Hybrid Operation Comprising Hepatic Artery Reconstruction and Endovascular Treatment for a Common-Proper Hepatic Artery Aneurysm Derived from Segmental Arterial Mediolysis

TL;DR

A hybrid surgical approach combining artery reconstruction and endovascular treatment successfully treated a large liver artery aneurysm without causing liver damage.

Contribution

A novel hybrid operation integrating hepatic artery reconstruction and endovascular techniques for treating complex hepatic artery aneurysms.

Findings

The hybrid operation successfully prevented liver ischemia while treating the aneurysm.

The patient showed no recurrence of aneurysms 18 months post-surgery.

Multidisciplinary cooperation was critical for the success of the complex procedure.

Abstract

The location and size of our patient’s hepatic artery aneurysm might suggest the possible inadequacy of endovascular treatment (EVT) only. We therefore devised a hybrid operation that included microscopic arterial reconstruction after dividing the hepatic artery with simultaneous EVT.

A 69-year-old man had multiple abdominal artery aneurysms that were derived from segmental arterial mediolysis. The main aneurysm, which was in the common-proper hepatic artery, was >3 cm in diameter. Complete coiling of the aneurysm might have resulted in hepatic ischemia, so we planned a simultaneous hybrid operation that comprised both hepatic artery reconstruction and EVT. First, the radiologists catheterized the common hepatic artery in preparation for aneurysm rupture. Then, hepato-biliary-pancreatic surgeons encircled and clipped 4 outflow arteries from this aneurysm: the gastroduodenal artery, right gastric artery, and the right and left hepatic arteries. Subsequently, with the help of plastic surgeons, left hepatic artery reconstruction was performed using the middle colic artery to ensure blood flow to the liver. Finally, the radiologists were able to perform coil embolization without fear of aneurysm rupture or dislocation of coils. The operation and EVT time was totaled to 567 min. The patient was discharged after 18 days without postoperative complications. Eighteen months after the operation, there has been no recurrence or regrowth of this treated aneurysm or growth of other aneurysms. Considering segmental arterial mediolysis as multiple visceral aneurysms, we performed MRA to confirm the absence of intracranial aneurysms.

With cooperation between hepato-biliary-pancreatic surgeons, plastic surgeons, and radiologists, we performed a hybrid operation that included microscopic arterial reconstruction after simultaneously dividing both hepatic arteries and performing EVT for the hepatic artery aneurysm to avoid liver ischemia. A flexible treatment plan that draws upon a breadth of knowledge, techniques, and devices, and involves the cooperation of multiple clinical departments, is suggested to be helpful in the treatment of difficult abdominal aneurysms.

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