Hepatic artery aneurysms remain a clinically significant entity. Their incidence continues to rise slowly and mortality from spontaneous rupture is high. Repair is recommended in those aneurysms greater than 2 cm in diameter. It is not surprising that vascular comorbidities, such as ischaemic heart disease, are common in surgical patients, particularly those with arterial aneurysms such as these. The decision of when to operate on patients who require urgent surgery despite having recently suffered an acute coronary syndrome remains somewhat of a grey and controversial area. We discuss the role of delayed surgery and postoperative followup of this vascular problem.
A 58-year-old man was admitted with a 5.5 cm hepatic artery aneurysm. The aneurysm was asymptomatic and was an incidental finding as a result of an abdominal computed tomography scan to investigate an episode of haemoptysis (Figure 1). Three weeks prior to admission, the patient had suffered a large inferior myocardial infarction and was treated by thrombolysis and primary coronary angioplasty. Angiographic assessment revealed a large aneurysm of the common hepatic artery involving the origins of the hepatic, gastroduodenal, left and right gastric arteries and the splenic artery (Figures 2 and 3). Endovascular treatment was not considered feasible and immediate surgery was too high-risk in the early post-infarction period. Therefore, surgery was delayed for 3 months when aneurysm repair with reconstruction of the hepatic artery was successfully performed. Graft patency was confirmed with the aid of an abdominal arterial duplex. Plasma levels of conventional liver function enzymes and of alpha-glutathione-S-transferase were within normal limits. This was used to assess the extent of any hepatocellular damage perioperatively. The patient made a good recovery and was well at his routine outpatient check-ups.
There is no significant difference in cardiac risk in patients who have undergone vascular surgery within 6 months of a myocardial infarction compared with those who have had the operation in the 6 to12 month time frame. Use of alpha-glutathione-S-transferase gives an indication of the immediate state of hepatic function and should be used in addition to traditional liver function tests to monitor hepatic function postoperatively.
Hepatic artery aneurysms (HAAs) are a rare but a clinically important phenomenon. A review of the literature between 1985 and 1995 showed that the HAA had surpassed splenic artery aneurysm (SAA) as the most frequently reported visceral artery aneurysm . This recent trend is thought to be due to the proliferation of centres performing invasive diagnostic and therapeutic hepatobiliary procedures, many of which have hepatic artery pseudo-aneurysm formation as a recognised complication. The natural history of HAA is poorly understood, however, it is suggested that mortality following spontaneous rupture is as high as 40% . Statistics such as these sanction an aggressive approach to the management of the HAA, whenever detected.
It is recommended that aneurysmal repair be considered in HAA larger than 2 cm . In our case, the situation was complicated by the fact that the patient had undergone a large myocardial infarction (MI) 3 weeks prior to admission. The decisions to observe and to operate were both high-risk options. The multidisciplinary team in conjunction with the patient and family had to decide if surgical correction of the HAA was still a viable option and if so, what if any window of the rehabilitation should be allowed before attempting surgical repair.
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