1. 1 23
Journal of Gastrointestinal Surgery
ISSN 1091-255X
J Gastrointest Surg
DOI 10.1007/s11605-016-3097-z
Hepatic Artery Pseudoaneurysm After
Liver Transplantation
Aleksandr A. Reznichenko, Alexander
Bondoc, Flavio Paterno & Shimul
A. Shah

2. 1 23
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3. GI IMAGE
Hepatic Artery Pseudoaneurysm After Liver Transplantation
Aleksandr A. Reznichenko1
& Alexander Bondoc1
& Flavio Paterno1
& Shimul A. Shah1
Received: 19 January 2016 /Accepted: 26 January 2016
# 2016 The Society for Surgery of the Alimentary Tract
Keywords Hepatic artery pseudoaneurysm . Liver
transplantation . Angiogram
Case Presentation
Hepatic artery pseudoaneurysms (HAPs) are rare after liver
transplantation with reported incidence of 0.5–2.0 %.1
They
can lead to life threatening hemorrhage. HAP usually occurs
at the arterial anastomosis and is often caused by infection
and/or technical failure.2
Early diagnosis and aggressive inter-
vention are essential. Several treatment modalities were de-
scribed and included excision with ligation, retransplantation,
excision with arterial reconstruction, balloon angioplasty with
stenting, endovascular embolization, and percutaneous throm-
bin injection. We are presenting a case of HAP following
liver transplantation, which was successfully treated by
surgical resection and primary arterial reconstruction of
the hepatic artery.
A 56-year-old female with prior history of gastric bypass
and open cholecystectomy developed end-stage liver disease
(ESLD) secondary to primary biliary cirrhosis and underwent
uncomplicated orthotopic liver transplantation in April of
2015. Her preoperative MELD score was 20 and she was
intubated prior to liver transplantation because of encephalop-
athy. The donor was a 35-year-old male DCD with history of
hypertension, heroin abuse, BMI of 26, and normal liver func-
tion tests. Due to DCD, tPAwas injected into the donor hepat-
ic artery prior to the performing of the portal vein anastomosis.
Arterial anastomosis was performed between donor common
hepatic artery and recipient common hepatic artery with 6-0
Prolene in a running fashion. Intraoperative Doppler ultra-
sound confirmed a good pulse in the hepatic artery and good
flow in the liver. Duct-to-duct biliary anastomosis was per-
formed with longitudinal ductoplasty on the donor site. Cold
ischemia time was 406 min, cold ischemia time was 36 min.
Immunosuppression included tacrolimus, cellcept, and pred-
nisolone. Steroids continued for 3 months after transplantation.
Patient presented 6 months after surgery with right upper
quadrant pain. All liver function tests were normal. A com-
puted tomography (CT) scan of the abdomen showed focal
aneurysmal dilation of the common hepatic artery. Subsequent
angiogram showed a 1 cm pseudoaneurysm arising from a
highly tortuous segment of the common hepatic artery, with
a short segment of narrowing proximal to the pseudoaneurysm
(Fig. 1). Due to the angulation and tortuosity of the hepatic
artery and pseudoaneurysm, it was felt that endovascular ap-
proach was not possible. After careful discussion of risks and
benefits of surgery with the patient, the decision was made to
proceed with operation which included resection of HPAwith
reconstruction.
We used the previous transplant incision to enter
intraabdominal cavity. After all adhesions were taken down,
porta hepatis was exposed. After hepatic artery aneurysm was
dissected out, distal and proximal control was obtained. The
pseudoaneurysm was larger than appeared on imaging studies,
reaching 2×1.5 cm in size (Fig. 2). There was no evidence of
infection around pseudoaneurysm. The pseudoaneurysm was
resected (Fig. 3). Direct anastomosis of the common hepatic
artery of the donor and of the common hepatic artery of the
recipient was performed with 7-0 Prolene in an interrupted
* Aleksandr A. Reznichenko
reznicaa@ucmail.uc.edu
1
Division of Transplant Surgery, Department of Surgery, University of
Cincinnati, 231 Albert Sabin Way, Suite 1555,
Cincinnati, OH 45267-0519, USA
J Gastrointest Surg
DOI 10.1007/s11605-016-3097-z
Author's personal copy

4. fashion. Intraoperative Doppler ultrasound showed a good
pulse in the hepatic artery and a good flow in the liver.
Pathology evaluation showed the segment of hepatic artery
with extra-luminal hematoma and associated hemorrhage,
consistent with pseudoaneurysm. Doppler ultrasound on post-
operative day 4 demonstrated normal waveforms in right, left,
and main hepatic arteries, with peak systolic velocity in the
main hepatic artery of 204 cm/s. The resistive indices were
normal. Patient had uneventful recovery and is pain free dur-
ing her follow-up in 4 months.
Surgical treatment was considered the first choice for HAP
management in the past, before advances in endovascular in-
terventions. However, it was universally recognized that sur-
gical resection and vascular reconstruction represent a chal-
lenge, secondary to postoperative adhesions and inflammatory
changes in the hepatic hilum. The natural histories of HAPs
are unknown. Commonly, they present when ruptured.
Surgery after rupture represents a salvage effort to protect the
allograft but commonly results in death or retransplantation. In
this case, the HAP was small but real. Observation was con-
sidered and if growing intervention would be necessary. But,
after careful discussion, it was felt that elective surgical man-
agement was most prudent since rupture was the likely conse-
quence at some point in the future.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no competing
interests.
References
1. Thorat A, Lee CF, Wu TH, Pan KT, Chu SY, Chou HS, Chan KM,
Wu TJ, Lee WC. Endovascular treatment for pseudoaneurysms aris-
ing from the hepatic artery after liver transplantation. Asian J Surg.
2014 Aug 30. pii: S1015-9584(14).
2. Madariaga J, Tzakis A, Zajko AB, Tzoracoleftherakis E, Tepetes K,
Gordon R, Todo S, Starzl TE. Hepatic artery pseudoaneurysm liga-
tion after orthotopic liver transplantation–a report of 7 cases.
Transplantation. 1992 Nov. 54(5):824–8.
Fig. 1 Angiogram. Pseudoaneurysm (yellow arrow) arising from a
highly tortuous segment of the common hepatic artery, with a short
segment of narrowing (red arrow) proximal to the pseudoaneurysm
Fig. 2 Intraoperative findings. Hepatic artery pseudoaneurysm (yellow
arrow) 2 × 1.5 cm in size
Fig. 3 Resected specimen. Hepatic artery pseudoaneurysm
J Gastrointest Surg
Author's personal copy