Eur Radiol (2008) 18: 2579–2581DOI 10.1007/s00330-008-1053-3 INTERVENTIONAL

Antonio BasileSalvatore RagazziDiego PiazzaDimitrios TsetisTommaso LupattelliMaria Teresa Patti

Received: 19 January 2008Revised: 7 April 2008Accepted: 20 April 2008Published online: 27 May 2008# European Society of Radiology 2008

Hepatic artery pseudoaneurysm treated usingstent-graft implantation and retrogradegastroduodenal artery coil embolization

Abstract Endovascular treatmentoptions for visceral artery pseudoaneurysms depend on lesion locationand size. Exclusion methods fall intotwo categories, embolization and stentplacement, and these procedures aimto exclude the pseudoaneurysm fromthe circulation and if possible tomaintain distal blood flow. Emboliza-tion of the afferent artery can be usedin pseudoaneurysms that arise from adonor artery without collateral supplysuch as a visceral branch, whereas inthe case of visceral arteries with well-established collateral supply, the em-bolization of both proximal and distalbranches to the pseudoaneurysm ismandatory in preventing backflow

from the collateral circulation. Adirect embolization delivering coils orglue into the sac can also be performedif the aneurismal neck is narrow.Stent-graft placement representsanother option to exclude the pseu-doaneurysm, in the case of wide neck,reduced arterial tortuosity and large-diameter arteries. We present a case ofcommon hepatic artery pseudoaneu-rysm involving the gastroduodenalartery origin treated by a combinationof techniques. An hepatic stent-graftimplantation plus retrograde emboli-zation of the gastroduodenal arterythrough the pancreaticoduodenalanastomosis from the superiormesenteric artery was performed.

Keywords Hepatic artery .Pancreatitis . Pseudoaneurysm .Embolization . Strent-graft

Introduction

Hepatic artery aneurysms and pseudoaneurysms make upapproximately 30% of visceral artery aneurysms and theirrupture can represent a challenging condition, especially inemergency cases [1]. Pseudoaneurysm can be secondary topancreatitis. Depending on the patient’s clinical conditionsseveral treatments have been reported in the therapeuticmanagement such as surgery or endovascular interventions[1, 2]. In high risk surgical patients, mininvasive interven-tional procedures (embolization, stent-graft implantation,etc.) represent the first choice, depending on location,anatomy, and technical skill. We present a case of a post-pancreatitis pseudoaneurysm of the common hepatic arteryinvolving the gastroduodenal artery (GDA) origin treatedby hepatic stent-graft implantation plus retrograde GDA

embolization through the superior mesenteric artery andthe pancreaticoduodenal anastomosis.

Results

A 38-year-old man was admitted because of acute onset ofepigastric pain with signs of hemorrhagic shock. Thehistory was notable for drug and alcohol addiction, HCVinfection, and chronic pancreatitis. An abdominal ultra-sound (US) examination showed dilated biliary tree with alarge partially thrombosed pseudoaneurysm in commu-nication with the common hepatic artery. Contrast-enhanced computed tomography (CT) confirmed the USfindings (Fig. 1) with dilation of intrahepatic biliary treedue to extrinsic coledocus compression operated by the

A. Basile (*) . M. T. PattiDepartment of Diagnostic andInterventional Radiology,Ospedale Ferrarotto,via Citelli 6,95124 Catania, Italye-mail: antodoc@yahoo.com

S. Ragazzi . D. PiazzaDepartment of Surgery I,Ospedale Vittorio Emanuele,via Plebiscito 125,95124 Catania, Italy

D. TsetisDepartment of Radiology,University Hospital of Heraklion,Medical School of Crete,Heraklion, Greece

T. LupattelliDepartment of InterventionalRadiology, Multimedica Holding,Sesto S. Giovanni (MI), Italy

aneurismal sac. The indication for arteriography andembolization was stated.

Celiac and superior mesenteric artery arteriography wasperformed by using 5 Fr Cobra C2 catheter (TerumoEurope, Leuven Belgium). A common hepatic arteryaneurysm was disclosed without any sign of bleedingfrom other branches and without visualization of the GDA(Fig. 2a). Due to the mass effect of the aneurysm, thehepatic artery was cranially displaced. This finding wasconsidered sufficiently favorable to implant a coveredstent, excluding the pseudoaneurysm neck. A 8×40 mmvascular stent-graft (Fluency, Bard Angiomed, Karlsruhe,De) was then inserted coaxially over an Amplatz super-stiff0.035” wire. At the final control no sign of contrastmedium filling was noted from the common hepatic artery(Fig. 2b). However after 12 h the patient’s clinicalcondition did not improve. A second angiogram wasperformed which showed active aneurismal filling throughthe GDA (Fig. 3a). The distal part of the GDA was

superselectively cannulated through the pancreaticoduode-nal anastomosis via superior mesenteric artery with amicrocatheter (Progreat, Terumo Europe, Leuven,Belgium)(Fig. 3b) and embolized by microcoils (Complex, BostonScientific, Fremont, USA). Postembolization angiographyshowed no signs of aneurismal sac filling (Fig. 3c). Thepatient’s clinical condition improved immediately after theintervention.

Interventional radiological procedures for hepatic arterypseudoaneurysms include US or CT guided percutaneousthrombin injection, percutaneous trans-catheter emboliza-tion, and stent-graft implantation. On the basis of the fact thatthrombin converts inactive fibrinogen into fibrin, leading tothrombus formation, this procedure has also been used totreat hepatic pseudoaneurysms. Coils are the preferredembolization material for hepatic pseudoaneurysms andwhen the neck is narrow, they can be catheter-directeddelivered into the sac itself, or positioned proximally anddistally to the origin of the aneurysm in order to occludepossible antegrade and retrograde sac fillings [2]. Stent-graft(covered stent) placement across the hepatic aneurysmalneck was first reported by Bürger et al. [3], and its use isrelated to a favorable arterial anatomy (i.e., reduced arterialtortuosity and large-diameter arteries) [2]. Retrograde can-nulation of the GDA through the superior mesenteric arteryhas been reported in the literature to treat celiac aneurysmswith ostial stenosis, and to reach the hepatic circulation incases of endovascular therapy for hepatocellular carcinomawith celiac trunk occlusion [4]. In such cases the possibilityto cannulate the GDA in retrograde fashion is possible due tothe hypertrophy of the inferior pancreaticoduodenal arterywith inverted flow towards the GDA secondary to thereduced filling from the celiac axis; in our case the flowfrom the hepatic artery to the GDA was occluded by thestent-graft. Hepatic aneurysms or pseudoaneurysmsproximal to the origin of the GDA are commonlytreated surgically by proximal and distal ligation andexcision of the aneurysmal sac, or recently by gastro-

Fig. 1 Coronal reformatted multidetector computed tomographyimage showing the pseudoaneurysm sac filled by contrast from thecommon hepatic artery

Fig. 2 a Selective hepatic arte-riography demonstrating thecontrast leak (white arrow)filling the aneurismal sac(black arrowheads). b Controlangiogram post stent-graftimplantation showing thecomplete coverage of thebleeding site with distal flowtowards the liver

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epiploic artery in situ bypass [5]. The endovascularoptions are limited to the embolization of hepatic arteryproximally and distally to the sac neck with occlusionof blood flow towards the liver. With the technique

hereby described we were able to exclude any aneuris-mal filling either antegrade from the hepatic artery, withstent-graft placement, or retrograde from the invertedflow, with the embolization of the GDA.

Fig. 3 a Selective arteriography of the inferior pancreaticoduodenalartery showing the inversed flow through the superior pancreaticartery (white arrow) toward the GDA (black arrow) filling theaneurismal sac. Gastroepiploic arcade was also seen (open arrow).

b Superselective cannulation of the proximal portion of the GDAwith a microcatheter (arrow) through the pancreaticoduodecalarcade. c Final control angiogram after microcoil embolizationshowing total exclusion of the pseudoaneurysm

References

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2. Saad NEA, Saad WEA, Davies MG,Waldman DL, Fultz PJ, Rubens DJ(2005) Pseudoaneurysms and the roleof minimally invasive techniques intheir management. Radiographics 25:S173–S189

3. Bürger T, Halloul Z, Meyer F, Grote R,Lippert H (2000) Emergency stent-graftrepair of a ruptured hepatic arterysecondary to local postoperativeperitonitis. J Endovasc Ther7(4):324–327

4. Schoder M, Cejna M, Längle F,Hittmaier H, Lammer J (2000) Glueembolization of a ruptured celiac trunkpseudoaneurysm via the gastroduode-nal artery. Eur Radiol 10(8):1335–1337

5. Kadohama T, Ohtani N, Sasajima T(2007) Hepatic artery aneurysminvolving the proper hepatic and gas-troduodenal artery treated using agastroepiploic artery in situ bypass.J Vasc Surg 45:1069–1071

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