Image – 1 - Ultrasound – liver – pre-embolization.

Image -2. Pre-embolization ultrasound.

Image – 3. Right hepatic artery selective angiography – pre-embolization

Image – 4. Selective right hepatic artery check angiography – post embolization.

Image – 5. Ultrasound post-embolization.

Legend: The above images are from a patient who presented with malena,biliary colic and anemia following a biliary stenting procedure. Images 1 shows a cystic lesion with Yin-Yang type of blood flow suggesting aneurysm. Image 2 shows the lesion in proximity to a part of the biliary stent (showing post-acoustic shadow.) Image 3 – selective right hepatic angiogram shows aneurysm arising from the right hepatic artery. Image 4 shows deployed coils within the lesion not showing any contrast filling suggesting adequate embolization. Image 5 – post embolization ultrasound image shows the lesion with absent Doppler flow.

Introduction: The hepatic artery is the second most common cause of visceral aneurysm, following splenic artery. Hepatic artery pseudo-aneurysms are uncommon but potentially lethal complications of hepatic, biliary, and pancreatic interventions. In the above case, it was secondary to arterial injury while biliary stenting.

Clinical features: The usual complaint is non specific abdominal pain. The lesion can sometimes partly communicate with biliary tree and cause hemobilia and malena. Sometimes it can directly rupture presenting with massive intra-peritoneal or surgical drain bleeding and can be fatal.

Imaging features: Ultrasound will reveal a cystic lesion Showing Yin-Yang pattern of flow secondary to both to and fro circular motion of the circulating blood within the aneurysm. The origin of the artery from a particular hepatic branch can also be demonstrated. The wall thickness, size and partial thrombotic status can all be determined.

On CT, the pseudoaneurysm will fill with contrast on arterial phase with density similar to abdominal aorta.
Conventional angiography is the gold standard method of diagnosing and characterising size and origin. However status of partial thrombosis cannot be demonstrated.

Treatment: Surgery had long been the only option for the treatment. It can sometimes be ineffective due to may be ineffective due to intrahepatic collateralization or extrahepatic feeding arteries arising from capsular branches or hepatoduodenal ligament. Extrahepatic pseudoaneurysms can often be excised with or without bypass grafting, but intrahepatic lesions usually require partial hepatic resection. Despite surgical treatment, the mortality rate remains high.

More recently, transcatheter embolization using a variety of embolizing materials has been considered the treatment of choice for true and false splanchnic and hepatic artery aneurysms. Endovascular treatment offers many advantages over surgery, such as precise localization of the pseudoaneurysm, assessment of collateral flow, and easier approach, especially in intrahepatic pseudoaneurysms; in combination, these benefits help reduce complication and mortality rates.

Hepatic artery embolization is usually well tolerated in patients with normal portal venous flow and does not alter the collateral vessels. Rarely distal embolization may lead to liver necrosis. Selective intra aneurismal embolization coil placement can be done without any such risk hemodynamic hepatic compromise. However, wide necked pseuroaneurysms can sometimes get complicated by dislodgement and distal coil embolization.
CT guided intra ansurysmal injection of thrombin is another option in the treatment but not widely followed due to the availability and advantages of trans-luminal approaches.
A newer approach in the various treatment options is based on repairing the arterial wall by implanting a stent-graft covered with either prosthetic material or autogenous vein.

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