Hepatic Artery Pseudoaneurysm

David Cheng, MD
Michael Meyerovitz, MD

June 10, 1997

Presentation

A 73-year-old woman presented with abdominal pain and laboratory evidence of pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and the common bile duct was swept with a basket for stones. No stones were recovered. Because of persistent symptoms, computed tomography (CT) was performed two days later.

Imaging Findings

ERCP image showing stone basket

Abdominal CT scans

Mesenteric angiograms

The ERCP image demonstrates the stone basket being passed in the common bile duct.

Abdominal CT images demonstrate inflammatory changes around the pancreas with areas of nonenhancement suggestive of necrosis. In addition, a 2 cm mass (black arrows) with surrounding low attenuation (white arrows) is visible in the medial segment of the left lobe of the liver. This mass displays contrast enhancement and washout parallel to the aorta. The findings are consistent with a pseudoaneurysm of the hepatic artery. Low attenuation fluid (which may represent pancreatic pseudocyst or blood) surrounds the pseudoaneurysm.

Mesenteric angiograms with selective injection of the hepatic artery demonstrate a 2 cm pseudoaneurysm (arrows) in the left lobe of the liver. It has a characteristic narrow mouth and is fed by a branch of the left hepatic artery. The artery was embolized using three platinum coils.

A fusiform dilatation of the right hepatic artery was incidentally noted. The finding is unrelated to the pseudoaneurysm.

Diagnosis

Hepatic artery pseudoaneurysm

Discussion

Pseudoaneurysms of the hepatic artery are rare. Causes include blunt or penetrating abdominal trauma, liver surgery, and less commonly, percutaneous interventional procedures involving the liver, such as biopsy or biliary stent placement (1, 2). Pancreatitis may also cause pseudoaneurysms of the hepatic artery but more frequently involves other branches of the celiac axis, most commonly the splenic branch (3, 4).

Clinical symptoms include right upper quadrant pain, hemobilia, gastrointestinal bleeding, intermittent jaundice, or bleeding from surgical drains (1, 5). An abdominal mass with bruit may be detected on physical examination. Rupture into the peritoneal cavity, portal vein, or pancreatic pseudocyst can also occur (4).

The diagnosis can be made via contrast-enhanced CT, ultrasound, magnetic resonance imaging, or arteriography. Ultrasound may reveal a hypoechoic, pulsatile mass with bidirectional flow on Doppler. In one reported case, however, the mass was nonpulsatile and no feeding artery was detectable (4). Treatment consists of embolization of the feeding artery or aneurysm itself, usually using coils.

References

1. Katz MC, Meng CH. Angiographic evaluation of traumatic intrahepatic pseudoaneurysm and hemobilia. Radiology 1970;94:95-99.

2. Rosen RJ, Rothberg M. Transhepatic embolization of hepatic artery pseudoaneurysm following biliary drainage. Radiology 1982;145:532-533.

3. Falkoff GE, Taylor KJW, Morse S. Hepatic artery pseudoaneurysm: diagnosis with real-time and pulsed Doppler US. Radiology 1986; 158: 55-56.

4. Borlaza GS, Kuhns LR, Seigel R, Pozderac R, Eckhauser F. Computed tomographic and angiographic demonstration of gastroduodenal artery pseudoaneurysm in a pancreatic pseudocyst. Journal of Computer Assisted Tomography 1979;3:612-614.

5. Foley WD, Berland LL, Lawson TL, Maddison FE. Computed tomography in the demonstration of hepatic pseudoaneurysm with hemobilia. Journal of Computer Assisted Tomography 1980; 4:863-865.

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