Rare aneurysm of the hepatic artery with overlap to the gastroduodenal artery in very uncommon coincidence with occurence of hepatomesenteric trunk
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- Bueschel*, P., Meyer*, F., Weber, M. et al. Wien Klin Wochenschr (2013) 125: 111. doi:10.1007/s00508-012-0317-8
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Aneurysms of visceral arteries are rare, but in case of rupture, they are potentially life threatening. In addition, there is a broad spectrum of the anatomic variability for the arterial supply of the liver.
Based on a real but very rare clinical case, including its diagnostic management and short-term course, the extraordinary coincidence of (i) an aneurysm of the gastroduodenal artery at its branching off from the hepatic artery and (ii) occurrence of hepatomesenteric trunk is described by the means of a scientific medical case report as well as an adequate and selective literature search.
Case presentation, therapeutic decision and clinical course
A 39-year-old woman (BMI, 24 kg/m2) was diagnosed (by coincidence) with an aneurysm of the proper hepatic artery (APHA) with overlap to the gastroduodenal artery in combination with an uncommon hepatomesenteric trunk using abdominal computed tomography (CT) scan (because of slight but recurrent episodes of urinary tract diseases) and, subsequently, systematic diagnostic comprising Duplex ultrasonography, magnetic resonance imaging (MRI), and conventional angiography. However, medical history was not significant for coincidence with possibly relevant chronic occlusive disease, mycotic embolization, trauma, Marfan syndrome, Klippel–Trenaunay syndrome or giant cell arteritis. Despite a moderate progression within a year to a size of actually 18 mm, we still favor watchful-waiting at this size (therapeutic [interventional] consequence, size > 20 mm) with short-term intervals for follow-up investigations using Duplex ultrasonography as the method of choice.
This is the first case in the accessible English-speaking literature to show this very infrequent coincidence especially indicating rare appearance of an APHA in combination with an also infrequent hepatomesenteric trunk (which potentiates the uncommon occurrence of such combination) based on the high anatomic variability of the arterial supply of the liver from the anatomic perspective.
KeywordsAneurysmVisceral artery aneurysmAneurysm of the hepatic arteryHepatomesenteric trunkArterial supply of the liverAnatomic variability
Seltenes Aneurysma der A. hepatica mit Übergriff auf die A. gastroduodenalis in noch weit seltener Koinzidenz mit einem Truncus hepatomesentericus
Aneurysmata der Viszeralarterien sind selten, allerdings im Rupturfall lebensbedrohlich. Daneben gibt es eine breite anatomische Variabilität in der arteriellen Gefäßversorgung der Leber.
Basierend auf einem realen, jedoch sehr seltenen klinischen Fall incl. seinem diagnostischen Management und mittelfristigen Verlauf, wird die außerordentliche Koinzidenz eines i) Aneurysmas der A. gastroduodenalis im Abgangsbereich aus der A. hepatica und ii) bestehenden Trunkus’ hepatomesentericus mittels wissenschaftlichem Fallbericht und einschlägiger (selektiver) Literaturrecherche beschrieben.
Fallpräsentation, Therapieentscheidung und klinischer Verlauf
Eine 39 Jahre alte Frau (BMI, 24 kg/m2) wurde zufällig mit einem Aneurysma der A. hepatica propria (APHA) mit Übergriff auf die A. gastroduodenalis in Kombination mit einem seltenen Truncus hepatomesentericus mittels Abdominal-CT (wegen rezidivierender Harnwegsinfektionen) und nachfolgend systematischer Diagnostik durch Duplexsonographie, MRT sowie DSA diagnostiziert. Die Anamnese war unauffällig hinsichtlich einer Koinzidenz mit pAVK, mycotischer Embolisation, Trauma, Marfan-Syndrom, Klippel-Trenaunay-Syndrom oder Riesenzellarteriitis. Trotz moderater Progression innerhalb eines Jahres auf eine Aneurysmagröße von gegenwärtig 18 mm wird nach wie vor die klinische Beobachtung mit Duplexsonographiekontrollen als Methode der Wahl in moderaten Zeitintervallen favorisiert (Op-Konsequenz: Durchmesser > 20 mm).
Es handelt sich hier um den ersten Fall in der zugänglichen Englisch-sprachigen Literatur, der die sehr seltene Kuriosität vor dem Hintergrund des seltenen Auftretens der AHPA zusammen mit einem ebenfalls seltenen Truncus hepatomesentericus schildert, womit die seltene Fallkonstellation noch potenziert wird trotz aller individueller Variabilität der arteriellen Leberversorgung aus anatomischer Sicht.
SchlüsselwörterAneurysmaViszeralarterienaneurysmaAneurysma der A. hepaticaTruncus hepatomesentericusarterielle Leberversorgunganatomische Variabilität
Aneurysms of visceral arteries are rare, but in case of rupture they are potentially life threatening. The incidence in different studies varies from 0.1 to 10 %. In this subcategory of aneurysms, there are (beside those from the coeliac trunk, the mesenteric artery and the splenic artery) the aneurysms of the hepatic artery—which constitute at about 20 % in this subcategory [1, 2]. Aneurysms of the gastroduodenal and pancreaticoduodenal artery are rare . An indication for treatment is given not only in symptomatic cases but also in asymptomatic cases depending on its location, size, and effect on the surrounding tissue (such as compression). The actual consent to initiate treatment is given at a diameter of approximately 20 mm. In particular, in combination with fibromuscular dysplasia and polyarteriitis nodosa, the intervention seems to be feasible [2, 4]. The technique varies from endovascular (stenting or embolization) to open and laparoscopic surgery. Even combinations of endovascular to open surgical procedures are possible. However, there is still a lack of studies demonstrating an advantage between the different procedures and the vascular surgeon/interventionalist should decide as the case arises [4, 5, 6].
This case report describes the extraordinary coincidence of a hepatomesenteric trunk with an aneurysm of the proper hepatic artery (plus overlap to the gastroduodenal artery) as one of the first cases ever reported and concludes with a short but representative view on the high anatomic variability of the liver’s blood supply.
A 39-year-old woman, a mother of a 9-year-old child with a BMI of 24 kg/m2 was admitted to our vascular outpatient clinic with a completed magnetic resonance imaging revealing an assured asymptomatic aneurysm of the hepatic artery. Her medical history included benign tumor resection on the lower limb during childhood and subtotal thyroidectomy at the age of 36 years. She had been suffering from arterial hypertension and hypothyreosis. Medical history was not significant for nicotine or alcohol abuse. Because of recurrent diseases of the urinary tract, an abdominal CT was performed 1 year ago which accidentally found APHA—measuring 7 mm in diameter. The patient was then transferred to our Division of Vascular Surgery. Follow-up MRI after 9 months of first diagnosis had been set up, and it showed an increase of the aneurysmatic diameter up to 16 mm—still asymptomatic (Figs. 1 and 2). Watchful waiting led us to a digital subtraction angiography (DSA) revealing hepatomesenteric trunk with the aneurysm at the transition from the common hepatic artery to the proper hepatic artery under involvement of the gastroduodenal artery. In this subsequent imaging, the aneurysma size was 18 mm (Fig. 3). Because of its specific location and the necessity of a preservation of the gastroduodenal artery, an endovascular approach was not possible. Therefore, the basic aim now was to follow up patient’s clinical status and local aneurysmatic finding with a reasonable imaging modality such as Duplex ultrasonography followed by computed tomographic angiography if necessary within a reasonable time interval. If there is further progression up to > 20 mm detectable, a vascular surgical approach for reconstruction of the proper hepatic artery (interposition of a short prosthetic segment) and gastroduodenal artery (reinsertion at the hepatic artery) is indicated.
In the present case, there are several remarkable aspects characterizing etiopathogenesis, clinical and morphological finding, and indicated therapeutic approach: e.g., there is no typical etiology of the aneurysmatic disease in this rare coincidence of a hepatomesenteric trunk with an APHA. Even more, there seems to be an at least moderate (9 months) progression of the size of the aneurysm as shown in the different diagnostic measures (duration of medical history in total, < 24 months since diagnosis has been found), which requires urgently further follow-up investigation within (a) reasonable time interval(s) of no more than 6 months including a repeat sensitive education of the patient. Furthermore, the anatomic variant of a hepatomesenteric trunk equal to type IX according to the classification of the liver’s arterial blood supply by MICHELS was shown by angiography, which itself occurs in 3–5 % of cases [3, 7]. In addition, there is an incidence of visceral arteries ranging from 0.1 to 10 % (average, approximately 2 %) with a lowering frequency (only 1/5 of the former range, resulting in 0.02–4 %) of the aneurysmatic site at the hepatic, gastroduodenal and pancreaticoduodenal artery [3, 7]. The combination of the aneurysm of the proper hepatic artery with an existing hepatomesenteric trunk potentiates the infrequent simultaneous occurrence of both aspects in morphology of visceral arteries. Last but not least, aneurysmatic site at the hepatic artery’s branching off to the gastroduodenal artery makes it even more rare.
The adequate therapeutic approach in this rare case appears to be open vascular surgery because of the involvement of the originating segment of the gastroduodenal artery, which needs vascular surgical reconstruction in case of further progression of aneurysmatic size > 20 mm [8, 9]. Currently, “watchful waiting” (“wait & see”) is favored including (1) results of follow-up investigation aiming for measuring aneurysmatic size and (2) possible clinical signs and symptoms [3, 4] of the patient for an adequate decision-making toward an appropriate therapeutic measure and adequate time point of the intervention in further patient’s clinical course.
Conflict of interest
We have no financial or other relations that could lead to conflict of interest regarding publication.