A Case Of Complicated Hepatic Artery Fistula

INTRODUCTION: True visceral aneurysms (VA) are rare. HAA is a VA occurring at the level of the extrahepatic, 80%, with common hepatic artery (CHA), right hepatic artery, and left hepatic artery, encountered at frequencies of 60%, 30%, and 5%. Due to its rarity, HAA, as well as VA in general, are often diagnosed late. This may present with life-threatening hemorrhage due to a high incidence of rupture. In the following report, we present a case of patient with a complicated HAA necessitating urgent surgical and endoscopic intervention. CASE DESCRIPTION/METHODS: A 61-year-old man with history of alcohol and tobacco abuse presented to the ER with 4 days of melena and epigastric pain. Lab tests were signifincat for hemoglobin of 8.0 g/dL (baseline of 12.5 g/dL) and total bilirubin, 4.4 mg/dL. CT and CTA revealed a 47 × 33 mm an aberrant CHA aneurysm from the proximal SMA. The aneurysm caused compression of the mid extrahepatic duct and there was blood in the intrahepatic raising the suspicon of a CHA-bile duct fistula (CBDF) (Figure 1). Urgent EGD revelaed active bleeding from the major papilla further raised the concern of a CBDF (Figure 2). He underwent urgent vasular repair. Intraoperative, the HAA was palpable and has extended to behind the head of the pancreas. He succesfuly underwent supraceliac aorto-hepatic bypass. Exploration of the aneurysm sac revealed arterial bleeding with mural thrombus and bile draining. Due to concern of bile leak the patients underwent intra-operative ERCP which revealed a leak above and below the anastamosis, thus, a fully covered metal stent was placed which resulted in clearance of profuse blood/clots (Figure 3). His liver function subsequently normalized and the leak resolved on subsequent ERCP. DISCUSSION: The majority of HAA are found incidentally on routine imaging for other unrelated etiologies. Approximately 30-50% are found during autopsy. The risk of rupture ranges from 20-80% and increases with greater aneurysm size. Clinical presentations of HAA varies with about one-third presents with Quincke triad: abdominal pain, obstructive jaundice, and haemobilia as in our case. In general, stable patient with obstructive jaundice secondary to HAA, ERCP with biliary stent placement may be a temporizing option; however, in the setting of haemobilia, ERCP may cause massive hemorrhage and definitive surgical management should take precedence. Prompt diagnosis with appropraite imaging and with multidisciplinary approach is paramount.Figure 1.: Computed tomography angiography of 61-year-old man presenting with hypovolemic shock and evidence of upper gastrointestinal bleed.Figure 2.: Upper endoscopy view at the second segment of the duodenum revealing active bleeding from the major papilla.Figure 3.: Fluoroscopic image revealing biliary leak and subsequent fully covered metal stent placement.