Transcatheter Embolization for Treatment of Post-Traumatic
Hepatic Artery and Portal Vein Pseudoaneurysms
Authors: Vallop Laopaiboon
Clinical findings: A 9-year-old girl fell off a tree with suspected of liver, lung and right kidney injuries .She underwent exploratory laparotomy and swabs were packed around the major lacerations in the liver and right kidney at a nearby hospital. A few days later, the patient developed acute renal failure, with declining hematocrit and hypotension. The patient was referred to our hospital. Imaging and Intervention Abdominal contrast enhanced CT reveals liver laceration and two pseudoaneurysms in the right lobe of the liver (Fig. 1). Digital subtraction angiography (DSA) demonstrated pseudoaneurysms arising from branches of right hepatic artery (Fig. 2a). Pseudoaneurysm of right hepatic artery branch was embolized with coils. Follow up DSA demonstrated complete exclusion of the pseudoaneurysm (distortion of hepatic artery branches may be due to post surgery and embolization) (Fig. 2b) Two weeks later, the patient had recovered from renal failure and shock but contrast enhanced CT demonstrated persistent pseudoaneurysm arising from a branch of right portal vein (Fig. 3). She was taken to the operating room, where transileocecal vein portography confirmed a large pseudoaneurysm arising from branch of the right portal vein (Fig. 4a) with suspected portal-venous shunt (Fig 4b). Because of portal venous shunt , large coils were used to embolize the pseudoaneurysm and right portal vein branch (Fig. 4c) The patient was asymptomatic at the 6-month follow-up visit. A follow up contrast enhanced CT demonstrated no evidence of pseudoaneurym (Fig 5).
Contrast CT shows two pseudoaneurysms in right lobe liver.
DSA before (A) and after (B) coil embolization of right hepatic artery pseudoaneurysm.
Contrast CT shows portal vein pseudoaneurysm.
Transileocecal vein portography shows pseudoaneurysm (arrow) of right portal vein branch (A) and suspected portal venous shunt to IVC (B ). Coil embolization of right portal vein pseudoaneurysm was performed (C).
CT 6 months after embolization shows no evidence of pseudoaneurysm.
Post traumatic hepatic pseudoaneurysm is rare, particularly in children. Post traumatic portal vein pseudoaneurym is also rare, especially association with simultaneous hepatic artery pseudoaneurysm. Pre-procedure imaging assessment is the method for correct diagnosis and early management of the patient with pseudoaneurysms. Selection proper size and appropriate embolic agents can prevent non target embolization (migration of embolic agents to IVC and lung) in case of Porto-venous shunt. CT has improved initial injury assessment, decreasing the need for laparotomy. Non operative management has become recognized as an appropriate treatment option for patients with blunt hepatic injury. Interventional radiology techniques to treat the potential complication of liver trauma have supported the trend toward non operative management, which has become widely accepted because of its low morbidity and mortality.