Innumerable Hepatic Artery Pseudoaneurysms Treated with Selective Intraarterial Delivery of Gelfoam

Purpose: Hepatic artery pseudoaneurysms are a rare vascular pathology that can be secondary to trauma or vasculopathies. Present-day first-line therapy is embolization. Here we report a case of atraumatic innumerable hepatic artery pseudoaneurysms with hemorrhage producing hemodynamic instability.

Materials and Methods: A 70-year-old woman with a history of gastroesophageal reflux, paroxysmal atrial fibrillation on direct oral anticoagulation, and monoclonal gammopathy of undetermined significance presented to an outside hospital with acute onset of right upper quadrant abdominal pain with radiation to the right shoulder and 1 month of diarrhea. Computed tomography (CT) at the time of presentation to the emergency department showed new tubular lesions within the liver and a new subcapsular fluid collection concerning for abscess or hematoma. Percutaneous image-guided aspiration of the fluid collection demonstrated sterile hematoma. The patient was transferred to a tertiary care center for evaluation by hepatology.

Results: Shortly after transfer, the patient became hemodynamically unstable, requiring massive transfusion protocol. CT demonstrated large-volume hemoperitoneum, soft tissue thickening around the celiac trunk, numerous pseudoaneurysms arising from the segmental hepatic artery branches, and extensive heterogeneity of the hepatic parenchyma consistent with a combination of hemorrhage, infarct, and edema. Extensive laboratory workup for inflammatory vasculitides was negative. Digital subtraction angiography (DSA) of the celiac trunk demonstrated innumerable 3- to 5-mm pseudoaneurysms arising from the right hepatic artery and segment 3 branches. Because of the extensive nature of the pseudoaneurysms, coiling each lesion was considered infeasible. Instead, the right hepatic and the segment 3 arteries were embolized with Gelfoam (Pfizer) slurry to five-beat stasis. Repeat DSA of the hepatic artery demonstrated no residual filling of the pseudoaneurysms. The patient remained hemodynamically stable and did not require further transfusions for the duration of hospitalization.

Conclusions: Management of hepatic pseudoaneurysms normally takes the form of endovascular embolization with coils. For innumerable hepatic pseudoaneurysms, we present an example of treatment with selective and superselective delivery of Gelfoam slurry with successful clinical management of life-threatening hemorrhage.