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Traumatic hepatic pseudoaneurysm with arterio-hepatic venous fistula: Diagnosis with MDCT angiography
Injury Extra (2006) 37, 349—352
www.elsevier.com/locate/inext
CASE REPORT
Traumatic hepatic pseudoaneurysm with arterio-hepatic venous fistula: Diagnosis with MDCT angiography Sheng-Che Hung a, Jen-Dar Chen a,b,*, Chui-Mei Tiu a,b, Yi-You Chiou a,b, Cheng-Yen Chang a,b a b
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan National Yang-Ming University, School of Medicine, Taipei, Taiwan
Accepted 7 March 2006
Introduction Neoplasm, trauma or iatrogenic injury are leading causes of hepatic arterio-portal fistulas (APFs). On the other hand a fistula between the hepatic arteries and hepatic veins is rare. We report a case of a traumatic hepatic pseudoaneurysm complicated by an arterio-hepatic venous fistula (AVF) and emphasize the value of multi-detector computer tomography (MDCT) in diagnosis and management planning.
Case report A 41-year-old gentleman, who had no remarkable past illness, was injured in a motorcycle-versus-vehicle crash and was transferred to our Emergency Department due to right upper abdominal pain. On arrival, his blood pressure was 112/76 mmHg, and heart rate was 90/min. Physical examination revealed right upper quadrant tenderness with muscular rigidity. * Corresponding author. Tel.: +886 2 28712121x7350; fax: +886 2 28769310. E-mail addresses: [email protected] (S.-C. Hung), [email protected] (J.-D. Chen), [email protected] (C.-M. Tiu), [email protected] (C.-Y. Chang).
Laboratory data showed only mildly abnormal liver function tests and other biochemical studies were normal. A contrast-enhanced dynamic CT examination was performed with a multi-detector CT (Sensation 16, Siemens, Erlangen, Germany). The arterial and the portal venous phase images were obtained at a 35 and 90 s delay after contrast injection (100 ml of Optiray [Isoversol], TYCO Healthcare, Canada). The CT scan disclosed a grade 4 liver injury and a 1 cm 1 cm 5 cm intrahepatic pseudoaneurysm, arising from the S7 branch of the right hepatic artery. In the arterial phase of the CT scan, the distal branches of the right hepatic vein were opacified simultaneously via a pseudoaneurysm of right hepatic artery (Figs. 1 and 2), with accompanying transient distal wedge-shaped subsegmental parenchymal enhancement, which usually exists in arterio-portal shunting. Considering the high-grade injury and the risk of rebleeding from the pseudoaneurysm, an emergency angiogram was performed. The angiogram revealed similar findings as those of the MDCT. A large pseudoaneurysm was found arising from the S7 branch of the right hepatic artery with early opacification of distal branches of the right hepatic vein (Fig. 3A). The proximal trunk of the right hepatic vein was not opacified from those
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.03.013
350
Figure 1 (A) Precontrast CT revealed liver laceration and hemoperitoneum. One relatively hypodense pseudoaneurysm (arrow) was seen in the hematoma. (B) Postcontrast CT on arterial phase showed the enhanced pseudoaneurysm (short arrow) with opacification of contiguous distal right hepatic vein (long arrow).
distal branches throughout the angiogram. These findings were unusual for an arterio-venous fistula. Because of the unusal hepatofugal direction of flow in the right hepatic vein, we reviewed the CT images and found a disruption of the right hepatic vein, just proximal to the communication site, where the right hepatic vein connected with the pseudoaneurysm. This explained the unusual angiographic appearance of the AVF. Similar wedge-shaped subsegmental enhancement was also noted during the hepatic arteriogram, followed by inverse intrahepatic portal flow in the delayed phase. We performed transcatheter arterial embolization of the pseudoaneurysm with microcoils (Fig. 3B). The patient was discharged about one week later uneventfully.
Discussion The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes in most instances. The incidence
S.-C. Hung et al.
Figure 2 (A) Thin-slab maximal intensity projection (MIP) demonstrated the relationship of the pseudoaneurysm (short arrow), right hepatic artery (long arrow) and distal right hepatic vein (medium-sized arrow). (B) Thinslab MIP reformation of portal phase CT demonstrated the communication between pseudoaneurysm (medium-sized arrow) and distal right hepatic vein (long arrow) and the occlusion site (dotted arrow) of proximal right hepatic vein (short arrow). MHV: middle hepatic vein. LHV: left hepatic vein.
of hepatic vascular injuries after blunt trauma is much lower than that after penetrating injury, and the incidence is still not established. Arteriovenous fistulae are rare in comparison arterioportal fistula. The leading causes of APFs are neoplasm,11 congenital anomaly2,4,7,14 and trauma, especially iatrogenic injury, such as needle biopsy or percutaneous drainage.13 Okuda et al.13 reported a series of 93 patients having angiography after a procedure of needle biopsy and 79 patients after percutaneous biliary drainage. Five and three patients were demonstrated to have APF, respectively, and only one case had an AVF with the right hepatic vein.
Traumatic hepatic pseudoaneurysm with AV fistula
Figure 3 (A) Right hepatic arteriogram revealed a pseduoaneurysm (middle arrow) arising from S7 branch of right hepatic artery (short arrow) and early opacification of right distal hepatic veins (long arrow) on arterial phase. (B) Transcatheter embolization was performed with several microcoils, and the pseudoaneurysm and arteriohepatic venous fistula were completely obliterated.
In the past, most of these injuries were treated surgically. However, up to 67% of operations in the past for bleeding from blunt hepatic trauma were non-therapeutic with bleeding often stopping spontaneously.15 Angiography was traditionally believed to be the gold standard and the only imaging modality to diagnose hepatic vascular injuries. Recent advances in computed tomographic (CT) technology and three-dimensional (3D) imaging software gave CT a vital role in the diagnosis of abdominal trauma. MDCT allows thinner collimation, shorter scanning time and better patienttolerance. 3D post-processing of CT angiography with multiplanar reformation
351 (MPR), maximal intensity projection (MIP) and volume rendering technique (VRT) is especially helpful in detection of vascular injuries.18 In this case, CT findings of early opacification of the hepatic arterial pseudoaneurysm and distal branches of right hepatic vein in arterial phase suggested AVF. Wedge-shaped transient subsegmental parenchymal enhancement (TSPE) is usually an indirect sign of APF9 and rarely seen in AVF because of the difference of flow direction. This unusual complication of AVF resulted in inverse intrahepatic portal flow probably due to an inverse pressure gradient, and if left unnoticed, the inverse flow may produce symptoms like those of the venoocclusive disease or traumatic APFs. Early symptoms include abdominal pain, diarrhoea, gastrointestinal bleeding from congestive vascular enteritis and, rarely, ascites. Late symptoms may be manifested as portal hypertension, such as bleeding oesophageal varices or haemobilia.5,8 Interventional techniques, especially angiographic embolisation, are well-known as useful adjuncts in non-operative management of blunt liver trauma.3,19 Early angiographic embolisation decreases the incidence of blood transfusion and number of liver-related operations.1 Treatment of pseudoaneurysms has shifted away from operative intervention and toward radiologic embolisation with various materials12 or even observation alone in some case reports.10 Transcatheter arterial embolisation has proved to be effective in treatment of arterioportal shunts, and its associated complications are rare.17 However, angiographic treatment of hepatic AVF is not established and seldom discussed. Embolisation has been effective in some reports16,6 but a larger series was still necessary. Embolisation in patients with blunt hepatic injury has not been proved to be effective for venous injury. Bleeding caused by major portal vein or hepatic vein injury may continue after embolisation. Fortunately, bleeding from these veins will often halt spontaneously because of intraabdominal tamponade. In conclusion, CT plays a vital role in decision making in blunt trauma. Angiographic embolisation can decrease the incidence of transfusion and the number of liver-related operations. MDCT angiography can be very helpful in proper planning before an interventional procedure.
Reference 1. Alicia MM, Robert FL, Allison B, et al. Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003;55:1077—101. 2. Brohee D, Franken P, Fievez M, et al. High-output right ventricular failure secondary to hepatic Arteriovenous
352
3.
4.
5.
6.
7.
8.
9.
10.
microfistulae. Selective arterial embolization treatment. Arch Int Med 1984;144:1282—4. Carrillo EH, Spain DA, Wohltmann CD, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619—22. Dieter B, Georg AS, Hans LM, et al. Hyperdynamic circulatory state due to Osler-Weber-Rendu disease with intrahepatic Arteriovenous fistulas. Am Heart J 1972;85:797—800. English WP, Johnson MB, Borman KR, et al. Mesenteric ischemia: an unusual presentation of traumatic intrahepatic arterioportal fistula. Am Surg 2001;67:865—7. Galeon M, Goffette P, Van Beers BE, et al. Post-traumatic intrahepatic pseudoaneurysm: diagnosis with helical CT angiography and management with embolization. JBR-BTR 1997;80:287—8. Howard JM, Malafa M, Coombs RJ, et al. Arteriovenous fistula between the hepatic artery and the hepatic vein. HPB Surg 1989;1:155—60. Kayser S, Marincek B, Schlumpf R, et al. Rapidly progressive portal hypertension 23 years after post-traumatic arterioportal fistula of liver. Am J Gastroenterol 1996;91:1442—6. Lee SJ, Lim JH, Lee WJ, et al. Transient subsegmental hepatic parenchyma enhancement on dynamic CT: a sign of postbiopsy arterioportal shunt. J Comput Assist Tomogr 1997;21: 355—60. Lockwood TE, Schorn L, Coln D. Nonoperative management of hemobilia. Ann Surg 1977;185:335—40.
S.-C. Hung et al. 11. Luo MY, Shan H, Jiang ZB, et al. Multidetector spiral CT findings of arteriovenous fistula associated with hepatocellular carcinoma. Ai Zheng 2004;23:833—8. 12. Martin AC, Timothy CF, Jon PS, et al. Traumatic hepatic artery pseudoaneurysm with hemobilia. Am J Surg 1994;168: 235—8. 13. Okuda K, Musha H, Nakajima Y, et al. Frequency of intrahepatic arteriovenous fistula as a sequela to percutaneous needle puncture of the liver. Gastroenterology 1978;74: 1204—7. 14. Ouchi K, Matsubara S, Mikuni J, et al. The radiologic presentation of Osler-Weber-Rendu disease of the liver. Am J Gastroenterol 1994;89:425—8. 15. Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin North Am 1996;76:763—82. 16. Roman CF, Cha SD, Incarvito J, et al. Transcatheter embolization of hepatic Arteriovenous fistula in Osler-Weber-Rendu disease–—a case report. Angiology 1987;38:484—8. 17. Schwartz RA, Teitelbaum GP, Katz MD, et al. Effectiveness of transcatheter embolization in the control of hepatic vascular injuries. J Vasc Interv Radol 1993;4:359—65. 18. Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR 2004;25:180— 204. 19. Wendy LW, Karla SA, Mary MB, et al. The need for early angiographic embolization in blunt liver injuries. J Trauma 2002;52:1097—100.
www.elsevier.com/locate/inext
CASE REPORT
Traumatic hepatic pseudoaneurysm with arterio-hepatic venous fistula: Diagnosis with MDCT angiography Sheng-Che Hung a, Jen-Dar Chen a,b,*, Chui-Mei Tiu a,b, Yi-You Chiou a,b, Cheng-Yen Chang a,b a b
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan National Yang-Ming University, School of Medicine, Taipei, Taiwan
Accepted 7 March 2006
Introduction Neoplasm, trauma or iatrogenic injury are leading causes of hepatic arterio-portal fistulas (APFs). On the other hand a fistula between the hepatic arteries and hepatic veins is rare. We report a case of a traumatic hepatic pseudoaneurysm complicated by an arterio-hepatic venous fistula (AVF) and emphasize the value of multi-detector computer tomography (MDCT) in diagnosis and management planning.
Case report A 41-year-old gentleman, who had no remarkable past illness, was injured in a motorcycle-versus-vehicle crash and was transferred to our Emergency Department due to right upper abdominal pain. On arrival, his blood pressure was 112/76 mmHg, and heart rate was 90/min. Physical examination revealed right upper quadrant tenderness with muscular rigidity. * Corresponding author. Tel.: +886 2 28712121x7350; fax: +886 2 28769310. E-mail addresses: [email protected] (S.-C. Hung), [email protected] (J.-D. Chen), [email protected] (C.-M. Tiu), [email protected] (C.-Y. Chang).
Laboratory data showed only mildly abnormal liver function tests and other biochemical studies were normal. A contrast-enhanced dynamic CT examination was performed with a multi-detector CT (Sensation 16, Siemens, Erlangen, Germany). The arterial and the portal venous phase images were obtained at a 35 and 90 s delay after contrast injection (100 ml of Optiray [Isoversol], TYCO Healthcare, Canada). The CT scan disclosed a grade 4 liver injury and a 1 cm 1 cm 5 cm intrahepatic pseudoaneurysm, arising from the S7 branch of the right hepatic artery. In the arterial phase of the CT scan, the distal branches of the right hepatic vein were opacified simultaneously via a pseudoaneurysm of right hepatic artery (Figs. 1 and 2), with accompanying transient distal wedge-shaped subsegmental parenchymal enhancement, which usually exists in arterio-portal shunting. Considering the high-grade injury and the risk of rebleeding from the pseudoaneurysm, an emergency angiogram was performed. The angiogram revealed similar findings as those of the MDCT. A large pseudoaneurysm was found arising from the S7 branch of the right hepatic artery with early opacification of distal branches of the right hepatic vein (Fig. 3A). The proximal trunk of the right hepatic vein was not opacified from those
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.03.013
350
Figure 1 (A) Precontrast CT revealed liver laceration and hemoperitoneum. One relatively hypodense pseudoaneurysm (arrow) was seen in the hematoma. (B) Postcontrast CT on arterial phase showed the enhanced pseudoaneurysm (short arrow) with opacification of contiguous distal right hepatic vein (long arrow).
distal branches throughout the angiogram. These findings were unusual for an arterio-venous fistula. Because of the unusal hepatofugal direction of flow in the right hepatic vein, we reviewed the CT images and found a disruption of the right hepatic vein, just proximal to the communication site, where the right hepatic vein connected with the pseudoaneurysm. This explained the unusual angiographic appearance of the AVF. Similar wedge-shaped subsegmental enhancement was also noted during the hepatic arteriogram, followed by inverse intrahepatic portal flow in the delayed phase. We performed transcatheter arterial embolization of the pseudoaneurysm with microcoils (Fig. 3B). The patient was discharged about one week later uneventfully.
Discussion The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes in most instances. The incidence
S.-C. Hung et al.
Figure 2 (A) Thin-slab maximal intensity projection (MIP) demonstrated the relationship of the pseudoaneurysm (short arrow), right hepatic artery (long arrow) and distal right hepatic vein (medium-sized arrow). (B) Thinslab MIP reformation of portal phase CT demonstrated the communication between pseudoaneurysm (medium-sized arrow) and distal right hepatic vein (long arrow) and the occlusion site (dotted arrow) of proximal right hepatic vein (short arrow). MHV: middle hepatic vein. LHV: left hepatic vein.
of hepatic vascular injuries after blunt trauma is much lower than that after penetrating injury, and the incidence is still not established. Arteriovenous fistulae are rare in comparison arterioportal fistula. The leading causes of APFs are neoplasm,11 congenital anomaly2,4,7,14 and trauma, especially iatrogenic injury, such as needle biopsy or percutaneous drainage.13 Okuda et al.13 reported a series of 93 patients having angiography after a procedure of needle biopsy and 79 patients after percutaneous biliary drainage. Five and three patients were demonstrated to have APF, respectively, and only one case had an AVF with the right hepatic vein.
Traumatic hepatic pseudoaneurysm with AV fistula
Figure 3 (A) Right hepatic arteriogram revealed a pseduoaneurysm (middle arrow) arising from S7 branch of right hepatic artery (short arrow) and early opacification of right distal hepatic veins (long arrow) on arterial phase. (B) Transcatheter embolization was performed with several microcoils, and the pseudoaneurysm and arteriohepatic venous fistula were completely obliterated.
In the past, most of these injuries were treated surgically. However, up to 67% of operations in the past for bleeding from blunt hepatic trauma were non-therapeutic with bleeding often stopping spontaneously.15 Angiography was traditionally believed to be the gold standard and the only imaging modality to diagnose hepatic vascular injuries. Recent advances in computed tomographic (CT) technology and three-dimensional (3D) imaging software gave CT a vital role in the diagnosis of abdominal trauma. MDCT allows thinner collimation, shorter scanning time and better patienttolerance. 3D post-processing of CT angiography with multiplanar reformation
351 (MPR), maximal intensity projection (MIP) and volume rendering technique (VRT) is especially helpful in detection of vascular injuries.18 In this case, CT findings of early opacification of the hepatic arterial pseudoaneurysm and distal branches of right hepatic vein in arterial phase suggested AVF. Wedge-shaped transient subsegmental parenchymal enhancement (TSPE) is usually an indirect sign of APF9 and rarely seen in AVF because of the difference of flow direction. This unusual complication of AVF resulted in inverse intrahepatic portal flow probably due to an inverse pressure gradient, and if left unnoticed, the inverse flow may produce symptoms like those of the venoocclusive disease or traumatic APFs. Early symptoms include abdominal pain, diarrhoea, gastrointestinal bleeding from congestive vascular enteritis and, rarely, ascites. Late symptoms may be manifested as portal hypertension, such as bleeding oesophageal varices or haemobilia.5,8 Interventional techniques, especially angiographic embolisation, are well-known as useful adjuncts in non-operative management of blunt liver trauma.3,19 Early angiographic embolisation decreases the incidence of blood transfusion and number of liver-related operations.1 Treatment of pseudoaneurysms has shifted away from operative intervention and toward radiologic embolisation with various materials12 or even observation alone in some case reports.10 Transcatheter arterial embolisation has proved to be effective in treatment of arterioportal shunts, and its associated complications are rare.17 However, angiographic treatment of hepatic AVF is not established and seldom discussed. Embolisation has been effective in some reports16,6 but a larger series was still necessary. Embolisation in patients with blunt hepatic injury has not been proved to be effective for venous injury. Bleeding caused by major portal vein or hepatic vein injury may continue after embolisation. Fortunately, bleeding from these veins will often halt spontaneously because of intraabdominal tamponade. In conclusion, CT plays a vital role in decision making in blunt trauma. Angiographic embolisation can decrease the incidence of transfusion and the number of liver-related operations. MDCT angiography can be very helpful in proper planning before an interventional procedure.
Reference 1. Alicia MM, Robert FL, Allison B, et al. Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003;55:1077—101. 2. Brohee D, Franken P, Fievez M, et al. High-output right ventricular failure secondary to hepatic Arteriovenous
352
3.
4.
5.
6.
7.
8.
9.
10.
microfistulae. Selective arterial embolization treatment. Arch Int Med 1984;144:1282—4. Carrillo EH, Spain DA, Wohltmann CD, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619—22. Dieter B, Georg AS, Hans LM, et al. Hyperdynamic circulatory state due to Osler-Weber-Rendu disease with intrahepatic Arteriovenous fistulas. Am Heart J 1972;85:797—800. English WP, Johnson MB, Borman KR, et al. Mesenteric ischemia: an unusual presentation of traumatic intrahepatic arterioportal fistula. Am Surg 2001;67:865—7. Galeon M, Goffette P, Van Beers BE, et al. Post-traumatic intrahepatic pseudoaneurysm: diagnosis with helical CT angiography and management with embolization. JBR-BTR 1997;80:287—8. Howard JM, Malafa M, Coombs RJ, et al. Arteriovenous fistula between the hepatic artery and the hepatic vein. HPB Surg 1989;1:155—60. Kayser S, Marincek B, Schlumpf R, et al. Rapidly progressive portal hypertension 23 years after post-traumatic arterioportal fistula of liver. Am J Gastroenterol 1996;91:1442—6. Lee SJ, Lim JH, Lee WJ, et al. Transient subsegmental hepatic parenchyma enhancement on dynamic CT: a sign of postbiopsy arterioportal shunt. J Comput Assist Tomogr 1997;21: 355—60. Lockwood TE, Schorn L, Coln D. Nonoperative management of hemobilia. Ann Surg 1977;185:335—40.
S.-C. Hung et al. 11. Luo MY, Shan H, Jiang ZB, et al. Multidetector spiral CT findings of arteriovenous fistula associated with hepatocellular carcinoma. Ai Zheng 2004;23:833—8. 12. Martin AC, Timothy CF, Jon PS, et al. Traumatic hepatic artery pseudoaneurysm with hemobilia. Am J Surg 1994;168: 235—8. 13. Okuda K, Musha H, Nakajima Y, et al. Frequency of intrahepatic arteriovenous fistula as a sequela to percutaneous needle puncture of the liver. Gastroenterology 1978;74: 1204—7. 14. Ouchi K, Matsubara S, Mikuni J, et al. The radiologic presentation of Osler-Weber-Rendu disease of the liver. Am J Gastroenterol 1994;89:425—8. 15. Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin North Am 1996;76:763—82. 16. Roman CF, Cha SD, Incarvito J, et al. Transcatheter embolization of hepatic Arteriovenous fistula in Osler-Weber-Rendu disease–—a case report. Angiology 1987;38:484—8. 17. Schwartz RA, Teitelbaum GP, Katz MD, et al. Effectiveness of transcatheter embolization in the control of hepatic vascular injuries. J Vasc Interv Radol 1993;4:359—65. 18. Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR 2004;25:180— 204. 19. Wendy LW, Karla SA, Mary MB, et al. The need for early angiographic embolization in blunt liver injuries. J Trauma 2002;52:1097—100.