Glue Embolization of a Blunt Traumatic Hepatic Arteriovenous Fistula under Inflow and Outflow Control

Covered stent placement for hepatic artery pseudoaneurysm

PURPOSE

To evaluate the efficacy and safety of covered stent placement for the treatment of hepatic artery pseudoaneurysm (HAP).

METHODS

Between March 2006 and March 2019, 17 consecutive patients underwent emergency covered stent placement for treatment of HAP. There were 12 men and 5 women aged 24-71 years, with an average age of 49.4 years. Eleven patients had undergone Whipple procedure, 3 had hepatic abscess following hepatectomy, 2 had undergone hepatectomy under extracorporeal circulation, and 1 had received surgical exploration after a car accident. The average interval from surgical intervention to massive bleeding was 15.3 days (range: 6-35 days). After HAP was confirmed by angiography, 1-3 covered stent grafts (3-8 mm in diameter and 13 mm-5 cm in length) were implanted. Adequate drainage, anti-infection treatment, and symptomatic treatment were offered after stent placement, and no anticoagulation or antiplatelet drug was used.

RESULTS

The interventions were successful in all 17 patients. Angiography revealed pseudoaneurysms in common hepatic artery in 16 patients (in gastroduodenal artery stumps in 4 patients) and hemorrhage from a ruptured right hepatic artery in 1 patient. All patients were successfully implanted with 1-3 covered stent grafts. Bleeding was completely controlled in 12 patients (stent diameter: 4.5-8 mm). Four patients (stent diameter: 3-4.5 mm) experienced bleeding recurrence 1 h to 3 days after stent implantation, and type 1 endoleaks were identified during second angiography. Finally, these 4 patients died of multiple organ failure 2-10 days after embolization/blockage. The remaining patient suffered from abdominal hemorrhage again 2 weeks after stent implantation, and second angiography showed hemorrhage from a branch of the superior mesenteric artery; no bleeding occurred after embolization. Thirteen patients survived at discharge, and the average length of hospital stay was 26.53 days (range: 11-58 days). The average follow-up time was 23 months (range: 16-37 months), during which 6 patients died of tumor progression. No bleeding recurred during the follow-up period, and routine color Doppler ultrasound revealed that the common hepatic artery was patent and the blood flow was smooth at the stent implantation site.

CONCLUSION

Covered stent placement is a safe and effective alternative for treating HAP patients with high risk of severe complications after hepatic artery embolization. Larger stent grafts (> 4 mm in diameter) may achieve better prognosis.