Splenic artery transposition graft usage for the supply of the right hepatic artery: a case report

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.

Visceral artery aneurysms: review on indications and current treatment strategies

Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.

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.