Operative management of hepatic artery aneurysms

Balloon-expandable covered stenting of a large right hepatic artery aneurysm

Hepatic artery aneurysms (HAAs) are rare visceral aneurysms with a high rupture rate. We report the case of an 88-year-old man with a 4.2-cm right HAA treated with covered stenting. Balloon-expandable covered stents effectively excluded the HAA with excellent proximal and distal seals. Our case is one of a limited number of reports on successfully repairing a hepatic aneurysm with a balloon-expandable stent graft. This case demonstrates that balloon expandable covered stenting is a viable approach in patients with appropriate anatomy and may be favorable in patients precluded from open bypass.

Hepatic Artery Aneurysms in Infective Endocarditis: Report of 10 Cases and Literature Review

BACKGROUND

Hepatic artery aneurysms (HAAs), albeit rare in infective endocarditis (IE), are associated with a life-threatening morbidity.

METHODS

Retrospective review of 10 HAA-IE patients based on a total of 623 IE patients managed in 2 institutions (2008-2020) versus 35 literature cases.

RESULTS

In our patient population, HAAs (10 males, mean age 48) were incidentally found during IE workup. All were asymptomatic. IE involved mitral (n = 6), aortic (n = 3), or mitral-aortic valve (n = 1). Predisposing factors for IE were as follows: prosthetic valve (n = 6), previous IE (n = 2), IV drug user (n = 1). Streptococcus species (spp.) were predominant (n = 4), then staphylococcus spp (n = 2) and E. faecalis (n = 2). All patients presented associated lesions: infectious aneurysms (n = 5), emboli (n = 9), abscesses (n = 5), and spondylitis/spondylodiscitis (n = 2). HAA patterns on abdominal CT angiography (CTA) were solitary (70%), mean diameter 11.7 mm (range 2-30), intrahepatic location (100%) involving the right HA in 9 out of 10 (90%) patients. In 2 patients, HAAs were complicated (rectorragia and hemobilia in 1, cholestasis in the other). Six patients underwent endovascular hepatic embolization (2 with multiple HAAs). Three HAA-IEs <15 mm resolved under antibiotherapy on abdominal CTA follow-up. All patients underwent cardiac surgery. Late outcome was favorable in all followed patients (5/10). Literature review showed the preponderance of Streptococcus spp., of right lobe and intrahepatic HAA localization. Complications revealed HAAs in patients under antibiotic therapy and/or after cardiac surgery in 17 literature cases of delayed diagnosis.

CONCLUSIONS

Abdominal CTA was pivotal in the initial IE workup. Small aneurysms (≤15 mm) resolved under antibiotherapy. The usual treatment modality was HAA embolization and endovascular embolization before valve surgery was safe.

Hepatic artery aneurysm post remote pancreaticoduodenectomy

We present a case of a 4.2-cm hepatic artery aneurysm following remote pancreaticoduodenectomy, which extended to the first division of the right hepatic artery. Given the absence of collateral flow from the superior mesenteric artery (SMA) and the inability to place a covered stent, we treated the patient with a saphenous vein graft to the right hepatic artery bifurcation. A CT scan at 1-year demonstrated a patent bypass to the right hepatic artery. We would advise caution when considering hepatic embolization following pancreaticoduodenectomy due to loss of SMA-based collaterals. Techniques that preserve arterial flow should be favored in this situation.

Visceral Aneurysms: Systematic Review and Meta-analysis of Endovascular Versus Open Repair

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 348699.

Endoscopy-Intravascular Treatment Combination for Duodenal Ulcer Hemorrhages Caused by Small Hepatic Pseudoaneurysms: A Case Report

Aim

Significant gastrointestinal hemorrhages, resulting from long-term compression of the duodenum by a hepatic pseudoaneurysm (HAPA), is an extremely rare condition. In fact, when the pseudoaneurysm is small in diameter, diagnosis can be particularly challenging. Timely and effective diagnosis and treatment is therefore of great significance, and in this case, endoscopy, combined with intravascular therapy, can provide an effective approach, especially since it removes the need for surgery while yielding favorable outcomes.

Case Summary

A 75-year-old old man presented to the hospital's emergency department with hematemesis and black stool. Despite conservative treatments such as "acid suppression, fluid resupply, hemostasis and blood transfusion", no significant improvement was noted. Emergency gastroscopy subsequently revealed an ulcer in the duodenal bulb (Figure 1), with an exposed thrombotic head and active bleeding on the surface. In addition, abdominal computed tomography (Figure 2) showed no obvious HAPA manifestations. After unsuccessful endoscopic hemostasis, angiography was performed (Figure 3) and a pseudotumor-like dilatation measuring 5.56 mm in diameter was found at the distal end of the proximal branch vessel of the common hepatic artery. Following spring coil embolization (Figure 4), the patient's condition improved and he was discharged from the hospital, with a follow-up after six months showing no signs of recurrence or complications.

Conclusion

Duodenal ulcer hemorrhages due to small hepatic pseudoaneurysms are very rare, with endoscopic intervention being effective for such cases.

A large common hepatic artery pseudo aneurysm: A case report

INTRODUCTION & IMPORTANCE

The Hepatic Artery Aneurysms (HAAs) are rare and asymptomatic with a high rate of rupture. The management is mandatory and depends on the size and the location of the aneurysm.

CASE PRESENTATION

We reported a case of 50 years old male, admitted to sharp epigastric pain. Radiological investigations confirmed a common hepatic artery aneurysm. We indicated an open surgery to repair the aneurysm, the postoperative course finished without any complications.

CLINICAL DISCUSSION & CONCLUSION

HAAs are considered the second most common type of splanchnic aneurysms. Although from the rare occurrence, HAAs have a high rate of rupture. Open repair of the HAAs remains the treatment of choice of degenerative HAAs, to preserve the arterial flow to the liver.

Management of Coeliac and Hepatic Artery Aneurysms: An Experience of 84 Cases

OBJECTIVE

To report outcomes following open or endovascular treatment of true hepatic and coeliac artery aneurysms at a single referral centre.

METHODS

This was a retrospective cohort study of consecutive patients treated for true hepatic and coeliac artery aneurysms between May 2002 and December 2021. Outcome measures included complications, graft patency, and survival rate.

RESULTS

Overall, 84 patients were included with a median age of 63 years (interquartile range 55, 79). The majority (76%) of the patients were men. Frequent comorbidities included a history of tobacco (69%), hypertension (65%), hyperlipidaemia (32%), and diabetes (15%). Multiple synchronous aneurysms were detected in 22 patients (26%). There were 33 (39%) symptomatic aneurysms (abdominal pain without rupture [n = 18], rupture [n = 10], and sepsis [n = 5]). Seventeen patients (20%) had mycotic aetiology. Fifty patients (60%) underwent endovascular treatment with either covered stent placement (n = 29) or coil embolisation (n = 21), and 34 patients (40%) were treated with open surgery using allogenic iliac artery (n = 15), autologous saphenous vein (n = 15), GoreTex graft (n = 2), or ligation (n = 2). The complication rate was 32% in the open group and 18% in the endovascular group (p = .048). The overall 90 day post-operative mortality rate was 1.2%, five year primary patency was 90.0%, five year survival rate was 81.2%, and mean follow up was 6.9 ± 4.2 years.

CONCLUSION

Endovascular treatment is the preferred approach whenever technically possible. Despite higher post-operative morbidity, an open approach with vascular reconstruction using autologous or allogenic vascular grafts yields acceptable long term results.

Endovascular repair of a giant common hepatic aneurysm

Hepatic artery aneurysms are a rare phenomenon but their diagnosis and prompt treatment are imperative due to a high risk of mortality and complications. Appropriate management depends on patient characteristics, anatomical location of the aneurysm, operative risk and collateral arterial supply. Management options include surgical and endovascular approaches. The endovascular approach has gained popularity over recent years as it is an effective and less invasive alternative to surgical management. In this case report, we present a giant common hepatic artery aneurysm and its successful endovascular management. The patient had a complete resolution of symptoms after the procedure and remained well 8 months postprocedure.

Clinical Profile, Management, and Outcome of Visceral Artery Pseudoaneurysms: 5-Year Experience in a Tertiary Care Hospital

Visceral artery pseudoaneurysms are potentially lethal lesions and tend to rupture in a high proportion of cases, thereby warranting an immediate and active intervention. We present our experience of splanchnic visceral artery pseudoaneurysms in a university hospital over a 5-year time interval with emphasis on etiology, clinical presentation, management (endovascular/surgical), and final outcome. This was a retrospective study in which we searched our image database for pseudoaneurysms of visceral arteries over a period of 5 years. The clinical and operative details were retrieved from the medical record section of our hospital. The lesions were analyzed for the vessel of origin, size, etiology, clinical features, mode of treatment, and outcome. Twenty-seven patients with pseudoaneurysms were encountered. Pancreatitis (8) was the most common cause, followed by previous surgery (7) and trauma (6). Fifteen were managed by the interventional radiology (IR) team, 6 by surgery, and in 6 no intervention was done. Technical and clinical success was achieved in all patients in the IR group with few minor complications. Surgery and no intervention carry a high mortality in such a setting (66 and 50%, respectively). Visceral pseudoaneurysms are potentially fatal lesions, commonly encountered after trauma, pancreatitis, surgeries, and interventional procedures. These lesions are easily salvageable by minimally invasive interventional techniques (endovascular embolotherapy), and surgeries carry a lot of morbidity and mortality in such cases and a prolonged hospital stay.

Right Gastroepiploic Artery Transposition for a Common Hepatic Artery and Proper Hepatic Artery Aneurysm Repair

Although hepatic artery aneurysms (HAAs) are uncommon, they are associated with risk of rupture. HAAs >2 cm in diameter require endovascular or open surgical repairs. For HAAs involving the proper hepatic artery or gastroduodenal artery, which is a collateral artery from the superior mesenteric artery, hepatic arterial reconstruction is especially important to avoid ischemic liver injury. In this study, right gastroepiploic artery transposition was performed in a 53-year-old man after a 4 cm common hepatic artery and proper hepatic artery aneurysm was identified. The patient was discharged without any complications on postoperative day 8.

Coil Embolization of True, Common and Proper, Hepatic Artery Aneurysms: Technique, Safety and Outcome

PURPOSE

To retrospectively assess the safety and efficacy of coil embolization for catheter-directed true common and proper hepatic artery aneurysm exclusion.

MATERIALS AND METHODS

Nine consecutive patients (2005-2021) in two university centers presenting with true common and proper hepatic artery aneurysms (> 2 cm in diameter) were treated with 'frontdoor-backdoor' coil embolization. Patients presenting with a hepatic artery pseudoaneurysm, mycotic aneurysm or patients with small (< 2 cm diameter) aneurysms and followed up by imaging were excluded. Technical and clinical success was defined as complete coil-exclusion of the aneurysm on completion angiography and absence of post-embolization adverse events, in particular mass effect or hemorrhage, respectively. Patient characteristics, technical and clinical success, liver function tests and follow-up results were assessed based on the patients' electronic medical records.

RESULTS

Technical and 30-day clinical success was achieved in all procedures (100%). No major procedural complications were reported. Liver function test values were available in 6/9 patients, showing transient elevation of bilirubin in one patient. No end organ ischemia was reported. The mean clinical follow-up period of the study patients was 72 months (12-168 months). Long-term stable occlusion of the hepatic aneurysms was achieved in 9/9 patients (100%). One patient showed late complication (3 years) with coil migration into a bulbar ulcer, without aneurysm recanalization, however with fatal outcome.

CONCLUSION

Coil embolization for the endovascular exclusion of true common and proper hepatic artery aneurysms is safe and effective.

Transarterial Embolization of Ruptured Pancreaticoduodenal Artery Pseudoaneurysm Related to Chronic Pancreatitis

We presented a 67-year-old woman with lightheadedness, diaphoresis, and acute epigastric and right hypochondrium pain, with a past medical history including stage 2 essential hypertension, chronic ischemic cardiomyopathy, and class 1 obesity. An abdominal contrast-enhanced CT scan showed an extensive hematoma (3 × 4 cm2 in size) located intra-abdominally, adjacent to the duodenojejunal area, with hyperdensity around the duodenum, positioned inferior to the pancreas (30–59 HU). Moreover, the CT scan also revealed an enhancing lesion as a pseudoaneurysm of the inferior pancreaticoduodenal artery, measuring 5 × 8 × 8 mm3 with active bleeding and associated hematoma. Following these investigations of the abdominal area, a decision was made to proceed with an endovascular intervention within the interventional radiology department. With the patient under conscious sedation, via a right common femoral artery approach, the superior mesenteric artery was catheterized. While injecting the contrast agent to obtain a better working projection, the pseudoaneurysm ruptured, and acute extravasation of the contrast agent was noted, followed by injection of a mixture of 1 mL Glubran 2 with 2 mL Lipiodol until complete obliteration of the pseudoaneurysm was obtained. The patient was hemodynamically stable at the end of the procedure and was discharged 6 days later in a good condition without active bleeding signs.

Open surgical repair of giant hepatic artery aneurysm

Hepatic artery aneurysms (HAAs) are visceral artery aneurysms with a significant risk of mortality upon rupture. HAAs can be treated with open or endovascular repair. The choice of treatment modality depends on aneurysm anatomy, adequacy of visceral collaterals, and overall health status of the patient. This case report describes the successful repair of a giant 14.9-cm HAA through open aneurysm resection and end-to-end anastomosis of the distal common hepatic artery to the gastroduodenal artery. The patient recovered postoperatively with no complications and normal liver function. This case report also reviews other giant HAAs that have been reported in literature.

Surgical repair of an emergent giant hepatic aneurysm with an abdominal aortic dissection: A case report

BACKGROUND

Hepatic artery aneurysm (HAA) is the second most common visceral aneurysm. A significant number of hepatic aneurysms are found accidentally on examination. However, their natural history is characterized by their propensity to rupture, which is very serious and requires urgent treatment. An emergent giant hepatic aneurysm with an abdominal aortic dissection is less commonly reported.

CASE SUMMARY

We report the complicated case of a giant hepatic aneurysm with an abdominal aortic dissection. A 66-year-old female presented with the complaint of sudden upper abdominal pain accompanied by vomiting. Physical examination showed that her blood pressure was 214/113 mmHg. Her other vital signs were stable. Computed tomography found a giant hepatic proper aneurysm and dissection of the lower segment of the abdominal aorta. Furthermore, angiography showed a HAA with the maximum diameter of approximately 56 mm originating from the proper hepatic artery and located approximately 15 mm from the involved bifurcation of the left and right hepatic arteries with no collateral circulation. Therefore, we decided to use a stent to isolate the abdominal aortic dissection first, and then performed open repair. After the operation, the patient recovered well without complications, and her 3-month follow-up checkup did not reveal any late complications.

CONCLUSION

Open surgery is a proven method for treating giant hepatic aneurysms. If the patient's condition is complex, staged surgery is an option.

Splenic artery transposition for reconstruction of a large hepatic artery aneurysm: A case report and literature review

Introduction and importance

Hepatic artery aneurysms (HAAs) are rare. Typical treatment options for HAAs are surgical resection and endovascular treatment but treatment choices remain controversial.

Case presentation

A 65-year-old woman was rushed to our hospital suspected to have hemorrhage. Contrast-enhanced CT showed a large 12 cm aneurysm of the common hepatic artery (CHA). We diagnosed duodenal hemorrhage due to imminent rupture of the HAA. Angiography was first performed. The inferior pancreaticoduodenal artery was embolized with a coil under interventional radiology technique for arterial bleeding control. Next, we performed resection of the aneurysm and total pancreatectomy with splenic artery reservation. We reconstructed via splenic artery transposition because of the reconstruction distance, vascular system, and stability of the anastomosis. The patient was discharged from the hospital on postoperative day 21 without any complications.

Clinical discussion

There are two key points in this report. Firstly, the choice of splenic artery transposition is optimal for caliber difference and reconstruction distance. The choice of splenic artery should be considered a reliable option. Secondly, total pancreatectomy avoids exposure to pancreatic juice at the anastomosis site due to pancreatic fistula.

Conclusion

Splenic artery transposition for HAA is advantageous in adjustability of the caliber difference and securing of sufficient distance. In addition, total pancreatectomy may be acceptable in patients with a normal pancreas to avoid fatal complications such as disruption of the anastomosis and reconstructed artery due to pancreatic juice exposure.

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Visceral artery aneurysms are rare and often involve the hepatic and splenic arteries.

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Typical treatment for HAAs are surgical resection and endovascular treatment but treatment choices remain controversial.

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The reconstruction via splenic artery transposition is an option for reconstruction after resection of HAAs.

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Splenic artery transposition is advantageous in adjustability of the caliber difference, securing of sufficient distance.

Open Repair of Large Hepatic Artery Pseudoaneurysm Without Collateral Circulation: A Case Report

Hepatic artery pseudoaneurysm is a rare arterial disease. This case report describes a patient with hepatic artery pseudoaneurysm who presented with recurrent epigastric pain over a 4-month period. Computed tomography angiography (CTA) showed aneurysmal enlargement of the hepatic artery measuring 55 mm × 46 mm. The angiographic information is as follows: (1) the common hepatic artery originated from the superior mesenteric artery; (2) the proper hepatic artery originated from the common hepatic artery; (3) the proper hepatic aneurysmal disease had no collateral circulation. After careful consideration, the patient underwent an open surgical repair (OSR). The patient recovered well without any associated complications. The 1-year follow-up of patients did not reveal any relevant complications. The treatment choice, puzzles, and reflections of this case are all discussed in this article.

Successful Treatment of Giant Common and Proper Hepatic Artery Aneurysm Complicating Autosomal Dominant Polycystic Kidney Disease1

Hepatic artery aneurysms (HAAs) complicating autosomal dominant polycystic kidney disease (ADPKD) are extremely rare. Owing to the large number of renal cysts in ADPKD, ingenuity is required to safely perform surgery for HAA. Here, we present the case of a 60-year-old man with a common and proper HAA of >60 mm complicated with ADPKD. In this patient, difficulty in maintaining the field of view was expected during surgery. Hence, we performed a hybrid approach with celiac-to-right hepatic artery bypass by puncturing the femoral artery and cannulating the splenic artery to allow celiac-splenic artery balloon occlusion in case of rupture. More than 5 years postoperatively, the graft is patent without intervention.

Assessment of open surgical and endovascular management of true hepatic artery aneurysms over 20 years highlights increased rupture risk in females

BACKGROUND

True hepatic artery aneurysms (HAAs) are rare but have been associated with a significant risk of rupture and associated mortality. The 2020 release of HAA-specific clinical practice guidelines represented an important step toward management standardization. However, it remains essential to build on the body of evidence to further refine these recommendations.

METHODS

The HAA management and outcomes from a single academic center during a 20-year period were retrospectively reviewed. We identified 72 patients from the institutional radiology database (November 24, 1999 to 2019). Pseudoaneurysms were excluded, and 48 patients were found to have had true HAAs. Forty-three HAA patients had sufficient medical records for inclusion in the analysis.

RESULTS

Of the 43 patients with HAA included, 65% were male. The mean age was 63 years (range, 22-89 years). Of the HAAs, 72% presented asymptomatically, 16% had ruptured, and 12% were symptomatic at presentation. Most HAAs were of atherosclerotic origin (74%). In addition, 16% of the patients had other visceral aneurysms and 12% had nonvisceral aneurysms on presentation. The mean HAA size overall was 3.3 cm (range, 0.8-10.8 cm), with most being solitary (72%) and involving the common hepatic artery (65%). Rupture was more common in females (40%) and those with vasculitis (67%), with females representing 86% of all patients with rupture. The mean size at intervention was 4.8 cm (21 patients [49%]). Ten patients (23%) had undergone open surgical repair (seven elective and three emergent because of rupture). Eleven patients (26%) had undergone endovascular intervention (64% elective and 36% emergent). Nonoperative management was selected for 22 patients (51%). These patients had a mean HAA diameter of 2.1 cm, and 59% had a life-limiting illness. Of the 18 patients who had been initially monitored for a mean of 3.9 ± 4.1 years, 3 had undergone elective repair and 2 had minimal growth. None of these patients had a subsequently documented rupture.

CONCLUSIONS

True HAAs are a rare but important clinical phenomenon, with 16% of patients presenting with rupture in this study. Endovascular intervention is a promising alternative to open surgical repair, with no 30-day mortality, and is suitable for ruptured HAAs. Importantly, for the first time, our findings have demonstrated an increased risk of rupture for females, highlighting the need for additional data and ultimately, sex-specific guidelines.

Vascular coil extrusion into the duodenum 6 years after hepatic artery aneurysm embolization

A 50-year-old man with a history of coil embolization of a symptomatic 5.3-cm hepatic artery aneurysm 6 years previously presented with a massive gastrointestinal bleed. He was found to have embolization coils extruding into the duodenum from a hepaticoduodenal arterioenteric fistula. The present case demonstrates that endovascular intervention for a large hepatic artery aneurysm can have long-term consequences. We have described a novel complication of embolization of a giant hepatic artery aneurysm that necessitated complex open repair.

True hepatic artery aneurysm

We present to you an interesting case of a woman who presented abdominal pain in the Emergency room with an unexpected diagnosis of ruptured left intrahepatic artery aneurism. The patient had no history of invasive biliary procedures that could provoke her condition. Endovascular definitive treatment was carried out with full left hepatic artery embolization. No complication regarding the treatment was noticed and the patient recovery successfully.

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

Visceral artery aneurysms (VAAs) are rare, usually asymptomatic and incidentally discovered during a routine radiological examination. Shared guidelines suggest their treatment in the following conditions: VAAs with diameter larger than 2 cm, or 3 times exceeding the target artery; VAAs with a progressive growth of at least 0.5 cm per year; symptomatic or ruptured VAAs. Endovascular treatment, less burdened by morbidity and mortality than surgery, is generally the preferred option. Selection of the best strategy depends on the visceral artery involved, aneurysm characteristics, the clinical scenario and the operator's experience. Tortuosity of VAAs almost always makes embolization the only technically feasible option. The present narrative review reports state of the art and new perspectives on the main endovascular and other interventional options in the treatment of VAAs. Embolization techniques and materials, use of covered and flow-diverting stents and percutaneous approaches are accurately analyzed based on the current literature. Visceral artery-related considerations and targeted approaches are also provided and discussed.

Management of a common and proper hepatic artery aneurysm

First-line management of hepatic artery aneurysms is via an endovascular approach. However, unfavorable anatomy may preclude this. We present a patient with an aneurysm involving most of the common hepatic artery and the entire proper hepatic artery including the emergence of the right and left hepatic artery and the gastroduodenal artery. The endovascular approach was not feasible due to unfavorable anatomy. The patient was successfully treated with an open bifurcated Dacron graft.

A common hepatic artery aneurysm with splenic artery involvement: an unusual cause of abdominal pain

Forty-eight year old man with epigastric pain. CT scan shows a common hepatic artery aneurysm (HAA) of 4,6 cm in size with permeable portal vein. Angiography demonstrates that it affects from the beginning of the celiac trunk until hepatic arteries bifurcation, producing a proximal splenic artery stenosis. Proximal and distal embolization is done achieving a complete aneurysm occlusion. A stent is placed in celiac trunk in order to maintain splenic flow. Permeability of distal hepatic artery through choledochal arteries is observed in a month follow-up CT scan. HAA are infrequent but potentially lethal. Endovascular techniques should be considered of choice currently. HAA embolization has an elevated risk of hepatic ischemia.

Management of hepatic artery aneurysms

We have read with interest the case published by Plua-Muñiz as an example of how endovascular treatment may be an acceptable and safe option even in an emerging situation as long as swift action is taken and the patient is stabilized previously. Hepatic artery aneurysms are an infrequent entity and their management is a great challenge. In the following letter we show our point of view and what the literature says about its management.

Surgical treatment for common hepatic aneurysm. Original one-step technique

Introduction

Hepatic artery aneurysms are rare, and their treatment represents a challenge for the surgeons.

Materials and methods

A new technique is presented for common hepatic artery (CHA) aneurysm: it requires minimal vascular surgical dissection and only one linear vascular stapler is applied at the bottom of aneurysm. Aneurysm exclusion is easily obtained, which allowed retrograde thrombosis. Liver blood supply is ensured to the right and left hepatic artery, through the gastroduodenal artery, and can be previously monitored, with temporary clamping of the section area, by visual control, enzyme evaluation and intraoperative ultrasound examination. We reported an open surgical treatment, with simultaneous removal of hepatic and adrenal metastases, secondary to colon cancer.

Results

The duration of vascular surgery was 30 min and did not involve complications. Postoperative controls confirmed the efficacy of the procedure.

Discussion

This original technique can be added to the various open and endovascular techniques so far described for the treatment of a CHA aneurysm. It is advisable as open surgery, mostly in case of associated pathologies.

Conclusions

The authors believe that this "one shot" technique by vascular staple of the distal part of CHA is minimally invasive and effective to obtain the exclusion of the aneurysm.

Ruptured Hepatic Artery Aneurysm

Aneurysmal ruptures are a life-threatening pathology, and while the aorta is the principal location, any aneurysmal rupture can be fatal. Most result from chronic diseases, such as hypertension, diabetes, and vasculitis. Nevertheless, a rupture can result in acute decompensation and must be recognized and addressed quickly to limit morbidity and mortality. The authors describe a case of a 66-year-old female who presented to the emergency department (ED) for abdominal pain and syncope. Even though imaging did not explicitly show the specific site of rupture of the hepatic artery, the positive Rapid Ultrasound for Shock and Hypotension (RUSH) exam and aortic dissection on computed tomography angiography along with her clinical picture (hypotension, abdominal pain, decreased capillary refill, grey skin) raised our suspicions for critical pathology. Exploratory laparotomy revealed a ruptured hepatic artery aneurysm. Her hospital course was complicated by ischemic necrosis of the gallbladder, spleen, and liver, requiring cholecystectomy, splenectomy, and partial hepatectomy, but she was discharged to rehabilitation and expected to make a recovery. This case displays the importance of using ultrasonography early to aid in expedited diagnosis and treatment as well as maintaining a high suspicion for vascular pathology in the setting of hemorrhagic shock.

Liver transplantation as a rescue surgery after failure of embolization of a giant hepatic artery pseudoaneurysm

We present the case of a male diagnosed with a giant hepatic artery aneurysm, which first presented with pain and hemorrhage due to a partial rupture of the aneurysm. After discarding treatment with a stent or surgery due to the wide extension, we chose to embolize the hepatic artery with coils. However, the progress was unfavorable after the procedure, with the appearance of liver failure that was resolved by an urgent liver transplantation. Giant hepatic artery pseudoaneurysms are an infrequent entity and their management is a great challenge. The diagnosis is usually delayed due to non-specific clinical signs and the life of the patient may be threatened in the case of rupture. Thus, endovascular or surgical treatment is recommended. Aneurysm embolization or ligation has been described in the literature as a valid treatment option in cases where revascularization by stent or bypass is not possible, as it preserves the viability of the liver due to the portal flow and collateral arteries. However, in the case of the failure of these treatments, liver transplantation is a rescue option.

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.

Rupture of a previously thrombosed hepatic artery aneurysm

Hepatic artery aneurysm (HAA) is a rare form of visceral artery aneurysm. Historically, most HAAs were ruptured at presentation, but advances in imaging have led to an increase in the diagnosis of asymptomatic HAAs. Description of the natural history of patent HAAs has been difficult because of their rarity, even more so for less common thrombosed HAAs. We report the case of a 74-year-old man who experienced the rupture of a previously thrombosed HAA. He was successfully surgically treated with ligation of the aneurysm. Our case provides insight into the progression and management of thrombosed HAAs.

Visceral Artery Aneurysms: Decision Making and Treatment Options in the New Era of Minimally Invasive and Endovascular Surgery

The abdominal viscera blood supply is derived from anterior branches of the abdominal aorta. Visceral artery aneurysms (VAAs) include aneurysms of the following arteries and their branches: the celiac artery, the hepatic artery, the splenic artery, the superior mesenteric artery, the inferior mesenteric artery, the pancreaticoduodenal artery, and the gastroduodenal artery. Overall VAAs comprise < 2% of all types of arterial aneurysms. Asymptomatic VAAs are now being encountered more frequently due to the widespread use of advanced diagnostic abdominal imaging. The incidental finding of a VAA frequently leaves clinicians with a dilemma as to the best course of management. The focus of this review is on current treatment options and management guidelines for both symptomatic and asymptomatic VAAs.

A case of giant common hepatic artery aneurysm successfully treated by transcatheter arterial embolization with isolation technique via pancreaticoduodenal arcade

Hepatic artery aneurysms are rare and sometimes life-threating. Various treatments for hepatic artery aneurysms, including surgical and endovascular techniques are present. Here, we report the case of a 68-year-old woman who presented with an about 9 cm of common hepatic artery aneurysm detected during a routine medical checkup; she did not exhibit any symptoms. We successfully treated the aneurysm with transcatheter arterial embolization with isolation technique via pancreatic duodenal arcade.

Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Visceral artery aneurysms (VAAs) are a rare, but serious clinical entity as rupture confers a high rate of mortality. Data regarding the prevalence, treatment, and prognosis of VAAs is largely from case series, as true randomized trials are lacking. The incidence of VAAs has risen over the decades with advances in imaging technology, availability, and utilization. Even in the presence of symptoms, the prompt diagnosis of VAAs may be challenging as symptoms are often nonspecific and varied. Although there are no definitive treatment guidelines, asymptomatic VAAs require treatment in the following scenarios: when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplant. Similar to therapeutic trends in other vascular beds, advances in endovascular devices and techniques have driven an "endovascular first" approach for the treatment of VAAs. However, although the success rates of endovascular repair are impressive, surgical intervention is still necessary in treating centers. This paper reviews the pathophysiology, clinical features, anatomic characteristics, and management strategies required for the effective diagnosis and treatment of VAAs.

Coil Embolisation for Endovascular Treatment of Proper Hepatic Artery Aneurysm Using the Balloon Occlusion Technique

INTRODUCTION

Endovascular repair (ER) as a minimally invasive approach can be effective for treating hepatic artery aneurysm (HAA) with gratifying results. Microcoil embolisation is the main technique used in ER. However, the coil embolisation of a large proper HAA (PHAA) with a very wide neck tends to be extremely troublesome owing to the limited length of the inflow and outflow artery. Moreover, it is difficult because of rapid blood flow in the proper hepatic artery (PHA) and the difficulty in preserving its branch flow. Microcoil embolisation of the inflow and outflow of a PHAA with the balloon occlusion technique through an originally developed single guiding sheath system was performed successfully.

REPORT

A 73 year old woman was diagnosed with large PHAA (65 mm) by computed tomography examination. The PHAA was successfully treated by endovascular embolisation with microcoils using the balloon occlusion technique through a single guiding sheath system.

DISCUSSION

This method is safe and effective for the treatment of a large PHAA.

Surgical treatment of a huge hepatic artery aneurysm without revascularization-Case Report

INTRODUCTION

Hepatic artery aneurysms (HAA) are rare and life-threatening.

PRESENTATION OF CASE

We report a case of a 68-year-old man with a huge HAA diagnosed incidentally. Computed tomography showed a huge HAA (67-84 mm diameter). The patient underwent aneurysm resection and ligation of the common and proper hepatic arteries via laparotomy. Revascularization was not performed because intraoperative ultrasound showed pulsatile inflow to the left hepatic lobe. Postoperative cholecystitis and hepatic infarction were temporarily observed. Two months after the previous discharge, cholecystectomy was performed.

DISCUSSION

A diameter ≥5 cm of HAA is thought to be rare in arterial aneurysm diseases. There is no consensus in the treatment policy and treatment is selected according to the patient's condition. In this case, we selected open surgery for this patient instead of endovascular surgery due to rupture risks, irregularity and narrowness of vessel structure, and prolonged irradiation-time. If revascularization is not performed at the time of resection, open surgery with cholecystectomy is capable of preventing postoperative cholangitis after resection of HAA, and should be taken into account even if collateral circulation can be confirmed.

CONCLUSION

This case highlights the difficulty of managing HAA and provides insight into a successful surgical treatment of HAA without complete revascularization.

Endovascular Repair of Ruptured Hepatic Artery Pseudoaneurysm Secondary to Fibromuscular Dysplasia

We describe successful endovascular treatment of a patient with fibromuscular dysplasia of the celiac axis leading to development of a common hepatic artery pseudoaneurysm with contained rupture. An 81-year-old woman was transferred to our quaternary care center with concern for a hepatic artery rupture. Further imaging demonstrated a common hepatic artery pseudoaneurysm with surrounding hematoma as well as multifocal areas of narrowing and dilatation in the celiac trunk consistent with fibromuscular dysplasia. A similar pattern was subsequently identified in the bilateral renal and carotid arteries. The patient underwent successful endovascular exclusion of the pseudoaneurysm with a balloon-expandable covered stent and was discharged home without incident. Fibromuscular dysplasia is a nonatherosclerotic arteriopathy that can lead to stenosis, occlusion, dissection, and aneurysm formation. While it primarily affects the carotid and renal arteries, there are rare case reports involving the mesenteric vasculature. Endovascular therapy appears to be a feasible treatment option for the complicated sequelae of this condition in the rare case of mesenteric arterial involvement.

Open Repair of Hepatic Artery and Celiac Artery Aneurysms in a Patient With Prior Aortic Dissection With an Iliac to Hepatic Artery Bypass

A 67-year-old male with a history of an aortic dissection was found to have a large hepatic and celiac artery aneurysm. Due to the extent of the dissection within the aorta, a bypass was performed from his iliac artery to the hepatic bifurcation, followed by exclusion and ligation of the aneurysms.

Splenic Artery Transposition Graft for Hepatic Artery Aneurysm and Occlusion

BACKGROUND

Hepatic artery aneurysms are rare but potentially fatal if undiagnosed or left untreated. Several open surgical and endovascular techniques for hepatic artery aneurysm (HAA) repair have been described. Splenic artery transposition has been reported in selected cases.

CASE REPORT

We herein present the case of a 73-year-old man with asymptomatic HAA and concomitant occlusion at the most proximal tract. The aneurysm involved the common and proper hepatic artery and was supplied by the gastroduodenal artery. Aneurysmectomy was performed, and the arterial blood flow was restored to the liver by splenic artery transposition graft. No signs of liver or spleen ischemia were detected at control computed tomography angiography. The patient is doing fine 3 months after surgery.

CONCLUSIONS

This case presented multiple challenges because of HAA location and extension and lack of a traditional inflow site for hepatic revascularization. In such setting, splenic artery transposition was shown to represent a feasible and successful technique.

Rare Case of Hepatic Artery Pseudoaneurysm

Hepatic artery aneurysms are rare, but potentially life-threatening vascular pathologies. They are usually discovered incidentally during imaging diagnostics of different pathologies. The study presented a rare case of hepatic artery pseudoaneurym with a fistula to the left branch of the portal vein.