Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report

Abstract

Background: When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established.

Case presentation: A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45.

Conclusion: Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.

Keywords: Gallbladder cancer; Hepatectomy; Portal vein arterialization; Pseudoaneurysm; Thrombosis.

Fig. 1

Intraoperative photographs. a Gallbladder cancer involving the PV and skeletonized hepatic artery after dissection of the hepatoduodenal ligament. The LHA was exfoliated to the threshold of the hepatic parenchyma, and the bifurcation of the LHA to A2, A3, and A4 was invisible. b After the right hepatectomy, extrahepatic duct resection, PV resection, and lymph node dissection were performed. CHA, common hepatic artery; PHA, proper hepatic artery; LHA, left hepatic artery; RHA, right hepatic artery; GDA, gastroduodenal artery; PV, portal vein; LPV, left portal vein; CHA, common bile duct; MHV, middle hepatic vein; IVC, inferior vena cava; A2, segment 2 artery; A3, segment 3 artery; A4, segment 4 artery

Fig. 2

Computed tomography revealing a 6-mm aneurysm of the left hepatic artery on postoperative day 6

Fig. 3

Angiography showing the hepatic artery pseudoaneurysm (arrow) on the bifurcation of the LHA to A2 plus A3 and A4. CHA, common hepatic artery; LHA, left hepatic artery; GDA, gastroduodenal artery; A2, segment 2 artery; A3, segment 3 artery; A4, segment 4 artery

Fig. 4

Computed tomography showing enlargement of the pseudoaneurysm (arrow) to a diameter of 10 mm on postoperative day 15

Fig. 5

Portal vein arterialization using the ICA and ICV. ICA, ileocolic artery; ICV, ileocolic vein

Fig. 6

a Selective embolization of the pseudoaneurysm with liquid thrombin. b Angiography 21 days after embolization of the aneurysm showed patency of the LHA. LHA, left hepatic artery; A2, segment 2 artery; A3, segment 3 artery; A4, segment 4 artery