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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by : Swaksh Nemani
Contributed by : Swaksh Nemani
Endovascular embolization of giant common hepatic artery aneurysm in a patient presented with midline pulsatile mass
Endovascular embolization of giant common hepatic artery aneurysm in a patient presented with midline pulsatile mass
Introduction:
Introduction:
Hepatic artery aneurysms are a rare disease entity. They usually occur in elderly patients with underlying vascular disorders or atherosclerotic vessels. Before the advancement in endovascular techniques, patients used to present with symptoms of rupture with significant morbidity. Now interventional radiology has decreased the need for open surgical management like ligation and proves vital in patients with high surgical risk. We discuss a case wherein the patient presented with midline pulsatile mass managed by endovascular coiling.
Hepatic artery aneurysms are a rare disease entity. They usually occur in elderly patients with underlying vascular disorders or atherosclerotic vessels. Before the advancement in endovascular techniques, patients used to present with symptoms of rupture with significant morbidity. Now interventional radiology has decreased the need for open surgical management like ligation and proves vital in patients with high surgical risk. We discuss a case wherein the patient presented with midline pulsatile mass managed by endovascular coiling.
Case presentation:
Case presentation:
A 49-year-old woman presented with abdominal pain since one year, insidious in onset and gradually progressive, dull aching in nature, localised to the epigastrium, without radiation of pain. She did not complain of any aggravating or relieving factors. There was associated episodic nausea and vomiting a few hours after consumption of meals, non-bilious, with food particles as content. She also complained of progressive abdominal distension since four months and loss of appetite. There is no past history suggestive of abdominal trauma or pancreatitis. No history of any comorbidities was obtained. Outside ultrasound examination of the abdomen revealed a well-defined predominantly anechoic cystic structure in the epigastric region with homogenously hyperechoic content against the posterior wall. On color doppler, bidirectional flow is seen within the anechoic region, suggestive of an aneurysm with partial thrombosis. On abdominal examination, a palpable lump was felt in the epigastrium, soft in nature, compressible and pulsatile.
A 49-year-old woman presented with abdominal pain since one year, insidious in onset and gradually progressive, dull aching in nature, localised to the epigastrium, without radiation of pain. She did not complain of any aggravating or relieving factors. There was associated episodic nausea and vomiting a few hours after consumption of meals, non-bilious, with food particles as content. She also complained of progressive abdominal distension since four months and loss of appetite. There is no past history suggestive of abdominal trauma or pancreatitis. No history of any comorbidities was obtained. Outside ultrasound examination of the abdomen revealed a well-defined predominantly anechoic cystic structure in the epigastric region with homogenously hyperechoic content against the posterior wall. On color doppler, bidirectional flow is seen within the anechoic region, suggestive of an aneurysm with partial thrombosis. On abdominal examination, a palpable lump was felt in the epigastrium, soft in nature, compressible and pulsatile.
Contrast enhanced CT scan of the abdomen and CT angiography show a saccular structure arising from the common hepatic artery with crescent shaped uptake of contrast and a filling defect in the remainder of the lumen. The gastroduodenal artery is seen arising from the aneurysm (Figure 1). Patient presented in our emergency surgical services with these findings. All her laboratory results were normal.
Contrast enhanced CT scan of the abdomen and CT angiography show a saccular structure arising from the common hepatic artery with crescent shaped uptake of contrast and a filling defect in the remainder of the lumen. The gastroduodenal artery is seen arising from the aneurysm (Figure 1). Patient presented in our emergency surgical services with these findings. All her laboratory results were normal.
Fig. 1 : Sagittal and 3D Multiplanar Reconstruction images of contrast enhanced CT show a well-defined spherical lesion in the right lumbar region with strong contrast enhancement in the arterial phase and a central filling defect, likely an abdominal aneurysm with an intra-luminal thrombus.
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1).
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1).
Video 1 : Selective celiac artery DSA shows opacification of the splenic artery and a giant aneurysmal sac seen arising from the origin of the common hepatic artery.
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1). So, coiling of proximal splenic artery with coils and closure of neck of aneurysm at the origin of common hepatic artery with vascular plug was planned. Cook Micro-nester coils were used to embolise the proximal splenic artery and Abbott AVP plug was used over the long sheath for the closure of neck of aneurysm (Video 2)(Figure 2).
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1). So, coiling of proximal splenic artery with coils and closure of neck of aneurysm at the origin of common hepatic artery with vascular plug was planned. Cook Micro-nester coils were used to embolise the proximal splenic artery and Abbott AVP plug was used over the long sheath for the closure of neck of aneurysm (Video 2)(Figure 2).
Figure 2: DSA image shows complete occlusion of the neck of the common hepatic artery with a Abbott Amplatz Vascular plug.
Video 2: Selective celiac artery DSA following proximal embolization of the splenic artery using pushable coils shows non-opacification of the splenic artery with filling of the aneurysmal sac.
Further, aortogram was performed it showed communication of aneurysm with gastroduodenal artery (Video 3).
Further, aortogram was performed it showed communication of aneurysm with gastroduodenal artery (Video 3).
Video 3: Aortogram following occlusion of the neck of the common hepatic artery with Abbott Amplatz Vascular Plug shows non-filling of the aneurysmal sac across the neck. There is gradual filling of the aneurysm distally from the superior mesenteric artery branches.
Selective cannulation of inferior pancreatico-duodenal artery (IPD) was done and gram performed confirmed the findings (Video 4). So distal to proximal coiling across this defect in gastro-duodenal artery was performed using Terumo Progreat microcatheter (Video 5)(Video 6).
Selective cannulation of inferior pancreatico-duodenal artery (IPD) was done and gram performed confirmed the findings (Video 4). So distal to proximal coiling across this defect in gastro-duodenal artery was performed using Terumo Progreat microcatheter (Video 5)(Video 6).
Videos 4, 5, 6
Video 4: Super-selective DSA of the inferior pancreatico-duodenal artery with shows filling of the aneurysmal sac through a defect in the gastro-duodenal artery.
Video 5: Super-selective DSA of the inferior pancreatico-duodenal artery following distal to proximal embolization of the proper hepatic artery with multiple micro-coils using Terumo Progreat micro-catheter shows continuous filling of the aneurysmal sac from the gastro-duodenal artery defect.
Video 6:.Selective superior mesenteric artery DSA shows non-filling of the aneurysmal sac following distal to proximal embolization of the gastro-duodenal artery with micro-coils.
Post embolization, complete exclusion of the aneurysmal sac from the visceral circulation is seen. Patient discharged on day 5 post procedure and asymptomatic during discharge. On the day of discharge, plain and contrast enhanced CT scan was performed which showed retained post procedure contrast on plain scan and absence of filling of aneurysmal sac on contrast enhanced scan (Figure 3).
Post embolization, complete exclusion of the aneurysmal sac from the visceral circulation is seen. Patient discharged on day 5 post procedure and asymptomatic during discharge. On the day of discharge, plain and contrast enhanced CT scan was performed which showed retained post procedure contrast on plain scan and absence of filling of aneurysmal sac on contrast enhanced scan (Figure 3).
Fig.3 : Axial image of post-procedure plain CT shows retention of contrast in the lumen of the aneurysm. Coronal image of post-procedure contrast enhanced CT shows non-opacification of the aneurysm in the arterial phase.
Discussion:
Discussion:
Hepatic artery aneurysms only account for 20 % of true visceral aneurysms but they have the highest rate of rupture (44%) among the splanchnic circulation. [1] Patients usually present with complications of rupture, rather than at the asymptomatic stage or with features like abdominal pain and distension which our patient presented with. [2]
Hepatic artery aneurysms only account for 20 % of true visceral aneurysms but they have the highest rate of rupture (44%) among the splanchnic circulation. [1] Patients usually present with complications of rupture, rather than at the asymptomatic stage or with features like abdominal pain and distension which our patient presented with. [2]
Extrahepatic aneurysms upon rupture usually cause peritoneal hemorrhage, whereas intrahepatic aneurysms more frequently rupture into the biliary tree, a complication responsible for Quinke’s triad of pain, jaundice, and hemobilia. [3]
Extrahepatic aneurysms upon rupture usually cause peritoneal hemorrhage, whereas intrahepatic aneurysms more frequently rupture into the biliary tree, a complication responsible for Quinke’s triad of pain, jaundice, and hemobilia. [3]
In a recent study by Abbas et al, of the 9 patients with ruptured or symptomatic hepatic artery aneurysms at presentation, 3 patients had fibromuscular dysplasia, 2 patients had polyarteritis nodosa, and 1 patient had a history of endocarditis. All ruptured aneurysms were of nonatherosclerotic cause. Another significant risk factor was multiple aneurysms seen in polyarteritis nodosa. [4] Atherosclerotic aneurysms are thus associated with a lower risk of rupture and may present late with abdominal pain and distension.
In a recent study by Abbas et al, of the 9 patients with ruptured or symptomatic hepatic artery aneurysms at presentation, 3 patients had fibromuscular dysplasia, 2 patients had polyarteritis nodosa, and 1 patient had a history of endocarditis. All ruptured aneurysms were of nonatherosclerotic cause. Another significant risk factor was multiple aneurysms seen in polyarteritis nodosa. [4] Atherosclerotic aneurysms are thus associated with a lower risk of rupture and may present late with abdominal pain and distension.
Repair of hepatic artery aneurysms is recommended when the aneurysm reaches 2 cm in size because of an elevated rupture risk approaching 25% for larger aneurysms and an associated 70% to 100% mortality with rupture. [5]
Repair of hepatic artery aneurysms is recommended when the aneurysm reaches 2 cm in size because of an elevated rupture risk approaching 25% for larger aneurysms and an associated 70% to 100% mortality with rupture. [5]
However, the current Society for Vascular Surgeons guidelines recommend intervention in the following: (1) all hepatic artery pseudoaneurysms; (2) all symptomatic hepatic artery aneurysms regardless of size; (3) asymptomatic patients without significant comorbidity in true hepatic artery aneurysms >2 cm, if the aneurysms enlarge by 0.5 cm/y or if a patient with significant comorbidities has an aneurysm greater than 5 cm. [6]
However, the current Society for Vascular Surgeons guidelines recommend intervention in the following: (1) all hepatic artery pseudoaneurysms; (2) all symptomatic hepatic artery aneurysms regardless of size; (3) asymptomatic patients without significant comorbidity in true hepatic artery aneurysms >2 cm, if the aneurysms enlarge by 0.5 cm/y or if a patient with significant comorbidities has an aneurysm greater than 5 cm. [6]
The first line of management of hepatic artery aneurysms is endovascular. [7]
The first line of management of hepatic artery aneurysms is endovascular. [7]
The most common method for treatment is percutaneous transcatheter embolization with metallic coils. Embolization is particularly preferred for intrahepatic aneurysms and high-risk surgical patients. The limited devascularization involved with embolization is associated with a low morbidity and a success rate of about 85 per cent in all splanchnic artery aneurysms. [8] The compensatory development of abdominal collaterals prevents widespread devascularisation and ischemic complications of endovascular procedures. There are complications involved with this procedure however, including migration of the coils leading to hepatic infarction, abscess formation, or rupture of the aneurysm. Due to the possibility of recanalization, routine follow-up is generally recommended and repeat embolization may be necessary. [9]
The most common method for treatment is percutaneous transcatheter embolization with metallic coils. Embolization is particularly preferred for intrahepatic aneurysms and high-risk surgical patients. The limited devascularization involved with embolization is associated with a low morbidity and a success rate of about 85 per cent in all splanchnic artery aneurysms. [8] The compensatory development of abdominal collaterals prevents widespread devascularisation and ischemic complications of endovascular procedures. There are complications involved with this procedure however, including migration of the coils leading to hepatic infarction, abscess formation, or rupture of the aneurysm. Due to the possibility of recanalization, routine follow-up is generally recommended and repeat embolization may be necessary. [9]
In general, assuming a stent–graft cannot be placed through an entire aneurysm, or across the neck of a pseudo-aneurysm, it is recommended in non-terminal vascular territories (such as the hepatic circulation) to occlude both upstream and downstream of the aneurysm to prevent both antegrade and retrograde perfusion. [10][11]
In general, assuming a stent–graft cannot be placed through an entire aneurysm, or across the neck of a pseudo-aneurysm, it is recommended in non-terminal vascular territories (such as the hepatic circulation) to occlude both upstream and downstream of the aneurysm to prevent both antegrade and retrograde perfusion. [10][11]
In our case, as per the Society for Vascular Surgery guidelines for a symptomatic common hepatic artery aneurysm, endovascular coiling was done and an occlusive plug was deployed. Proximal filling was managed by embolization of splenic artery and the feeder common hepatic artery and distal re-filling was prevented by occlusion of the gastro-duodenal artery using micro-coils.
In our case, as per the Society for Vascular Surgery guidelines for a symptomatic common hepatic artery aneurysm, endovascular coiling was done and an occlusive plug was deployed. Proximal filling was managed by embolization of splenic artery and the feeder common hepatic artery and distal re-filling was prevented by occlusion of the gastro-duodenal artery using micro-coils.
References:
References:
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1. Arneson MA, Smith RS. Ruptured hepatic artery aneurysm:
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