Must interventional surgery be performed for hepatic arterioportal fistula complicated with giant pseudoaneurysm?—a case description

Introduction

Pseudoaneurysm is a tumor-like dilatation caused by the destruction of the arterial wall structure due to various reasons. Hepatic artery pseudoaneurysm (HAPA) is a rare and potentially life-threatening complication that frequently occurs after blunt or penetrating liver injury (1,2). Due to the extremely low incidence of this disease, most relevant studies are case reports, and there is a scarcity of large sample studies (3,4). Currently, the incidence and prognosis of pseudoaneurysms have not been reported, and there is no clear standard for their treatment. Most pseudoaneurysms have been treated with interventional arterial embolization (5,6). The patient in this case had a hepatic arterioportal fistula (HAPF) with a giant pseudoaneurysm. At present, reports on the treatment and prognosis of HAPF with a giant pseudoaneurysm are very rare. The presentation of this patient will provide a reference for the treatment of pseudoaneurysms.

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 73-year-old male patient with a 7-year history of diabetes was managing his condition with dietary control. The patient underwent loop resection during colonoscopy for colon and rectal polyps, both measuring 0.6 cm. Subsequently, 1–2 days after surgery, the patient developed a fever with a body temperature of 39.9 ℃. His laboratory indicators were as follows: white blood cells, 9.4×10⁹/L; hemoglobin, 126 g/L; alanine aminotransferase (ALT), 75 U/L; aspartate aminotransferase (AST), 52 U/L. Anti-infective therapy (supraxen, 3.0 mg, intravenously guttae, Q12 h) was administered. The blood culture results showed Klebsiella pneumoniae. Ultrasound (US) revealed a 4.7 cm × 4.3 cm mixed echo mass in the right lobe of the liver, indicating a liver abscess.

On the third day after surgery, with the patient’s informed consent and under the guidance of contrast-enhanced ultrasound (CEUS), percutaneous catheter drainage of the liver abscess (5.5 cm × 5.0 cm) was performed, guided by real-time US (Figure 1A,1B). A total of 4 mL of pus, blood, and blood clots was extracted during the procedure. Figure 1C shows the CEUS manifestations of the hepatic abscess. After the echo of blood clots was observed on the US images, the intraoperative drainage tube was removed due to excessive bleeding. Postoperative exploration revealed a small anechoic zone around the liver. Postoperative bleeding was suspected after CEUS (Figure 1D). Hemocoagulase (2.0 mg, intravenous, QD) was immediately administered, and the patient was returned to the ward for observation with recommendations for bed rest and reduced activity. The culture result of the pus showed Klebsiella pneumoniae.

Figure 1 US and CEUS images of this patient for percutaneous catheter drainage of a liver abscess. (A) Grayscale US images of hepatic abscess. (B) US-guided hepatic abscess puncture catheter drainage, the white arrow indicates the puncture needle. (C) CEUS of the liver abscess, showing a small amount of contrast filling in the solid part of the liver abscess. (D) The white arrow indicates the area of postoperative bleeding considered by CEUS after percutaneous catheter drainage. US, ultrasound; CEUS, contrast-enhanced ultrasound.

On postoperative day 5, the patient still had a low fever and continued anti-infective therapy (Tenone, 0.5 mg, intravenously guttae, Q8 h). The patient self-reported chest tightness and shortness of breath, and an emergency pulmonary artery computed tomography angiography (CTA) was performed. CTA confirmed a pulmonary branch embolism, and thrombolytic therapy was administered (low molecular weight heparin calcium injection, 4,100 U, subcutaneous injection, Q12 h). Portable US showed that the liver abscess was 4.5 cm × 4.0 cm in size. On postoperative day 6, the patient developed abdominal distension and mild tenderness in the right upper abdomen. Considering intraoperative bleeding, the doctor in charge immediately stopped thrombolytic therapy (low molecular weight heparin calcium injection), replaced it with Xarelto (15 mg, oral, bid), and continued anti-infection therapy, supine rest, and reduced activity. On postoperative days 7–12, the patient received continuous symptomatic therapy (Tylenol), berberine thrombolytic therapy, supine rest, and reduced activity.

On postoperative day 13, a CT reexamination showed HAPF with HAPA (Figure 2). Since the patient did not have obvious hemodynamic abnormalities, Beterol was discontinued. After a multidisciplinary team (MDT) discussion with experts from various departments, HAPA and pulmonary embolism were considered, and symptomatic supportive treatment was performed without anticoagulation or hemostasis.

Figure 2 CT image of HAPF with pseudoaneurysm in this patient. (A) White arrows indicate the CT images of HAPF with pseudoaneurysm in this patient. (B) Simultaneous enhancement of the hepatic artery (white arrow) and portal vein (black arrow) after HAPF enhancement. CT, computed tomography; HAPF, hepatic arterioportal fistula.

An US examination was performed on postoperative day 14 (Figure 3), revealing an anechoic area in the right liver measuring 5.9 cm × 3.2 cm. A cloud-like echo was observed rolling in the cyst cavity, which was filled with a color blood flow signal. The ultrasonography indicated that HAPF was accompanied by a pseudoaneurysm. The maximum velocity of the fistula was 493.2 cm/s, and its long axis was consistent with the puncture needle tract. The puncture point area, 0.58 cm from the liver envelope, was considered to be caused by liver artery injury due to blood overflow after anticoagulation and needle expansion. Continued anti-infection treatment, bed rest, and reduced activity were recommended. The liver abscess measured 4.4 cm × 2.7 cm.

Figure 3 US images of the patient 14 days post-surgery. (A) The US image shows HAPA as a fuzzy echo rolling (white arrow). (B) The distance between HAPA and the liver capsule was approximately 0.58 cm (white arrow). (C) The blood flow at HAPF is shown as the spectrum of an arteriovenous fistula with a flow velocity of 493.2 cm/s. US, ultrasound; HAPA, hepatic artery pseudoaneurysm; HAPF, hepatic arterioportal fistula.

The patient continued anti-infection treatment, supine rest, reduced activity, and other symptomatic treatments. Continuous US monitoring showed that the volume of the pseudoaneurysm gradually decreased over the course of the disease (Figure 4). The echo around the aneurysm gradually increased, the boundary became clearer, and the volume of the abscess also continued to decrease. Figure 5 is a line chart showing the changes in the maximum flow velocity of the HAPF, and Figure 6 is a line chart showing the changes in the size of the liver abscess.

Figure 4 Line chart showing the size change of the HAPA. HAPA, hepatic artery pseudoaneurysm.

Figure 5 The line chart showing the changes in the maximum flow velocity of the HAPF. HAPF, hepatic arterioportal fistula.

Figure 6 Line chart showing the size change of the liver abscess.

At 63 days after surgery, 50 days after discovering HAPF combined with a pseudoaneurysm, the size of the pseudoaneurysm was 2.4 cm × 2.0 cm (Figure 7A). Thrombus echoes were visible in the cavity of the pseudoaneurysm, and no obvious color blood flow signal was seen in the cavity (Figure 7B).

Figure 7 US results 63 days after surgery. (A) Further shrinkage of the HAPA (white arrow). (B) No obvious color blood flow signal in the HAPA (white arrow). (C) HAPF was still present with a fistula flow rate of 373.7 cm/s. US, ultrasound; HAPA, hepatic artery pseudoaneurysm; HAPF, hepatic arterioportal fistula.

The maximum velocity of the HAPF was 373.7 cm/s (Figure 7C), and the size of the hepatic abscess was 1.6 cm × 1.2 cm.

Discussion

With the continuous progress of medical technology, the mortality rate of liver injuries has decreased year by year, but complications after liver injuries remain common (7,8). About 11–16% of patients develop liver-specific complications after liver injury, such as bile tumors, bile leakage, and hepatic pseudoaneurysms (9,10). HAPA is a rare complication following liver injury and iatrogenic liver injury, mainly involving a hematoma caused by artery wall injury, usually associated with percutaneous puncture and endoscopic surgery (11,12). HAPF with pseudoaneurysm can be caused by trauma, tumors, and iatrogenic injury (13-15), and the treatment methods differ slightly. Simple HAPA can be cured by embolization of the mother vessel as well as the pseudoaneurysm, but HAPF with pseudoaneurysm must be treated simultaneously for the arteriovenous fistula and the lumen outside the hepatic artery wall. If either condition remains untreated, complications such as hemodynamic changes may necessitate surgical or interventional treatment (16-18).

In this case, the patient had an initial right hepatic artery injury, HAPF complicated by a huge pseudoaneurysm, and the long axis of the pseudoaneurysm was consistent with the puncture path. It was considered that the aneurysm formed after blood from the intrahepatic artery expanded the puncture needle passage following thrombolytic therapy. The nearest point from the pseudoaneurysm to the liver capsule was located at the puncture point, approximately 0.58 cm away from the capsule. Since activity or trauma could have led to liver rupture and endangered life (4,19,20), bed rest was adopted. Given the patient’s liver abscess, there was an increased risk of various postoperative complications. A US performed 3 days after the discovery of the pseudoaneurysm showed that although the tension of the pseudoaneurysm was increasing and its volume was slightly increased, the echo of the hepatic tissue around the pseudoaneurysm changed from iso-echoic to hyperechoic, and the flow velocity of HAPF decreased from 493.2 to 272 cm/s. However, the patient’s hemodynamics did not change significantly, including the internal diameter and flow rate of the main portal vein. These changes gave us great confidence to adopt conservative treatment for the patient. Combined with the US changes around the pseudoaneurysm and the low-enhancement area indicated by CEUS, we believed that the liver tissue around the pseudoaneurysm was fibrosing and may have formed a granuloma. At the same time, we also noticed that the distance between the pseudoaneurysm and the liver capsule increased, and the flow rate of HAPF gradually decreased. At 50 days after the discovery of the pseudoaneurysm, thrombus echoes were found in the pseudoaneurysm, and no obvious color blood flow signal was observed, but HAPF remained.

The premise that the pseudoaneurysm of this patient can be improved by conservative treatment is based on the patient’s good compliance, advanced age, and limited daily activity, which help prevent the rupture of HAPA caused by external forces. In our case, catheter drainage was the main cause of hepatic vascular injury in the patient with a liver abscess. We believe that if there is a large amount of blood loss during catheter drainage and a large liver artery passes through the puncture route, it is necessary to conduct an imaging evaluation for patients with puncture failure or within 2 days after surgery. We performed a US examination of the patient on the day after the operation, and no pseudoaneurysm was detected. CT images 10 days after the operation showed HAPF with a pseudoaneurysm. Combined with the drug treatment process, we concluded that thrombolytic therapy used 3 days after surgery for pulmonary embolism resulted in hepatic arterial hemorrhage, leading to the formation of HAPF with a pseudoaneurysm. Therefore, avoiding anticoagulants as much as possible after catheter drainage is a method to prevent the formation of pseudoaneurysms. Of course, serious pulmonary embolism and venous thrombosis that threaten patient safety should be considered, as appropriate.

Conclusions

Although active interventional embolization is considered the treatment of choice for HAPF with pseudoaneurysm, if embolization of difficult sites may lead to surgical failure or other complications, close observation and conservative treatment can also be effective. In this case, for example, supportive treatment based on bed rest had very good curative effects.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-785/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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