Atypical presentation of a hepatic artery pseudoaneurysm: A case report and review of the literature

Abstract

Classically, hepatic artery pseudoaneurysms (HAPs) arise secondary to trauma or iatrogenic causes. With an increasing prevalence of laparoscopic procedures of the hepatobiliary system the risk of inadvertent injury to arterial vessels is increased. Pseudoaneurysm formation post injury can lead to serious consequences of rupture and subsequent hemorrhage, therefore intervention in all identified visceral pseudoaneurysms has been advocated. A variety of interventional methods have been proposed, with surgical management becoming the last step intervention when minimally invasive therapies have failed. The authors present a case of a HAP in a 56-year-old female presenting with jaundice and pruritis suggestive of a Klatskin’s tumor. This presentation of HAP in a patient without any significant past medical or surgical intervention is atypical when considering that the majority of HAP cases present secondary to iatrogenic causes or trauma. Multiple minimally invasive approaches were employed in an attempt to alleviate the symptomology which included jaundice and associated inflammatory changes. Ultimately, a right hepatic trisegmentectomy was required to adequately relieve the mass effect on biliary outflow obstruction and definitively address the HAP. The presentation of a HAP masquerading as a malignancy with jaundice and pruritis, rather than the classic symptoms of abdominal pain, anemia, and melena, is unique. This presentation is only further complicated by the absent history of either trauma or instrumentation. It is important to be aware of HAPs as a potential cause of jaundice in addition to the more commonly thought of etiologies. Furthermore, given the morbidity and mortality associated with pseudoaneurysm rupture, intervention in identifiable cases, either by minimally invasive or surgical interventions, is recommended.

Keywords: Klatskin tumor, Cholangitis, Hepatic artery pseudoaneurysm, Biliary obstruction, Trisegmentectomy

Core tip: Hepatic artery pseudoaneurysms (HAPs) typically arise from secondary trauma or iatrogenic causes. Most of HAPs are asymptomatic but can be complicated with rupture and bleeding. Biliary obstruction due to HAPs is a rare phenomenon and can present clinically as Quinke’s triad (hematobilia, abdominal pain, and jaundice). Most cases can be managed with non-operative vascular and endoscopic interventions. This case report presents an atypical presentation of HAP with a multidisciplinary approach to a complex problem.