|Year : 2021 | Volume
| Issue : 3 | Page : 257-260
Giant hepatic artery aneurysm: A rare case report
S Arun Prasath, Vella Duraichi, N Sritharan, S Prathap Kumar, P Ilayakumar, I Devarajan
Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India
|Date of Submission||11-May-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||6-Jul-2021|
S Arun Prasath
Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
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 26];8:257-60. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/257/320624
| Introduction|| |
Hepatic artery aneurysms (HAAs) constitute 20% of all splanchnic aneurysms. Although rare, they still carry a high propensity faor rupture, thus demanding early diagnosis and treatment.
| Case Report|| |
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.
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].
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.
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 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|| |
Aneurysms of the hepatic artery are mostly located in the extrahepatic vascular tree 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.,
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.,
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.,,
Surgery is the preferred treatment of choice for extrahepatic aneurysms, whereas percutaneous embolization is more appropriate for intrahepatic aneurysms.,
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.,, 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.,,
Endovascular technique in the form of coil embolization/stenting is ideal for lesion situated within liver parenchyma., These patients should however be monitored for parenchymal necrosis postoperatively by conventional liver function tests and alpha-glutathione S transferase.
| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
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