aneurysm, hepatic, aneurysm, therapy, hepatic arteries, therapeutic blockade

60-year old woman

The patient was admitted with abdominal pain without other prior remarkable past history, such as alcoholism, or clinical symptoms and signs.

On contrast-enhanced abdomen CT, a round, well circumscribed, brightly enhancing lesion was seen within another larger round lesion with low density content and rim like calcifications (Fig. 1). On celiac angiogram, a partially thrombosed, large aneurysm, shaped like a peanut, with a wide neck of about 2cm, originating from the common hepatic artery was seen. The aneurysm compressed the common hepatic artery partially and the left gastric artery completely (Fig. 2). After positioning the catheter tip into the aneurysm sac and using a 5F headhunter catheter (Cook, Bloomington, USA), one MWCE-38-8-15 coil (Cook, Bloomington, USA) was deployed into the aneurysm sac. Then three MWCE-38-5-5 coils and one 38-2-3 coil were deployed into the proximal and distal portions of the aneurysm, respectively. Postembolization celiac (Fig. 3) and superior mesenteric artery (Fig. 4) angiograms revealed barely any flow into aneurysm but intact original and accessory right hepatic arteries and patent right gastric artery, left gastric artery, and left hepatic artery. Follow-up contrast-enhanced abdomen CT at 6 days after embolization revealed almost completely thrombosed aneurysm (Fig. 5). The patient remained in a stable condition without abdominal pain and was discharged after follow-up imaging study.

Fig. 1. Initial contrast-enhanced abdomen CT shows a round, well-circumscribed, brightly enhancing lesion within another larger round lesion with low density content and rimlike calcifications.

Fig. 2. Initial celiac angiogram demonstrates a partially thrombosed, large aneurysm, shaped like a peanut, with a wide neck of about 2cm, originating from the common hepatic artery. The aneurysm is compressing the common hepatic artery partially and the left gastric artery completely.

Fig. 3. After embolization using microcoils, the aneurysm is not visualized.

Fig. 4. Postembolization superior mesenteric artery angiogram reveals barely any flow into aneurysm but intact original and accessory right hepatic arteries and patent right gastric artery, left gastric artery, and left hepatic artery.

Fig. 5. Follow-up contrast-enhanced abdomen CT at 6 days after embolization reveals almost completely thrombosed aneurysm.

Hepatic artery aneurysms represent about 20% of all visceral aneurysms, of which 80% are extrahepatic, and of these 63% affect the common hepatic artery. Most of them are probably due to atherosclerotic changes. Clinically, only one third of patients present with the Quinke's classic triad of abdominal pain, hemobilia, and obstructive jaundice, while the majority of patients (60-80%) present with rupture at their first clinical presentation. Therefore, it is important to recognize and treat hepatic artery aneurysms before they rupture. Suggested treatments have been transarterial embolization (TAE), direct percutaneous embolization, and surgery, of which TAE is the least invasive. For successful TAE, it is important to perform occlusion either on the neck or on both sides of the neck of the aneurysm, as it was done in our case. Sometimes embolization may be complicated by infarction of nearby visceral organs, such as the liver or stomach, so it important to confirm intact collateral supplies, which was done in our case as well. Although common hepatic artery aneurysms consist a small percentage of all visceral artery aneurysms, they may be complicated by rupture, accompanied by lifethreatening hemorrhage, therefore, their timely treatment is important and may be successfully achieved by transarterial embolization, using metal coils as in our case.

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