Unsuccessful Stent Graft Repair of a Hepatic Artery Aneurysm Presenting with Haemobilia: Case Report and Comprehensive Literature Review

Abstract

Aims To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature. Methods Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected. Results A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months. Comprehensive literature review Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder. Conclusions Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings.

Combined Endovascular Repair of a Giant Symptomatic Hepatic Aneurysm: A Case Report and Comprehensive Literature Review

“…Postoperative complications were reported in five cases (13.5%) [19,35,39,41,43], whereas the mortality rate was 0%. Two of the five cases were managed with an endovascular approach [19,43], while the rest with an open repair [35,39,41].…”

“…Postoperative complications were reported in five cases (13.5%) [19,35,39,41,43], whereas the mortality rate was 0%. Two of the five cases were managed with an endovascular approach [19,43], while the rest with an open repair [35,39,41]. Ferrero et al reported that a 3.4 cm HAA previously treated with two multilayer stents showed a stent dislocation and sac expansion in 18 months follow-up [19].…”

“…Fifteen patients (36.6%) were treated using stent grafts and closed-cell and double-layer micromesh stent [8,11,12,14,16,19,21,24,25,30,31,34,36,42,43]. Ten patients were treated exclusively by coils (24.4%) [10,13,17,23,26,27,29,32,37,44], but in most cases, a combination of endovascular methods was used (liquid embolic agent+vascular plug [22,42], coils+vascular plug [15,33,35], covered stents+coils [38,39], coils+liquid embolic agent [28,40], coils+vascular plug+peripheral occlusion device [42]). In one case, a stent graft complex was deployed into the aorta to seal the orifice of the celiac trunk, due to aneurysm extension and lack of proximal landing zone [9].…”

“…In Clark et al, a coil embolization within the sac and the covered stent was required three weeks postoperatively due to endoleak through collaterals [43]. In Gao et al, an open repair was chosen due to presented aerobilia, sepsis, in-stent thrombosis, endoleak Ia, and infection of the aneurysm [39]. Lastly, Kar and Patel report a recurrent filling of the aneurysmal sac in six months, which was treated with coil, stent graft, and plug placement [41].…”