and hepatic arteriography. At that time, the patient was also diagnosed to have an intraperitoneal abscess at the bottom of his left diaphragm. Administering antibiotics, we tried to embolize the aneurysm because of fear of rupture, but this manever failed because it was difficult to insert the wire in to the aneurysm to produce a stenosis around its proximal neck. However, because the aneurysm was not detectable on the 37th postoperative day, it was assumed to have embolized spontaneously. This relatively rare case revealed a hepatic artery aneurysm that spontaneously regressed after ABO incompatible LDLT.

Simultaneous treatment of unresectable hepatocelluar carcinoma and hepatic artery aneurysm, case report

INTRODUCTION

Hepatic artery aneurysm is uncommon with an estimated incidence of less than 0.25%. Because most patients are asymptomatic, the diagnosis is usually made as an incidental finding on imaging studies performed for other reasons. Because of their propensity to rupture with potential catastrophic intraperitoneal hemorrhage, early diagnosis is important. Herein, relatively asymptomatic aneurysm of the common hepatic artery mostly of atherosclerotic etiology is presented. The importance of imaging findings in the diagnosis of this condition is discussed and relevant literature is reviewed (1, 2). Hepatocellular carcinoma (HCC) ranks among the most common malignancies worldwide, and the prognosis for patients with HCC is typically poor. Chemoembolization has become the mainstay of treatment for patients with unresectable HCC. Transcatheter arterial chemoembolization is intended to deliver a highly concentrated dose of chemotherapy to tumor cells, prolong the contact time between the chemotherapeutic agents and the cancer cells, and minimize systemic toxicity. Ideally, achieving these goals will result in a tumor shrinkage, symptomatic relief, improved quality of life, and increased patient survival (3).

METHODS

We will present a case of male patient, 72 years old, who was referred for transcatheter arterial chemoembolization for unresectable hepatocelluar carcinoma.

RESULTS

Helical CT scan showed right lobe mass infiltrating the peritoneum with enhancement in the early arterial phase together with hepatic artery aneurysm that was successfully treated at the same time using emulsion of N-butyl cyanoacylate and lipodol with a concentration of 1:1.

CONCLUSION

Hepatic artery aneurysms are uncommon lesions that have varied clinical presentations. Early diagnosis is essential because the natural tendency of the lesion is to rupture into peritoneal cavity or surrounding organs. Chemoembolization has become the mainstay of treatment for patients with unresectable HCC. Our case is notable, because atherosclerotic aneurysms of the hepatic artery are extremely rare with very few cases reported so far and to diagnose a hepatic artery aneurysm and to treat it in one setting with chemoembolization of unresectable HCC without rupture of the aneurysm is also unusual.

Iatrogenic pseudoaneurysms of the extrahepatic arterial vasculature: management and outcome

BACKGROUND

Pseudoaneurysms of the extrahepatic arterial vasculature are relatively uncommon lesions following surgery and trauma. In this report we analyze the presentation, management and outcomes of these vascular lesions. Of the related surgical procedures, the reported incidence is highest following laparoscopic cholecystectomy. We hereby analyze the literature on this subject and report our experience, specifically with extrahepatic pseudoaneurysms, drawing an important distinction from intrahepatic pseudoaneurysms.

METHODS

From September 1995 until July 2004, six patients, including three males and three females with a mean age of 67 years, were treated for seven extrahepatic arterial pseudoaneurysms. Patients were evaluated by endoscopy, ultrasound, computerized tomography, and angiography. Management included coil embolization or arterial ligation and/or hepatic resection.

RESULTS

The mean pseudoaneurysm size was 4.9-cm (range 1.0-11.0-cm) and the locations included the right hepatic artery (n = 5), inferior pancreaticoduodenal artery (n = 1), and gastroduodenal artery (n = 1). All six patients had prior surgical or percutaneous procedures. Median latency period between the original procedure and treatment of pseudoaneurysm was 17 weeks (range one month-16 years). Clinical features ranged from the dramatic presentation of hypotension secondary to intraperitoneal aneurysmal rupture to the subtle presentation of obstructive jaundice secondary to pseudoaneurysm mass effect. The range of patient presentations created diagnostic challenges, proving that accurate diagnosis is made only by early consideration of pseudoaneurysm. Management was ligation of the right hepatic artery (n = 4) and embolization of the pseudoaneurysms (n = 2). Post-treatment sequelae included liver failure requiring liver transplant (n = 1), intrahepatic biloma requiring percutaneous drainage (n = 1) and cholangitis with right hepatic duct strictures requiring right lobectomy and biliary reconstruction (n = 1). These complications followed arterial ligation, with no complications resulting from embolization. All six patients are alive and well after a mean follow-up of 53 months.

CONCLUSIONS

Our six patients demonstrate the diversity and unpredictability with which a pseudoaneurysm of the extrahepatic arterial vasculature may present in terms of initial symptoms, prior procedures, and the latency period between presentation and prior procedure. Through our experience and an analysis of the literature, we recommend a diagnostic and management approach for these patients.