We report a case of leaking pseudoaneurysm of right hepatic artery in a 54-year old female after laparoscopic cholecystectomy who presented with massive gastrointestinal haemorrhage and was successfully managed with angiography and coil embolization

Khan, Muhammad Rizwan

Raza, Rushna

Salam, Basit

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eCommons@AKUSection of General Surgery Department of SurgeryMay 2011Leaking pseudoaneurysm of hepatic artery: apotentially life-threatening complication of acommon procedureMuhammad Rizwan KhanAga Khan UniversityRushna RazaAga Khan UniversityBasit SalamAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_genPart of the Surgery CommonsRecommended CitationKhan, M., Raza, R., Salam, B. (2011). Leaking pseudoaneurysm of hepatic artery: a potentially life-threatening complication of acommon procedure. Journal of the Pakistan Medical Association, 61(5), 504-6.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_gen/17AbstractWe report a case of leaking pseudoaneurysm of righthepatic artery in a 54-year old female after laparoscopiccholecystectomy who presented with massivegastrointestinal haemorrhage and was successfully managedwith angiography and coil embolization.Keywords: Pseudoaneurysm, Laparoscopiccholecystectomy, Complication, Angio-embolization.IntroductionDespite the increasing frequency of laparoscopiccholecystectomy for gallstones, vascular injuries areuncommon complications of this procedure and only afew cases of pseudoaneurysm of hepatic artery havebeen reported in the literature. Bleeding frompseudoaneurysm of hepatic artery may lead to life-threatening situation, if a prompt diagnosis is not made.The diagnosis and treatment of this infrequent situationneeds to be emphasized in clinical literature to increasethe awareness of general physicians and practicingsurgeons.The case of a 54 year old female with leakingpseudoaneurysm of the hepatic artery, managedsuccessfully is presented. Case ReportA 54-year old female, a known diabetic andhypertensive, presented with three months history ofintermittent rectal bleeding. She underwent an electivelaparoscopic cholecystectomy five months back forsymptomatic gallstones. The surgical procedure wasapparently uneventful and the patient was dischargedhome the day after surgery. Rectal bleeding was initiallyin the form of intermittent maelena which later becamemore frequent with some fresh blood mixed with stools.She also had an episode of haemetemesis one monthbefore her presentation to our hospital. She had no historyof abdominal pain or weight loss but complained oflethargy. Her diabetes and hypertension were well-Vol. 61, No. 5, May 2011 504Case ReportLeaking pseudoaneurysm of hepatic artery: a potentiallylife-threatening complication of a common procedure Muhammad Rizwan Khan,1 Rushna Raza,2 Basit Salam3Department of Surgery,1,2 Department of Radiology,3 Aga Khan University & Hospital, Karachi, Pakistan.Figure-1: Abdominal CT with IV contrast highlighting the pseudoaneurysm in theright hepatic artery.controlled on insulin and atenolol, respectively. She wasadmitted to other hospitals for a couple of times in lastthree months to investigate the cause of rectal bleeding.Her work-up included colonoscopy which was reported asnormal except for a small rectal ulcer. Her rectal bleedingwas assumed to be due to a bleeding peptic ulcer as shehad a history of use of non-steroidal anti-inflammatorydrugs for her knee pain and was managed with proton-pump inhibitors. A day before coming to our hospital, she presentedto another hospital with a fresh episode of significant rectalbleeding. At the time of presentation, she was found to behaemodynamically unstable and anaemic. Her abdominalexamination was unremarkable except for the smalllaparoscopy scars. Her haemoglobin level had dropped to 5mg/dL, but other laboratory work-up including liverfunction tests were within normal limits. After resuscitation,an upper GI endoscopy was done which showed an ulcer infirst part of duodenum (D1 segment) with a blood clot. Apulsatile mass was observed deep to the ulcer. Subsequently,an abdominal CT scan with contrast was carried out whichdemonstrated a 2.5cm contrast-enhancing pseudoaneurysmof the right hepatic artery (Figure-1). The patient was subsequently shifted to our hospitalwhere further resuscitation with blood products was carriedout. She was planned for an emergency mesentericangiography. Access was gained through the right femoralartery and selective cannulation of coeliac trunk and hepaticartery was done. Initial angiogram revealed apseudoaneurysm arising from the segmental branch of righthepatic artery. The segmental branch was super-selectivelycannulated using the micro catheter technique. This wasfollowed by placement of multiple coils distal and proximalto the pseudoaneurysm. Final run of contrast showed noresidual filling of the pseudoaneurysm (Figure-2).Patient remained stable after the procedure.Omeprazole was continued orally and she was started oniron and folic acid supplements. Her haemoglobin levelshowed a rising trend over the next few weeks. Anabdominal ultrasound done four months after the procedurewas normal with absent gall bladder.DiscussionLaparoscopic cholecystectomy has taken over opensurgical techniques for gall bladder removal and has provento be safer with lesser post-operative complications andrecovery time. Despite the well documented safety of thesurgical procedure, biliary and, uncommonly, vascularinjuries are still likely.1 Vascular complications may includevessel laceration, transection and occlusion, and can becaused by either direct trauma or thermal injury due toinadvertent use of electrocautery.2 A pseudoaneurysm isusually formed when the wall of an artery is disrupted andblood is forced into surrounding tissues, creating ahaematoma or an inflammatory mass. Among the reportedcases of pseudoaneurysms resulting from upper abdominalsurgeries, laparoscopic cholecystectomy bears the burden ofthe most.3 This could occur anywhere in the hepatic andcystic arteries.4,5 Variant biliary anatomy and conversion toopen surgery are possible risk factors,4,6 though our patienthad neither of these. If the pseudoaneurysm communicateswith the biliary tree, patient would present with haemobilia.Incidence of right hepatic artery pseudoaneurysmis rare and has been reported as up to 0.6% in previousliterature.3 Time of presentation varies from first few daysto months after surgery.2,4 The presentation differs widelyas well, from mild symptoms of abdominal discomfortwith or without jaundice and anaemia, to grosshaemorrhage due to rupture resulting in life threateninggastrointestinal bleeding, acute abdomen and/or liverinfarction.7-9 The mode of presentation, to some extent,depends on the size of the pseudoaneurysm as larger oneshave greater risk of rupture.4Endoscopy is usually the initial investigation ofchoice when the presentation is of GI bleeding though it isoften inconclusive.4,10 In our case, a pulsating mass wasobserved which prompted further investigation. ContrastCT scan, dynamic CT angiography and Doppler Ultrasoundare other modalities that can point to diagnosis, however,visceral angiography is considered the gold-standard.1,8 Italso enables localization of the vascular defect andtreatment by embolization.10 Success rates ofpseudoaneurysm obliteration are also high inangioembolization compared to open vascular repair withfewer complication rates.1,3This case elicits a rare but possibly life-threateningcomplication of a very common surgery. High index ofsuspicion is necessary to diagnose pseudoancurysm afterlaparoscopic cholecystectomy. Treatment withangioembolization is the best available option.References1. Rivitz SM, Waltman AC, Kelsey PB. Embolization of a Hepatic Artery505 J Pak Med AssocFigure-2: Angiogram showing the pseudoaneurysmbefore and after coil embolization.Pseudoaneurysm Following Laparoscopic Cholecystectomy. CardiovascIntervent Radiol 1996; 19: 43-6.2. Milburn JA, Hussey JK, Bachoo P, Gunn IG. Right Hepatic ArteryPseudoaneurysm Thirteen Months Following Laparoscopic Cholecystectomy.Eur J Vasc Endovasc Surg 2007; 13: 1-3.3. Christensen TL. Matsuoka L, Heestand G, Palmer S, Mateo R, Genyk Y, et al.Iatrogenic Pseudoaneurysms of the Extrahepatic Arterial Vasculature:Management and Outcome. HPB (Oxford) 2006; 8: 458-64.4. Parthenis DG, Skevis K, Stathopoulos V, Bellenis I, Vassilakopoulos T.Postlaparoscopic Iatrogenic Pseudoaneurysms of the Arteries of the Peritonealand Retroperitoneal Space: Case Report and Review of the Literature. SurgLaparosc Endosc Percutan Tech 2009; 19: 90-7.5. Moses V, Keshava SN, Wann VC, Joseph P, Sitaram V. Cystic arterypseudoaneurysm after laparoscopic cholecystectomy presenting ashaemobilia: a case report. Trop Gastroenterol 2008; 29: 107-9.6. Masannat YA, Al-Naser S, Al-Tal Y, Al-Koteesh J, Sharaf UI. A rarecomplication of a common operation; hepatic artery pseudo aneurysmfollowing cholecystectomy report of a case. Ir J Med Sci 2008; 177: 397-8.7. Bulut T, Yamaner S, Bugra D, Akyuz A, Acarli K, Poyanli A. False Aneurysmof the Hepatic Artery after Laparoscopic Cholecystectomy. Acta Chir Belg2002; 102: 459-63.8. Cheung HY, Tang CN, Fung KH, Li MK. Bleeding pseudoaneurysmscomplicating upper abdominal surgery. Hong Kong Med J 2007; 13: 449-52. 9. Liu TT, Hou MC, Lin HC, Chang FY, Lee SD. Life-threatening hemobiliacaused by hepatic artery pseudoaneurysm: A rare complication of chroniccholangitis. World J Gastroenterol 2003; 9: 2883-4. 10. Nicholson T, Travis S, Ettles D, Dyet J, Sedman P, Wedgewood K, etal; Hepatic Artery Angiography and Embolization for HemobiliaFollowing Laparoscopic Cholecystectomy. Cardiovasc InterventRadiol 1999; 22: 20-4.Vol. 61, No. 5, May 2011 506

Leaking pseudoaneurysm of hepatic artery: A potentially life-threatening complication of a common procedure

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Leaking pseudoaneurysm of hepatic artery: A potentially life-threatening complication of a common procedure

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