A rare intraabdominal tumor: giant hepatic artery aneurysm.

Abstract

A 55-year-old man was investigated for right upper abdominal quadrant pain. He had no history of abdominal trauma or surgery. Imaging studies showed a common hepatic artery aneurysm involving the gastroduodenal artery. Following aneurysmectomy, examination with a hand Doppler apparatus yielded clear arterial signals from the liver surface. Therefore, vascular reconstruction was not performed. He had an uneventful postoperative course.

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CASE
A 55-year-old man whocomplained of abdominal
pain of three weeks duration was referred with the
diagnosis of an intraabdominal tumor.Theavailable
magnetic resonanceimaging films showedahepatic
artery aneurysm(8× 12× 8cm) compressing thesur-
rounding hepatoduodenal ligamentstructures. Two
cavernous hemangiomas of the left lobe were also
noted. His blood chemistry showed elevated levels
of alkaline phosphatase (ALP)(971U/L, range:30-
135), gamma-glutamyl transpeptidase(GGT)(1020U/L,
range:5-85),aspartate aminotransferase(AST)(122U/
L, range:5-42),alanine aminotransferase(ALT) (539
U/L, range:5-45) andtotal bilirubin(1,8mg/dL, range:
0, 20-1,0). Viral markers for hepatitis-anti HAV IgM,
HBsAg, anti HBsAg andanti HCV-wereall negative.
The patient had nohistory ofany abdominal trauma
or surgery.
Computerizedtomography(CT) angiographyshowed
theaneurysmwithrimcalcifications(Figure1).Celiac
and mesenteric angiography identifiedcollateral cir-
culationfromtheproximal splenic artery totheliver.
The gastroduodenal artery was alsoinvolvedby the
aneurysm(Figure 2).
Atlaparotomy,theaneurysmwasfoundtobetightly
associated with the hepatoduodenal ligament struc-
tures;the common hepatic artery was normal within
3cmof the celiac trunk. Following clamping of the
artery, pulsation within the aneurysmstopped. The
neck was double-ligatedanddivided.Thelefthepatic
artery and thegastroduodenal artery wereidentified
andclipped.Thecommonbileductwasidentifiedand
preserved. Cholecystectomy and partial aneurys-
mectomy were performed. Thehemangiomas were
enucleated. Intraoperative examinationwithahand
Doppler apparatus yieldedclear arterial signals from
the liver surface. Therefore, vascular reconstruction
was considered unnecessary.
Thepatienthadanuneventfulpostoperativecourse;
the elevated blood enzyme and bilirubin levels fell
CASE REPORT
A rare intraabdominal tumor: gianthepatic artery aneurysm
BayindirCimsit, Ilgin Ozden, and Ali Sami Emre
Department ofGeneral Surgery, Hepatopancreatobiliary Unit, Istanbul University, Istanbul Faculty
ofMedicine, Turkey
Abstract: A 55-year-old man was investigated for right upper abdominal quadrant pain.He had
nohistory ofabdominaltraumaorsurgery.Imagingstudiesshowedacommonhepaticartery aneurysm
involving thegastroduodenal artery.Following aneurysmectomy,examination with ahandDoppler
apparatusyielded clear arterial signalsfrom theliver surface.Therefore,vascular reconstruction
wasnotperformed.Hehadanuneventfulpostoperativecourse. J .Med.Invest.53:174-176,February,2006
Keywords : hepaticartery, aneurysm, intraabdominal tumor
Received for publication May３ １ , 2005; accepted September
１ ４ , 2005.
AddresscorrespondenceandreprintrequeststoBayindir Cimsit,
M.D.Ballisk.No:1Levent,Istanbul,TurkeyandFax:+90-212-2814296.
Figure１ :
aneurysmwith mural thrombus.
CT angiography showing contrastinthelumenofthe
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tonormal/near normal values within five days:ALP
(161U/L), GGT (313U/L), AST (23U/L), ALT (100
U/L), total bilirubin(0,6mg/dL).Hewas discharged
on the fifth postoperative day. Histopathological ex-
aminationoftheaneurysmectomyspecimenrevealed
acalcifiedatheroscleroticplaqueandalarge,adherent
thrombus. Culture of the aneurysmwall yieldedno
organisms.
Follow-upabdominal computed tomography at 4
months showedthecalcifiedremnantaneurysmwall,
there was norecurrence.
DISCUSSION
AlthoughareviewoftheEnglishlanguageliterature
from1985to1995showed that hepatic artery aneu-
rysms (HAA) were the most frequently reported
visceral artery aneurysmduring thatdecade,thetotal
number oftrue HAA was only51(1) . Among patients
seen at the MayoClinic between1980and1998, only
36were diagnosed as having aHAA-an incidence of
0,002% -(2) .A seriesfromFranceincludedonly3cases
ofcommonhepatic artery aneurysmforaperiodof27
years (3). Although these lesions are rare, they are
clinically importantbecausethey oftenremainsilent
until rupture.
Theetiologyisatherosclerosisin32%ofthecases,me-
diointimal degeneration in 24% , trauma in 22%and
mycotic infections in10% . In66%of cases, the aneu-
rysmis located extrahepatically;the most common
siteistherighthepaticartery(47% ),followedbythecom-
mon hepatic artery (22% ), proper hepatic artery (16% ),
left hepatic artery (13% ) and the cystic artery (1% ) (4).
As there is no correlation between diameter and
risk of rupture, all diagnosedlesions shouldbecon-
sideredfor treatment(5-9) .Ruptureismorefrequent
in aneurysms involving the hepatic artery (80% )
(10,11).
The diagnostic work up must determine the
need forreconstructionofthehepaticvasculature.Baggio
et al. recommendedpreoperativespiral CT scanand
angiography to define the dimensions of the aneu-
rysm, todistinguishbetweentruelumenandparietal
thrombus, reveal signs ofruptureandassessitsasso-
ciationwiththeneighboring structures.Angiography
provides afiner evaluationofanatomic variationsand
collateral circulation(4).
Treatmentoptionsincludesurgicalandendovascular
techniques ; although the issue is still controver-
sial,manyauthorstakethestatusofthegastroduodenal
artery involvement as a reference point (8). Aneu-
rysmectomy and reconstruction of the vasculature
via direct suturing or interposition of autologous
material or heterologous material is a traditional
approach, especially in lesions involving the gas-
troduodenalartery(4) .Directligationoftheaneurysm
neck is an acceptable approach, when applicable.
On the other hand, endovascular techniques are
becoming morefrequentfor thetreatmentofhepatic
artery aneurysms, especially for lesionswithconvenient
morphological characteristics (saccular or fusiform,
withor withoutaneck) (4) .Ramietal.havedescribed
stent-graft treatment of bleeding hepatic artery
branches (12) . Some authors suggest endovascu-
lar treatment as a first-line option in most cases,
including emergencies, providedthehemodynamic
status of the patient can be maintained (3,13).
Inour case,althoughwetriedtodefinetheanatomy
of the aneurysm by various imaging techniques, it
was notpossibletoidentifytheoutflowtractprecisely.
Therefore, an endovascular stent graft approach
was ruled out. Because of the size oftheaneurysm,
coil embolization was not considered effective by
theradiologydepartment.Therefore,aneurysmectomy
and autologous saphenous vein graft interposition
wereplanned.Following aneurysmectomy,examination
with ahand Doppler apparatus yieldedclear arterial
signals fromtheliver surface.Therefore, vascularre-
construction was not performed. The reported ex-
perience also shows that common HAA may often
be treated with aneurysmectomy or aneurysmal ex-
clusion without arterial reconstruction(12).
Although the small number of cases do not
allow definite recommendations, it is reasonable to
recommend repair of HAA greater than 2cm in a
Figure 2:
(C) tothe liver originating fromthe proximal splenic artery (S) .
Note the gastroduodenal artery involvement (arrow) . Bold ar-
rows:thrombosed margins of the aneurysm. (left lateral oblique
view)
Angiographic imagedemonstratingcollateralcirculation
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patient who is a good operative risk and has a life
expectancy ofmorethan2years.Inpatients withmar-
ginal or poor healthwitha2to5cmHAA, carefulob-
servation may be warranted, but the decision to
intervene must be made on an individual basis.
HAA greater than 5cm should generally undergo
repair, embolisation or ligation (2) .
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