Ann Vasc Dis Vol. 8, No. 3; 2015; pp 271–273 ©2015 Annals of Vascular Diseases
Online August 14, 2015 doi:10.3400/avd.cr.15-00061
Case Report
Surgical Treatment of a Giant Right Hepatic Artery Aneurysm with an Aberrant Left Hepatic Artery: Report of a Case Kota Shukuzawa, MD,1 Naoki Toya, MD, PhD,1 Soichiro Fukushima, MD,1 Masamichi Momose, MD,1 Tadashi Akiba, MD, PhD,2 and Takao Ohki, MD, PhD3
Hepatic artery aneurysms are rare. We describe a case of a successful surgical treatment of a giant hepatic aneurysm without revascularization. A 63-year-old female was admitted to our department complaining of abdominal pain. Computed tomography showed a thrombosed hepatic artery aneurysm measuring 5.5 cm in diameter. A celiac angiography revealed an aberrant left hepatic artery and a right hepatic aneurysm. Liver blood flow and the right hepatic aneurysm were visualized via collateral pathway from the aberrant left hepatic artery. We performed an aneurysmorrhaphy without revascularization. Postoperative course was uneventful and the patient is doing well 3 months after surgery.
Keywords: hepatic artery, aneurysm, surgical treatment
Introduction Hepatic artery aneurysm (HAA) is rare entity. Most cases are asymptomatic, therefore, they are incidentally indicated in ultrasound, computed tomography (CT) and magnetic resonance imaging. As with the development of endovascular devices, various treatment options for HAA were reported, including not only surgical and laparoscopic treatments but also endovascular treatments.1) Endovascular treatment is the least invasive treatment. However, it is depends on anatomy of aneurysm and general status of the patient that HAA can be treated by endovascular technique. Division of Vascular Surgery, Department of Surgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan 2Department of Surgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan 3Department of Vascular Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan 1
Received: June 22, 2015; Accepted: July 26, 2015 Corresponding author: Kota Shukuzawa, MD. Division of Vascular Surgery, Department of Surgery, Jikei University Kashiwa Hospital, 163-1, Kashiwashita, Kashiwa, Chiba 277-8567, Japan Tel: +81-4-7164-1111, Fax: +81-4-7163-3488 E-mail: [email protected]
Annals of Vascular Diseases Vol. 8, No. 3 (2015)
Here, we report the surgical treatment of a giant right HAA (RHAA) with an aberrant left hepatic artery, which grew up to 6.0 × 5.5 cm in diameter, in spite that the aneurysm was thrombosed.
Case Report In July 2013, a 63-year-old female patient was admitted to our emergency department with sudden abdominal pain. The patient had undergone coronary artery bypass graft for angina pectoris and Dor procedure for left ventricular aneurysm. Because of those operations, she required warfarin. She had no history of cholecystitis, pancreatitis, previous abdominal operation and trauma. Abdominal examination revealed a large mass in right upper quadrant and moderate discomfort with deep palpation in the epigastric area. The laboratory data were within normal limit. CT showed an unruptured thrombosed HAA measuring 5.3 × 5.3 cm in diameter. Her symptom improved gradually with administration of antiulcer drugs in a few days, therefore the aneurysm was observed with CT twice a year. Until in July 2014, diameter of the aneurysm did not change. In Feb 2015, she was readmitted to our department with sudden abdominal pain. In this time, she had tender mass in right upper quadrant, and CT showed that the aneurysm grew up to 6.0 × 5.5 cm in diameter without enhancement of contrast medium (Fig. 1). A celiac angiography through the femoral artery was performed. The angiography revealed a giant RHAA. An origin of the right hepatic artery was calcified and occluded and the left hepatic artery arose from the celiac trunk. Moreover, blood flow in a RHAA was visualized via collateral blood flow from the left hepatic artery in the late phase angiogram (Fig. 2). The aneurysm was indicated for operation because of impending rupture. At operation, the aneurysm was exposed through a hokey-stick incision. The left hepatic artery, the common hepatic artery (CHA) and the gastroduodenal artery (GDA) were under control (Fig. 3A). We clamped CHA and GDA, and incised the aneurysm longitudinally. After removing the thrombus in the aneurysm, the collateral 271
Shukuzawa K, et al.
A
LHA
GDA
CHA
B
Fig. 1 A n enhanced CT revealed a right hepatic artery aneurysm measuring 6.0 × 5.5 cm in diameter without enhancement of contrast medium (arrow), hepatic angioma (arrowhead). CT: computed tomography
LHA An
GDA
CHA
Fig. 2 A celiac angiogram revealed a hepatic angioma (black arrowhead). The left hepatic artery arose from the celiac trunk, and fed the aneurysm and intrahepatic flow via the collateral pathway (white arrow). Most of the aneurysm was thrombosed. The black arrow depicts the origin of the right hepatic artery. An: aneurysm; CHA: common hepatic artery; GDA: gastroduodenal artery; LHA: left hepatic artery
Fig. 3 (A) The aneurysm (black arrow) was exposed. LHA, CHA, GDA were exposed and taped. (B) The aneurysm was incised longitudinally. After removing the clot in the aneurysm, the collateral blood flow from the aberrant left hepatic artery (white arrow) was found at the bottom of the aneurysm. LHA: left hepatic artery; CHA: common hepatic artery; GDA: gastroduodenal artery
point was the wall of the aneurysm, and we stopped the bleeding by using an electric knife and TachoSil® Tissue Sealing sheet (Takeda GmbH, Linz, Austria). The patient recovered from the reoperation without any major complications, and plasma levels of liver function were within normal limits during the whole period. Postoperative course was uneventful and the patient was well for 3 months after surgery.
Discussion and Conclusion blood flow from the left hepatic artery was found at the bottom of the aneurysm (Fig. 3B). The collateral vessel was ligated at the inside of the aneurysm. Because intrahepatic flow was supplied from the left hepatic artery, we performed the aneurysmorrhaphy without revascularization of the right hepatic artery. Postoperative hemorrhage required reoperation on the 7th day after the first operation, 3 days after starting the anticoagulant therapy for Dor procedure. The bleeding 272
The HAA is the second most common visceral aneurysm following splenic artery aneurysm, accounting for 20% of all visceral aneurysms.2) Abbas et al.3) reported that HAA was identified in only 36 patients (0.002%) of about two million consecutive patients. Although HAA is rare, the incidence of rupture was 14%–80%,3) and the mortality was 21%–44%.4) Despite that all HAAs should be treated before rupture, the relationship between aneurysm size and risk for rupture is unclear. The patients with HAA of nonatherosclerotic origin (e.g. fibromuscular dysplasia, polyarteritis Annals of Vascular Diseases Vol. 8, No. 3 (2015)
Surgical Treatment of a Hepatic Artery Aneurysm
nodosa), and with multiple HAAs have increased risk for rupture.3) This case highlights importance of selective angiography. CT angiography is the ideal modality for diagnosis and additionally identifies other aneurysms (there are commonly more than one) and associated pathology (such as arterioportal fistulas, feeding vessels) and elucidates variant anatomy.2) In this case, selective angiography of celiac revealed more information than CT angiography. The information was the presence of the aberrant left hepatic artery, the absence of anterograde flow to RHAA, and collateral pathway to the liver and RHAA from the aberrant left hepatic artery. Endovascular treatment of visceral aneurysm is an alternative to conventional surgery with lower procedural mortality and morbidity, reducing aneurysm related symptoms with high technical success rates.5) Most favorable morphology for endovascular treatment includes saccular aneurysms, aneurysms with adequate collateral flow, and aneurysms of vessels that are not the only provider of blood supply to the organ.6) Regarding the hemodynamics, this case could be able to treat with endovascular treatment. However, we chose surgical operation, because the collateral pathway from the aberrant left artery to RHAA was very narrow and complex. Open surgical treatment includes ligation and aneurysm exclusion, excision or revascularization.7) Collateral circulation is usually sufficient through GDA to the liver, therefore CHA aneurysm was ligated or resected without revascularization. However, the aneurysm of the proper hepatic or proximal right or left hepatic arteries require restoration of normal hepatic blood flow.8) Revascularization techniques were reported as venous or prosthetic grafting, vein patch angioplasty,8) and arterial grafting.9) In our case, the angiography revealed the presence of the aberrant left hepatic artery and the collateral flow to the liver, therefore we decided to ligate and aneurysmorrhaphy without revascularization. In order to avoid injury of the collateral pathway, we performed carefully and minimal exposure of the RHAA and the aberrant left hepatic artery. Previous reports have suggested that it is reasonable to recommend repair of HAA greater than 2 cm in a patient
Annals of Vascular Diseases Vol. 8, No. 3 (2015)
who is at good operative risk and has a life expectancy greater than 2 years, and HAA greater than 5cm should generally undergo repair, embolization, or ligation.3) Even if HAA was thrombosed, we should considered operation at the initial visit of the patient. We conclude that the HAA should be observed carefully even if it is thrombosed in CT. Furthermore, the HAA should be considered operation aggressively according to the size, and the selective angiography is useful at operation.
Disclosure Statement All authors have no conflict of interest.
References 1) Cavalcante RN, Couto VA, da Fonseca AV, et al. Endovascular treatment of a giant hepatic artery aneurysm with Amplatzer vascular plug. J Vasc Surg 2014; 60: 500-2. 2) O’Driscoll D, Olliff SP, Olliff JF. Hepatic artery aneurysm. Br J Radiol 1999; 72: 1018-25. 3) Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg 2003; 38: 41-5. 4) Lu M, Weiss C, Fishman EK, et al. Review of visceral aneurysms and pseudoaneurysms. J Comput Assist Tomogr 2015; 39: 1-6. 5) Huang YK, Hsieh HC, Tsai FC, et al. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Endovasc Surg 2007; 33: 293-301. 6) Chadha M, Ahuja C. Visceral artery aneurysms: diagnosis and percutaneous management. Semin Intervent Radiol 2009; 26: 196-206. 7) Lynch J, Montgomery A, Shelmerdine S, et al. Ruptured aneurysm of an aberrant left hepatic artery. BMJ Case Rep 2013; doi: 10.1136/bcr-2013-201409. 8) Nishibe M, Nishibe T, Koizumi J, et al. Surgical treatment of a dissecting aneurysm of the proper hepatic artery: report of a case. Ann Thorac Cardiovasc Surg 2013; 19: 326-9. 9) Kadohama T, Ohtani N, Sasajima T. Hepatic artery aneurysm involving the proper hepatic and gastroduodenal artery treated using a gastroepiploic artery in situ bypass. J Vasc Surg 2007; 45: 1069-71.
273
Online August 14, 2015 doi:10.3400/avd.cr.15-00061
Case Report
Surgical Treatment of a Giant Right Hepatic Artery Aneurysm with an Aberrant Left Hepatic Artery: Report of a Case Kota Shukuzawa, MD,1 Naoki Toya, MD, PhD,1 Soichiro Fukushima, MD,1 Masamichi Momose, MD,1 Tadashi Akiba, MD, PhD,2 and Takao Ohki, MD, PhD3
Hepatic artery aneurysms are rare. We describe a case of a successful surgical treatment of a giant hepatic aneurysm without revascularization. A 63-year-old female was admitted to our department complaining of abdominal pain. Computed tomography showed a thrombosed hepatic artery aneurysm measuring 5.5 cm in diameter. A celiac angiography revealed an aberrant left hepatic artery and a right hepatic aneurysm. Liver blood flow and the right hepatic aneurysm were visualized via collateral pathway from the aberrant left hepatic artery. We performed an aneurysmorrhaphy without revascularization. Postoperative course was uneventful and the patient is doing well 3 months after surgery.
Keywords: hepatic artery, aneurysm, surgical treatment
Introduction Hepatic artery aneurysm (HAA) is rare entity. Most cases are asymptomatic, therefore, they are incidentally indicated in ultrasound, computed tomography (CT) and magnetic resonance imaging. As with the development of endovascular devices, various treatment options for HAA were reported, including not only surgical and laparoscopic treatments but also endovascular treatments.1) Endovascular treatment is the least invasive treatment. However, it is depends on anatomy of aneurysm and general status of the patient that HAA can be treated by endovascular technique. Division of Vascular Surgery, Department of Surgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan 2Department of Surgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan 3Department of Vascular Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan 1
Received: June 22, 2015; Accepted: July 26, 2015 Corresponding author: Kota Shukuzawa, MD. Division of Vascular Surgery, Department of Surgery, Jikei University Kashiwa Hospital, 163-1, Kashiwashita, Kashiwa, Chiba 277-8567, Japan Tel: +81-4-7164-1111, Fax: +81-4-7163-3488 E-mail: [email protected]
Annals of Vascular Diseases Vol. 8, No. 3 (2015)
Here, we report the surgical treatment of a giant right HAA (RHAA) with an aberrant left hepatic artery, which grew up to 6.0 × 5.5 cm in diameter, in spite that the aneurysm was thrombosed.
Case Report In July 2013, a 63-year-old female patient was admitted to our emergency department with sudden abdominal pain. The patient had undergone coronary artery bypass graft for angina pectoris and Dor procedure for left ventricular aneurysm. Because of those operations, she required warfarin. She had no history of cholecystitis, pancreatitis, previous abdominal operation and trauma. Abdominal examination revealed a large mass in right upper quadrant and moderate discomfort with deep palpation in the epigastric area. The laboratory data were within normal limit. CT showed an unruptured thrombosed HAA measuring 5.3 × 5.3 cm in diameter. Her symptom improved gradually with administration of antiulcer drugs in a few days, therefore the aneurysm was observed with CT twice a year. Until in July 2014, diameter of the aneurysm did not change. In Feb 2015, she was readmitted to our department with sudden abdominal pain. In this time, she had tender mass in right upper quadrant, and CT showed that the aneurysm grew up to 6.0 × 5.5 cm in diameter without enhancement of contrast medium (Fig. 1). A celiac angiography through the femoral artery was performed. The angiography revealed a giant RHAA. An origin of the right hepatic artery was calcified and occluded and the left hepatic artery arose from the celiac trunk. Moreover, blood flow in a RHAA was visualized via collateral blood flow from the left hepatic artery in the late phase angiogram (Fig. 2). The aneurysm was indicated for operation because of impending rupture. At operation, the aneurysm was exposed through a hokey-stick incision. The left hepatic artery, the common hepatic artery (CHA) and the gastroduodenal artery (GDA) were under control (Fig. 3A). We clamped CHA and GDA, and incised the aneurysm longitudinally. After removing the thrombus in the aneurysm, the collateral 271
Shukuzawa K, et al.
A
LHA
GDA
CHA
B
Fig. 1 A n enhanced CT revealed a right hepatic artery aneurysm measuring 6.0 × 5.5 cm in diameter without enhancement of contrast medium (arrow), hepatic angioma (arrowhead). CT: computed tomography
LHA An
GDA
CHA
Fig. 2 A celiac angiogram revealed a hepatic angioma (black arrowhead). The left hepatic artery arose from the celiac trunk, and fed the aneurysm and intrahepatic flow via the collateral pathway (white arrow). Most of the aneurysm was thrombosed. The black arrow depicts the origin of the right hepatic artery. An: aneurysm; CHA: common hepatic artery; GDA: gastroduodenal artery; LHA: left hepatic artery
Fig. 3 (A) The aneurysm (black arrow) was exposed. LHA, CHA, GDA were exposed and taped. (B) The aneurysm was incised longitudinally. After removing the clot in the aneurysm, the collateral blood flow from the aberrant left hepatic artery (white arrow) was found at the bottom of the aneurysm. LHA: left hepatic artery; CHA: common hepatic artery; GDA: gastroduodenal artery
point was the wall of the aneurysm, and we stopped the bleeding by using an electric knife and TachoSil® Tissue Sealing sheet (Takeda GmbH, Linz, Austria). The patient recovered from the reoperation without any major complications, and plasma levels of liver function were within normal limits during the whole period. Postoperative course was uneventful and the patient was well for 3 months after surgery.
Discussion and Conclusion blood flow from the left hepatic artery was found at the bottom of the aneurysm (Fig. 3B). The collateral vessel was ligated at the inside of the aneurysm. Because intrahepatic flow was supplied from the left hepatic artery, we performed the aneurysmorrhaphy without revascularization of the right hepatic artery. Postoperative hemorrhage required reoperation on the 7th day after the first operation, 3 days after starting the anticoagulant therapy for Dor procedure. The bleeding 272
The HAA is the second most common visceral aneurysm following splenic artery aneurysm, accounting for 20% of all visceral aneurysms.2) Abbas et al.3) reported that HAA was identified in only 36 patients (0.002%) of about two million consecutive patients. Although HAA is rare, the incidence of rupture was 14%–80%,3) and the mortality was 21%–44%.4) Despite that all HAAs should be treated before rupture, the relationship between aneurysm size and risk for rupture is unclear. The patients with HAA of nonatherosclerotic origin (e.g. fibromuscular dysplasia, polyarteritis Annals of Vascular Diseases Vol. 8, No. 3 (2015)
Surgical Treatment of a Hepatic Artery Aneurysm
nodosa), and with multiple HAAs have increased risk for rupture.3) This case highlights importance of selective angiography. CT angiography is the ideal modality for diagnosis and additionally identifies other aneurysms (there are commonly more than one) and associated pathology (such as arterioportal fistulas, feeding vessels) and elucidates variant anatomy.2) In this case, selective angiography of celiac revealed more information than CT angiography. The information was the presence of the aberrant left hepatic artery, the absence of anterograde flow to RHAA, and collateral pathway to the liver and RHAA from the aberrant left hepatic artery. Endovascular treatment of visceral aneurysm is an alternative to conventional surgery with lower procedural mortality and morbidity, reducing aneurysm related symptoms with high technical success rates.5) Most favorable morphology for endovascular treatment includes saccular aneurysms, aneurysms with adequate collateral flow, and aneurysms of vessels that are not the only provider of blood supply to the organ.6) Regarding the hemodynamics, this case could be able to treat with endovascular treatment. However, we chose surgical operation, because the collateral pathway from the aberrant left artery to RHAA was very narrow and complex. Open surgical treatment includes ligation and aneurysm exclusion, excision or revascularization.7) Collateral circulation is usually sufficient through GDA to the liver, therefore CHA aneurysm was ligated or resected without revascularization. However, the aneurysm of the proper hepatic or proximal right or left hepatic arteries require restoration of normal hepatic blood flow.8) Revascularization techniques were reported as venous or prosthetic grafting, vein patch angioplasty,8) and arterial grafting.9) In our case, the angiography revealed the presence of the aberrant left hepatic artery and the collateral flow to the liver, therefore we decided to ligate and aneurysmorrhaphy without revascularization. In order to avoid injury of the collateral pathway, we performed carefully and minimal exposure of the RHAA and the aberrant left hepatic artery. Previous reports have suggested that it is reasonable to recommend repair of HAA greater than 2 cm in a patient
Annals of Vascular Diseases Vol. 8, No. 3 (2015)
who is at good operative risk and has a life expectancy greater than 2 years, and HAA greater than 5cm should generally undergo repair, embolization, or ligation.3) Even if HAA was thrombosed, we should considered operation at the initial visit of the patient. We conclude that the HAA should be observed carefully even if it is thrombosed in CT. Furthermore, the HAA should be considered operation aggressively according to the size, and the selective angiography is useful at operation.
Disclosure Statement All authors have no conflict of interest.
References 1) Cavalcante RN, Couto VA, da Fonseca AV, et al. Endovascular treatment of a giant hepatic artery aneurysm with Amplatzer vascular plug. J Vasc Surg 2014; 60: 500-2. 2) O’Driscoll D, Olliff SP, Olliff JF. Hepatic artery aneurysm. Br J Radiol 1999; 72: 1018-25. 3) Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg 2003; 38: 41-5. 4) Lu M, Weiss C, Fishman EK, et al. Review of visceral aneurysms and pseudoaneurysms. J Comput Assist Tomogr 2015; 39: 1-6. 5) Huang YK, Hsieh HC, Tsai FC, et al. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Endovasc Surg 2007; 33: 293-301. 6) Chadha M, Ahuja C. Visceral artery aneurysms: diagnosis and percutaneous management. Semin Intervent Radiol 2009; 26: 196-206. 7) Lynch J, Montgomery A, Shelmerdine S, et al. Ruptured aneurysm of an aberrant left hepatic artery. BMJ Case Rep 2013; doi: 10.1136/bcr-2013-201409. 8) Nishibe M, Nishibe T, Koizumi J, et al. Surgical treatment of a dissecting aneurysm of the proper hepatic artery: report of a case. Ann Thorac Cardiovasc Surg 2013; 19: 326-9. 9) Kadohama T, Ohtani N, Sasajima T. Hepatic artery aneurysm involving the proper hepatic and gastroduodenal artery treated using a gastroepiploic artery in situ bypass. J Vasc Surg 2007; 45: 1069-71.
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