Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 257-260

Giant hepatic artery aneurysm: A rare case report


Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission11-May-2020
Date of Decision06-Jun-2020
Date of Acceptance06-Jun-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
S Arun Prasath
Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_57_20

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  Abstract 


Hepatic artery aneurysms (HAAs) are extremely rare entities. Given the high mortality rates with rupture, they should be treated early with either open or endovascular repair. We present a case of a 60-year-old man with HAA treated successfully by open surgical repair.

Keywords: Extra hepatic aneurysm, hepatic artery aneurysm, large vessel vasculitis


How to cite this article:
Prasath S A, Duraichi V, Sritharan N, Kumar S P, Ilayakumar P, Devarajan I. Giant hepatic artery aneurysm: A rare case report. Indian J Vasc Endovasc Surg 2021;8:257-60

How to cite this URL:
Prasath S A, Duraichi V, Sritharan N, Kumar S P, Ilayakumar P, Devarajan I. Giant hepatic artery aneurysm: A rare case report. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:257-60. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/257/320624




  Introduction Top


Hepatic artery aneurysms (HAAs) constitute 20% of all splanchnic aneurysms.[1] Although rare, they still carry a high propensity faor rupture, thus demanding early diagnosis and treatment.


  Case Report Top


A 60-year-old farmer presented with complaints of sudden-onset nonradiating pain abdomen localized to the epigastric region of 24 h duration. The patient did not report any episode of abdominal or back pain in the past and had nil comorbid illness. He is a betel nut chewer.

On examination, the patient was pale, nonicteric, hemodynamically stable. Per abdomen examination revealed a huge pulsatile mass measuring 15 cm × 13 cm predominantly in the epigastrium, extending to both hypochondria [Figure 1]. The pulsation was expansile, swelling, and nontender, and all borders could be well made out.
Figure 1: Clinical picture showing abdominal mass

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All peripheral pulses were normal.

Clinical diagnosis of abdominal aortic aneurysm was made, and urgent computed tomographic (CT) angiogram was taken which showed aneurysm arising from the hepatic artery measuring 16 cm × 12 cm [Figure 2], [Figure 3], [Figure 4].
Figure 2: Computed tomographic angiogram showing aneurysm sac

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Figure 3: Axial view of the sac

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Figure 4: Large sac with calcified wall

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After adequate optimization, he was taken up for surgery within 12 h.

Under endotracheal tube intubation general anaesthesia, the patient was explored through midline laparotomy incision. Once peritoneum was opened, huge aneurysm sac in the upper abdomen displacing stomach laterally was seen [Figure 5]. Supraceliac aortic control was taken. Aorta was cross-clamped; aneurysm sac with calcified wall was opened, thrombus evacuated, rent in the sac was repaired with 3-0 prolene, and excess sac was excised [Figure 6]. Back bleed from the hepatic artery was repaired with 3-0 prolene. Aorta was declamped (clamp time – 13 min). Abdomen was closed in layers after securing hemostasis. Sac was sent for histo pathological examination (HPE) and culture.
Figure 5: Huge sac displacing stomach

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Figure 6: Sac wall after evacuation of thrombus, repair of rent

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Postoperative period was uneventful, and repeat CT angiogram showed no residual hepatic aneurysm sac/leak [Figure 7], [Figure 8], [Figure 9]. A small aneurysm arising from superior mesentric artery (SMA) (<2 cm) was noted in the postoperative CT angiogram, which could not be visualized in preoperative CT angiogram [Figure 10].
Figure 7: Postoperative computed tomographic angiogram

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Figure 8: Lateral view of postoperative angiogram

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Figure 9: Postoperative cut-section showing no aneurysm sac

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Figure 10: SMA aneurysm detected in postoperative computed tomographic angiogram

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Sac culture was positive for Acinetobacter sensitive to capsule doxycycline which was prescribed for 12 weeks. Inflammatory markers were elevated (ESR – 24 mm/h, CRP – 48 mcg/ml). anti streptolysin O, rheumatoid factor and anti neutrophil antibody were negative.

HPE was suggestive of large vessel vasculitis, and hence, the patient was started on immunomodulators (tablet prednisolone 35 mg OD, tablet methotrexate 5 mg/week) and was discharged on the postoperative day 10 along with antiplatelets, statins, and antibiotics.

Currently, the patient is on follow-up and is serially monitored for SMA; planned for intervention should there be an increase in size of SMA or the patient becomes symptomatic.


  Discussion Top


Aneurysms of the hepatic artery are mostly located in the extrahepatic vascular tree[1] and usually asymptomatic. They can also present as vague pain abdomen. Quincke's triad (hemobilia + jaundice + right upper quadrant pain) is seen in the rupture of aneurysm into biliary tree. Rupture of sac is a fatal complication with a high mortality rate.

Atherosclerosis is the most common etiology; other less common causes include infection, iatrogenic intervention, and vasculitis.[2],[3]

Three-dimensional CT angiography is the investigation of choice in hemodynamically stable patients. Arteriography, the gold standard procedure, is not routinely done unless concomitant interventional procedures are being planned.[4],[5]

Owing to its rarity, no consensus regarding the treatment of asymptomatic aneurysm exists. Small aneurysm up to 2 cm can be safely observed. Given the high mortality rate associated with rupture, the threshold for intervention should be low. All symptomatic patients, patients with sac size of >2 cm, patients with the presence of multiple HAA, and those with pseudoaneurysm should be intervened.[1],[6],[7]

Surgery is the preferred treatment of choice for extrahepatic aneurysms, whereas percutaneous embolization is more appropriate for intrahepatic aneurysms.[8],[9]

Surgical options include aneurysmorrhaphy with or without patch angioplasty and ligation with or without reconstruction depending on the site of involvement. Aneurysm of the common hepatic artery can be safely ligated if gastroduodenal artery (GDA) is patent. Sac distal to the GDA usually warrants arterial reconstruction.[1],[9],[10] Ligation of the right hepatic artery should be accompanied by cholecystectomy as the gallbladder may go for necrosis following ligation of the right hepatic artery.[1],[10],[11]

Endovascular technique in the form of coil embolization/stenting is ideal for lesion situated within liver parenchyma.[1],[12] These patients should however be monitored for parenchymal necrosis postoperatively by conventional liver function tests and alpha-glutathione S transferase.[6]


  Conclusion Top


Although a rare entity, HAA should be borne in mind as early diagnosis and appropriate treatment can avoid life-threatening complications and save the life of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sidawy AN, Perler BA. Rutherford's Vascular Surgery and Endovascular Therapy. Ch. 85. 9th ed.. Philadelphia: Elsevier, Splanchnic Artery Aneurysms; 2019. p. 1114-6.  Back to cited text no. 1
    
2.
Parmar H, Shah J, Shah B, Patkar D, Varma R. Imaging findings in a giant hepatic artery aneurysm. J Postgrad Med 2000;46:104-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Tétreau R, Beji H, Henry L, Valette PJ, Pilleul F. Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients. Diagn Interv Imaging 2016;97:81-90.  Back to cited text no. 3
    
4.
Hubloue I, Keymeulen B, Delvaux G, Somers G. Hepatic artery aneurysm. Case reports with review of the literature. Acta Clin Belg 1993;48:246-52.  Back to cited text no. 4
    
5.
Narula HS, Kotru A, Nejim A. Hepatic artery aneurysm: An unusual cause for gastrointestinal haemorrhage. Emerg Med J 2005;22:302.  Back to cited text no. 5
    
6.
Jaunoo SS, Tang TY, Uzoigwe C, Walsh SR, Gaunt ME. Hepatic artery aneurysm repair: A case report. J Med Case Rep 2009;3:18.  Back to cited text no. 6
    
7.
Chaudhari D, Saleem A, Patel P, Khan S, Young M, LeSage G. Hepatic artery mycotic aneurysm associated with staphylococcal endocarditis with successful treatment: Case report with review of the literature. Case Reports Hepatol 2013;2013:610818.  Back to cited text no. 7
    
8.
Pilleul F, Valette PJ. Management of aneurysms of the hepatic artery. 15 patients. Presse Med 2001;30:1139-42.  Back to cited text no. 8
    
9.
Lumsden AB, Mattar SG, Allen RC, Bacha EA. Hepatic artery aneurysms: The management of 22 patients. J Surg Res 1996;60:345-50.  Back to cited text no. 9
    
10.
Arneson MA, Smith RS. Ruptured hepatic artery aneurysm: Case report and review of literature. Ann Vasc Surg 2005;19:540-5.  Back to cited text no. 10
    
11.
Man CB, Behranwala KA, Lennox MS. Ruptured hepatic artery aneurysm presenting as abdominal pain: A case report. Cases J 2009;2:8529.  Back to cited text no. 11
    
12.
Christie AB, Christie DB 3rd, Nakayama DK, Solis MM. Hepatic artery aneurysms: evolution from open to endovascular repair techniques. Am Surg 2011;77:608-11.  Back to cited text no. 12
    


    Figures

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



 

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