EUS-guided coiling of hepatic artery pseudoaneurysm in 2 stages

Hepatic artery pseudoaneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudoaneurysms constitute 20% of all visceral artery aneurysms. They carry a very high risk of rupture with severe bleeding into the peritoneal cavity, bile duct, or portal vein. Essentially all pseudoaneurysms, whether symptomatic or not, require early treatment to prevent lethal adverse events. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity in comparison with endovascular treatment. The goal of endovascular treatment of hepatic artery aneurysms is to obtain a complete, stable exclusion of the sac from the arterial circulation with preservation of the parent vessel. Endovascular, percutaneous, and EUS-guided interventions are used in the treatment of visceral artery pseudoaneurysms.

A 20-year-old man was seen because he had experienced abdominal pain in the right-upper quadrant for the previous 2 months. He had undergone US-guided aspiration of a liver abscess 2 months earlier. US of the abdomen showed an aneurysm arising from the hepatic artery. CT angiography of the abdomen confirmed a saccular pseudoaneurysm arising from the proximal part of the hepatic artery (Fig. 1A). The lesion was not considered feasible for percutaneous intervention. The interventional radiologist suggested hepatic artery stent placement across the neck of the aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction resulting from stent stenosis, thrombosis, and distal migration of the stent. After a discussion of the pros and cons of the EUS-guided procedure, the patient chose EUS-guided coil embolization (Video 1, available online at www.VideoGIE.org). Packing the sac with helical coils was planned. Packing with one 10-mm coil and five 6-mm coils through a 19-gauge needle caused 80% obliteration of the sac (Figs. 1B-D). Five days later, EUS assessment showed that the injected coils were collected into the most distal part of the aneurysm, but the flow into a smaller cavity continued with high velocity (Fig. 1E). During the second attempt, four 10-mm coils were deployed. EUS assessment after coiling still showed a flow into the aneurysm. Three more 8-mm coils were placed, and complete obliteration of the aneurysm was confirmed by the injection of contrast material and EUS (Figs. 1F and G). One week later, follow-up color Doppler of the abdomen showed no flow in the pseudoaneurysm (Fig. 1H).

This case shows the practical problems of EUS-guided coil embolization of a hepatic artery aneurysm. The initial attempt resulted in 80% obliteration of the aneurysm cavity but did not cause progressive thrombosis of the rest of the cavity. However, successful and complete obliteration of the pseudoaneurysm was achieved during the second attempt at coiling.