Hepatic artery pseudoaneurysm after liver ... - BIR Publications

5 downloads 0 Views 254KB Size Report
Hepatic artery pseudoaneurysm after liver transplantation: definitive treatment with a stent-graft after failed coil embolisation. 1G MALEUX, MD, 2J PIRENNE, MD ...
The British Journal of Radiology, 78 (2005), 453–456 DOI: 10.1259/bjr/12679319

E

2005 The British Institute of Radiology

Case report

Hepatic artery pseudoaneurysm after liver transplantation: definitive treatment with a stent-graft after failed coil embolisation 1

G MALEUX, MD, 2J PIRENNE, MD, PhD, 2R AERTS, MD and 3F NEVENS, MD, PhD

Departments of 1Radiology, 2Abdominal Transplantation Surgery and 3Hepatology, University Hospitals Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium

Abstract. A 69-year-old woman presented with massive upper gastrointestinal bleeding owing to a ruptured hepatic pseudoaneurysm located at the surgical arterial anastomosis, 2 months after combined liver and kidney transplantation. Initially the pseudoaneurysm was successfully coiled but 3 weeks later recurrence of her symptoms occurred. Hepatic angiography revealed partial reperfusion of the coiled pseudoaneurysm; definitive treatment was performed by placement of an expanded-polytetrafluoroethylene (e-PTFE) covered coronary stent-graft, completely excluding the pseudoaneurysm. Radiological follow-up studies demonstrate a patent stent-graft functioning normally.

Formation of a pseudoaneurysm of the hepatic artery after liver transplantation is a rare, but potentially lethal complication. Pseudoaneurysms usually occur within the first months following transplantation and can present either with aspecific pain symptoms or massive upper gastrointestinal bleeding and haemodynamic shock. Classic treatment options include surgical resection of the pseudoaneurysm and revascularization of the injured vessel segment, ligation of the hepatic artery, retransplantation or radiological coil embolisation with preservation of the arterial flow to the graft. We report on a case of a bleeding extrahepatic pseudoaneurysm of the hepatic artery in a liver transplant patient, initially treated by coil embolisation, and definitively managed 3 weeks later by implantation of a stent-graft.

Case report A 69-year-old woman with primary biliary cirrhosis was referred because of a rapidly progressive deterioration of liver function, jaundice, oesophageal varices, grade II encephalopathy and refractory ascites. The Child-Pugh score was C12. Additionally the patient developed irreversible hepatorenal syndrome. 4 months later, she subsequently underwent combined orthotopic liver and kidney transplantation. A standard orthotopic liver transplant was first performed through a bisubcostal incision and was followed by a classic heterotopic kidney transplant in the iliac fossa. Arterial reperfusion of the liver graft was via an end-to-end hepatic artery anastomosis, using the native hepatic artery just above the gastroduodenal artery and a patch of donor coeliac trunk. Arterial anastomosis was performed using a running suture 7-0 prolene. Portal reperfusion was via an end-toend anastomosis between the donor and the recipient portal vein (running suture 5-0 prolene). Bile duct Received 1 June 2004 and in final form 29 November 2004, accepted 26 January 2005.

The British Journal of Radiology, May 2005

reconstruction was with a duct-to-duct anastomosis using running 5-0 polydioxanone. Her post transplant course was uneventful except for a biliary stricture that developed 13 days post transplant that required biliary dilatation and endoscopic placement of a polyethylene biliary stent. The patient gradually recovered and left the hospital 47 days after the combined transplantation. At day 73 post-transplantation the patient suddenly developed haemodynamic shock with massive upper gastrointestinal bleeding. After resuscitation and blood transfusion, hepatic angiography was performed, detecting a false aneurysm arising at the arterial anastomosis (Figure 1a). Superselective catheterization using a microcatheter (Prowler Plus; Cordis, Johnson & Johnson, Miami, FL) and packing of the aneurysmal lumen using microcoils (Boston Scientific Target, Fremont, CA) eventually stopped the bleeding (Figure 1b). Although the patient suffered a myocardial infarction during her hypovolemic shock, the post embolisation course was uneventful. 3 weeks later, the patient presented with recurrent symptoms of upper gastrointestinal bleeding and haemodynamic shock. Emergency visceral angiography was performed and revealed partial revascularization of the hepatic artery false aneurysm (Figure 2a). Because of the rather broad neck of the aneurysm and the rapid recurrence of bleeding, additional coil embolisation was not considered the best treatment option. Because of her moribund condition (shock, age, recent myocardial infarction), it was thought that she would not be fit enough to tolerate open surgery, and the decision to place a balloon-expandable coronary stent-graft (Jostent coronary stent-graft; Jomed, Rangendingen, Germany) was made. After insertion of a 7 French sheath (Terumo Europe, Leuven, Belgium) in the right groin, a 7 French hockey-stick guiding catheter (Cordis, Roden, The Netherlands) was placed in the hepatic artery. A stentgraft, mounted on a monorail stent-delivery catheter was constructed using a sandwich technique, whereby an ultra 453

G Maleux, J Pirenne, R Aerts and F Nevens

(a)

(b)

(c)

Figure 1. (a) Selective angiography of the common hepatic artery, branching from the superior mesenteric artery, clearly shows the pseudoaneurysm (arrowheads) originating at the surgical anastomosis of the donor–receptor hepatic artery. Note also the moderate stenosis at the surgical anastomosis (arrow). (b) Superselective catheterization of the false aneurysm (arrowheads) with use of a microcatheter. The plastic, biliary stent is clearly visible (arrows). (c) Completion angiography shows complete packing of the false aneurysm with microcoils and a fully patent hepatic artery.

thin layer of e-PTFE is placed between two stainless steel stents. The stent-graft having a length of 12 mm was expanded up to 5 mm diameter and placed completely covering the neck of the false aneurysm, resulting in complete exclusion of the aneurysm and preservation of the arterial blood flow to the graft. The patient became haemodynamically stable after the procedure without evidence of further bleeding and recovered well after this second episode of massive haemorrhage. For the first 2 months past stent-graft placement a daily administration of 75 mg of clopidogrel (Plavix; Sanofi Pharma, Paris, France) was prescribed to prevent early stent thrombosis. Follow-up of 20 months has shown no recurrence of bleeding. Duplex-ultrasound of the hepatic artery shows a normal arterial signal; multislice CT-angiography at 454

6 months and MR-angiography 9 months post-stent insertion revealed a normally patent extrahepatic and intrahepatic artery; the stented segment itself could not be adequately examined because of the major artefacts of the metallic stent-skeleton and the adjacent micro coils. At last follow-up (14 months) liver function tests were normal.

Discussion Hepatic artery pseudoaneurysms are a rare complication after liver transplantation and have an incidence of between 0.3% and 1.3% [1]. Clinical presentation may be non-specific with unexplained fever or biliary colic, or The British Journal of Radiology, May 2005

Case report: Hepatic artery pseudoaneurysm after liver transplantation

(a)

(b)

Figure 2. (a) Selective hepatic angiography 3 weeks after coiling, at the time recurrence of massive upper gastrointestinal bleeding, demonstrates the partial reperfusion of the false aneurysm (arrow). (b) Placement of a coronary stent-graft (arrows) with complete exclusion of the false aneurysm and preservation of the arterial flow.

laboratory analysis may demonstrate abnormal liver function tests. They may also present as sudden and profound haemodynamic shock with life-threatening haemorrhage into the peritoneum or gastrointestinal tract. Intrahepatic pseudoaneurysms are mostly the result of iatrogenic injury whereas extrahepatic pseudoaneurysms are commonly associated with localized infection or are due to technical, anastomotic problems [2]. In our patient no episode of localized infection or generalized sepsis was encountered although some low grade localized infection due to the transient post-operative bile duct obstruction may have occurred. Although we do not have angiographic evidence of contrast extravasation into the biliary tract or directly into the bowel, it is likely that the upper gastrointestinal bleeding occurred due to a fistula between the pseudoaneurysm and the common bile duct because of their close anatomical location and the possible pathophysiological mechanism as described above. The mortality of a bleeding hepatic pseudoaneurysm following liver transplantation is very high, 69%, owing to a combination of factors such as the poor general condition of the patient, poor graft function and medical complications in the post-operative course [1, 2]. Therefore minimally invasive treatment options have to be considered as an alternative to surgical treatment, which consists of resection of the pseudoaneurysm and creating an arterial reconstruction using an interposition graft or arterial conduit [1–5]. Radiological embolisation techniques have been described, to definitively close the pseudoaneurysm with preservation of the arterial flow to the graft: coil embolisation [6] with packing of the aneurysm or CT-guided direct percutaneous puncture of the aneurysmal lumen and injection of thrombin [7]. At first presentation we also opted for coil embolisation of the aneurysmal lumen, and although initially successful, recurrence of bleeding occurred due to partial reperfusion The British Journal of Radiology, May 2005

of the pseudoaneurysm. Additional coiling was not considered because of the broad neck of the pseudoaneurysm and potential coil migration into the distal hepatic circulation. Direct puncture also seemed to be impossible because the reperfused portion of the aneurysm was small. Therefore we decided to exclude the pseudoaneurysm with a stent-graft. This technique, which may be performed immediately following the diagnostic angiography, has the unique advantage of completely excluding the pseudoaneurysm without injecting embolic agents into the aneurysm and concomitantly preserving the arterial blood flow to the graft. To our knowledge, successful exclusion of a bleeding, anastomotic hepatic artery pseudoaneurysm by stent-graft placement in a liver transplant patient has not been previously described. Implantation of a stent-graft to exclude a visceral pseudoaneurysm has previously been described in patients developing a false aneurysm after Whipple’s operation [8– 10] and in splenic [11] and renal artery aneurysms [12, 13]. Sakai et al [13] described a similar case of a post transplant hepatic pseudoaneurysm. In their case the cause of aneurysm formation was probably an iatrogenic injury of the hepatic artery during surgery and the pseudoaneurysm was asymptomatic. The indication for treatment was a progressive increase in size of the aneurysm and the definitive treatment also consisted of placement of a coronary stent-graft. Most of the published case reports are of technical successes, but it has to be noted that stentgraft implantation in a visceral artery is not always possible. This may be due to tortuous anatomy making it impossible to negotiate some curved vessel segments by the stent catheter or due to the fact that the post interventional anticoagulation therapy, mandatory after an endovascular stent-procedure, is contraindicated. In particular, when implanting a stent-graft in the coronary 455

G Maleux, J Pirenne, R Aerts and F Nevens

arteries, an aggressive and longstanding antiplatelet therapy seems to be mandatory [14]. Additionally, placement of a stent or a graft in an infected area can provoke late graft disintegration and consequently rupture of the aneurysm [15], although some reports describe the long-term success of endovascular exclusion of a proven infected aneurysm [16]. In conclusion, placement of a stent-graft to definitively exclude a bleeding hepatic artery pseudoaneurysm following liver transplantation should be considered, in some selected cases, as an effective and minimally invasive alternative to surgery.

References 1. Marshall MM, Muiesan P, Srinivasan P, et al. Hepatic artery pseudoaneurysm following liver transplantation: incidence, presenting features and management. Clin Radiol 2001;56:579–87. 2. Leelaudomlipi S, Bramhall SR, Gunson BK, et al. Hepaticartery aneurysm in adult liver transplantation. Transplant Int 2003;16:257–61. 3. Bonham CA, Kapur S, Geller D, Fung JJ, Pinna A. Excision and immediate revascularization for hepatic artery pseudoaneurysm following liver transplantation. Transplant Proc 1999;31:443. 4. Rudich SM, Kinkhabwala MM, Murray NG, See DM, Busuttil RW, Imagawa DK. Successful treatment of mycotic hepatic pseudoaneurysm with arterial reconstruction and liposomal amphotericin B. Liver Transpl Surg 1998;4: 91–3. 5. Fichelle JM, Colacchio G, Castaing D, Bismuth H. Infected false hepatic artery aneurysm after orthotopic liver transplantation treated by resection and reno-hepatic vein graft. Ann Vasc Surg 1997;11:300–3.

456

6. Ozkan OS, Walser EM, Akinci D, Nealon W, Goodacre B. Gugielmi detachable coil erosion into the common bile duct after embolization of iatrogenic hepatic artery pseudoaneurysm. J Vasc Intervent Radiol 2002;13:935–8. 7. Patel JV, Weston MJ, Kessel DO, Prasad R, Toogood GJ, Robertson I. Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection. Transplantation 2003;75:1755–7. 8. Paci E, Antico E, Candelari R, Alborina S, Marmorale C, Landi E. Pseudoaneurysm of the common hepatic artery: treatment with a stent-graft. Cardiovasc Intervent Radiol 2000;23:472–84. 9. Bu¨rger T, Halloul Z, Meyer F, Grote R, Lippert H. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther 2000;7:324–7. 10. Venturini M, Angeli E, Salvioni M, et al. Hemorrhage from a right hepatic artery pseudoaneurysm: endovascular treatment with a coronary stent-graft. J Endovasc Ther 2002;9:221–4. 11. Larson RA, Solomon J, Carpenter JP. Stent graft repair of visceral artery aneurysms. J Vasc Surg 2002;36:1260–3. 12. Tan WA, Chough S, Saito J, Wholey MH, Eles G. Covered stent for renal artery aneurysm. Catheter Cardiovasc Intervent 2001;52:106–9. 13. Sakai H, Urasawa K, Oyama N, Kitabatake A. Successful covering of a hepatic artery aneurysm with a coronary stent graft. Cardiovasc Intervent Radiol 2004;27:274–7. 14. Stankovic G, Colombo A, Presbitero P, et al. Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts. The randomized evaluation of polytetrafluoroethylene COVERed stent in saphenous vein grafts (RECOVERS) trial. Circulation 2003;108:37–42. 15. Chuter TA, Lukaszewicz GC, Reilly LM, et al. Endovascular repair of a presumed aortoenteric fistula: late recurrence due to recurrent infection. J Endovasc Ther 2000;7:240–4. 16. Callaert JR, Fourneau I, Daenens K, Maleux G, Nevelsteen A. Endoprosthetic treatment of a mycotic superficial femoral artery aneurysm. J Endovasc Ther 2003;10:843–5.

The British Journal of Radiology, May 2005