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Hepatic Artery Aneurysm

MCQ Discussion - Hepatic Artery Ligation

Question: Regarding hepatic artery ligation, which statement is false?

a) Last resort in hemobilia, when angioembolization is not successful

b) Not useful in primary hepatoma

c) Hepatic infarction can result if proper hepatic artery is ligated

d) Must be covered by antibiotic administration

Answer: B

  • Hepatic artery ligation can be useful in treating primary hepatomas, as the hepatic artery is the primary blood supply to liver tumors, and reducing this blood flow can control the growth of the tumor.

Key Points:

  • Hepatic artery ligation is used as a last resort in hemobilia when angioembolization fails (Answer A is true).
  • Hepatic infarction is a risk if the proper hepatic artery is ligated, especially if collateral circulation is inadequate (Answer C is true).
  • Antibiotic administration is necessary to prevent infections after the procedure (Answer D is true).

MCQ Discussion - Hepatic Artery Aneurysm

Question: All are true about hepatic artery aneurysm except:

a) It constitutes about 20% of all visceral artery aneurysms

b) Quincke described triad of jaundice, hemobilia, and biliary colic

c) This triad is present in 70-80% of cases

d) Endovascular treatment is a feasible option

Answer: C

  • The Quincke triad (jaundice, hemobilia, biliary colic) is not present in 70-80% of cases; it is observed in a much smaller percentage of cases, typically 20-30%.

Key Points:

  • Hepatic artery aneurysms constitute about 20% of all visceral artery aneurysms (Answer A is true).
  • Quincke's triad is a classical description for patients with hemobilia caused by hepatic artery aneurysms (Answer B is true).
  • Endovascular treatment is a feasible option and commonly used for managing hepatic artery aneurysms (Answer D is true).

Hepatic Artery Aneurysm: Key Facts and Misconceptions

Prevalence and Classification

  • Hepatic artery aneurysms (HAAs) constitute about 20% of all visceral artery aneurysms, making them the second most common after splenic artery aneurysms ([1])
  • HAAs can be classified as extrahepatic (78%) or intrahepatic (22%) ([2])

Clinical Presentation

  • Quincke's triad of jaundice, hemobilia, and biliary colic is associated with HAAs
  • However, this triad is not present in 70-80% of cases, contrary to the statement in option c
  • Many HAAs are asymptomatic and discovered incidentally ([3])
  • Common symptoms include:
    • Right upper quadrant pain (most frequent)
    • Transaminitis
    • Obstructive jaundice ([4])

Risk Factors

  • Hypertension
  • Vascular disease
  • Pancreatitis
  • Diabetes
  • Tobacco use
  • Autoimmune diseases
  • Previous transplantation ([3])

Diagnosis

  • Imaging modalities play a crucial role in diagnosis:
    • Ultrasonography
    • Computed tomography (CT)
    • CT angiography
    • Arteriography (for surgical planning) ([5])

Treatment Options:

Management Approach:

  • Lesions <2 cm:
    • Followed with serial imaging to monitor for changes.
    • Only up to 27% may show growth over time, and many can remain stable without immediate intervention.

High-Risk Patient Groups:

  • Patients with underlying connective tissue disorders or vascular diseases are at higher risk for developing HAAs and rupture, including:
    • Fibromuscular dysplasia.
    • Polyarteritis nodosa.
    • Marfan syndrome.
    • Ehlers-Danlos syndrome.
    • Systemic Lupus Erythematosus (SLE).
    • Scleroderma.

Endovascular Treatment

  • Endovascular treatment is indeed a feasible option for HAAs ([3])
  • Techniques include:
    • Coil embolization
    • Stent placement ([4])
  • Advantages:
    • Less invasive
    • Potentially lower morbidity and mortality compared to open surgery ([1])

Open Surgical Repair

  • Remains the mainstay treatment for many HAAs, especially those involving the proper hepatic artery ([4])
  • Techniques include:
    • Excision with vein or synthetic graft
    • Endoaneurysmorrhaphy
    • Ligation (in select cases) ([2])

Perioperative Mortality Rates:

  • Elective repair of HAA has a perioperative mortality rate of 5%.
  • Emergent repair for ruptured aneurysms carries a much higher risk, with a mortality rate of 22% to 33%.

Complications and Prognosis

  • Risk of rupture is significant (14%)
  • Mortality from rupture can be as high as 40% ([2])
  • Risk factors for rupture:
    • Multiple HAAs
    • Non-atherosclerotic origin ([2])
  • Overall survival rate of 86% at 5 years after treatment ([4])