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Hepatic Artery Aneurysm

HAA

Hepatic artery aneurysms are rare; they have a high rate of spontaneous rupture and hemorrhage leading to mortality. The increase in the incidence of hepatic artery aneurysms may be attributed to the frequent use of imaging tests.


Presentation

Most patients with hepatic artery aneurysms are asymptomatic and the aneurysm is discovered as an incidental finding on imaging being performed to work up unrelated symptoms or conditions. Patients with a hepatic artery aneurysm may present with abdominal pain, particularly epigastric discomfort, right upper quadrant pain, obstructive jaundice, and/or hemobilia [1] [2] [3]. In rare instances, a patient with a giant aneurysm may present with a pulsatile mass in the right upper abdomen. Patients often become clinically symptomatic when there is erosion into the biliary tree or the portal vein resulting in the development of portal hypertension or rupture of an aneurysm into the peritoneal or retroperitoneal cavity. Approximately one-third of patients present with hemobilia, characterized by jaundice, gastrointestinal bleeding, and biliary colic (Quincke's triad) [4]. Discovery of a hepatic artery aneurysm in an asymptomatic individual occurs as an incidental finding on a computed tomography or ultrasound exam being performed for an unrelated purpose [2] [3].

Abdominal Bruit
  • On examination abdominal bruit or a pulsatile mass may be found. The aneurysm may rupture into the peritoneal cavity, duodenum, portal vein and stomach or rarely into the gall bladder [2] , [3] .[jpgmonline.com]
  • Physical examination may reveal a pulsatile mass or abdominal bruit, but is usually normal.[eurorad.org]
  • Otherwise they may present with especially abdominal pain, nausea, vomiting and as a pulsatile mass or abdominal bruit. Some Aneurysm are not discovered until they complicate with rupture.[atmph.org]
Decreased Bowel Sounds
  • Abdominal examination revealed decreased bowel sounds without any palpable mass. However, there was a direct and indirect tenderness over the right upper quadrant and epigastrium with a positive Murphy's sign.[synapse.koreamed.org]
Vascular Disease
  • The great improvement in the diagnosis of vascular diseases and the increasing incidence of atherosclerosis have resulted in a wider recognition of these pathologies.[ncbi.nlm.nih.gov]
  • Among the former group, atherosclerosis, arthritis, and collagen vascular disease are the most common, whereas liver biopsy or other radiologic interventions (ie, percutaneous abscess drainage) are frequent iatrogenic causes.[ncbi.nlm.nih.gov]
  • diseases I73.0 Raynaud's syndrome I73.00 …… without gangrene I73.1 Thromboangiitis obliterans [Buerger's disease] I73.8 Other specified peripheral vascular diseases I73.89 Other specified peripheral vascular diseases I73.9 Peripheral vascular disease[icd10data.com]
  • diseases [ 2 ] .[em-consulte.com]
  • No history of diabetes or peripheral vascular disease was found. The USG of abdomen revealed hypoechoic mass of size 15 15 mm at the expected location of celiac trunk.[atmph.org]
Joint Swelling
  • He has not had fevers, weight loss, arthralgias, myalgias, hernia, joint swelling, laxity or dislocation, easy bruisability, visual changes, or lens dislocations, and has no family history of aneurysmal disease dissection, connective tissue disorders,[thoracickey.com]

Workup

Most diagnostic algorithms for patients presenting with symptoms associated with hepatic artery aneurysm (e.g. mid-epigastric discomfort, abdominal pain) include imaging. The most common imaging modalities used to evaluate hepatic artery aneurysm (and generalized abdominal pain) are ultrasound scan (US), computed tomography (CT) scan with contrast, and angiogram.

On the US, a hepatic artery aneurysm may appear as a mixed echogenic mass with cystic and solid components. Calcifications are usually present in the wall of an aneurysm [5] [6]. Color doppler will demonstrate turbulent or arterial pulsatile flow that is suggestive of the lesion being vascular in origin. US can be used to rule out other vascular conditions such as arteriovenous malformations or fistulas [7] [8] [9].

Hepatic artery aneurysm can be diagnosed by a contrast-enhanced CT scan or three-dimensional CT scan. In general, a CT scan will demonstrate the characteristics of an aneurysm, adjacent anatomical structures, and any signs of rupture. Calcifications will usually be present in the vessel's wall. Thrombotic deposits in the vessel's lumen appear as ring-shaped or semilunar areas of hypodensity. Intravenous contrast allows a more definitive view of the vessel lumen.

A CT angiogram is able to further delineate small aneurysms and provide anatomical details including identification of the artery of origin. Use of CT angiogram often provides a definitive diagnosis, without the need of angiography, however, intravenous contrast is contraindicated in some patients with renal dysfunction [10] [11].

Three-dimensional contrast-enhanced magnetic resonance imaging (MRI) angiography may also be used for the diagnosis of hepatic artery aneurysm in lieu of angiography. Three-dimensional MRI is a quick, sensitive, accurate test and it provides better delineation of the arterial anatomy [12] [13].

Angiography is considered the gold standard diagnostic test for hepatic artery aneurysm. It is highly efficacious with a sensitivity of 100% [13]. Angiography, while invasive, permits diagnosis, identification of additional aneurysms, feeding vessels, and provides information necessary for treatment of an aneurysm [14].

Treatment

  • There is still a lack of studies demonstrating the comparative efficacy or inefficacy of any particular treatment, so there are currently no precise indications for determining which type of treatment should be used.[ncbi.nlm.nih.gov]
  • Endovascular stent placement and coil embolization have become established options in the treatment of visceral arterial aneurysms.[ncbi.nlm.nih.gov]
  • Hepatic artery aneurysm rupture is a rare condition that requires urgent diagnosis and treatment in order to avoid a potentially fatal outcome. The clinical presentation is often non-specific.[ncbi.nlm.nih.gov]
  • Surgical treatment resolved peritonitis but Entamoeba histolytica was detected in the colonic mucosa.[ncbi.nlm.nih.gov]
  • In this report, we describe the endovascular treatment of a giant common hepatic artery aneurysm with an Amplatzer vascular plug.[ncbi.nlm.nih.gov]

Prognosis

  • Hepatocellular carcinoma (HCC) ranks among the most common malignancies worldwide, and the prognosis for patients with HCC is typically poor. Chemoembolization has become the mainstay of treatment for patients with unresectable HCC.[ncbi.nlm.nih.gov]
  • While only four patients had successfully undergone surgical repair prior to 1951, vascular techniques have improved the previous grave prognosis.[jamanetwork.com]
  • A precise evaluation using computed tomography and magnetic resonance imaging is important in the treatment planning, which will influence the prognosis.[rb.org.br]
  • Treatment and prognosis Treatment options include: trans-catheter coil embolisation surgery (historically treated with surgery) Once successfully treated (embolotherapy, surgical resection), prognosis is generally good for an individual lesion.[radiopaedia.org]
  • Park, Kim, Han, Goo, Han, Bae, and Park: Hemobilia from Ruptured Hepatic Artery Aneurysm in Polyarteritis Nodosa Abstract Hemobilia, in patients with the diagnosis of polyarteritis nodosa, is rare at clinical presentation and has a grave prognosis.[kjim.org]

Etiology

  • We conclude that unexplained findings of visceral arterial aneurysms should prompt investigations for vasculitis as the etiology.[ncbi.nlm.nih.gov]
  • The etiology of prune belly syndrome (PBS) is poorly understood, but new evidence suggests that it is caused by mesodermal delay during the fetal development because of an intrauterine injury.[ncbi.nlm.nih.gov]
  • Rupture risk of HAA is poorly defined but seems to correlate with size and etiology.[thoracickey.com]
  • Herein, relatively asymptomatic aneurysm of the common hepatic artery mostly of atherosclerotic etiology is presented. The importance of imaging findings in the diagnosis of this condition is discussed and relevant literature is reviewed (1, 2).[ncbi.nlm.nih.gov]
  • The common hepatic artery is the most frequent location(63%), followed by the right hepatic artery(28%), the left hepatic artery(5%), and both hepatic arteries(4%). 7) The leading etiology is atherosclerosis in 32% of these patients.[synapse.koreamed.org]

Epidemiology

  • Among categorical data, in addition to the epidemiological variables such as age and sex, we considered factors related to arterial and portal hypertension: we therefore evaluated the recipient gender, the presence in the medical history of previous surgery[journals.plos.org]
Sex distribution
Age distribution

Pathophysiology

  • This report reviews the pathophysiology and management of PAN and the diagnosis and management of HAA.[ncbi.nlm.nih.gov]
  • References Steer ML: Pathophysiology and pathogenesis of acute pancreatitis; in Bradley III EL (ed): Acute Pancreatitis: Diagnosis and Therapy. New York, Raven Press, 1994.[karger.com]
  • Pathophysiology Pseudoaneurysms form when enzyme-rich peripancreatic fluid, often within a pseudocyst, leads to autodigestion and weakening of the walls of adjacent arteries.[emedicine.medscape.com]

Prevention

  • This will prevent the wrong diagnosis of vasculitis and subsequent treatment with potentially toxic medications. We present 2 cases of FMD involving the renal and hepatic arteries that illustrate this diagnostic challenge.[ncbi.nlm.nih.gov]
  • In cases with huge extrahepatic artery aneurysms, an aggressive approach to restore the hepatic arterial continuity seems appropriate for the prevention of ischemic damage to the liver.[ncbi.nlm.nih.gov]
  • The first intervention was to place a stent into the hepatic artery to prevent further ischemic damage.[ncbi.nlm.nih.gov]
  • Essentially all pseudoaneurysms, whether symptomatic or not, require early treatment to prevent lethal adverse events.[endoscopedia.com]
  • Prevention Prevention of hepatic aneurysm The disease no effective preventive measures, early detection of early diagnosis is the key to prevention and treatment of this disease.[healthfrom.com]

References

Article

  1. Arneson MA, Smith RS. Ruptured hepatic artery aneurysm: case report and review of literature. Ann Vasc Surg. 2005; 19:540-5.
  2. Lumsden AB, Mattar SG, Allen RC, Bacha EA. Hepatic artery aneurysms: the management of 22 patients. J Surg Res. 1996; 60:345-50.
  3. Baggio E, Migliara B, Lipari G, Landoni L. Treatment of six hepatic artery aneurysms. Ann Vasc Surg. 2004; 18: 93-9.
  4. Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg. 2003 Jul;38(1):41-5.
  5. Paolella LP, Scola FH, Cronan JJ. Hepatic artery aneurysm:an ultrasound diagnosis.J Clin Ultrasound. 1985; 13:360-2.
  6. Parmar H, Shah J, Shah B, et al. Imaging findings in a giant hepatic artery aneurysm. J Postgrad Med. 2000; 46:104-5.
  7. Chandramohan C, Khan AN, Fitzgerald S, et al. Sonographic diagnosis and follow-up of idiopathic hepatic artery aneurysm, an unusual cause of obstructive jaundice. J Clin Ultrasound. 2001; 29:466-71.
  8. Rigaux A, Vossen P, Van Baarle A, et al. A.Hepatic artery aneurysm: ultrasonic diagnosis. J Clin Ultrasound. 1986; 14:401-3.
  9. Stokland E, Wihed A, Ceder S, et al. Ultrasonic diagnosis of an aneurysm of the common hepatic artery. J Clin Ultrasound. 1985; 13:360-2.
  10. Howling SJ, Gordon H, McArthur T, et al. Hepatic artery aneurysms: Evaluation using three dimensional spiral CT angiography. Clin Radiol. 1997; 52:227-30.
  11. Shanley CJ, Shah NL, Messina LM. Common splanchnic artery aneurysms: splenic, hepatic, and celiac. Ann Vasc Surg. 1996;10:315-22.
  12. Pilleul F, Beuf O. Diagnosis of splanchnic artery aneurysms and pseudoaneurysms, with special reference to contrast enhanced 3D magnetic resonance angiography: a review. Acta Radiol. 2004;45:702-8.
  13. Liu Q, Lu JP, Wang F, Wang L, Tian JM. 3D Contrast-enhanced MR angiography of aortic dissection: a pictorial essay. Radiographics. 2007;27:1311-21.
  14. Warshauer DM, Keefe B, Maura MA. Intrahepatic hepatic artery aneurysm: computed tomography and color-flow Doppler ultrasound findings. Gastrointest Radiol. 1991;16:175-7.

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Last updated: 2018-06-21 23:47