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 Luckhurst CM et al . Hepatic artery pseudoaneurysm presenting as Klatskin's tumor 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.

An Odd Case of Melena: Chronic Celiac Artery Dissection and Hepatic Arterioduodenal Fistula

“…The noniatrogenic causes encompass trauma, acute and chronic pancreatitis, arteriosclerosis, polyarteritis nodosa (PAN), necrotizing vasculitis, infection, and hepatocellular carcinoma, all of which were ruled out in our patient. 3 However, as seen in our patient, chronic dissection of the common hepatic artery leading to arterioduodenal fistula presenting as melena is very unusual and not reported previously. 4 In cases of dissecting visceral artery aneurysms, the most common treatment modality offered was surgery, but with immediate mortality approaching 5%.…”

Atypical Presentation of Left Hepatic Artery Pseudoaneurysm

“…It is very rare to see all 3 present together and occurs in only 22%–35% of the cases. 5 Hemobilia can lead to the development of blood clots in the biliary tree, which can lead to obstructive jaundice and right upper quadrant or epigastric pain. 3 HAP associated with a liver abscess in the absence of iatrogenic injury has been rarely reported.…”

‘Whippled to death: an uncommon case of fatal gastrointestinal bleeding’

“…Although a PSA is most often asymptomatic, it can present with complications ranging from mild abdominal pain, anemia and hemobilia, to biliary obstruction and life-threatening hemorrhagic shock. Intervention in all identified visceral pseudoaneurysms is advocated regardless of symptoms because of the high risk of rupture compared to true aneurysms, exsanguinating hemorrhage and subsequent death [ 3 ]. Advances in imaging techniques have enhanced the detection rate of pseudoaneurysms.…”

“…Advances in imaging techniques have enhanced the detection rate of pseudoaneurysms. Due to the high mortality associated with surgery for this condition, an endovascular procedure is now the preferred method of intervention [ 2 , 3 ]. Gastroenterologists should have a high index of suspicion of a bleeding PSA in post-Whipple patients who present with acute gastrointestinal bleeding.…”