Atypical presentation of a hepatic artery pseudoaneurysm: A case report and review of the literature

Abstract

Classically, hepatic artery pseudoaneurysms (HAPs) arise secondary to trauma or iatrogenic causes. With an increasing prevalence of laparoscopic procedures of the hepatobiliary system the risk of inadvertent injury to arterial vessels is increased. Pseudoaneurysm formation post injury can lead to serious consequences of rupture and subsequent hemorrhage, therefore intervention in all identified visceral pseudoaneurysms has been advocated. A variety of interventional methods have been proposed, with surgical management becoming the last step intervention when minimally invasive therapies have failed. The authors present a case of a HAP in a 56-year-old female presenting with jaundice and pruritis suggestive of a Klatskin's tumor. This presentation of HAP in a patient without any significant past medical or surgical intervention is atypical when considering that the majority of HAP cases present secondary to iatrogenic causes or trauma. Multiple minimally invasive approaches were employed in an attempt to alleviate the symptomology which included jaundice and associated inflammatory changes. Ultimately, a right hepatic trisegmentectomy was required to adequately relieve the mass effect on biliary outflow obstruction and definitively address the HAP. The presentation of a HAP masquerading as a malignancy with jaundice and pruritis, rather than the classic symptoms of abdominal pain, anemia, and melena, is unique. This presentation is only further complicated by the absent history of either trauma or instrumentation. It is important to be aware of HAPs as a potential cause of jaundice in addition to the more commonly thought of etiologies. Furthermore, given the morbidity and mortality associated with pseudoaneurysm rupture, intervention in identifiable cases, either by minimally invasive or surgical interventions, is recommended.

Keywords: Biliary obstruction; Cholangitis; Hepatic artery pseudoaneurysm; Klatskin tumor; Trisegmentectomy.

Figure 1

Computerized tomography scan demonstrating pseudoaneurysm and significant biliary ductal dilatation. A: Triple contrast computerized tomography scan of abdomen demonstrates hepatic artery pseuodoaneurysm; B: With significant thrombus formation adjacent to aneurysm; C: Significant biliary ductal dilatation in the right and left hepatic ducts.

Figure 2

Interventional attempts to embolize the hepatic artery pseudoaneurysm. A: Angiogram of common hepatic artery demonstrates pseudoaneurysmal formation off right hepatic artery; B and C: Interventional fluoroscopic and ultrasound-guided embolization of right hepatic artery pseudoaneurysm with multiple coils, gelfoam, and thrombin.

Figure 3

Histochemical analyses of resected hepatic artery. A: H and E of hepatic artery with organized thrombus dissecting into the vessel wall, 40 × magnification; B: Verhoeff-Van Gieson (VVG) staining of the hepatic artery with eccentric fibrous intimal thickening with adherent thrombus, 20 × magnification (B, inlet). Internal elastic lamina is highlighted by the VVG stain with notable fibrous intimal thickening, 100 × magnifications.

Figure 4

Histologic analyses of hepatic artery pseudoaneurysm and adjacent liver. A: H and E of fibrous capsule of the contained pseudoaneurysmal rupture adjacent to liver, 20 × magnification (A, inlet). Liver with centrilobular cholestasis, 200 × magnification; B: Liver with bile duct reaction and bile plugs consistent with biliary obstruction, 200 × magnification.