K.E.M. Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Contributed by : Swaksh Nemani
Endovascular embolization of giant common hepatic artery aneurysm in a patient presented with midline pulsatile mass
Introduction:
Hepatic artery aneurysms are a rare disease entity. They usually occur in elderly patients with underlying vascular disorders or atherosclerotic vessels. Before the advancement in endovascular techniques, patients used to present with symptoms of rupture with significant morbidity. Now interventional radiology has decreased the need for open surgical management like ligation and proves vital in patients with high surgical risk. We discuss a case wherein the patient presented with midline pulsatile mass managed by endovascular coiling.
Case presentation:
A 49-year-old woman presented with abdominal pain since one year, insidious in onset and gradually progressive, dull aching in nature, localised to the epigastrium, without radiation of pain. She did not complain of any aggravating or relieving factors. There was associated episodic nausea and vomiting a few hours after consumption of meals, non-bilious, with food particles as content. She also complained of progressive abdominal distension since four months and loss of appetite. There is no past history suggestive of abdominal trauma or pancreatitis. No history of any comorbidities was obtained. Outside ultrasound examination of the abdomen revealed a well-defined predominantly anechoic cystic structure in the epigastric region with homogenously hyperechoic content against the posterior wall. On color doppler, bidirectional flow is seen within the anechoic region, suggestive of an aneurysm with partial thrombosis. On abdominal examination, a palpable lump was felt in the epigastrium, soft in nature, compressible and pulsatile.
Contrast enhanced CT scan of the abdomen and CT angiography show a saccular structure arising from the common hepatic artery with crescent shaped uptake of contrast and a filling defect in the remainder of the lumen. The gastroduodenal artery is seen arising from the aneurysm (Figure 1). Patient presented in our emergency surgical services with these findings. All her laboratory results were normal.
Fig. 1 : Sagittal and 3D Multiplanar Reconstruction images of contrast enhanced CT show a well-defined spherical lesion in the right lumbar region with strong contrast enhancement in the arterial phase and a central filling defect, likely an abdominal aneurysm with an intra-luminal thrombus.
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1).
Video 1 : Selective celiac artery DSA shows opacification of the splenic artery and a giant aneurysmal sac seen arising from the origin of the common hepatic artery.
The patient was planned for Digital subtraction angiography with sos embolization. Celiac angiogram showed a giant aneurysm arising from origin of common hepatic artery (Video 1). So, coiling of proximal splenic artery with coils and closure of neck of aneurysm at the origin of common hepatic artery with vascular plug was planned. Cook Micro-nester coils were used to embolise the proximal splenic artery and Abbott AVP plug was used over the long sheath for the closure of neck of aneurysm (Video 2)(Figure 2).
Figure 2: DSA image shows complete occlusion of the neck of the common hepatic artery with a Abbott Amplatz Vascular plug.
Video 2: Selective celiac artery DSA following proximal embolization of the splenic artery using pushable coils shows non-opacification of the splenic artery with filling of the aneurysmal sac.
Further, aortogram was performed it showed communication of aneurysm with gastroduodenal artery (Video 3).
Video 3: Aortogram following occlusion of the neck of the common hepatic artery with Abbott Amplatz Vascular Plug shows non-filling of the aneurysmal sac across the neck. There is gradual filling of the aneurysm distally from the superior mesenteric artery branches.
Selective cannulation of inferior pancreatico-duodenal artery (IPD) was done and gram performed confirmed the findings (Video 4). So distal to proximal coiling across this defect in gastro-duodenal artery was performed using Terumo Progreat microcatheter (Video 5)(Video 6).
Videos 4, 5, 6
Video 4: Super-selective DSA of the inferior pancreatico-duodenal artery with shows filling of the aneurysmal sac through a defect in the gastro-duodenal artery.
Video 5: Super-selective DSA of the inferior pancreatico-duodenal artery following distal to proximal embolization of the proper hepatic artery with multiple micro-coils using Terumo Progreat micro-catheter shows continuous filling of the aneurysmal sac from the gastro-duodenal artery defect.
Video 6:.Selective superior mesenteric artery DSA shows non-filling of the aneurysmal sac following distal to proximal embolization of the gastro-duodenal artery with micro-coils.
Post embolization, complete exclusion of the aneurysmal sac from the visceral circulation is seen. Patient discharged on day 5 post procedure and asymptomatic during discharge. On the day of discharge, plain and contrast enhanced CT scan was performed which showed retained post procedure contrast on plain scan and absence of filling of aneurysmal sac on contrast enhanced scan (Figure 3).
Fig.3 : Axial image of post-procedure plain CT shows retention of contrast in the lumen of the aneurysm. Coronal image of post-procedure contrast enhanced CT shows non-opacification of the aneurysm in the arterial phase.