Table of Contents  
CASE SERIES
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 62-66

Posttraumatic Pseudoaneurysms in Hepatic Artery Branches with Endovascular N-Butyl Cyanoacrylate Embolization: Case Series


Department of Radiology, MIOT International Hospital, Chennai, Tamil Nadu, India

Date of Web Publication8-Jun-2016

Correspondence Address:
Bhavik Patel
Department of Radiology, MIOT International Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.183639

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  Abstract 


Posttraumatic pseudoaneurysm of hepatic artery is an uncommon complication. However, when diagnosed, they need early treatment to prevent rupture. Currently, the treatment of choice for hepatic artery pseudoaneurysm is endovascular embolization depending on the location. We present a series of 4 cases of posttraumatic intrahepatic pseudoaneurysm in branches of hepatic artery who were successfully treated with n-butyl cyanoacrylate embolization.

Keywords: Endovascular treatment, hepatic artery, hepatic trauma, n-butyl cyanoacrylate embolization, pseudoaneurysm


How to cite this article:
Patel B, Krishnaswami M, Ramachandran M, Gnanaprakasam F. Posttraumatic Pseudoaneurysms in Hepatic Artery Branches with Endovascular N-Butyl Cyanoacrylate Embolization: Case Series. Indian J Vasc Endovasc Surg 2016;3:62-6

How to cite this URL:
Patel B, Krishnaswami M, Ramachandran M, Gnanaprakasam F. Posttraumatic Pseudoaneurysms in Hepatic Artery Branches with Endovascular N-Butyl Cyanoacrylate Embolization: Case Series. Indian J Vasc Endovasc Surg [serial online] 2016 [cited 2019 Nov 21];3:62-6. Available from: http://www.indjvascsurg.org/text.asp?2016/3/2/62/183639




  Introduction Top


Posttraumatic pseudoaneurysm of hepatic artery and its branches is a rare complication of blunt abdominal injury. Most of these are diagnosed as an incidental finding; however, timely intervention is essential as they can rupture and cause life-threatening hemorrhage. The management of hepatic artery pseudoaneurysm is changing day-by-day due to the introduction of new endovascular and percutaneous techniques.

We report a series of cases of posttraumatic hepatic artery pseudoaneurysm which were embolized with n-butyl cyanoacrylate.


  Case Reports Top


Case 1

A 19-year-old male patient presented with liver injuries following road traffic accident. Computerized tomography (CT) showed multiple liver contusions with a large hematoma in the left lobe of liver and hemoperitoneum [Figure 1] which was surgically managed by suturing of the laceration.
Figure 1: Noncontrast-computerized tomography of the abdomen showing a large hematoma in the left lobe of liver with hemoperitoneum

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One month after this, the patient developed severe pain in the epigastrium and right hypochondrium. Repeat contrast-enhanced CT (CECT) of the abdomen showed a large active hemorrhage from the left lobe of liver with hemoperitoneum [Figure 2]. Arterial phase reconstruction showed a pseudoaneurysm of the left hepatic artery [Figure 3]. With this, diagnosis of ruptured pseudoaneurysm of the left hepatic artery was made, and the patient was immediately taken up for endovascular management.
Figure 2: Contrast-enhanced computed tomography of the abdomen showed active hemorrhage in the left lobe of liver with increase in contrast density in the delayed phase

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Figure 3: Arterial phase maximum intensity projection and three-dimensional reconstruction images show a small pseudoaneurysm from left hepatic artery

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Under general anesthesia with right femoral access, microcatheter (echelon, marathon) with microwire (Microvention-Traxcess) was taken across the site of pseudoaneurysm and embolization was done with 40% n-butyl cyanoacrylate embolization (NBCA) and complete exclusion of the pseudoaneurysm was achieved [Figure 4]. This patient recovered well.
Figure 4: Selective catheterization showing active ruptured pseudoaneurysm from left hepatic artery which was embolized

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Case 2

A 19-year-old male had a blunt abdominal trauma, following which he had severe abdominal pain which was increasing in intensity. CECT of the abdomen done 15 days after the trauma showed a large intrahepatic hematoma in segments 6, 7, and 8 of the liver [Figure 5]. Arterial phase showed a small pseudoaneurysm in segment 7 of the liver [Figure 6], and the patient was taken up for endovascular management.
Figure 5: Contrast-enhanced computed tomography of the abdomen showed a large hematoma in the right lobe of liver

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Figure 6: Arterial phase maximum intensity projection and three-dimensional reconstruction showing small pseudoaneurysm from a branch of right hepatic artery. Note - hepatic artery proper is arising directly from superior mesenteric artery

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Diagnostic angiogram revealed hepatic artery directly arising from superior mesenteric artery and a small pseudoaneurysm from a branch of the right hepatic artery. Pseudoaneurysm was selectively catheterized and 17% NBCA was injected to occlude the pseudoaneurysm along with the branch proximal and distal to it [Figure 7].
Figure 7: Superselective catheterization of the right hepatic artery branch pseudoaneurysm with selective embolization

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Case 3

An 18-year-old male presented with the history of road traffic accident. CT scan performed showed laceration in the left lobe of liver with hemoperitoneum. He underwent an exploratory laparotomy and primary suture of the liver laceration was done. He was discharged in stable condition.

He developed sudden-onset pain in the epigastrium 2 months after the trauma. CECT of the abdomen was done which showed a pseudoaneurysm of the left hepatic artery.

Diagnostic angiogram confirmed a small pseudoaneurysm from the left hepatic artery. Left hepatic artery was directly arising from the left gastric artery. Pseudoaneurysm was selectively accessed and 20% NBCA was injected occluding the pseudoaneurysm and a segment of artery proximal and distal to the pseudoaneurysm. Checked angiogram revealed complete exclusion of pseudoaneurysm from the circulation [Figure 8].
Figure 8: Superselective catheterization of left hepatic artery pseudoaneurysm and its selective embolization

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Case 4

A 13-year-old boy had a blunt injury while playing football with his friends and was treated conservatively.

One week after the injury, he developed fever, epigastric pain, and multiple episodes of vomiting. CECT of the abdomen showed intrahepatic hematoma in the left lobe of liver with hemoperitoneum [Figure 9]. Arterial phase showed a pseudoaneurysm in a branch of the left hepatic artery [Figure 10].
Figure 9: Contrast-enhanced computed tomography of the abdomen showing hematoma in the left lobe of liver

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Figure 10: Arterial phase maximum intensity projection and three-dimensional reconstruction showing a pseudoaneurysm from a branch of left hepatic artery

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Diagnostic angiogram confirmed a small pseudoaneurysm with active leak from branch of left hepatic artery. Pseudoaneurysm was accessed and embolized with 20% NBCA. Checked angiogram revealed complete exclusion of pseudoaneurysm from the circulation [Figure 11].
Figure 11: Superselective catheterization of left hepatic artery branch pseudoaneurysm and its selective catheterization

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  Discussion Top


Liver is more prone to blunt and penetrating abdominal injury as it is relatively large and fixed in position. Road traffic accident is the most common cause of liver injuries, and hepatic artery pseudoaneurysms are mostly due to traumatic laceration of the artery. Other causes include liver transplantation or an indwelling biliary catheter. At present, the incidence of hepatic artery pseudoaneurysm is on rise due to increase in percutaneous and laparoscopic biliary procedures, but traumatic injuries to liver remain the most common cause.[1],[2],[3],[4],[5]

Early diagnosis of hepatic artery pseudoaneurysm is a must as it has a rupture risk of 14%,[6] which can cause life-threatening hemorrhage.[7] CECT of the abdomen is the modality of choice for investigating a case of suspicious hepatic artery pseudoaneurysm. It will also give additional information regarding the grade of liver injury, amount of hemoperitoneum, presence of other abdominal injuries, and a roadmap to further endovascular management. This will help the management team to make a confident decision for the treatment required.[8],[9],[10]

Management of hepatic trauma has undergone a drastic evolution from surgical to nonsurgical method.[6],[11],[12] Currently, endovascular management of hepatic artery pseudoaneurysm is the most commonly used technique in hemodynamically stable patients.[7],[13],[14],[15],[16],[17],[18],[19] Endoluminally inaccessible superficial pseudoaneurysm can be managed by direct percutaneous coil or thrombin embolization.[6],[20] Endoluminally accessible pseudoaneurysm can be managed by embolization of the pseudoaneurysm itself or placement of a stent across the artery.[6],[15] As stent placement is not possible in small branches of hepatic artery like in our cases, direct embolization of the pseudoaneurysm becomes the treatment of choice.

Direct endovascular embolization of hepatic artery pseudoaneurysms with NBCA (b-braun-histoacryl) has excellent success rates, especially when stent or coil embolization is not possible. NBCA is a permanent liquid embolic agent. Lipiodol (Guerbet) is used to mix with NBCA for increasing polymerization time and radio-opacity. Proper care should be taken while forming this mixture. Superselective catheterization of pseudoaneurysm is always preferable and embolic agent can be delivered in the pseudoaneurysm along with the segment of artery harboring the pseudoaneurysm. NBCA incites an acute inflammatory reaction in the vessel wall, which progresses to chronic inflammation, fibrosis and gives a permanent treatment. The only disadvantage of using NBCA is its passage into distal circulation causing hepatic necrosis in patients with compromised portal venous flow. However, this is very rare in expert hands and the dual blood supply of liver is an additional protection.[16],[17],[18],[19],[20],[21]

The alternative endovascular technique is to deposit coils proximal and distal to pseudoaneurysm, trapping the pseudoaneurysm. If accurate coiling cannot be obtained, then there is a chance of pseudoaneurysm recanalization.[6],[14]

In our series of four patients, pseudoaneurysm was present mostly in the branches of the right and left hepatic artery. Superselective catheterization was achieved and aneurysm was occluded with NBCA. All patients recovered without any complication or damage to liver parenchyma.


  Conclusion Top


Posttraumatic hepatic artery pseudoaneurysm is a rare complication in abdominal trauma but a life-threatening condition. Timely diagnosis with endovascular intervention is essential. N-butyl cyanoacrylate is embolic agent of choice in peripheral branches of hepatic artery pseudoaneurysm as it is very effective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Keller MS. Blunt injury to solid abdominal organs. Semin Pediatr Surg 2004;13:106-11.  Back to cited text no. 1
    
2.
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Inoue H, Tano S, Takayama R, Nimomiya K, Nishikawa K, Katurahara M, et al. Right hepatic artery pseudoaneurysm: Rare complication of plastic biliary stent insertion. Endoscopy 2011;43 Suppl 2 UCTN: E396.  Back to cited text no. 3
    
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Yao CA, Arnell TD. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Am J Surg 2010;199:e10-1.  Back to cited text no. 4
    
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Almogy G, Bloom A, Verstandig A, Eid A. Hepatic artery pseudoaneurysm after liver transplantation. A result of transhepatic biliary drainage for primary sclerosing cholangitis. Transpl Int 2002;15:53-5.  Back to cited text no. 5
    
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Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics 2005;25:87-104.  Back to cited text no. 8
    
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David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, et al. Evolution in the management of hepatic trauma: A 25-year perspective. Ann Surg 2000;232:324-30.  Back to cited text no. 11
    
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Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 2000;231:804-13.  Back to cited text no. 12
    
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Mohanty S, Mukhopadhyay S, Yusuf J, Tyagi S. Emergency hepatic artery embolization in a patient with post-traumatic ruptured hepatic artery pseudoaneurysm. J Emerg Trauma Shock 2014;7:246-7.  Back to cited text no. 13
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Janík V, Laboš M, Vyhnánek F (2012) Embolization of Post-Traumatic Pseudoaneurysm of the Proper Hepatic Artery. Surgery Curr Res 2:119. doi: 10.4172/2161-1076.1000119  Back to cited text no. 14
    
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Won YD, Ku YM, Kim KT, Kim KH, Kim JI. Successful management of a ruptured hepatic artery pseudoaneurysm with a stent-graft. Emerg Radiol. 2009 May; 16(3):247-9.  Back to cited text no. 15
    
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Ou HY, Concejero AM, Yu CY, Huang TL, Chen TY, Tsang LL, et al. Hepatic arterial embolization for massive bleeding from an intrahepatic artery pseudoaneurysm using N-butyl-2-cyanoacrylate after living donor liver transplantation. Transpl Int 2011;24:e19-22.  Back to cited text no. 16
    
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Garg A, Banait S, Babhad S, Kanchankar N, Nimade P, Panchal C. Endovascular treatment of pseudoaneurysm of the common hepatic artery with intra-aneurysmal glue (N-butyl 2-cyanoacrylate) embolization. Cardiovasc Intervent Radiol 2007;30:999-1002.  Back to cited text no. 17
    
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Tokuda T, Tanigawa N, Shomura Y, Kariya S, Kojima H, Komemushi A, et al. Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate. Minim Invasive Ther Allied Technol 2009;18:361-5.  Back to cited text no. 18
    
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Kish JW, Katz MD, Marx MV, Harrell DS, Hanks SE. N-butyl cyanoacrylate embolization for control of acute arterial hemorrhage. J Vasc Interv Radiol 2004;15:689-95.  Back to cited text no. 19
    
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Abbas MA, Fowl RJ, Stone WM, Panneton JM, Oldenburg WA, Bower TC, et al. Hepatic artery aneurysm: Factors that predict complications. J Vasc Surg 2003;38:41-5.  Back to cited text no. 20
    
21.
Lorenz JM, van Beek D, Van Ha TG, Lai J, Funaki B. Percutaneous thrombin injection in an infant to treat hepatic artery pseudoaneurysm after failed embolization. Pediatr Radiol 2013;43:1532-5.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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