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Çildağ MB, Gök M, Öztürk T, Köseoğlu ÖFK. Endovascular Treatment of a Giant Aneurysm of the Aberrant Right Hepatic Artery in a Patient with Osler-Weber-Rendu Syndrome: A Case Report. Vasc Specialist Int 2023; 39:25. [PMID: 37667663 PMCID: PMC10480046 DOI: 10.5758/vsi.230055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/24/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Osler-Weber-Rendu syndrome (OWR) is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous or visceral telangiectasias, and arteriovenous malformations in the lungs, liver, brain, and gastrointestinal tract. Hepatic artery aneurysms (HAAs) can also occur in OWR patients. HAAs are the second most common type of visceral artery aneurysm, and mortality rates are high owing to the lack of a tamponade effect. Anatomical variations of the celiacomesenteric vasculature are common, and the most common variation is that of the right hepatic artery originating from the superior mesenteric artery (SMA). We present the endovascular treatment of a patient with OWR and an aberrant right HAA originating from the SMA, with coil embolization and stent grafting. Giant HAAs can be treated endovascularly. However, stent graft placement should be reconsidered because of the need for antithrombotic medication, which may increase the incidence of epistaxis attacks in that patient group.
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Affiliation(s)
- Mehmet Burak Çildağ
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Mustafa Gök
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Tuğba Öztürk
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Ömer Faruk Kutsi Köseoğlu
- Department of Interventional Radiology, Katip Çelebi University Training and Research Hospital, İzmir, Turkey
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Naganuma H, Ishida H, Kuroda H, Suzuki Y, Ogawa M. Hereditary hemorrhagic telangiectasia: how to efficiently detect hepatic abnormalities using ultrasonography. J Med Ultrason (2001) 2020; 47:421-433. [PMID: 32390074 DOI: 10.1007/s10396-020-01022-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/30/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT) is a multiorgan genetic angiodysplastic affection characterized by visceral vascular malformations. It affects mainly the brains, lungs, gastrointestinal tract, and nasal mucosa. Unlike those organs, hepatic involvement, although very frequently occurring, is insufficiently recognized, mainly because of the complex vascular structure of this organ. Thus, treating HHT patients requires a solid understanding of these hepatic anomalies. It is especially important for any general clinicians to be able to recognize clinical findings in HHT, which leads to a high suspicion of HHT and have an index of suspicion for liver abnormalities of HHT. For this purpose, keen awareness of clinical as well as hepatic sonographic (US) findings is paramount. AIM The aim of this review is to summarize previously reported findings on the hepatic US through a thorough analysis of related articles, and to (a) determine the role of US in the diagnosis of hepatic involvement in HHT patients and (b) propose the most simple and easy way to detect HHT-related abnormalities during routine US examinations. CONCLUSION Hepatic US serves to diagnose the detailed complex hepatic changes typical of HHT, and contributes to increased diagnostic confidence of hepatic changes in HHT patients, with the most simple way not to overlook HHT-related abnormalities being to find hepatic artery dilatation.
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Affiliation(s)
- Hiroko Naganuma
- Department of Gastroenterology, Yokote Municipal Hospital, 5-31 Negishi-cho, Yokote, Akita, 013-8602, Japan.
| | - Hideaki Ishida
- Center of Diagnostic Ultrasound, Akita Red Cross Hospital, Akita, Japan
| | - Hidekatsu Kuroda
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Yasuaki Suzuki
- Department of Gastroenterology, Nayoro City General Hospital, Hokkaido, Japan
| | - Masahiro Ogawa
- Department of Gastroenterology and Hepatology, Nihon University Hospital, Tokyo, Japan
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Droege F, Thangavelu K, Stuck BA, Stang A, Lang S, Geisthoff U. Life expectancy and comorbidities in patients with hereditary hemorrhagic telangiectasia. Vasc Med 2018; 23:377-383. [DOI: 10.1177/1358863x18767761] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There are only a few published studies that demonstrate associations between life expectancy, severe comorbidities, and their complications in patients with hereditary hemorrhagic telangiectasia (HHT). Relatives of 73 deceased patients with suspected HHT completed a questionnaire about causes of death, and symptoms and comorbidities that the patients had developed. We compared the data for 55 cases where HHT had been clinically confirmed with the general population. Patients suffering from HHT lost, on average, 19 years (SD 11 years) of potential life compared to the general population. Among the deceased HHT patients, 35% (95% CI: 23–48%) died from sepsis, 26% (95% CI: 16–38%) from cardiac failure, 20% (95% CI: 9–28%) from a severe bleeding episode, and 13% (95% CI: 6–24%) from terminal cancer. Congestive heart failure (69%, 95% CI: 56–80%) and pulmonary hypertension (23%, 95% CI: 14–36%) were the main non-fatal comorbidities in patients with HHT. Patients with HHT appear to have a lower life expectancy than the general population. Sepsis and cardiac failure were the main causes of death. Optimized and targeted screening programs for the most frequent comorbidities followed by improved management of infectious complications may increase life expectancy.
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Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Boris A Stuck
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Andreas Stang
- Center of Clinical Epidemiology, Institute of Medical Informatics, Biometry and Epidemiology, Essen University Hospital, Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Peinado Cebrián FJ, Estebanez Seco S, Flores-Herrero A, Montoya Ching R, Mendez Feria B, Soto Valdés D, Lamarca Mendoza MP, Orgaz Perez-Grueso A. Giant Symptomatic Aneurysm Secondary to Hereditary Hemorrhagic Telangiectasia of a Main Hepatic Artery with Aberrant Origin in Superior Mesenteric Artery. Ann Vasc Surg 2017; 44:417.e5-417.e9. [PMID: 28461180 DOI: 10.1016/j.avsg.2016.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/19/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare disease consistent in vascular dysplasias affecting different organs. Liver involvement includes telangiectases, arteriovenous shunting, and ischemic cholangitis, and its prevalence ranges from 8% to 31%. Spontaneous pseudoaneurysms have never been reported associated to HHT. Several variations in the origin of the main hepatic artery (MHA) have been described in large radiological series and can be found in around 4% of general population. METHODS A 64-year-old woman with history of HHT was diagnosed of acute symptomatic saccular aneurysm involving the MHA. The associated portovenous fistulae suggested that liver perfusion could be impaired if embolization of the MHA without revascularization was performed. Because of an aberrant origin on the superior mesenteric artery, a hybrid procedure was designed, consistent on endovascular exclusion of the MHA associated with a surgical aortic-hepatic bypass graft. RESULTS Angio computed tomography (Angio CT) was performed at discharge, 1 month, and 6 months after intervention, revealed complete exclusion of the aneurysm, which reduced 50% in diameter after 6 months. Aneurysms of the MHA can be associated with HHT when intrahepatic arteriovenous fistulae are present. This complication is rare, and the reported cases have been treated by surgical and totally endovascular procedures. The confluence of this very rare condition with an uncommon vascular anatomy makes this a unique case that required the design of a customized intervention. CONCLUSIONS Hybrid procedures are useful to treat conditions that cannot be solved with standard interventions. Longer series of cases with long-term surveillance are needed to asses the results of these techniques in these complex pathology.
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Affiliation(s)
| | - Santiago Estebanez Seco
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
| | - Angel Flores-Herrero
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
| | - Ricardo Montoya Ching
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
| | - Benito Mendez Feria
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
| | - Diego Soto Valdés
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
| | | | - Antonio Orgaz Perez-Grueso
- Servicio de Angiología y Curugía Vascular, Hospital Virgen de la Salud de Toledo, Nambroca, Toledo, Spain
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Pancytopenia in a Patient with Rendu-Osler-Weber Syndrome and Uncommon Vascular Abnormalities. Case Rep Hematol 2016; 2016:3016402. [PMID: 27803822 PMCID: PMC5075613 DOI: 10.1155/2016/3016402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/04/2016] [Accepted: 09/19/2016] [Indexed: 11/17/2022] Open
Abstract
Rendu-Osler-Weber syndrome, or hereditary hemorrhagic teleangiectasia (HHT), is a rare autosomal dominant vascular disorder, characterized by multiple mucocutaneous teleangiectases with recurrent nasal and gastrointestinal bleedings and/or solid-organ arteriovenous shunts. We describe the first case to our knowledge of pancytopenia in a 53-year-old patient, with a known history of HHT and recurrent nasal and gastrointestinal bleedings, who was found to have a major splenic artery aneurysm and other uncommon vascular abnormalities. In the absence of other evident causes of pancytopenia, hypersplenism was diagnosed. The patient underwent coil embolization of the splenic artery aneurysm, followed by rapid and sustained increase of white blood cell and platelet count. Splenic artery aneurysms are extremely uncommon in HHT as only anecdotal cases have been reported to date. However, we believe that the aneurysm critically contributed to the progression of splenomegaly and the development of pancytopenia.
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Ozawa H, Ohki T, Kanaoka Y, Maeda K, Hagiwara S. Open arterial reconstruction of multiple hepatic artery aneurysms in a patient with hereditary hemorrhagic telangiectasia: A case report. Medicine (Baltimore) 2016; 95:e5430. [PMID: 27861387 PMCID: PMC5120944 DOI: 10.1097/md.0000000000005430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is characterized by mucocutaneous telangiectasia and visceral vascular malformations (VMs). Liver involvement with VMs may lead to high-output cardiac failure, portal hypertension, and biliary disease. There is no curative treatment for the disease, and liver transplantation is indicated for life-threatening complications. Herein, we report a case of multiple hepatic artery aneurysms (HAAs) in a patient with HHT in which open arterial reconstruction was performed. There have only been a few case reports on HAA occurring with HHT. Thus, this case provides important information for the management of HHT-associated HAAs. CASE SUMMARY A 62-year-old female with known HHT was referred to our facility to seek further treatment for a giant HAA. She denied any symptoms except recurrent epistaxis. A computed tomography (CT) scan revealed a right HAA with a diameter of 72 mm, in addition to 2 other minor HAAs. The CT scan also revealed the VMs that were scattered in the liver, and a continuously dilated and tortuous artery existing from the celiac trunk to the right and left hepatic arteries. We performed open arterial reconstruction of the HAAs. Her postoperative course was uneventful. CONCLUSIONS When treating HAAs, there are a variety of options. However, hepatic VMs might affect HHT patients in various ways postprocedurally. Ligation and embolization of the hepatic artery may lead to complications, such as massive hepatic necrosis. Hepatectomy should be avoided if possible, because a postoperative hyperperfusive state in the remaining liver can cause adverse events. We believe that arterial reconstruction of HHT-associated HAAs might reduce the risk of postprocedural complications with minimal hemodynamic changes in the liver, thus obviating the need for hepatectomy or liver transplantation.
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Chou YH, Chiou HJ, Tiu CM, Wang HK, Lai YC, Lin YH, Chiu TC, Chiou YY. Ultrasonic Contrast Portography for Demonstration of Intrahepatic Porto-systemic Shunts. J Med Ultrasound 2016. [DOI: 10.1016/j.jmu.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Diagnostic imaging in the study of visceral involvement of hereditary haemorrhagic telangiectasia. Radiol Med 2008; 113:547-66. [DOI: 10.1007/s11547-008-0276-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
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Milot L, Dumortier J, Boillot O, Pilleul F. Giant aneurysm of the main hepatic artery secondary to hereditary hemorrhagic telangiectasia: 3D contrast-enhanced MR angiography features. ACTA ACUST UNITED AC 2007; 31:297-9. [PMID: 17396089 DOI: 10.1016/s0399-8320(07)89377-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This case report describes a patient with Hereditary Hemorrhagic Telangiectasia and a giant hepatic artery aneurysm. Aneurysms of the hepatic artery are the second most common form of visceral artery aneurysms. The causes of hepatic artery aneurysms are atherosclerosis in 30% of cases, arteritides, periarterial inflammation, liver transplantation, and hepatic tumor embolization. To our knowledge no giant hepatic artery aneurysm has been described in relation to Weber-Rendu-Osler disease in the literature. These aneurysms probably develop because of hepatic arterio-venous fistulas and secondary to changes in arterial hemodynamics. The increased use of non invasive imaging techniques such as MRI before liver transplantation in patients with hereditary hemorrhagic telangiectasia reveals these asymptomatic aneurysms and makes it possible to choose the best therapeutic approach.
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Caselitz M, Bahr MJ, Bleck JS, Chavan A, Manns MP, Wagner S, Gebel M. Sonographic criteria for the diagnosis of hepatic involvement in hereditary hemorrhagic telangiectasia (HHT). Hepatology 2003; 37:1139-46. [PMID: 12717395 DOI: 10.1053/jhep.2003.50197] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is highly variable and may lead to severe clinical symptoms such as heart failure. This controlled, prospective study defined sonographic criteria for hepatic involvement in HHT. Color Doppler sonography and pulsed Doppler sonography were used to study 25 patients with HHT and liver involvement, 20 patients with HHT without liver involvement, 25 patients with cirrhosis, and 25 patients without liver disease. The diagnosis of hepatic manifestation was confirmed by computed tomography and/or angiography. Liver size, parenchymal changes of the liver, vessel diameters, and flow velocities of the portal vein and the hepatic artery were determined. Resistance index (RI) and pulsatility index (PI) were calculated. The diameter of the common hepatic artery was significantly dilated without overlap between HHT patients with liver involvement and the 3 control groups (mean 11.3 +/- 2.8 mm [HHT with liver involvement], 4.6 +/- 0.9 mm [HHT without liver involvement], 4.8 +/- 1.0 mm [cirrhosis], and 4.4 +/- 1.0 mm [healthy controls], P <.001). Doppler parameters of the proper hepatic artery differed significantly (all P <.001). In all patients with HHT and liver involvement, areas with intrahepatic hypervascularization caused by dilated intrahepatic arteries were observed in varying intensity. Cardiac output significantly correlated with the diameter of the common hepatic artery (r = 0.53, P =.007) and the portal vein (r = 0.42, P =.05). In conclusion, the diameter of the common hepatic artery (>7 mm) and intrahepatic hypervascularization are suitable sonographic diagnostic parameters of HHT with high sensitivity and specificity. Dilated diameters of the hepatic feeding vessels are indicators for systemic circulatory distress in these patients.
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Affiliation(s)
- Martin Caselitz
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Germany.
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Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is an hereditary disorder that results in fibrovascular dysplasia with the development of telangiectasias and arteriovenous malformations. It predominantly involves the skin, mucous membranes, viscera, lungs, and brain. Hereditary hemorrhagic telangiectasia shows great genetic heterogeneity, and its phenotypes have been classified based on the recently identified mutated genes: endoglin (HHT-1) and activin-like kinase receptor-1 (HHT-2). Other families with phenotypic HHT do not bear these mutations; therefore, other genes are probably involved as well. Liver involvement is reported in up to 30% of persons affected by HHT. Large arteriovenous malformations in the liver can lead to significant complications, including high-output congestive heart failure, portal hypertension, hepatic encephalopathy, biliary ischemia, and liver failure. Embolization of large arteriovenous malformations in the liver remains controversial; however, liver transplantation can successfully eradicate these complications.
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Affiliation(s)
- Anne M Larson
- Department of Medicine, University of Washington, Seattle, 98195-6174, USA.
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Chou YH, Chiou HJ, Tiu CM, Chiou SY, Lin CC, Wu JC. Osler-Weber-Rendu Disease: Transhepatic Portography Using Ultrasonic Contrast Agents to Demonstrate Intrahepatic Porto-systemic Shunts. J Med Ultrasound 2003. [DOI: 10.1016/s0929-6441(09)60040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Lin CC, Wu JC, Chou YH, Huang YH, Chang FY, Lee SD. Hereditary hemorrhagic telangiectasia: demonstration of portosystemic venous shunts using power Doppler sonography and sonographically guided percutaneous transhepatic portovenography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2001; 29:517-522. [PMID: 11745863 DOI: 10.1002/jcu.10012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Hereditary hemorrhagic telangiectasia is a rare autosomal dominant inherited disease associated with vascular abnormalities, which may occur in any organ. Cases of hereditary hemorrhagic telangiectasia accompanied by intrahepatic portosystemic venous shunts, however, have rarely been described. We report a case of hereditary hemorrhagic telangiectasia in which intrahepatic portosystemic shunts were detected using power Doppler sonography and portovenography with percutaneous transhepatic contrast agent injection. On gray-scale sonography, the common hepatic artery was dilated, and dilated tubular structures mimicking dilated biliary tracts were found. Power Doppler sonography demonstrated the continuity of tortuous vascular channels connecting a branch of the right portal vein to a branch of the right hepatic vein. The dilated vascular channels and tributaries of the right hepatic vein showed a monophasic waveform pattern on spectral analysis. Portovenography showed a tangle of vascular structures connecting with a branch of the right hepatic vein.
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Affiliation(s)
- C C Lin
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, 201 Shih-Pai Road, Section 2, Taipei 112, Taiwan
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