Successful treatment of an iatrogenic right hepatic artery pseudoaneurysm and stenosis with a stent graft

Abstract

A 53-year-old woman presented with an iatrogenic right hepatic artery pseudoaneurysm after a laparoscopic cholecystectomy. Approximately 1 year after the cholecystectomy, liver transaminases were elevated, and she complained of recurrent "crampy" right upper quadrant pain that radiated posteriorly to her back. Imaging studies demonstrated an aneurysm or pseudoaneurysm of the hepatic artery at the porta hepatis, with possible infiltration into the parenchyma between the right and left lobes of the liver. Selective celiac arteriography showed a 90% stenosis of the right hepatic artery with a large pseudoaneurysm arising from the stenotic segment. This was treated with a 3- x 16-mm stent graft (Jostent; Abbott Vascular, Temecula, Calif) with good result. The completion arteriogram showed wide patency of the stent graft with total exclusion of the pseudoaneurysm. Follow-up serial duplex scans up to 40 months after the procedure showed no evidence of residual pseudoaneurysm and wide patency of the stent graft, with no evidence of focal velocity changes in the right hepatic artery. The patient continues to do well clinically.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

“…Among the cases which specified the gender or age of the patient, 45.2% were male and the age ranged from 12-81 years with a mean age of 49.8 years. 4,5,[9][10][11][12][13]15,[17][18][19][20][21][24][25][26][27][28][29][30][31][33][34][35][37][38][39][40][41][42][43][46][47][48]51,57,58,60,62 The time of presentation following the LC procedure ranged from six days to five years with a mean of 36 days. [3][4][5][7][8][9][10][11][12][13]15,…”

“…18,29,31 The size of the PSAs ranged from 13-200 mm, with a mean size of 43 mm. 4,6,13,15,17,26,30,31,33,37,39,42,43,57 The modality of management was transarterial embolisation (TAE) in 72.3%, endovascular stent placement in 4.0%, exploratory laparotomy and ligation of the hepatic artery in 5.0% and thrombin injection in 4.0% of cases. The TAE procedure alone failed to control bleeding in four cases (5.5%), resulting in a 94.5% success rate.…”

“…4 However, the RHA is usually the most commonly involved vessel. 28,30,32,33,[39][40][41]57 Other involved sites include the cystic artery and, in some cases, the common hepatic and gastroduodenal arteries. 4,9,37,38,44,47,58 a e t i o pat h o g e n e s i s A PSA may arise due to multiple mechanisms of injury, including laceration, transection or occlusion of the blood vessels following a mechanical or thermal injury to the artery.…”

“…checking the patient's surgical history), an upper GI endoscopy, regular or Doppler ultrasonography, a contrast CT scan and/or an angiogram. 6,9,13,18,20,23,29,[33][34][35]37,53 Ultrasonography may lead to the detection of an aneurysm or fluid consistent with haemorrhage; however, the diagnostic accuracy of this option is directly related to the size of the PSA and the operator's experience. 13,16,25 Three-dimensional (3D) CT reconstruction or catheter angiography can also help to define the aneurysm and its feeding vessels.…”

“…66 t r e at m e n t A diagnosis of PSA is considered an acute emergency and requires immediate and aggressive intervention, as a rupture could lead to life-threatening exsanguination; the rupture of a PSA in the hepatic artery has been associated with a mortality rate of 21-43%. 17,18,22,33 Historically, PSAs were principally managed via surgery, which involved resectioning of the PSA and ligation of the cystic artery stump or RHA. 6 However, due to significant advances in catheter-based therapies, PSAs are now primarily treated with TAE by occluding the sac or the feeding vessel with a variety of embolic agents, including gel foam, coils, N-butyl cyanoacrylate and thrombin, before ideally embolising the vessel distal and proximal to the PSA in order to prevent collateral filling of the PSA.…”