Endoscopic ultrasound-guided coiling of hepatic artery pseudo-aneurysm in two stages

BACKGROUND: Hepatic artery pseudo-aneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudo-aneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct, or portal vein. Essentially, all pseudo-aneurysms, whether symptomatic or not symptomatic, require early treatment to prevent lethal complications. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity compared to endovascular treatment. The goal of endovascular treatment of hepatic aneurysms is to obtain a complete, stable exclusion of the sac from arterial circulation with preservation of the parent vessel. Endovascular, percutaneous, and endoscopic ultrasound (EUS)-guided interventions are used in the treatment of visceral artery pseudo aneurysms. CASE REPORT: A 20-year-old male presented with abdomen pain in right upper quadrant for two months. He had undergone ultrasound-guided aspiration of liver abscess two months ago. Ultrasound abdomen showed an aneurysm arising from hepatic artery. Computed tomography angiography of the abdomen confirmed a saccular pseudo-aneurysm arising from proximal part of hepatic artery. The lesion was not considered feasible for percutaneous intervention. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of the stent. After discussing the pros and cons of EUS-guided procedure, the patient chose EUS-guided coil embolization. The sack packing with helical coils was planned. Packing with one coil of 10 mm and five coils of 6mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later, EUS assessment showed the injected coils were collected into the most distal part of the aneurysm but the flow into a smaller cavity continued with high velocity. During the second attempt, four coils of 10 mm size were deployed. Postcoiling EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later, follow-up color Doppler abdomen showed no flow in the pseudo-aneurysm. CONCLUSION: This case showed the practical problems of EUS-guided coil embolization of hepatic artery aneurysm. Initial attempt resulted in 80% obliteration of aneurysm cavity but did not cause progressive thrombosis of rest of the cavity of the aneurysm. However, successful and complete obliteration of pseudo-aneurysm was achieved in second attempt of coiling.