1st Mar 2021

ICRI CASE OF THE WEEK

CContributed By : Dr. Amar Mukund, Dr. Navojit Chatterjee
Department of Interventional Radiology

Institute of Liver and Biliary Sciences, New Delhi

Copyright of the Case belongs to : Dr Amar Mukund

Clinical details

• A 16 year old boy presented with a history of abdominal pain and
passage of dark stool for one week. On general physical examination
there was pallor and jaundice. On palpation, there was tenderness in the
right upper quadrant. There was no history of trauma/procedure done.

• Blood work showed raised bilirubin with an obstructive jaundice pattern
(Total - 9.35 mg/dl, Direct - 6.1 mg/dl, Indirect - 3.2 mg/dl), raised
alkaline phosphatase (369 IU/L), Gamma Glutyl Transferase (306 IU/L)
and decreased hemoglobin (9.1 g/dl).

What is the likely diagnosis?
What is Quincke’s triad?

• Chest and abdominal radiographs
were unremarkable.

• USG showed echogenic mobile
contents in gallbladder lumen. There
was dilatation of the CBD with mild
bilobar IHBR dilatation.

• CECT thorax and abdomen was done
for further workup.

What can be the attenuation values of contents seen within the gall bladder
and CBD (marked by block arrows)?

What can be the causes of this finding?

Name the arteries labelled by block arrows. What is the location of the lesion?
Does the imaging findings correlate with the patient’s symptoms?

Which of the following is true regarding hepatic artery aneurysms?

a) Hepatic artery aneurysms are the most common non traumatic visceral
artery aneurysms.

b) Extrahepatic location is more common than intrahepatic location.

c) Surgery is the treatment of choice for aneurysms with intrahepatic
location.

d) Aneurysms in intrahepatic location are more commonly attributed to
degenerative/ dysplastic changes of the arterial wall.

12 3

What can be the possible etiology of the necrotic lymph nodes (block arrow
in image 1) and how to confirm?

Can the filling defects in the segmental branches of pulmonary artery (block
arrow in image 3) be attributed to the mediastinal nodes?

Can the hepatic artery aneurysm be attributed to the same etiology?

Diagnosis and follow up

• Endoscopic USG guided FNAC from the subcarinal lymph node
showed granulomatous etiology with occasional acid fast bacilli.

• Final Diagnosis - Tubercular mediastinal lymphadenopathy with right
lower lobe segmental pulmonary artery branch thrombus with
ruptured pseudoaneurysm of anterior sectoral branch near the
bifurcation of right hepatic artery with hemobilia.

• The pseudoaneurysm and pulmonary artery thrombus may be
attributed to septic emboli from necrotic mediastinal lymph nodes.

Anterior sectoral branch DSA run with microcatheter tip in anterior
RHA sectoral branch of right hepatic artery
shows the pseudoaneurysm (block arrow)
Posterior sectoral branch arising from the vessel.

The microcatheter was negotiated to reach
distal to the neck of the pseudoaneurysm.

1 A 3 x 3 mm coil was used to embolise the artery
distal to the neck of the pseudoaneurysm blocking its
efferent supply (1).

A 14 x 3 mm coil was used to embolise the feeding
artery proximal to the neck of the pseudoaneurysm
2 blocking its afferent supply (2).

Why was coil embolisation preferred over covered
stent placement in this case?

Why is there no risk of ischemia after coil
embolisation of hepatic artery in this case?

Contrast opacification of Check angiogram post coil deployment
pseudoaneurysm showed faint contrast opacification of the
pseudoaneurysm suggesting that the
Coils pseudoaneurysm was not completely
excluded from the circulation.

What to do now ?

Glue + Lipoidol The microcatheter was manipulated
Coils adjacent to the larger coil and a mixture of
glue and lipoidol was injected into the
pseudoaneurysm sac.

Glue + Lipoidol Post glue injection DSA run showed
Coils satisfactory result with non opacification of
the pseudoaneurysm sac.

CT Angiography MIP coronal section shows
metallic artifact due to coils and lipoidol.
No contrast opacification of the
pseudoaneurysm is seen.

Discussion

• Hepatic artery aneurysm is the second most common type of
nontraumatic abdominal visceral artery aneurysm. (MC - splenic
artery aneurysm)

• Affected patients are often asymptomatic. A triad of epigastric pain,
upper gastrointestinal bleed, and obstructive jaundice (Quincke triad)
is seen in up to one-third of cases.

• One should search for the possibility of aneurysm multiplicity, which
is known to occur in 20% of hepatic artery aneurysms.

Hepatic artery aneurysm Pseudoaneurysm True aneurysm
Incidence Less common (20%) More common (80%)
Wall Layers missing - more prone to All three layers - less prone to
rupture rupture
Etiology Iatrogenic, traumatic, mycotic Degenerative, FMD
Epidemiology No age/sex prediliction Older males
Most common location Intrahepatic branches (RHA >LHA) Extrahepatic branches (CHA, PHA)
Treatment Coil or glue embolisation Surgery, Covered stent

• Mediastinal lymphadenopathy without significant pulmonary
parenchymal involvement is a common presentation of primary
pulmonary tuberculosis.

• However, septic thromboembolism to pulmonary artery branches is a
rare presentation.

• Since there is no other attributable cause for the hepatic artery
pseudoaneurysm, mycotic pseudoaneurysm secondary to septic
thromboembolism due to primary pulmonary tuberculosis was
proposed as the likely etiology which makes it a very rare entity.

CHA Aneurysm (True > Pseudo) PHA aneurysm (True > Pseudo) Intrahepatic branch aneurysm (Pseudo >
True)

1) Compensated by 1) Large area of ischemia if embolisation 1) Small area of ischemia if embolisation
pancreaticoduodenal arcade if done. done.
embolisation done. 2) Not compensated by PV/ 2) Compensated by portal venous blood
2) If the artery is large (>6 mm) pancreaticoduodenal arcade. supply.
and not tortuous - covered stent 3) If the artery is large (>6 mm) and not 3) Small and tortuous artery - covered
can be deployed. tortuous - covered stent can be deployed. stent cant be deployed.

SURGERY > COVERED SURGERY > COVERED STENT EMBOLISATION (coil/glue)
STENT/ EMBOLISATION

• Indications for treatment in a hepatic artery aneurysm are - a)
diameter>2 cm, b) if the patient is symptomatic, c) high-risk lesions (eg,
in patients with polyarteritis nodosa, fibromuscular dysplasia, and
pseudoaneurysms in whom treatment is recommended regardless of
lesion size).

[Criteria met by our case are shown in yellow]

• Since the pseudoaneurysm was intrahepatic in location involving the
anterior sectoral branch of the right hepatic artery, coil embolisation
was preferred over surgery and stent deployment.

• Since the pseudoaneurysm could not be excluded from the circulation
by using coils alone, microcatheter was manipulated through the coil
upto the neck of the pseudoaneurysm and selective embolisation with
glue and lipoidol was done with check angiogram showing satisfactory
result.

Teaching Points

• A triad of epigastric pain, upper gastrointestinal bleed, and obstructive
jaundice (Quincke triad) should raise the suspicion of hemobilia.
Ruptured hepatic artery aneurysm should be kept as a differential in
such a scenario.

• Hepatic artery pseudoaneurysm is generally intrahepatic in location
while true hepatic artery aneurysms involve the common and proper
hepatic arteries.

• Surgery is preferred for aneurysms involving the common and proper
hepatic arteries while coil embolisation is preferred for aneurysms with
intrahepatic location.

• Proper hepatic artery aneurysms should never be embolised due to lack
of collateral supply to the liver post embolisation.

• If coil embolisation fails to completely treat a pseudoaneurysm,
embolisation of the sac with glue can be used as an effective adjunct.