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Percutaneous Embolization for the Management of Hepatic Artery Aneurysms
Vol. 73, No. 5
GASTROENTEROLOGY 73:1142-1146, 1977 Copyright © 1977 by the American Gastroenterological Association
Printed in U.S A .
CASE REPORTS PERCUTANEOUS EMBOLIZATION FOR THE MANAGEMENT OF HEPATIC ARTERY ANEURYSMS M. GoLDBLATT, M.B., CH.B ., F.F.RAD.(D)(S.A.), D.M.R.D., A. R. GoLDIN, M.B.B.CH., F.C.P.(S.A.), F.R.C.R., AND M. I. SHAFF, M.B.B.CH., F.R.C.R. Department of Radiology, Groote Schuur Hospital , Observatory, Cape Town , South Africa
The significant mortality and morbidity of hepatic artery aneurysms indicate the need for new approaches to therapy. Seven cases of intrahepatic aneurysms diagnosed by percutaneous arteriography over a 7-yr period are discussed. Three patients were treated surgically and 4 by percutaneous embolization. The latter method appears to enjoy certain advantages and it may prove to be the treatment of choice for this often fatal condition. Intrahepatic aneurysms of the hepatic artery are unusual. Of 250 reported cases of hepatic artery aneurysms reviewed by Lataste et al. 1 in 1971, only 50 arose from the intrahepatic arterial tree. Of these, 10 cases presented with hemobilia. Hemobilia may be suspected clinically by a triad of gastrointestinal bleeding, right upper quadrant colic, and jaundice. Arteriography will establish the diagnosis in the majority of cases and discriminate hemobilia from other causes of gastrointestinal bleeding. 2• a Hepatic artery aneurysms may be caused by blunt and penetrating trauma (including liver biopsy), septic emboli associated with subacute bacterial endocarditis, malignant disease, syphilis, tuberculosis, arteriosclerosis, malaria, pregnancy, and polyarteritis nodosa, and some are congenital in origin. 4 • 5 Seven cases of intrahepatic aneurysms of the hepatic artery were diagnosed by arteriography between 1969 and 1977. Three patients were treated by surgery and 4 by percutaneous transcatheter embolization. The case reports of 3 of the latter group are presented. The 4th patient has already been documented. 6
Case Reports Case 1 . A 55-year-old female presented with brisk hematemesis and symptoms of general debility. Stool was positive for occult blood and hemoglobin was 10.4 g per 100 ml. The liver was slightly enlarged, but no jaundice was evident clinically or biochemically. Three units of blood were administered and gastroscopy demonstrated superficial gastric erosions. One day later, severe hematemesis associated with hypotension recurred. Six units of blood were administered and gastroscopy was repeated. Fresh bleeding from the second part of the duodenum was seen, but the exact site was not visualized. Received December 18, 1976. Accepted May 10, 1977. Address requests for reprints to: Dr. Merwyn Goldblatt, Department of Radiology, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
Celiac axis arteriography demonstrated a large tortuous, aneurysmal sac arising from a branch of the left hepatic artery (fig. 1, top). Superselective embolization was carried out by injecting pledgets of gelfoam suspended in contrast medium.7-10 Postembolization, transient jaundice with elevation ofliver enzymes occurred. There was no further bleeding and recovery was uneventful. Celiac arteriography 7 weeks after embolization demonstrated no recurrence of the aneurysm (fig. 1, bottom).
Case 2. A 30-year-old male schizophrenic confined to a mental hospital and receiving phenothiazines presented with intermittent hematemesis and melena accompanied by jaundice, pyrexia, epigastric tenderness, and an elevated WBC. Ultrasound demonstrated cystic areas in the left lobe of the liver consistent with intrahepatic abscesses. Endoscopy demonstrated bleeding from the second part of the duodenum. Shortly thereafter, the patient developed massive hematemesis and melena, abdominal swelling, and circulatory collapse with cardiac arrest. Resuscitation was successful and emergency laparotomy was performed. Hemoperitoneum and hemobilia were present with the biliary tree grossly distended by blood clot, and a small necrotic hemorrhagic area in the left lobe of the liver. This area was biopsied and a T-tube was placed in the biliary tree. The abdomen was closed and in the presence of continuing hemobilia, celiac arteriography was carried out. Gross extravasation of contrast medium into a cavity in the left lobe of the liver was demonstrated (fig. 2). Selective catheterization and embolization of the left hepatic artery controlled the extravasation (fig. 3). Postembolization no further hepatic bleeding occurred. The biopsy of the left lobe of the liver taken at laparotomy confirmed the diagnosis of pyogenic abscess. Case 3. A 17-year-old male suffered a major gunshot wound of the upper abdomen. Exploration revealed laceration of the stomach and gross disruption of the right lobe of the liver associated with profuse intraperitoneal hemorrhage. The stomach was repaired, liver edges were debrided and approximated, and cholecystectomy was performed. Two days postoperatively, sudden, profuse bleeding from the wound drains with a drop in hemoglobin occurred and celiac axis arteriography was carried out. A false aneurysm arising from a small proximal branch of the right hepatic
1142
FIG .
1. Top, early film during celiac axis arteriography, demonstrating large fusiform aneurysm arising from an intrahepatic branch
(a rrowhead) of the left hepatic artery. The gallbladder is distended by blood (arrows). Bottom, celiac axis arteriogram 7 weeks postemboliza-
tion shows total occlusion of previously demonstrated large aneurysm and no apparent disturbance of intrahepatic arterial architecture. 1143
t
FrG. 2. Early and late arterial phases of celiac axis arteriogram with extravasation of contrast from a left hepatic artery branch into an irregular intrahepatic cavity (arrows).
FrG. 3. Early and late arterial phases of selective left hepatic arteriogram after Gelfoam embolization, showing occlusion of left hepatic artery (arrowhead) and no fresh extravasation of contrast medium into liver. 1144
November 1977
CASE REPORTS
1145
FIG. 4. Top, selective hepatic arteriogram showing intrahepatic aneurysm arising from small branch of right hepatic artery. Bottom, postembolization film showing occlusion of arterial branch with no evidence of residual filling of aneurysm (arrowhead) .
1146
Vol . 73, No . 5
CASE REPORTS
artery was demonstrated (fig. 4, top). Embolization using autologous clot via a superselective coaxial catheter resulted in occlusion of the small feeding vessel (fig. 4, bottom) . No further hepatic bleeding occurred thereafter, but the patient's recovery was complicated by subphrenic and pelvic abscesses and his convalescence was protracted.
Discussion Interest in embolic therapy for the management of hepatic artery aneurysms was stimulated by the unsatisfactory results of surgery in the 3 cases, which predated those treated by embolization. Ofthese patients, 2 who were treated by hepatic artery ligation died and the 3rd underwent partial hepatectomy and suffered major postoperative complications. Hemorrhage was controlled in the 4 patients treated by embolization (including the case documented by Bass and Crozier6) and no complications attributable to the procedure occurred. These two groups of patients cannot however be regarded as comparable as the management of 2 of the surgical cases was suboptimal. To date there are no controlled series comparing surgical and embolic therapy, but review of the result of surgery indicates the need for an improved method of treatment. Most of the cases reported have been treated by oversewing of superficial aneurysms, 11- 13 proximal hepatic artery ligation, 4 • 14 • 15 or hepatic artery ligation distal to the gastroduodenal artery. 4 The ability of the liver to withstand arterial ligation is dependent on normal portal blood flow and hepatic necrosis is infrequent in the absence of preexisting liver disease. 1&- 19 In the presence of cirrhosis and decreased portal blood flow however, proximal hepatic artery ligation has a mortality of 27 to 67%. 4 Proximal ligation for the control of hepatic artery aneurysms may also fail to control bleeding owing to distal filling via collateral vessels. 4 • 10 Partial or total hepatic lobectomy for hepatic trauma is a more difficult procedure than ligation and carries a mortality of over 40% .4 • 2()-22 In contrast to surgery, percutaneous hepatic artery embolization is a minor procedure carried out under local anesthesia. The immediate control of hemorrhage after embolization is apparent on repeat arteriography and the option of surgery remains open in the advent of technical failure. The risk of hepatic necrosis is dependent on the area of liver deprived of arterial supply and on the adequacy of portal blood flow. Superselective catheterization and embolization can be performed with occlusion of only a small part of the hepatic arterial tree, in contrast to surgical ligation, in which technical considerations dictate more proximal ligation. Experimental evidence23 suggests that embolic therapy may be the method of choice for hepatic artery aneurysms and experience to date in these 4 cases appears to substantiate this.
REFERENCES 1. Lataste J, Albou JC, Melet J : Intrahepatic aneurysm complicated by hemobilia, cured by right hepatectomy. Presse Med 79:1809-1811, 1971 2. Sutton D, Lawton G: Angiographic diagnosis of aneurysms involving the hepatic artery. Clin Radiol 24:43-48, 1973 3. Gupta S, Cope V: Hepatic artery aneurysm as a cause of gastrointestinal blood loss. Br J Radiol 45:726-729, 1972 4. Erskine JM: Hepatic artery aneurysm. Vase Surg 7:106-125, 1973 5. Berenson MM, Freston JW: Intrahepatic artery aneurysm associated with hemobilia. A case report. Gastroenterology 66:254259, 1974 6. Bass EM, Crosier JH: Percutaneous control of post-traumatic hepatic hemorrhage by gelfoam embolization. J Trauma 17: 6163 , 1977 7. Goldstein HM, Medellin H, Beydoun MT, et al: Transcatheter embolization of renal cell carcinoma. Amer J Roentgenol Radium Ther Nucl Med 557-562, 1975 8. Ben Menachem Y, Crigler CM, Corriere JN: Elective transcatheter renal artery occlusion prior to nephrectomy. J Urol114:355359, 1975 9. Carey LS , Grace DM: The brisk bleed: control by arterial catheterization and gelfoam plug. J Can Assoc Radiol 25:113, 1974 10. Athanasoulis CA, Waltman AC, Novelline RA, et al: Angiography: its contribution to the emergency management of gastrointestinal haemorrhage. Radiol Clin North Am 14:265-280, 1976 11. Anderson EM: Aneurysms: report of cases. Am J Surg 33:129, 1919 12. Glassman E, Skerret PV: Rupture of an intrahepatic aneurysm due to polyarteritis nodosa. Am J Med 28:143-146, 1960 13. Dwonczyk J, Serlin 0, Skerret PV: Spontaneous rupture of the liver: report of a case secondary to polyarteritis nodosa. Ann Surg 150:327-330, 1959 14. Macdonald JA, Baker CB, Welsh WK: Hepatic artery aneurysm: report of a case. Ann Surg 161:94-96, 1965 15. Guynn VL, Reynolds JT: Surgical management of hemobilia. Arch Surg 83:73-81, 1961 16. Bruwer AJ, Hollenbeck GA: Aneurysm of the hepatic artery: roentgenologic features in one case. Am J Roentgenol Radium Ther Nucl Med 78:270-272, 1957 17. Monafo WW, Ternberg JL, Kempson R: Accidental ligation of the hepatic artery. Arch Surg 92:643-652, 1966 18. Almersjo 0, Bengmark S, Rudenstam CM, et al. : Evaluation of hepatic dearterialization in primary and secondary cancer of the liver. Am J Surg 124:5-9, 1972 19. Baker JW, Chan AP, Anderson FH: Survival after hepatic artery ligation: present controversy and rationale of management, with a case report. Can J Surg 17:135-138, 1974 20. Cohen Y, Chow KW, Seah CS: Intrahepatic aneurysm diagnosed pre-operatively and treated by resection. Br J Surg 53:602-606, 1966 21. Aronsen KF, Bengmark S, Dahlgren S, et al: Liver resection in treatment of blunt injuries to the liver. Surgery 63:236-246, 1968 22. McDermott WV, Ottinger LW: Elective hepatic resection. Am J Surg 112:376-381, 1966 23. Cho KJ , Reuter SR, Schmidt R: Effects of experimental hepatic artery embolization on hepatic function. Am J Roentgenol Radium Ther Nucl Med 127:563-567, 1976
GASTROENTEROLOGY 73:1142-1146, 1977 Copyright © 1977 by the American Gastroenterological Association
Printed in U.S A .
CASE REPORTS PERCUTANEOUS EMBOLIZATION FOR THE MANAGEMENT OF HEPATIC ARTERY ANEURYSMS M. GoLDBLATT, M.B., CH.B ., F.F.RAD.(D)(S.A.), D.M.R.D., A. R. GoLDIN, M.B.B.CH., F.C.P.(S.A.), F.R.C.R., AND M. I. SHAFF, M.B.B.CH., F.R.C.R. Department of Radiology, Groote Schuur Hospital , Observatory, Cape Town , South Africa
The significant mortality and morbidity of hepatic artery aneurysms indicate the need for new approaches to therapy. Seven cases of intrahepatic aneurysms diagnosed by percutaneous arteriography over a 7-yr period are discussed. Three patients were treated surgically and 4 by percutaneous embolization. The latter method appears to enjoy certain advantages and it may prove to be the treatment of choice for this often fatal condition. Intrahepatic aneurysms of the hepatic artery are unusual. Of 250 reported cases of hepatic artery aneurysms reviewed by Lataste et al. 1 in 1971, only 50 arose from the intrahepatic arterial tree. Of these, 10 cases presented with hemobilia. Hemobilia may be suspected clinically by a triad of gastrointestinal bleeding, right upper quadrant colic, and jaundice. Arteriography will establish the diagnosis in the majority of cases and discriminate hemobilia from other causes of gastrointestinal bleeding. 2• a Hepatic artery aneurysms may be caused by blunt and penetrating trauma (including liver biopsy), septic emboli associated with subacute bacterial endocarditis, malignant disease, syphilis, tuberculosis, arteriosclerosis, malaria, pregnancy, and polyarteritis nodosa, and some are congenital in origin. 4 • 5 Seven cases of intrahepatic aneurysms of the hepatic artery were diagnosed by arteriography between 1969 and 1977. Three patients were treated by surgery and 4 by percutaneous transcatheter embolization. The case reports of 3 of the latter group are presented. The 4th patient has already been documented. 6
Case Reports Case 1 . A 55-year-old female presented with brisk hematemesis and symptoms of general debility. Stool was positive for occult blood and hemoglobin was 10.4 g per 100 ml. The liver was slightly enlarged, but no jaundice was evident clinically or biochemically. Three units of blood were administered and gastroscopy demonstrated superficial gastric erosions. One day later, severe hematemesis associated with hypotension recurred. Six units of blood were administered and gastroscopy was repeated. Fresh bleeding from the second part of the duodenum was seen, but the exact site was not visualized. Received December 18, 1976. Accepted May 10, 1977. Address requests for reprints to: Dr. Merwyn Goldblatt, Department of Radiology, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
Celiac axis arteriography demonstrated a large tortuous, aneurysmal sac arising from a branch of the left hepatic artery (fig. 1, top). Superselective embolization was carried out by injecting pledgets of gelfoam suspended in contrast medium.7-10 Postembolization, transient jaundice with elevation ofliver enzymes occurred. There was no further bleeding and recovery was uneventful. Celiac arteriography 7 weeks after embolization demonstrated no recurrence of the aneurysm (fig. 1, bottom).
Case 2. A 30-year-old male schizophrenic confined to a mental hospital and receiving phenothiazines presented with intermittent hematemesis and melena accompanied by jaundice, pyrexia, epigastric tenderness, and an elevated WBC. Ultrasound demonstrated cystic areas in the left lobe of the liver consistent with intrahepatic abscesses. Endoscopy demonstrated bleeding from the second part of the duodenum. Shortly thereafter, the patient developed massive hematemesis and melena, abdominal swelling, and circulatory collapse with cardiac arrest. Resuscitation was successful and emergency laparotomy was performed. Hemoperitoneum and hemobilia were present with the biliary tree grossly distended by blood clot, and a small necrotic hemorrhagic area in the left lobe of the liver. This area was biopsied and a T-tube was placed in the biliary tree. The abdomen was closed and in the presence of continuing hemobilia, celiac arteriography was carried out. Gross extravasation of contrast medium into a cavity in the left lobe of the liver was demonstrated (fig. 2). Selective catheterization and embolization of the left hepatic artery controlled the extravasation (fig. 3). Postembolization no further hepatic bleeding occurred. The biopsy of the left lobe of the liver taken at laparotomy confirmed the diagnosis of pyogenic abscess. Case 3. A 17-year-old male suffered a major gunshot wound of the upper abdomen. Exploration revealed laceration of the stomach and gross disruption of the right lobe of the liver associated with profuse intraperitoneal hemorrhage. The stomach was repaired, liver edges were debrided and approximated, and cholecystectomy was performed. Two days postoperatively, sudden, profuse bleeding from the wound drains with a drop in hemoglobin occurred and celiac axis arteriography was carried out. A false aneurysm arising from a small proximal branch of the right hepatic
1142
FIG .
1. Top, early film during celiac axis arteriography, demonstrating large fusiform aneurysm arising from an intrahepatic branch
(a rrowhead) of the left hepatic artery. The gallbladder is distended by blood (arrows). Bottom, celiac axis arteriogram 7 weeks postemboliza-
tion shows total occlusion of previously demonstrated large aneurysm and no apparent disturbance of intrahepatic arterial architecture. 1143
t
FrG. 2. Early and late arterial phases of celiac axis arteriogram with extravasation of contrast from a left hepatic artery branch into an irregular intrahepatic cavity (arrows).
FrG. 3. Early and late arterial phases of selective left hepatic arteriogram after Gelfoam embolization, showing occlusion of left hepatic artery (arrowhead) and no fresh extravasation of contrast medium into liver. 1144
November 1977
CASE REPORTS
1145
FIG. 4. Top, selective hepatic arteriogram showing intrahepatic aneurysm arising from small branch of right hepatic artery. Bottom, postembolization film showing occlusion of arterial branch with no evidence of residual filling of aneurysm (arrowhead) .
1146
Vol . 73, No . 5
CASE REPORTS
artery was demonstrated (fig. 4, top). Embolization using autologous clot via a superselective coaxial catheter resulted in occlusion of the small feeding vessel (fig. 4, bottom) . No further hepatic bleeding occurred thereafter, but the patient's recovery was complicated by subphrenic and pelvic abscesses and his convalescence was protracted.
Discussion Interest in embolic therapy for the management of hepatic artery aneurysms was stimulated by the unsatisfactory results of surgery in the 3 cases, which predated those treated by embolization. Ofthese patients, 2 who were treated by hepatic artery ligation died and the 3rd underwent partial hepatectomy and suffered major postoperative complications. Hemorrhage was controlled in the 4 patients treated by embolization (including the case documented by Bass and Crozier6) and no complications attributable to the procedure occurred. These two groups of patients cannot however be regarded as comparable as the management of 2 of the surgical cases was suboptimal. To date there are no controlled series comparing surgical and embolic therapy, but review of the result of surgery indicates the need for an improved method of treatment. Most of the cases reported have been treated by oversewing of superficial aneurysms, 11- 13 proximal hepatic artery ligation, 4 • 14 • 15 or hepatic artery ligation distal to the gastroduodenal artery. 4 The ability of the liver to withstand arterial ligation is dependent on normal portal blood flow and hepatic necrosis is infrequent in the absence of preexisting liver disease. 1&- 19 In the presence of cirrhosis and decreased portal blood flow however, proximal hepatic artery ligation has a mortality of 27 to 67%. 4 Proximal ligation for the control of hepatic artery aneurysms may also fail to control bleeding owing to distal filling via collateral vessels. 4 • 10 Partial or total hepatic lobectomy for hepatic trauma is a more difficult procedure than ligation and carries a mortality of over 40% .4 • 2()-22 In contrast to surgery, percutaneous hepatic artery embolization is a minor procedure carried out under local anesthesia. The immediate control of hemorrhage after embolization is apparent on repeat arteriography and the option of surgery remains open in the advent of technical failure. The risk of hepatic necrosis is dependent on the area of liver deprived of arterial supply and on the adequacy of portal blood flow. Superselective catheterization and embolization can be performed with occlusion of only a small part of the hepatic arterial tree, in contrast to surgical ligation, in which technical considerations dictate more proximal ligation. Experimental evidence23 suggests that embolic therapy may be the method of choice for hepatic artery aneurysms and experience to date in these 4 cases appears to substantiate this.
REFERENCES 1. Lataste J, Albou JC, Melet J : Intrahepatic aneurysm complicated by hemobilia, cured by right hepatectomy. Presse Med 79:1809-1811, 1971 2. Sutton D, Lawton G: Angiographic diagnosis of aneurysms involving the hepatic artery. Clin Radiol 24:43-48, 1973 3. Gupta S, Cope V: Hepatic artery aneurysm as a cause of gastrointestinal blood loss. Br J Radiol 45:726-729, 1972 4. Erskine JM: Hepatic artery aneurysm. Vase Surg 7:106-125, 1973 5. Berenson MM, Freston JW: Intrahepatic artery aneurysm associated with hemobilia. A case report. Gastroenterology 66:254259, 1974 6. Bass EM, Crosier JH: Percutaneous control of post-traumatic hepatic hemorrhage by gelfoam embolization. J Trauma 17: 6163 , 1977 7. Goldstein HM, Medellin H, Beydoun MT, et al: Transcatheter embolization of renal cell carcinoma. Amer J Roentgenol Radium Ther Nucl Med 557-562, 1975 8. Ben Menachem Y, Crigler CM, Corriere JN: Elective transcatheter renal artery occlusion prior to nephrectomy. J Urol114:355359, 1975 9. Carey LS , Grace DM: The brisk bleed: control by arterial catheterization and gelfoam plug. J Can Assoc Radiol 25:113, 1974 10. Athanasoulis CA, Waltman AC, Novelline RA, et al: Angiography: its contribution to the emergency management of gastrointestinal haemorrhage. Radiol Clin North Am 14:265-280, 1976 11. Anderson EM: Aneurysms: report of cases. Am J Surg 33:129, 1919 12. Glassman E, Skerret PV: Rupture of an intrahepatic aneurysm due to polyarteritis nodosa. Am J Med 28:143-146, 1960 13. Dwonczyk J, Serlin 0, Skerret PV: Spontaneous rupture of the liver: report of a case secondary to polyarteritis nodosa. Ann Surg 150:327-330, 1959 14. Macdonald JA, Baker CB, Welsh WK: Hepatic artery aneurysm: report of a case. Ann Surg 161:94-96, 1965 15. Guynn VL, Reynolds JT: Surgical management of hemobilia. Arch Surg 83:73-81, 1961 16. Bruwer AJ, Hollenbeck GA: Aneurysm of the hepatic artery: roentgenologic features in one case. Am J Roentgenol Radium Ther Nucl Med 78:270-272, 1957 17. Monafo WW, Ternberg JL, Kempson R: Accidental ligation of the hepatic artery. Arch Surg 92:643-652, 1966 18. Almersjo 0, Bengmark S, Rudenstam CM, et al. : Evaluation of hepatic dearterialization in primary and secondary cancer of the liver. Am J Surg 124:5-9, 1972 19. Baker JW, Chan AP, Anderson FH: Survival after hepatic artery ligation: present controversy and rationale of management, with a case report. Can J Surg 17:135-138, 1974 20. Cohen Y, Chow KW, Seah CS: Intrahepatic aneurysm diagnosed pre-operatively and treated by resection. Br J Surg 53:602-606, 1966 21. Aronsen KF, Bengmark S, Dahlgren S, et al: Liver resection in treatment of blunt injuries to the liver. Surgery 63:236-246, 1968 22. McDermott WV, Ottinger LW: Elective hepatic resection. Am J Surg 112:376-381, 1966 23. Cho KJ , Reuter SR, Schmidt R: Effects of experimental hepatic artery embolization on hepatic function. Am J Roentgenol Radium Ther Nucl Med 127:563-567, 1976