Purpose: To assess the efficacy of endovascular management for ruptured hepatic artery pseudoaneurysm (HAP). Methods: Six cases of HAP in five patients (four men and one women; mean age, 50; range, 28 - 62) were treated with transcatheter arterial coil embolization using microcoil (Boston Scientific, Watertown, MA, USA) and Tornado Coil (Cook, Bloomington, IN, USA) with or without stent graft between January 2007 and September 2008. They were analyzed with regard to the clinical presentation, radiological findings with procedure, and clinical and radiologic outcomes. Results: All patients presented with epigastric pain or gastrointestinal bleeding. The pseudoaneurysms were ranged from 0.6 to 4.4 cm in size and located in the common hepatic artery (n = 1), junction between proper and right hepatic artery (n = 1), proper hepatic artery (n = 2), the left hepatic artery (n = 1), right hepatic artery (n = 1). Embolization was performed with microcoils in all pseudoaneurysmal sac with or without both afferent and efferent segment. A self-expandable stent (n = 1) was also used. Overall technical success was 100% (6 of 6) and complete occlusions of HAPs were achieved in 5 out of 6 cases, 83.3% of clinical success rate. Re-bleeding occurred in one case of stent graft at proper hepatic artery following coil packing for pseudoaneurysmal sac. Clinical success rate of embolization for both afferent and efferent segment was 100% (3 of 3). Procedure-related minor complications happened in 2 of 5 patients, and they were treated conservatively. Conclusion: Transcatheter coil embolization for ruptured HAP is sufficiently effective and additional embolization in both afferent segment and efferent segment can improve clinical success rate.
Hepatic artery aneurysms are rare but represent approximately 20% of all visceral artery aneurysms [
The approval of our institutional review board was obtained for a retrospective review of medical records including radiologic exams of five consecutive patients, who were diagnosed as ruptured HAP according to dynamic abdominopelvic CT that shows arterial hypervascular enhancing sac with ill defined, high attenuated hemorrhages, and treated with transcatheter arterial embolization with or without stent graft between January 2007 and September 2008.
There were five patients (4 men, 1 women; age 28 - 62 years, mean age 50 years) diagnosed as ruptured HAPs and one of 5 patients underwent the interventional procedure twice because of newly developed HAP in proper hepatic artery around resection margin. Therefore, 6 cases of endovascular treatments in 5 patients were analyzed about initial clinical and radiologic presentation, progress and final outcomes.
After diagnosis of ruptured HAP on dynamic abdominopelvic CT scans, angiography was performed. Selective angiography of celiac axis and superior mesenteric artery (SMA) was done to analyze the location, size, shaped of the HAP using a 5 F catheter.
For endovascular treatment of ruptured HAP, 5 F introducer sheath was exchanged in the right femoral artery and superselection of the vessels supplying the ruptured pseudoaneurysm was followed with a tip of 2.0 and 2.2 F microcatheter coaxially place through the 5 F catheter. Endovascular procedures were performed using microcoil (Boston Scientific, Watertown, MA, USA) and Tornado Coil (Cook, Bloomington, IN, USA) without (n = 5) or with (n = 1) self-expandable stent (Neuroform, Stryker, Kalamazoo, Michigan, USA).
Technical success was defined as complete exclusion of the pseudoaneurysm after the procedure, and a lack of active extravasation. Clinical success was defined as the cessation of active bleeding or no evidence of recurrent bleeding on follow-up CT, and lack of hepatic ischemia [
The major initial presentation was upper gastrointestinal bleeding such as melena, hematemesis or anemia. Also upper abdominal pain was associated in 3 cases. Two patients had history of Whipple’s operation but the others had no history of abdominal surgery. The detail description was shown in
Selective angiography of celiac axis and superior mesenteric artery revealed six HAPs in each patient. Two of them were located at the proper hepatic artery in patients with history of Whipple’s operation, the others were respectively located at common hepatic artery, at junction between proper hepatic and right hepatic artery, at right hepatic artery and at left hepatic artery. The largest dimension of them was ranged from 0.6 to 4.4 mm in long axis diameter.
Embolization was performed thorough placement of microcoils in aneurysmal sacs or both afferent and efferent segments in all 6 endovascular procedures of 5 patients. Additional self-expandable stent was placed in one procedure. The mean follow up period was 13 months (range, 5 - 24 months). After only coil embolization, hemostasis was achieved in 4 out of 5 patients without re-bleeding after follow up. In one patient, coil embolization of pseudoaneurysm sac was performed at junction between proper and right hepatic artery with placement
Procedure | Patient | Sex | Age | Initial presentation | Previous history |
---|---|---|---|---|---|
1 | 1 | F | 28 | Melena | Gastritis |
2 | 2 | M | 51 | Melena | Whipple’s operation for CBD cancer |
3 | Hematemesis, epigastric pain, hypotension | Resection of hepatic arterial aneurysm | |||
4 | 3 | M | 60 | Anemia | Whipple’s operation for CBD cancer |
5 | 4 | F | 62 | Epigastric pain | Gastritis |
6 | 5 | M | 52 | RUQ pain and fever | None |
of self-expandable stent due to pre-existing hepatic ischemia. However, re-bleeding was noted in 5 day after procedures and the patient underwent surgical removal of coiled aneurysmal sac (
another newly developed pseudoaneurysm was discovered at proper hepatic artery. He was treated with coil embolization but expired due to septic shock after 18 days after the second procedure. The detail procedural description was summarized in
Immediate technical success was 100% (6 of 6) and complete occlusions of HAPs were achieved in 5 out of 6 cases, 83.3% of clinical success rate. Embolization of both afferent and efferent segment was performed in three procedures and there was no evidence of re-bleeding on follow up, 100% of clinical success rate (
Procedure-related minor complications happened in two patients. One is mild biliary dilatation and the other is focal hepatic parenchymal ischemia which was managed conservatively.
The accurate incidence of HAP is not clearly known but is approximately 0.02% in the general population and second most common visceral artery pseudoaneurysms [
Procedure | Patient | Location | Size (cm) | Procedures | Re-bleeding | Complication |
---|---|---|---|---|---|---|
1 | 1 | CHA | 3 × 2 | Coil packing | (−) | (−) |
2 | 2 | PHA/RHA | 1.2 × 1.1 | Stent graft with coil packing | (+) | (−) |
3 | PHA | 0.6 × 0.4 | Coil packing | (−) | (−) | |
4 | 3 | PHA | 4.4 × 3.6 | Coil embolization both afferent & efferent segments | (−) | (−) |
5 | 4 | LHA | 2.0 × 1.5 | Coilpacking and embolization both afferent & efferent segments. | (−) | Mild biliary dilatation |
6 | 5 | RHA | 3.6 × 2.5 | Coil embolization both afferent & efferent segments. | (−) | Mild hepatic ischemia |
CHA: common hepatic artery; PHA: proper hepatic artery; RHA: right hepatic artery; LHA: left hepatic artery.
gradually increasing due to laparoscopic hepatobiliary surgery and invasive percutaneous procedures [
HAPs are often asymptomatic before rupture but the patient with ruptured HAP manifests hemobilia, epigastric or right upper quadrant pain and jaundice, so called Quincke’s triad up to one third of cases [
CT angiography is the first step for optimal treatment planning [
In our study, clinical success rate depended on the kinds of procedures despite 100% of technical success rate. Coil-packing of pseudoaneurysm only was less effective with 66% of clinical success rate than that procedure with additional embolization in both afferent and efferent segments with 100% of clinical success rate. This method might reduce risk of re-bleeding. We consider stenting as a useful modality for unique supplying artery for liver, which had spastic change, or underlying hepatic infarct but it should be handled more carefully because re-bleeding happened in the stent-replaced HAP. Simultaneous coil embolization and stent insertion for bleeding pseudoaneurysm, especially at branching segment, is not frequently performed, and which may be one of factors of recurred bleeding. Furthermore immediate following surgical procedure cannot be excluded for the reason of re-bleeding.
Two controllable complications were noted after coil embolization. One is mildly decreased hepatic parenchymal enhancement and the other is mild intrahepatic bile duct dilatation in corresponding arterial territories. These are related to hepatic arterial insufficiency distal to gastroduodenal artery. Only one case of coil embolization of distal branches to gastroduodenal artery did not result in arterial insufficiency, because enough collaterals were verified on hepatic arteriography.
Because of rarity of HAP, most published reports were case reports and few original articles with small numbers of patients [
In conclusion, transcatheter arterial coil embolization for ruptured HAP is sufficiently effective and additional coil embolization in both afferent and efferent segment can improve clinical success rate. Further study and long-term follow-up is necessary.
The authors declared no conflicts of interest.
Seo, J.W. (2017) Effectiveness of Endovascular Coil Embolization of Ruptured Hepatic Artery Pseudoaneurysm. Advances in Computed Tomography, 6, 7-15. https://doi.org/10.4236/act.2017.62002
HAP: hepatic artery pseudoaneurysm.
CT: computed tomography.