Posttraumatic hepatic artery pseudoaneurysm is a rare, but life threatening condition which should be considered in patients
with a history of blunt abdominal trauma who present with abdominal pain or gastrointestinal bleeding. We report a
case of a patient with such a pseudoaneurysm discovered five months after a bicycle accident resulting in hepatic rupture
that was treated conservatively. The patient presented with fatigue, dizziness, inability to tolerate major exertion and gastrointestinal
bleeding. After extensive diagnostic procedures, a right hepatic artery pseudoaneurysm was found. The condition
was treated successfully with transcatheter coil embolization

ANTE TONKIĆ

LIANA CAMBJ–SAPUNAR

MARINA MARAS–ŠIMUNIĆ

MIROSLAV ŠIMUNIĆ

NIKOLA PERKOVIĆ

TONKA PIPLOVIĆ–VUKOVIĆ

ŽARKO ARDALIĆ

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 1www.signavitae.comPosttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleedingABSTRACTPosttraumatic hepatic artery pseudoaneurysm is a rare, but life threatening condition which should be considered in pati-ents with a history of blunt abdominal trauma who present with abdominal pain or gastrointestinal bleeding. We report a case of a patient with such a pseudoaneurysm discovered five months after a bicycle accident resulting in hepatic rupture that was treated conservatively. The patient presented with fatigue, dizziness, inability to tolerate major exertion and gastro-intestinal bleeding. After extensive diagnostic procedures, a right hepatic artery pseudoaneurysm was found. The condition was treated successfully with transcatheter coil embolization.LIANA CAMBJ–SAPUNAR (  ) •MARINA MARAS–ŠIMUNIĆDepartment of Diagnostic and Interventional RadiologyUniversity Hospital Center Spinčićeva 1. 21 000 Split, Croatia E-mail: lianacambj@hotmail.comTONKA PIPLOVIĆ–VUKOVIĆ • MIROSLAV ŠIMUNIĆ •ŽARKO ARDALIĆ • ANTE TONKIĆ • NIKOLA PERKOVIĆDepartment of Internal Medicine University Hospital Center, Split, CroatiaLIANA CAMBJ–SAPUNAR • MIROSLAV ŠIMUNIĆ • ANTE TONKIĆ • MARINA MARAS–ŠIMUNIĆUniversity of Split School of Medicine Split, CroatiaLIANA CAMBJ–SAPUNAR • TONKA PIPLOVIĆ–VUKOVIĆ • MIROSLAV ŠIMUNIĆ • ŽARKO ARDALIĆ • ANTE TONKIĆ • NIKOLA PERKOVIĆ • MARINA MARAS–ŠIMUNIĆCASE REPORTS   SIGNA VITAE 2014; 9(1)Key words: blunt abdominal trauma, hepatic artery, pseudoaneurysm, embolization, gastrointestinal blee-ding, abdominal painIntroductionPosttraumatic hepatic artery pseudoa-neurysm is a rare, but life threatening condition. (1)  The enteric fistulization of such a pseudoaneurysm is even rarer. (2) The condition should be considered in patients with a history of blunt abdo-minal trauma presenting with abdominal pain or gastrointestinal (GI) bleeding of unclear origin. Symptoms can occur even years after the trauma. (3,4) We report an unusual case of a patient with a giant posttraumatic hepatic artery pseudoaneurysm which presented as GI bleeding, without detectable enteric fistulization, five months after a bicycle accident. Case reportA 46-year old man was referred to hos-pital because of fatigue, dizziness and inability to tolerate major exertion. He also reported one black stool three days prior to admission. The patient had a history of smoking and chronic alcohol abuse and was not on any prescrip-tion medication. His medical history was remarkable for a bicycle accident that occurred five months earlier which resulted in a mandibular and clavicular fracture, chest contusion and hepatic rupture that was treated conservatively. During the physical examination he was pale, with a heart rate of 60 bpm and arterial blood pressure of 120/70 mmHg. The abdomen was soft, without tenderness or any obvious masses. On digitorectal examination fresh blood was found. Laboratory data on admissi-on revealed severe normocytic anemia (red blood cell count 1,71 x 1012/L, hemoglobin 49 g/L, hematocrit 0,159%, mean corpuscular volume 92,7 fL), as well as elevated gamma- glutamyltran-sferase (599 U/L) and creatine kina-se (297 U/L) levels. Other laboratory parameters were within normal range or not significantly altered. The initial B-mode abdominal ultrasound showed an enlarged liver with a cystic formation in the right liver lobe, around 80 mm in diameter, classified as a hemato-ma. Upper GI endoscopy indicated no abnormalities. The patient was treated with transfusions of deplasmatized eryt-2 www.signavitae.comhrocytes, proton pump inhibitors and antibiotics. On the third day of hospita-lization the patient became febrile with an axillary measured body temperature of 38.8°C and started complaining of pain in the right upper abdominal qua-drant. Laboratory data at that time reve-aled an elevated white cell count (28.11 x 109/L), rise in aspartate – aminotran-sferase (48 U/L) and alanine – amino-transferase (148 U/L ), as well as high C-reactive protein (164,7 mg/L), and CA 19,9 (363,36 U/mL) values. Severe ana-emia was still present despite ongoing treatment. Coagulated but also freshly hemolysis blood was observed during colonoscopy with no clear source of bleeding. To further elucidate the possi-ble site of GI bleeding, an abdominal multidetector computed tomography (MDCT) of the abdomen, with intravas-cular application of contrast media, was performed. There were no signs of bowel wall bleeding but a giant pseudoaneury-sm (10x8 cm in diameter) of the right hepatic artery was discovered (figure 1). MDCT 2D reconstructions also revealed fast flow into the portal circulation in the late arterial phase of imaging sug-gesting a communication between the pseudoaneurysm and segmental portal vein (figure 2A). We hypothesized that the high pressure in the portal circulation was causing occasional bleeding from different sites of the enteric wall. This ‘hemodynamic changes’ hypothesis would be able to explain the episode of black stool and the episodes of fresh blood in the colon. In consultation with a vascular surgeon and interventional radiologist it was concluded that the treatment of choice would be pseudo-aneurysm transcatheter embolization. (5-8) A giant pseudoaneurysm was confirmed by digital subtraction angi-ography (DSA) (figure 2B). Segmental embolization was successfully perfor-med with five complex helical 8x12 mm coils (Boston Scientific Corporation, Pl. Natick, MA; USA) (figure 3A). One 10x14 mm helical coil was also deployed but it was too wide for the segmental artery and it was deployed into the right hepa-tic artery. Control abdominal MDCT two weeks after the procedure showed no Figure 3. A Digital subtraction angiography following embolization showing almost complete absence of contrast filling of the pseudoaneurysmal sac.  B Multidetector computed tomography  reconstruction two weeks following  embolization showing complete occlusion of the pseudoe-neurysmal sac.Figure 1. Volume rendering technique (VRT) computed tomography showing giant posttraumatic pseudoaneurysm of the right hepatic artery.Figure 2. A Multidetector computed tomography 2D reconstructions showing fast flow into the portal circulation in the late arterial phase sugge-sting a communication between the pseudoaneurysm and portal veins.  B Giant pseudoaneurysm confirmed on digital subtraction angio-graphy prior to embolization. 3www.signavitae.comREFERENCES1. Luo X, Tan S, Wang J, Qian C. Upper gastrointestinal haemorrhage from hepatic artery pseudoaneurysm secondary to trauma:a case report. Med Princ Pract 2010;19:493-5.2. Gondolesi GE, Matsumoto C, Wayne M, Schwartz ME. Post-traumatic pseudoaneurysm of the common hepatic artery with duodenal fistula. HPB (Oxford) 2002;4:183-6.3. Aboujaoude M, Noel B, Beaudoin M, Ghattas G, Lalonde L, The Bao Bui, et all. Pseudoaneurysm of the proper hepatic artery with duodenal fistula appearing as a late complication of blunt abdominal trauma. J Trauma 1996;40:123-5.4. Bardes JM, Caranasos TG, Vaughan RA. Hepatic artery pseudoaneurysm: delayed presentation after bicycle accident. J Trauma 2011;71:783.5. Vainas T, Klompenhouwer E, Duijm L, Tielbeek X, Teijink J. Endovascular treatment of a hepatic artery pseudoaneurysm associated with gastrointestinal tract bleeding.  J Vasc Surg 2012;55:1145-9.6. Balderi A, Antonietti A, Ferro L, Peano E, Pedrazzini F, Fonio P, et all. Endovascular treatment of visceral artery aneurysms and pseudoa-neurysms: our experience. Radiol Med 2012;117:815-30.7. Ikeda O, Tamura Y, Nakasone Y, Iryou Y, Yamashita Y. Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization.  J Vasc Surg 2008;47:1212-9.8. Reiter DA, Fischman AM, Shy BD. Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature. J Emerg Med 2013 Jan;44(1):100-3.9. Matthes G, Stengel D, Seifert J, Rademacher G, Mutze S, Ekkernkamp A. Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography. World J Surg 2003;27:1124-30.10. Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock 2011 Jan-Mar; 4(1):114–9.11. Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics 2005;25:87-104.12. Taourel P, Vernhet H, Suau A, Granier C, Lopez FM. Vascular emergencies in liver trauma. Eur J Radiol 2007;64:73-82.13. Janik V, Labos M, Vyhnanek F. Embolization of Post-Traumatic Pseudoaneurysm of the Proper Hepatic Artery. Surgery Curr Res 2012;2:4.14. Gondolesi GE, Matsumoto C, Wayne M, Schwartz ME. Post-traumatic pseudoaneurysm of the common hepatic artery with duodenal fistula. HPB (Oxford) 2002;4:183-6.15. Reiter DA, Fischman AM, Shy BD. Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature. J Emerg Med 2013 Jan;44(1):100-3.further circulation towards the pseudo-aneurysm and segmental portal vein (figure 3B). Apart from the above men-tioned embolization, the patient was treated with repeated transfusions of deplasmatized erythrocytes and fresh frozen plasma, intravenous antibiotics (ceftriaxone and metronidazole), proton pump inhibitors, analgesics and anxiol-ytics. He was discharged 29 days after admission in good condition with all laboratory values within normal range or not significantly altered.DiscussionBecause of its size and relatively fixed position, the liver is an organ which is very prone to injury when patient suffers blunt trauma to the abdomen. The esti-mated prevalence of this kind of injury, in polytraumatised patients, is 1-8%. (9) In the early 1970s, more than 80% of liver injuries were managed operatively, but by the end of the 1990s, 80–90% of these injuries were successfully mana-ged using non-operative methods. (10) The reported prevalence of complicati-ons during this kind of treatment of blunt liver trauma ranges from 5% to 23%. Of the delayed complications, hemorrha-ge is the most frequent ranging from 1.7 – 5.9%. Others include abscess, posttraumatic pseudoaneurysm and hemobilia, while biliary complications such as biloma and bile peritonitis are more common in patients with severe, complex liver injuries. (11) Posttrau-matic hepatic artery pseudoaneurysm is a rare delayed complication. (12) No information on actual prevalence can be found in the literature as it has only been reported in the form of case reports. The majority of these case reports refer to blunt abdominal trau-ma in children rather than adults. We can assume that this could be related to children having thinner abdominal walls and weaker musculature so the liver is less protected than in adults. As was the case with our patient, dia-gnosis is typically delayed, because of non-specific clinical manifestations. The most frequent complaint is right upper abdominal pain, but the con-dition may also present as unexplai-ned upper gastrointestinal bleeding, hemoperitoneum, hemobilia, jaundice, and abdominal mass. If gastrointestinal bleeding is present, endoscopy is usu-ally not helpful in identifying the source of bleeding. Abdominal ultrasound is usually the first screening method for right upper quadrant abdominal pain and in combination with color Doppler can be helpful in raising suspicion of the presence of a hepatic artery pseu-doaneurysm. (13,14) Diagnosis can be confirmed by MSCT or magnetic reso-nance angiography, (11,13,14) while the gold diagnostic standard is still conventional DSA. (15) Although earlier reports on this topic suggested that surgical ligation of the hepatic artery should be performed, authors of more recent studies agree that the treatment of choice, for hemodynamically stable patients with this condition, is endovas-cular coil embolization. (15) In conclusion, although very rare, a posttraumatic pseudoaneurysm of the celiac trunk arteries should be con-sidered in cases of abdominal pain and/or gastrointestinal bleeding pre-senting after blunt abdominal trauma. Diagnostic approach should include abdominal ultrasound, preferably with Doppler ultrasound, abdominal MDCT with intravenous contrast agent and DSA in cases when embolization is the treatment of choice. 

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Posttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleeding

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Posttraumatic hepatic artery pseudoaneurysm presenting as gastrointestinal bleeding

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