- Email: [email protected]
Giant Bilobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft
Accepted Manuscript Giant Bi-lobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft Katie E. Shean, MD, Charles V. Strom, MD, Scott R. Johnson, MD, Scott G. Prushik, MD, Frank B. Pomposelli, MD, Nikhil Kansal, MD PII:
S0890-5096(17)30329-1
DOI:
10.1016/j.avsg.2016.10.039
Reference:
AVSG 3175
To appear in:
Annals of Vascular Surgery
Received Date: 15 June 2016 Revised Date:
18 August 2016
Accepted Date: 24 October 2016
Please cite this article as: Shean KE, Strom CV, Johnson SR, Prushik SG, Pomposelli FB, Kansal N, Giant Bi-lobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.039. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Giant Bi-lobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis:
2
Repair Using a Bifurcated Graft
3
Katie E. Shean, MD1, Charles V. Strom, MD2, Scott R. Johnson, MD1, Scott G. Prushik, MD1, Frank
5
B. Pomposelli, MD1, Nikhil Kansal, MD1
RI PT
4
6 1
Division of Vascular and Endovascular Surgery, St. Elizabeth’s Medical Center, Boston, MA 02135
8
2
Division of Transplant Surgery, Tufts Medical Center, Boston, MA 02111
SC
7
M AN U
9
10
11
13
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12
Presented at the 34th Annual Meeting of the Southern California Vascular Surgery Society,
15
La Jolla CA, April 29 – May 1, 2016.
17 18 19 20 21 22 23 24 25 26 27 28
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16
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14
Corresponding Author/Reprints: Katie Shean, MD Nikhil Kansal, MD St. Elizabeth’s Medical Center 736 Cambridge Street, Suite CCP#8 Boston, MA 02135 Telephone: 617-789-3309 E-mail: [email protected]; [email protected]
ACCEPTED MANUSCRIPT
Abstract: Hepatic artery aneurysms are uncommon, with fewer than 500 cases noted in the
2
literature. Bi-lobed hepatic artery aneurysms are extremely rare, with no documented cases in the
3
literature. Though often asymptomatic, these visceral aneurysms are at high risk of rupture. We
4
present an interesting case report of a bi-lobed hepatic artery aneurysm with occlusion of the celiac
5
axis in a 72-year-old woman. She was asymptomatic at the time of presentation and diagnosis was
6
made on CT scan. She was not a candidate for endovascular repair due to the anatomy of the
7
aneurysm and a chronically occluded celiac artery origin. Surgical repair using a bifurcated graft
8
with ligation of the gastroduodenal artery was performed.
M AN U
9
SC
RI PT
1
Introduction: Hepatic artery aneurysms (HAAs) represent the second most common visceral artery
11
aneurysm, accounting for about 20% of these lesions.1 Wilson was the first to describe an HAA in
12
1809 and the first successful ligation occurred in 1903 by Kehr.2 HAAs have the highest rate of
13
rupture among all splanchnic artery aneurysms and warrant an aggressive management strategy.3,4
14
The majority of these aneurysms are found incidentally during cross-sectional imaging or
15
ultrasound.5 Repair options vary depending on the anatomic location of the aneurysm as well as
16
patient factors; both endovascular and open surgical repair have been described.6-12
EP
17
TE D
10
Case Report: A 72-year-old female with a past medical history of progressive supranuclear palsy
19
presented to the Emergency Department with complaints of left lower quadrant abdominal pain. She
20
underwent CT scan and was diagnosed with a kidney stone. An incidental finding of a mass
21
prompted repeat imaging which demonstrated the mass to be a 6-cm bi-lobed aneurysm arising from
22
the celiac axis. The patient subsequently underwent a CT angiogram, which more clearly identified a
23
6.0 x 4.2 x 3.7-cm bi-lobed hepatic artery aneurysm arising from a chronically occluded celiac artery
24
(Fig. 1A). The primary blood flow to the aneurysm was from the gastroduodenal artery (GDA) via
AC C
18
ACCEPTED MANUSCRIPT
1
high flow pancreaticoduodenal collaterals (Fig. 1B). The patient was referred to our Vascular
2
Surgery service for treatment.
3
On presentation, physical exam revealed a palpable mass in the subxiphoid region. She denied any symptoms at this time. Angiogram was performed, which demonstrated a large bi-lobed
5
aneurysm with the first portion involving the proximal common hepatic artery and the second
6
including the proper hepatic artery as well as the origin of the GDA (Fig. 2). The GDA was
7
markedly dilated and was providing retrograde flow into the celiac artery circulation, which was
8
occluded at its origin. Given the large size of the aneurysm and the high risk of rupture in this patient
9
population, we recommended open surgical repair and bypass. Though the literature reports that
M AN U
SC
RI PT
4
10
HAAs can be treated safely with endovascular repair,8-10 the patient’s occluded celiac axis precluded
11
direct access to the aneurysm, and therefore was not an option. The occlusion of the celiac artery
12
required that blood flow needed to be maintained to both the hepatic and the splenic arteries.
13
Exposure to the abdomen was obtained through a subcostal incision. Upon entering the abdomen, the aneurysm was easily identified under the edge of the left lobe of the liver. The
15
proximal lobe of the aneurysm involved the majority of the common hepatic artery. The right and
16
left hepatic arteries originated from the distal aspect of the aneurysm sac. Inflow to the aneurysm
17
sac, as well as the hepatic and splenic circulation, was supplied through retrograde perfusion from the
18
GDA. A 14x7-mm bifurcated Dacron graft was sewn end-to-side to the supraceliac aorta. The left
19
limb of the bypass graft was anastomosed in end-to-end fashion with the splenic artery. An end-to-
20
end anastomosis was fashioned from the right limb of the bypass graft to a Carrel patch of the
21
aneurysm sac that included the origins of the right and left hepatic artery. The GDA was ligated at
22
the level of the aneurysm. Her postoperative course was uneventful and she was discharged home on
23
post-operative day #6. Post-operative imaging confirmed graft exclusion and graft limb patency.
24
She underwent repeat imaging at six months and again at two years postoperatively, which
AC C
EP
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14
ACCEPTED MANUSCRIPT
1
demonstrated continued limb patency, as well as no evidence of aneurysmal degeneration of the
2
hepatic artery anastomosis (Fig. 3).
3
Discussion: Hepatic artery aneurysms, like all splanchnic aneurysms, represent a rare pathology.
5
They have previously been documented as the second most common visceral aneurysm, behind the
6
splenic artery, but recent data suggest they may be more common.1,13 It is projected that the
7
incidence is less than 0.4% of the population, however, this is only an estimate, as most are
8
discovered incidentally.14 The overall incidence has been rising, which is likely due to the increased
9
use of cross-sectional imaging as a diagnostic tool, as well as increasing hepatobiliary
M AN U
SC
RI PT
4
10
interventions.7,8,15 These aneurysms are often asymptomatic, but can present as abdominal or back
11
pain when expanding. HAAs have the highest risk of rupture of all visceral aneurysms, and thus an
12
aggressive approach to operative management is warranted when discovered.3
13
Though the natural course of hepatic artery aneurysms is not clearly defined, the current guidelines recommend repair for those greater than 2.0-cm or those with multiple aneurysms.16 Our
15
patient’s anatomy was very unique; to date, there have been no documented cases of bi-lobed HAAs.
16
Though we cannot know the exact clinical implications of being bi-lobed, given the guidelines
17
above, repair was the clear choice in our opinion, due to its having more than one aneurysmal sac and
18
its larger size. Additionally, the reports of giant HAAs are infrequent, with less than 20 found in the
19
literature. Though no true size criterion exists for the definition of “giant” HAA, previous reports
20
have defined these as any HAA with a diameter greater than 5.5-cm.17 Open surgical repair has been
21
the traditional approach for repair of these aneurysms, though reports of endovascular repair are
22
increasing.11,12,18,19 As discussed previously, our patient’s anatomical features precluded her from
23
being a candidate for endovascular repair.
24 25
AC C
EP
TE D
14
While there are only a few limited series reporting endovascular treatment of HAAs, this approach has the potential advantage of lower morbidity and mortality when compared to open
ACCEPTED MANUSCRIPT
repair. Open repair has long been the standard, and has provided a safe and durable treatment for
2
patients. Recent data suggest that endovascular repair is a safe alternative to open repair,8-10
3
however, little is known about its durability and long-term outcomes. An extensive literature review
4
of giant HAAs repaired endovascularly revealed only a single documented follow-up beyond one
5
year.20,21 Similarly, those with open surgical repair from the same patient population also failed to
6
yield any long-term follow-up.22-24 Our patient underwent CT scan two years after her bypass,
7
confirming the Carrel patch did not undergo aneurysmal degeneration, as well as confirming graft
8
limb patency. This is the longest follow-up ever reported following repair of a giant HAA. Current
9
treatment guidelines do not define what appropriate long-term surveillance these patients need, and is
M AN U
SC
RI PT
1
typically decided at the discretion of the surgeon. As these rare visceral artery aneurysms are
11
discovered with increasing frequency, we may develop a better understanding of their natural history
12
and the indications for repair. Open repair remains a good option for repair of these aneurysms and
13
can be performed safely with acceptable morbidity and mortality.
EP AC C
14
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10
ACCEPTED MANUSCRIPT
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M AN U
SC
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1. Shanley CJ, Shah NL, Messina LM. Uncommon splanchnic artery aneurysms: pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and colic. Ann Vasc Surg 1996;10:506-15. 2. Guida PM, Moore SW. Aneurysm of the hepatic artery. Report of five cases with a brief review of the previously reported cases. Surgery 1966;60:299-310. 3. Zachary K, Geier S, Pellecchia C, Irwin G. Jaundice secondary to hepatic artery aneurysm: radiological appearance and clinical features. Am J Gastroenterol 1986;81:295-8. 4. Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg 2003;38:41-5. 5. Pasha SF, Gloviczki P, Stanson AW, Kamath PS. Splanchnic artery aneurysms. Mayo Clin Proc 2007;82:472-9. 6. Marone EM, Mascia D, Kahlberg A, Brioschi C, Tshomba Y, Chiesa R. Is open repair still the gold standard in visceral artery aneurysm management? Ann Vasc Surg 2011;25:936-46. 7. Salcuni PF, Spaggiari L, Tecchio T, Benincasa A, Azzarone M. Hepatic artery aneurysm: an ever present danger. J Cardiovasc Surg (Torino) 1995;36:595-9. 8. Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular management of visceral artery aneurysm. J Endovasc Ther 2001;8:150-5. 9. Sachdev U, Baril DT, Ellozy SH, et al. Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg 2006;44:718-24. 10. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83; discussion 83. 11. Christie AB, Christie DB, 3rd, Nakayama DK, Solis MM. Hepatic artery aneurysms: evolution from open to endovascular repair techniques. Am Surg 2011;77:608-11. 12. Melissano G, Mascia D, Gabriel SA, et al. Hepatic artery aneurysms: open and endovascular repair. J Cardiovasc Surg (Torino) 2016. 13. Hiramoto JS, Messina LM. Visceral Artery Aneurysms. Curr Treat Options Cardiovasc Med 2005;7:109-17. 14. Arneson MA, Smith RS. Ruptured hepatic artery aneurysm: case report and review of literature. Ann Vasc Surg 2005;19:540-5. 15. Lumsden AB, Mattar SG, Allen RC, Bacha EA. Hepatic artery aneurysms: the management of 22 patients. J Surg Res 1996;60:345-50. 16. Parent BA, Cho SW, Buck DG, Nalesnik MA, Gamblin TC. Spontaneous rupture of hepatic artery aneurysm associated with polyarteritis nodosa. Am Surg 2010;76:1416-9. 17. Shukuzawa K, Toya N, Fukushima S, Momose M, Akiba T, Ohki T. Surgical Treatment of a Giant Right Hepatic Artery Aneurysm with an Aberrant Left Hepatic Artery: Report of a Case. Ann Vasc Dis 2015;8:271-3. 18. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: A 25-year experience. J Vasc Surg 2008;48:334-42. 19. Grotemeyer D, Duran M, Park EJ, et al. Visceral artery aneurysms--follow-up of 23 patients with 31 aneurysms after surgical or interventional therapy. Langenbecks Arch Surg 2009;394:1093100. 20. Qu L, Jing Z, Feng R. Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm. J Vasc Surg 2005;42:159-62. 21. Rossi M, Virgilio E, Laurino F, et al. Giant Hepatic Artery Aneurysm Associated with Immunoglobulin G4-Related Disease Successfully Treated Using a Liquid Embolic Agent. Korean J Radiol 2015;16:953-4.
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References
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22. Cimsit B, Ozden I, Emre AS. A rare intraabdominal tumor: giant hepatic artery aneurysm. J Med Invest 2006;53:174-6. 23. Shiraishi M, Takahashi M, Yamaguchi A, Adachi H. Hepatic artery pseudoaneurysm with extrahepatic biliary obstruction. Ann Vasc Dis 2012;5:100-3. 24. Sohn ME, Stonerock CE, Dalsing MC. Multiple giant superior mesenteric artery branch aneurysms. Ann Vasc Surg 2007;21:280-3.
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Figure 1A: CT scan of the large bi-lobed hepatic artery aneurysm (HAA)
Figure 1B: CT scan showing the occlusion of the celiac artery axis and a large
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pancreaticoduodenal collateral vessel
ACCEPTED MANUSCRIPT Figure 2: Angiogram of the bi-lobed HAA with blood flow from the markedly dilated
M AN U
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gastroduodenal artery (GDA), providing retrograde flow into the celiac artery circulation
Figure 3: Follow-up CT reconstruction depicting continued limb patency and no evidence of
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aneurysmal degeneration of the hepatic artery anastomosis
S0890-5096(17)30329-1
DOI:
10.1016/j.avsg.2016.10.039
Reference:
AVSG 3175
To appear in:
Annals of Vascular Surgery
Received Date: 15 June 2016 Revised Date:
18 August 2016
Accepted Date: 24 October 2016
Please cite this article as: Shean KE, Strom CV, Johnson SR, Prushik SG, Pomposelli FB, Kansal N, Giant Bi-lobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.039. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Giant Bi-lobed Hepatic Artery Aneurysm with Occlusion of the Celiac Axis:
2
Repair Using a Bifurcated Graft
3
Katie E. Shean, MD1, Charles V. Strom, MD2, Scott R. Johnson, MD1, Scott G. Prushik, MD1, Frank
5
B. Pomposelli, MD1, Nikhil Kansal, MD1
RI PT
4
6 1
Division of Vascular and Endovascular Surgery, St. Elizabeth’s Medical Center, Boston, MA 02135
8
2
Division of Transplant Surgery, Tufts Medical Center, Boston, MA 02111
SC
7
M AN U
9
10
11
13
TE D
12
Presented at the 34th Annual Meeting of the Southern California Vascular Surgery Society,
15
La Jolla CA, April 29 – May 1, 2016.
17 18 19 20 21 22 23 24 25 26 27 28
AC C
16
EP
14
Corresponding Author/Reprints: Katie Shean, MD Nikhil Kansal, MD St. Elizabeth’s Medical Center 736 Cambridge Street, Suite CCP#8 Boston, MA 02135 Telephone: 617-789-3309 E-mail: [email protected]; [email protected]
ACCEPTED MANUSCRIPT
Abstract: Hepatic artery aneurysms are uncommon, with fewer than 500 cases noted in the
2
literature. Bi-lobed hepatic artery aneurysms are extremely rare, with no documented cases in the
3
literature. Though often asymptomatic, these visceral aneurysms are at high risk of rupture. We
4
present an interesting case report of a bi-lobed hepatic artery aneurysm with occlusion of the celiac
5
axis in a 72-year-old woman. She was asymptomatic at the time of presentation and diagnosis was
6
made on CT scan. She was not a candidate for endovascular repair due to the anatomy of the
7
aneurysm and a chronically occluded celiac artery origin. Surgical repair using a bifurcated graft
8
with ligation of the gastroduodenal artery was performed.
M AN U
9
SC
RI PT
1
Introduction: Hepatic artery aneurysms (HAAs) represent the second most common visceral artery
11
aneurysm, accounting for about 20% of these lesions.1 Wilson was the first to describe an HAA in
12
1809 and the first successful ligation occurred in 1903 by Kehr.2 HAAs have the highest rate of
13
rupture among all splanchnic artery aneurysms and warrant an aggressive management strategy.3,4
14
The majority of these aneurysms are found incidentally during cross-sectional imaging or
15
ultrasound.5 Repair options vary depending on the anatomic location of the aneurysm as well as
16
patient factors; both endovascular and open surgical repair have been described.6-12
EP
17
TE D
10
Case Report: A 72-year-old female with a past medical history of progressive supranuclear palsy
19
presented to the Emergency Department with complaints of left lower quadrant abdominal pain. She
20
underwent CT scan and was diagnosed with a kidney stone. An incidental finding of a mass
21
prompted repeat imaging which demonstrated the mass to be a 6-cm bi-lobed aneurysm arising from
22
the celiac axis. The patient subsequently underwent a CT angiogram, which more clearly identified a
23
6.0 x 4.2 x 3.7-cm bi-lobed hepatic artery aneurysm arising from a chronically occluded celiac artery
24
(Fig. 1A). The primary blood flow to the aneurysm was from the gastroduodenal artery (GDA) via
AC C
18
ACCEPTED MANUSCRIPT
1
high flow pancreaticoduodenal collaterals (Fig. 1B). The patient was referred to our Vascular
2
Surgery service for treatment.
3
On presentation, physical exam revealed a palpable mass in the subxiphoid region. She denied any symptoms at this time. Angiogram was performed, which demonstrated a large bi-lobed
5
aneurysm with the first portion involving the proximal common hepatic artery and the second
6
including the proper hepatic artery as well as the origin of the GDA (Fig. 2). The GDA was
7
markedly dilated and was providing retrograde flow into the celiac artery circulation, which was
8
occluded at its origin. Given the large size of the aneurysm and the high risk of rupture in this patient
9
population, we recommended open surgical repair and bypass. Though the literature reports that
M AN U
SC
RI PT
4
10
HAAs can be treated safely with endovascular repair,8-10 the patient’s occluded celiac axis precluded
11
direct access to the aneurysm, and therefore was not an option. The occlusion of the celiac artery
12
required that blood flow needed to be maintained to both the hepatic and the splenic arteries.
13
Exposure to the abdomen was obtained through a subcostal incision. Upon entering the abdomen, the aneurysm was easily identified under the edge of the left lobe of the liver. The
15
proximal lobe of the aneurysm involved the majority of the common hepatic artery. The right and
16
left hepatic arteries originated from the distal aspect of the aneurysm sac. Inflow to the aneurysm
17
sac, as well as the hepatic and splenic circulation, was supplied through retrograde perfusion from the
18
GDA. A 14x7-mm bifurcated Dacron graft was sewn end-to-side to the supraceliac aorta. The left
19
limb of the bypass graft was anastomosed in end-to-end fashion with the splenic artery. An end-to-
20
end anastomosis was fashioned from the right limb of the bypass graft to a Carrel patch of the
21
aneurysm sac that included the origins of the right and left hepatic artery. The GDA was ligated at
22
the level of the aneurysm. Her postoperative course was uneventful and she was discharged home on
23
post-operative day #6. Post-operative imaging confirmed graft exclusion and graft limb patency.
24
She underwent repeat imaging at six months and again at two years postoperatively, which
AC C
EP
TE D
14
ACCEPTED MANUSCRIPT
1
demonstrated continued limb patency, as well as no evidence of aneurysmal degeneration of the
2
hepatic artery anastomosis (Fig. 3).
3
Discussion: Hepatic artery aneurysms, like all splanchnic aneurysms, represent a rare pathology.
5
They have previously been documented as the second most common visceral aneurysm, behind the
6
splenic artery, but recent data suggest they may be more common.1,13 It is projected that the
7
incidence is less than 0.4% of the population, however, this is only an estimate, as most are
8
discovered incidentally.14 The overall incidence has been rising, which is likely due to the increased
9
use of cross-sectional imaging as a diagnostic tool, as well as increasing hepatobiliary
M AN U
SC
RI PT
4
10
interventions.7,8,15 These aneurysms are often asymptomatic, but can present as abdominal or back
11
pain when expanding. HAAs have the highest risk of rupture of all visceral aneurysms, and thus an
12
aggressive approach to operative management is warranted when discovered.3
13
Though the natural course of hepatic artery aneurysms is not clearly defined, the current guidelines recommend repair for those greater than 2.0-cm or those with multiple aneurysms.16 Our
15
patient’s anatomy was very unique; to date, there have been no documented cases of bi-lobed HAAs.
16
Though we cannot know the exact clinical implications of being bi-lobed, given the guidelines
17
above, repair was the clear choice in our opinion, due to its having more than one aneurysmal sac and
18
its larger size. Additionally, the reports of giant HAAs are infrequent, with less than 20 found in the
19
literature. Though no true size criterion exists for the definition of “giant” HAA, previous reports
20
have defined these as any HAA with a diameter greater than 5.5-cm.17 Open surgical repair has been
21
the traditional approach for repair of these aneurysms, though reports of endovascular repair are
22
increasing.11,12,18,19 As discussed previously, our patient’s anatomical features precluded her from
23
being a candidate for endovascular repair.
24 25
AC C
EP
TE D
14
While there are only a few limited series reporting endovascular treatment of HAAs, this approach has the potential advantage of lower morbidity and mortality when compared to open
ACCEPTED MANUSCRIPT
repair. Open repair has long been the standard, and has provided a safe and durable treatment for
2
patients. Recent data suggest that endovascular repair is a safe alternative to open repair,8-10
3
however, little is known about its durability and long-term outcomes. An extensive literature review
4
of giant HAAs repaired endovascularly revealed only a single documented follow-up beyond one
5
year.20,21 Similarly, those with open surgical repair from the same patient population also failed to
6
yield any long-term follow-up.22-24 Our patient underwent CT scan two years after her bypass,
7
confirming the Carrel patch did not undergo aneurysmal degeneration, as well as confirming graft
8
limb patency. This is the longest follow-up ever reported following repair of a giant HAA. Current
9
treatment guidelines do not define what appropriate long-term surveillance these patients need, and is
M AN U
SC
RI PT
1
typically decided at the discretion of the surgeon. As these rare visceral artery aneurysms are
11
discovered with increasing frequency, we may develop a better understanding of their natural history
12
and the indications for repair. Open repair remains a good option for repair of these aneurysms and
13
can be performed safely with acceptable morbidity and mortality.
EP AC C
14
TE D
10
ACCEPTED MANUSCRIPT
TE D
M AN U
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22. Cimsit B, Ozden I, Emre AS. A rare intraabdominal tumor: giant hepatic artery aneurysm. J Med Invest 2006;53:174-6. 23. Shiraishi M, Takahashi M, Yamaguchi A, Adachi H. Hepatic artery pseudoaneurysm with extrahepatic biliary obstruction. Ann Vasc Dis 2012;5:100-3. 24. Sohn ME, Stonerock CE, Dalsing MC. Multiple giant superior mesenteric artery branch aneurysms. Ann Vasc Surg 2007;21:280-3.
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Figure 1A: CT scan of the large bi-lobed hepatic artery aneurysm (HAA)
Figure 1B: CT scan showing the occlusion of the celiac artery axis and a large
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pancreaticoduodenal collateral vessel
ACCEPTED MANUSCRIPT Figure 2: Angiogram of the bi-lobed HAA with blood flow from the markedly dilated
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gastroduodenal artery (GDA), providing retrograde flow into the celiac artery circulation
Figure 3: Follow-up CT reconstruction depicting continued limb patency and no evidence of
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aneurysmal degeneration of the hepatic artery anastomosis