Journal of Emergencies, Trauma, and Shock
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LETTER TO EDITOR  
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 246-247
Emergency hepatic artery embolization in a patient with post-traumatic ruptured hepatic artery pseudoaneurysm


Department of Cardiology, GB Pant Hospital and Associated Maulana Azad Medical College, Delhi, India

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Date of Web Publication16-Jul-2014
 

How to cite this article:
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

How to cite this URL:
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 [serial online] 2014 [cited 2019 Dec 14];7:246-7. Available from: http://www.onlinejets.org/text.asp?2014/7/3/246/136878


Dear Editor,

Hepatic artery pseudoaneurysms (HAP) are usually a consequence of abdominal trauma, inadvertent arterial injury during abdominal surgery or chronic pancreatitis. [1],[2] They are infrequently seen in clinical practice and have an unpredictable clinical course and can present acutely with rupture of the aneurysm. Emergency management of the bleeding is very important, and a delay can be catastrophic. We present a case of acute severe abdominal bleeding secondary to rupture of the HAP, which was managed by an emergency coil embolization of the right hepatic artery (RHA). The case demonstrates the importance of early recognition and the efficacy of emergency coil embolization in such cases. Awareness of this relatively simple procedure can be helpful and potentially life-saving in other similar cases with acute visceral artery bleeding.

A 21-year-male presented with blunt trauma to right side of chest and abdomen with clinical features of peritonitis. Exploratory laparotomy revealed a right hepatic lobe laceration with active bleeding, which was surgically repaired and bleeding points secured. All other solid and hollow viscera were normal. Patient had bilious discharge from the suture line post-operatively, which stopped by the 20 th post-operative day. On the 23 rd day, while having his meals, patient suddenly developed profuse bleeding from the suture line needing urgent blood transfusions. He was immediately referred to our center for an opinion and possible intervention. Emergency selective angiogram showed a large RHA pseudoaneurysm with active bleeding [Figure 1] and [Figure 2]. A distal hepatic artery-portal vein fistula was also noted. It was decided to embolize the RHA both proximal and distal to the aneurysm to prevent any retrograde filling of the HAP from the fistula. Distal coil embolization was done with two 4 × 6 mm coils, another 6 × 8 mm coil was released across the aneurysm, and then proximal artery was embolized with two 4 × 6 mm coils, one 6 × 8 mm coil and one 8 × 6 mm coil. There was no communication with the aneurysm in the final angiogram [Figure 3]. The patient showed good recovery and had an uneventful subsequent hospital stay and discharge.
Figure 1: Image shows active bleeding from the right hepatic artery with multiple jets. The arterio-venous fistula has caused the filling of the portal venous system in the late phase

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Figure 2: Image shows the outline of the hepatic artery pseudoaneurysm with active bleeding from the hepatic artery. Distal coils have been deployed

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Figure 3: Image shows the final angiogram with no filling of the aneurysm and complete cessation of bleeding

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The clinical presentation of HAPs may vary from incidental detection to an emergency presentation with rupture. There may be subtle signs like fatigue, vague pain abdomen, nausea, back pain etc., which are often ignored. Since the clinical course of these aneurysms is unpredictable with a possibility of rupture and acute hemodynamic compromise, detection of a HAP warrants a definite intervention irrespective of the size or symptoms. [3] The HAP may rupture into the adjacent portal vein system, biliary tract, or even the abdominal cavity depending on its location. The treatment options include surgical resection, endovascular coil embolization, ultrasound-guided thrombin injection, or covered stent implantation. The percutaneous interventions have provided an alternative to open surgical repair, especially in an emergency. Endovascular coil embolization is a safe and effective procedure with no major complications. [4] Since the major vascular supply to the liver is from the portal system, hepatic artery occlusion is unlikely to cause any significant hepatic ischemia. Endovascular stent implantation has also been used. [5] However, since the covered stent grafts have a poor profile, it may not be easy to deliver them distally in a tortuous vessel, and they are not readily available in all sizes. Coils are, however, commonly available, are inexpensive, and relatively easy to deliver.

In a difficult situation like acute severe bleeding from a ruptured HAP, with hemodynamic compromise, coil embolization can be used as a relatively simple emergency procedure to arrest bleeding. Awareness of this complication, and its emergency management, can help in early diagnosis and intervention in such potentially fatal cases.

 
   References Top

1.Otah E, Cushin BJ, Rozenblit GN,Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137:55-9.  Back to cited text no. 1
    
2.Dikaiakos P, Paschalidis N,Markakis CH, Voultsos M, Malagari K, Moschouris H, et al. Angiographic embolization of a post-traumatic splenic pseudoaneurysm. Hellenic JSurg 2013;85:207-11.  Back to cited text no. 2
    
3.Tessier DJ, Stone WM, Fowl RJ,Abbas MA, Andrews JC, Bower TC, et al. Clinical features and management of splenic artery pseudoaneurysm:Caseseries and cumulative review of literature. J Vasc Surg 2003;38:969-74.  Back to cited text no. 3
    
4.Yi IK, Miao FL, Wong J,Narasimhan KL, Lo RH, Yee L,et al. Prophylactic embolization of hepatic artery pseudoaneurysm after blunt abdominal trauma in a child. J Pediatr Surg 2010;45:837-9.  Back to cited text no. 4
    
5.Qu L, Jing Z, Feng R. Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm.J Vasc Surg 2005;42:159-62.  Back to cited text no. 5
    

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Correspondence Address:
Subhendu Mohanty
Department of Cardiology, GB Pant Hospital and Associated Maulana Azad Medical College, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.136878

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  [Figure 1], [Figure 2], [Figure 3]



 

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