Application of resuscitative endovascular balloon occlusion in post-transplant mycotic hepatic artery pseudoaneurysm rupture in the setting of Aspergillus Constellatus bacteremia

Abstract

Hepatic artery pseudoaneurysm (HAP) is a rare, highly morbid and frequently fatal complication of liver transplantation. Most are a mycotic mediated weakness of the arterial wall, with associated bacterial or fungal infection of ascitic fluid. As it is usually asymptomatic prior to rupture, the majority present in acute hemorrhagic shock and dire extremis. Resuscitative endovascular balloon occlusion (REBOA) was initially developed for the management of noncompressible hemorrhagic shock in trauma; however, remains underutilized and understudied in the non-trauma setting. We present the case of a mycotic hepatic artery pseudoaneurysm rupture due to Streptococcus constellatus and Klebsiella pneumoniae post directed donor orthoptic liver transplant, in which REBOA was employed in the setting of impending exsanguination as a bridge to definitive surgical intervention. Although this patient passed away of multiorgan system failure prior to re-transplant, this case demonstrates the importance of a heightened suspicion of this devastating complication, especially in the setting of bilioenteric reconstruction and perihepatic fluid collection, as well as the benefit of utilizing resuscitative techniques such as REBOA prior to definitive surgical or endovascular therapy to mitigate the high morbidity and mortality of this condition.

Prognostic value of ultrasound in early arterial complications post liver transplant

“…HAP often occurs at the arterial anastomosis site or at the site of intervention or puncture[ 25 ]. The peripheral soft tissue wrapping hematoma forms due to the ruptured hemorrhage of the arterial wall[ 26 , 27 ]. Gray-scale ultrasound shows the cystic anechoic area of the hepatic artery with a clear boundary.…”

The novel use of resuscitative endovascular balloon occlusion of the aorta for uncontrolled bleeding in a surgically inaccessible abdomen: The ruptured proper hepatic artery in a frozen abdomen

“…Traumatic indications for the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) include disruption of distal thoracic, abdominal, and pelvic visceral structures, while non-traumatic indications include rapid gastrointestinal bleeding, ruptured aortic aneurysm, and obstetric bleeding from post-partum hemorrhage or placental pathology [ 1 , 2 ]. Balloon occlusion at aortic zones increases cardiac afterload and proximal aortic pressure, resulting in increased myocardial and cerebral perfusion as a bridge to definitive endovascular or surgical treatment of the hemorrhage [ 2 , 3 ]. We present the case of a patient who suffered severe polytrauma from a motor vehicle accident (MVA) and developed a common hepatic artery rupture 20 days after the initial trauma.…”