SONOWORLD : Hepatic artery pseudoaneurysm

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Vascular » Visceral vascular

Hepatic artery pseudoaneurysm

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Author(s) :

Ashok Bhanushali, MD

Pamela T. Johnson, MD

Chaitali Shah, FRCR

Presentation A 65 year old woman with a history of cholecystitis, melanotic stool and resolving jaundice presents with vague right upper quadrant pain. An abdominal ultrasound was performed.

Caption: Sagittal view of the liver at the porta hepatis.

Description: A hypoechoic rounded structure is seen at the level of the porta hepatis.

Caption: Oblique color Doppler scan.

Description: The structure partially fills with color and is seen in very close proximity to the hepatic artery. The portal vein is seen adjacent to the hepatic artery [rounded red structure].

Caption: Color Doppler image at the porta hepatis.

Description: The rounded hypoechoic structure shows bidirectional and turbulent color flow. It was noted to arise from a branch of the hepatic artery. These features are consistent with that of a pseudoaneurysm.

Caption: Spectral analysis of the periphery of the mass.

Description: Color Doppler shows a yin-yang appearance to the flow within the pseudoaneurysm, and spectral analysis documents flow not typical of the normal hepatic artery.

Caption: Spectral analysis of the adjacent hepatic artery.

Description: A normal arterial waveform is noted.

Differential Diagnosis Hepatic artery pseudoaneurysm.

Final Diagnosis Hepatic artery pseudoaneurysm.

Discussion Hepatic artery pseudoaneurysms are not very common, but they can develop following blunt or penetrating abdominal trauma, iatrogenic hepatic, biliary or pancreatic procedures and rarely as a sequela to inflammatory pathologies of the same or due to atherosclerosis. These pseudoaneurysms can also occur as a vascular complication in hepatic transplant patients. Hepatic artery aneurysms are known to be associated with a triad of abdominal pain, hemobilia and jaundice; although not all patients present with all these complaints. This entity needs to be identified as it can rupture into the peritoneal cavity and cause life threatening bleeding. They can also rupture into the biliary tract causing hemobilia and are a cause of unexplained GI bleeding. If the bleed into the biliary tree is small and chronic, it may present with recurrent melena [as was the presentation in the above patient].

On ultrasound, a pseudoaneurysm appears as a cystic structure often close to the hepatic hilum or sometimes they can be intrahepatic in location. Color Doppler may show a pulsatile, disorganized arterial flow pattern or characteristic bidirectional flow. CT scan shows an enhancing mass communicating with the hepatic artery or one of its branches. Angiography is thought to be the gold standard in delineating the vascular anatomy and the pseudoaneurysm can be treated simultaneously via coil embolization.

Case References 1. Falkoff GE, et al. Hepatic artery pseudoaneurysm: diagnosis with real-time and pulsed Doppler US. Radiology. 1986 Jan; 158(1):55-6.
2. Dolapci M, et al. Hepatic artery aneurysm. Ann Vasc Surg. 2003 Mar; 17(2):214-6. Epub 2003 Mar 06.
3. Chen MF, et al. Hematobilia from ruptured hepatic artery aneurysm. Report of two cases. Arch Surg. 1983 Jun; 118(6):759-61.
4. Ayuso JR, et al. Hepatic artery aneurysm: diagnosis by duplex-Doppler ultrasound. Case Report. Eur J Radiol. 1988 Nov; 8(4):263-5.
5. Zachary K, et al. Jaundice secondary to hepatic artery aneurysm: radiological appearance and clinical features. Am J Gastroenterol. 1986 Apr; 81(4):295-8.
6. Iseki j, et al. Hepatic artery aneurysm. Report of a case and review of the literature. Gastroenterol JPN. 1983 Apr; 18(2):84-92.
7. Griffith J, et al. A case of obstructive jaundice. Brit J Radiology, 70 (1997): 107-8.

Follow Up An aneurysm arising from a tiny arterial branch of the right hepatic artery was noted on angiography. This aneurysm was seen to be communicating with the bile duct system and was successfully embolized. Follow up Doppler scan showed no flow.