Arterial pseudoaneurysm is an uncommon life-threatening complication in blunt trauma patients. Blunt liver injury may lead to hepatic artery pseudoaneurysm. Radiological intervention is the method of choice in diagnosis and treatment of hepatic artery pseudoaneurysm. However, surgical intervention is advised for unstable patients with large leaking defects. This study reports a case of 53-year-old female who was admitted with vague abdominal pain. She had experienced a blunt abdominal trauma a year ago and had gone under liver packing procedure. The CT-scan results showed hematoma in RUQ region and leaking pseudoaneurysm of right hepatic artery. Hematoma was drained and partial liver resection and hepatic arterioraphy were done through laparotomy

Jafari, Hamid Reza

Kolahdouzan, Mohsen

Sanei, Behnam

kashan university of medical sciences

Arch Trauma Res. 2017 June; 6(2):e40787.
Published online 2017 June 30.
doi: 10.5812/atr.40787.
Case Report
Intrahepatic Artery Pseudoaneurysm as a Delayed Presentation of
Blunt Abdominal Trauma
Behnam Sanei,1 Mohsen Kolahdouzan,2,* and Hamid Reza Jafari3
1General Surgery Specialist, Pancreatic and Hepatobiliary and Transplant Subspecialist, Assistant Professor, Isfahan University of Medical Sciences, Isfahan, IR Iran
2General Surgery Specialist, Thoracic Surgery Subspecialist, Associate Professor of Isfahan University of Medical Sciences, Isfahan, IR Iran
3MD, Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran
*Corresponding author: Mohsen Kolahdouzan, General Surgery Specialist, Thoracic Surgery Subspecialist, Associate Professor of Isfahan University of Medical Sciences,
Isfahan, IR Iran. E-mail: kolahdouzan@med.mui.ac.ir
Received 2016 July 13; Revised 2016 November 21; Accepted 2017 January 12.
Abstract
Arterial pseudoaneurysm is an uncommon life-threatening complication in blunt trauma patients. Blunt liver injury may lead to
hepatic artery pseudoaneurysm. Radiological intervention is the method of choice in diagnosis and treatment of hepatic artery
pseudoaneurysm. However, surgical intervention is advised for unstable patients with large leaking defects. This study reports a
case of 53-year-old female who was admitted with vague abdominal pain. She had experienced a blunt abdominal trauma a year ago
and had gone under liver packing procedure. The CT-scan results showed hematoma in RUQ region and leaking pseudoaneurysm
of right hepatic artery. Hematoma was drained and partial liver resection and hepatic arterioraphy were done through laparotomy.
Keywords: Hepatic Artery, Pseudoaneurysm, Blunt Abdominal Trauma
1. Introduction
Hepatic artery pseudoaneurysm (HAP) is a rare compli-
cation of liver injuries following blunt abdominal trauma
(1-3). HAP rupture is the most dangerous and fatal obstacle,
which usually presents itself as vague abdominal discom-
fort, gastrointestinal bleeding, and hemobilia (4-6). Al-
though radiological intervention may prevent the need of
aggressive treatments, mortality rate is still about 20% to
50% (7, 8). Hereon, we present a case of intrahepatic artery
pseudoaneurysm 1 year after multiple trauma.
2. Case Presentation
A 53-year-old female patient was admitted to our sur-
gical department with abdominal pain. The pain started 8
days before patient’s admission and it was located in RUQ
and became severe during the last 3 hours before admis-
sion. The patient had no fever, nausea, vomiting, melena,
or hematemesis. During her recent physical exam in our
surgical department, she was awake with unstable vital
signs. Her heart rate was 115 per minute and blood pres-
sure was 100/90 mmHg. Abdominal examination revealed
severe tenderness around RUQ and epigastric area. Heart
sounds were normal and there was no evidence of respi-
ratory distress. Her laboratory data showed anemia and
leukocytosis. The emergency abdominal ultrasonography
demonstrated a suspicious mass in her liver. Furthermore,
emergency MDCT scan demonstrated extended hematoma
in the anterior segment of the right lobe of the liver and
a contrast leakage, which raised the suspicious of leaking
pseudoaneurysm of right hepatic artery (Figures 1 and 2).
Figure 1. Multi Slice CT-Scan with Contrast
According to her past medical history, she had been
registered in a local hospital with vague abdominal pain
and resistant hypotension, tachypnea, and tachycardia af-
ter experiencing a car- motorcycle accident about a year
ago. According to her previous documents, emergency
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Sanei B et al.
Figure 2. Contrast Leakage in the Arterial Phase
FAST had shown free liquid in abdominal region, while
there had been a hypoechogenic area in the middle part
of the right liver lobe, highly suggestive of hematoma.
Fourth left rib and several right ribs were fractured in her
chest X-ray. Thus, resuscitative measures such as NGT, bi-
lateral chest tube, central venous catheter, and sufficient
hydration had been adapted for the patient. Due to her
signs and symptoms, internal bleeding of liver injury due
to trauma had been the most probable diagnosis. After
laparotomy, liver packing had been done for the patient;
there was no bleeding at the site 48 hours after laparotomy.
According to her previous surgical report, a 7 to 8 cm lac-
eration was observed on the 7th segment. Proper hepato-
tomy and vessel ligation were done. She was released 7 days
after the recovery, but no follow- up was done.
Based on her past medical history and our recent find-
ings, she became a candidate for surgery. After general
anesthesia, a Chevron incision was made and exploring be-
gun. During our first inspection, segments 2, 3, and 4 were
hypertrophic. The right and left lobes of the liver were
released from its ligaments. First, the Pringle maneuver
was done. After that, a large hematoma was opened and
large amount of blood and clots were suctioned from the
area. A fibrotic layer, surrounding the hematoma, and a de-
fect were found in the side of the hepatic artery at its base
(Figure 3). Due to the destruction of segments 5, 6, 7, and
8, we performed a partial hepatic resection. Hepatotomy
was continued and the hepatic artery, which was the lead-
ing cause of bleeding in the lesion, went through arterio-
raphy. Based on our surgical observation, it was assumed
that the fibrotic layer of the hematoma and liver segments
hypertrophy demonstrated a silent long-lasting pseudoa-
neurysm. However, its sudden massive rebleeding made it
symptomatic. In the end, the rest of the hepatic area was
amended and the surgical incision was closed.
Figure 3. Surgical View
The arrow shows the arterioraphy location.
3. Discussion
Liver is prone to injury during blunt abdominal
trauma because of its fixed location and histological struc-
ture. About 25% of liver injuries after blunt trauma leads
to complications of biliary tree disruptions such as hemo-
bilia, biloma, peritonitis, and abscess formation, however,
they are resolved nonoperatively in 80% of the cases (3, 5,
9, 10). To date, only 13 cases of HAPs have been reported as
this condition is rare (Table 1). As a matter of fact, hepatic
artery pseudoaneurysm is a delayed outcome of blunt liver
trauma, which mostly involves common (CHA) and right
hepatic artery (RHA) (9, 11). Based on our literature review,
8 cases of HAPs were found in RHA and CHA. Female gender,
obesity, vessel calcification or atherosclerosis, and antico-
agulant usage are some risk factors of iatrogenic arterial
pseudoaneurysm although vascular injuries are the funda-
mental well-known cause of HAP in blunt trauma cases (5,
8, 9, 12).
HAPs are commonly asymptomatic. However, rup-
ture and bleeding (into gastrointestinal tract or the peri-
toneum) force these patients to refer to emergency depart-
ments as well as posing a 25% to 50% risk of mortality (3, 9,
13). One study in 2015 reported the death of a HAP patient
due to hypovolemia and shock although necessary mea-
sures had been taken operatively at the time of admission
(Table 1). CT scan is the mostly used diagnostic tool in HAPs.
Some centers suggest doing CT scan as a follow-up a week
after confirmed blunt liver injuries (8, 9). In these 13 HAPs,
CT scan was used after trauma patients had shown symp-
toms of GIB, abdominal discomfort, and fever (Table 1). In-
terestingly, bleeding through laparotomy incision led to
HAP diagnosis by CT scan 3 weeks after blunt chest trauma
(5). One research study on 188 blunt liver trauma cases
declared that 4% of HAP forms within 5 days of trauma.
Nonetheless, no relationship was found between HAP in-
cidence and grade of liver injury (7). On the other hand,
2 Arch Trauma Res. 2017; 6(2):e40787.
Sanei B et al.
some retrospective studies on liver blunt trauma cases
found CT scan follow-up nonessential (7-9). Also, CT scan
exposes children and pregnant liver trauma victims to ra-
diation. Despite the fact that CT scan is the gold standard
approach in diagnosing HAPs, using Doppler ultrasonog-
raphy as a follow-up is still on an ongoing debate among
radiological investigations (4, 7-9, 11).
With respect to HAP management, surgical repair and
simple ligation were firstly used to control the pseu-
doaneurysm bleeding. Large size or unstable pseudoa-
neurysm, lack of necessary equipment and staff during
radiology intervention, and active or massive bleeding
are the most certain indications of surgical management
among HAPs. Moreover, surgical approach successfully re-
duces the risks of rebleeding and hepatic abscess forma-
tion, while it provides the opportunity of direct visualiza-
tion of pseudoaneurysm in spite of its invasive nature (3,
6, 8, 9, 11, 13-15). Considering the reported cases of HAP af-
ter blunt liver trauma (Table 1), angiography is the first re-
liable method of diagnosis and treatment. In general, an-
gioembolization is the initial line in management of HAPs
(6, 8, 15, 16), which successfully controlled the bleeding in
80% of the cases. Among these reported cases, handling
bleeding was achieved with success by noninvasive man-
agement (Table 1). This approach eliminates the need of us-
ing an exploratory laparotomy and general anesthesia al-
though it has its own disadvantages such as rupture, infec-
tion, sepsis, contrast-induced nephropathy, radiation ex-
posure, ascites, gall bladder necrosis, biliary disturbance,
and recurrence or nullification due to retrograde flow of
collaterals. Also, suitable hardware, radiation safety, and
trained technical staff besides the embolization method
can affect the outcome of radiological interventions (2, 4,
6-8, 11, 13, 15-17).
Based on the presented case and review of previous re-
ports (Table 1), hemorrhagic shock can be caused by deep
liver laceration (> 3 cm) in abdominal blunt trauma pa-
tients. If during an emergency surgery, this hypothesis is
proved, it is advised to find the real source of bleeding. The
fibrosis around hematoma showed a long-lasting HAP in
our patient. Angioembolization, as a reliable nonoperative
method, requires both sufficient equipment and a trained
radiologist. When the exact bleeding vessels are not found
during initial laparotomy among liver blunt trauma candi-
dates, delayed HAP formation is a probability and regular
follow-up by CT scan or Doppler US is advised to provide the
opportunity of using an elective noninvasive management
before catastrophic fatal outcomes occur.
Acknowledgments
None.
Footnotes
Financial Disclosure: No financial support was required.
Conflict of Interest: The authors of this study declare no
conflict of interest.
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Table 1. Review of Hepatic Artery Pseudoaneurysm Reports After Blunt Abdominal Trauma (1, 3, 5, 6, 12-19)
Num Year Age, y Gender Case Presentation/Diagnosis Management Final Outcome
1 1996 - - Upper GI bleeding 3 years after
trauma/Proper HAP with duodenal
fistulization
Ligation of hepatic artery and fistula
repair
Success
2 2001 8 - Hemobilia 15 days after multiple
trauma/Left HAP
Direct percutaneous embolization Success
3 2002 29 Male Upper GI bleeding 3 months after
multiple trauma/common HAP with
duodenal fistula
Ligation of hepatic artery and fistula
repair
Success
4 2006 23 Male Subphrenic abscess 10 days after car
accident/complex subphrenic abscess
and right HAP
Transchateter embolization and
collection drainage
Success
5 2010 11 Male Hematemesis and melena 1 year after
hepatorrhexsis/right HAP
Transchateter arterial embolization Success
6 2010 10 Male Hypovolemia and tachycarida 4 days
after bicycle handle bar abdominal
trauma/left HAP
Arterial embolization Success
7 2010 18 Male Choluria, pruritus, vomiting, nausea,
and abdominal pain 6 months after
motorcycle accident/common HAP
and dilated intrahepatic bile ducts
Arterial embolization and direct
injection of thrombin after
embolization failure
Success
8 2011 84 Male RUQ abdominal pain 3 days after 5
m-falling/multiple intra-HAP
Transchateter coil embolization Success
9 2014 46 Male Melena and dizziness 5 months after a
bicycle accident/right HAP
Transchateter embolization Success
10 2014 21 Male Bleeding from laparotomy incision 23
days after blunt trauma to chest and
RUQ/right HAP and distal hepatic
artery-portal vein fistula
Coil embolization Success
11 2015 34 Male Epigastric tenderness and
hematemesis 1.5 months after
trauma/left HAP and duodenal ulcer
Distal gastrectomy, cholecystectomy,
and removal of pseudoaneurysm
Died of hypovolemia 9 h after
admission
12 2015 11 Female Abdominal pain, hematochezia, and
hematemesis 2 weeks after falling
down of stairs/right HAP and biliary
ductal dilatation
Coil embolization Success
13 2016 7 Female Fever and abdominal pain 2 days after
trauma/common HAP
Coil embolization Success
Abbreviations: GI, gastrointestinal; HAP, hepatic artery pseudoaneurysm; RUQ, right upper quadrant.
Arch Trauma Res. 2017; 6(2):e40787. 5


Intrahepatic Artery Pseudoaneurysm as a Delayed Presentation of Blunt Abdominal Trauma

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Intrahepatic Artery Pseudoaneurysm as a Delayed Presentation of Blunt Abdominal Trauma

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