Hepatic pseudoaneurysm

Fig. 7.1a,b. Coeliac angiography in a patient with life threatening haemobilia 24 h post cholecystectomy revealed a large hepatic pseudoaneurysm (a) treated successfully by proximal and distal coil embolization (b)... 

They reported the successful direct needle-injection of thrombin to thrombose peripheral pseudoaneurysms such as common iliac, peroneal, and hepatic pseudoaneurysms. Despite this interesting report, it was not until a decade later that the first report of ultrasound-guided direct thrombin-injection to close iatrogenic groin pseudoaneurysms was published, by Liau et al. [16]. 

Extra-hepatic pseudoaneurysms are usually not treated with coil embolization since it would sacrifice a major branch to a lobe or even the entire liver. Successful percutaneous thrombin injection of an anastomotic pseudoaneurysm has been described [12]. Recently, a number of case reports have been published on the use of stent grafts to repair these... 

Fig. 8.3. a Celiac angiogram in a patient with portal hypertension demonstrating a distal splenic artery aneurysm, b Celiac angiogram from another patient with multiple splenic aneurysms associated with portal hypertension who has undergone liver transplantation. Note the large hepatic pseudoaneurysm just medial to the upper pole of the right kidney, c Selective common hepatic artery injection in the patient from b... 

Satoh, H., Takeda, T., Takashima, M., Sumlyoshl, K., Imaizninl, N. Gas-forming liver abscess following transcatheter hepatic arterial embolization for an iatrogenic intrahepatic pseudoaneurysm report of a case. Jpn. J. Surg. 1995 25 361 -364... 

Congenital anomalies and aneurysms in the hepatic arteries are very rare. (129) Acquired aneurysms are the result of vessel wall damage, injuries or inflammatory processes. (I3l, 133, 136) Pseudoaneurysms may occur after acute pancreatitis and the formation of pseudocysts. (135) (s. tab. 39.5)... 

Pinsky, M.A., May, E.S., Taxier, M.S., Blackford, J. Late manifestation of hepatic artery pseudoaneurysm case presentation and review. Amer. J. Gastroenterol. 1987 82 467-469... 

Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Buchler MW (1998) Superselective microcoil embolization treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 186 325-330... 

Haemobilia requires treatment as spontaneous resolution is exceedingly rare and the mortality from ruptured pseudoaneurysms is in excess of 90%. Technically endovascular management is relatively simple and involves the proximal and distal embolization, with tightly packed steel coils, of the hepatic... 

Fig. 7.3a,b. Hepatic arteriogram in a 26-year-old man with a small inoperable neuroendocrine tumour in the head of his pancreas. The papilla of Vater could not be accessed at ERCP and he underwent a percutaneous stenting procedure at which two self-expanding stents were inserted (lower arrowheads) apparently side by side (a). 12 hours later repeat ERCP revealed a significant haemorrhage from the papilla. The angiogram revealed a segment 4 arterial pseudoaneurysm (upper arrowheads) which was embolized successfully with coils (b)... 

Choi D, Lim HK, Rhim H et al (2007) Percutaneous radiofrequency ablation for recurrent hepatocellular carcinoma after hepatectomy long-term results and prognostic factors. Ann Surg Oncol 14(8) 2319-2329 Chuang CH, Chen CY, Tsai HM (2005) Hepatic infarction and hepatic artery pseudoaneurysm with peritoneal bleeding after radiofrequency ablation for hepatoma. Clin Gastroenterol Hepatol 3(11) A23... 

Fig. 7.6. a Hepatic arteriogram in a patient who developed bleeding several days after a Whipple operation. A pseudoaneurysm (arrow) is seen where the gastroduodenal artery was resected, b A balloon occlusion catheter (arrow) was inflated across the arterial defect to tamponade bleeding until a decision was made regarding deflnitive therapy, c A bare balloon expandable stent (arrows) was placed across the arterial defect with plans to pass microcoils through the stent however, this post-stent study showed that the arterial defect had been sealed by the uncovered stent alone... 

Patel JV, Weston MJ, Kessel DO, Prasad R, Toogood GJ, Robertson I (2003) Hepatic artery pseudoaneurysm after liver transplantation treatment with percutaneous thrombin injection. Transplantation 75 1755-1757... 

Venturini M, Angeli E, Salvioni M, de Cobelli F, Trentin C, Carlucci M, et al. (2002) Hemorrhage from a right hepatic artery pseudoaneurysm endovascular treatment with a coronary stent-graft. J Endovasc Ther 9 221-224... 

Tessier DJ, Fowl RJ, Stone WM, McKusick MA, Abbas MA, Sarr MG et al. (2003) Iatrogenic hepatic artery pseudoaneurysms an uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vase Surg 17 663-669... 

Pad E, Antico E, Candelari R, Alborino S, Marmorale C, Landi E (2000) Pseudoaneurysm of the common hepatic artery treatment with a stent-graft. Cardiovasc Intervent Radiol 23 472-474... 

Ozkan OS, Walser EM, Akinci D, Nealon W, Goodacre B (2002) Guglielmi detachable coil erosion into the common bile duct after embolization of iatrogenic hepatic artery pseudoaneurysm. J Vase Interv Radiol 13 935-938... 

There have been reports of recanalization of pseudoaneurysms after percutaneous embolization. Follow-up ultrasound, CT, or MRI can be performed to assess success of embolization [4,15]. One must be aware of the relatively frequent anatomic variation seen in the hepatic artery distribution. 

As long as there is no celiac, proper hepatic, or SMA origin occlusion, the GDA can be sacrificed. If the GDA is required to maintain perfusion of the liver or, if flow into the SMA is dependent upon the celiac, then direct coiling of GDA pseudoaneurysms is preferable. This can he accomplished with stent placement over the aneurysm neck and microcoil deposition through the interstices via a microcatheter. A small-caliher stent graft such as a Jostent could theoretically be used in this situation. However, use of this device is still not approved by the FDA. Appel et al. described the placement of a 26-mm stent graft for humanitarian treatment of a traumatic pseudoaneurysm of the SMA [34]. 

Fig. 23.1a-d. Liver trauma in a 15-year-old boy. a CT-scan revealed the presence of an arterial pseudoaneurysm, b Selective catheterization of the hepatic artery confirmed the pseudoaneurysm, c With a coaxial system (Tracker Renegade) we overpass the pseudoaneurysm and occlude the exit branch with a coil. Then, we occlude the pseudoaneurysm with glue followed by the occlusion of the afferent artery by a coil, d Control angiogram revealed a complete occlusion of the pseudoaneurysm... 

---