hepatic artery aneurism in deceased donor

8/3/2019 Hepatic Artery Aneurism in Deceased Donor

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Hepatic artery aneurism in deceased donor. Is it a contra-indication for

transplantation?

Mello, FPT; Monte Filho, AP; Ribeiro, J; Coelho, RJ; Basto, ST; Sousa, C; Andrade, RO;Pimentel, LMS; Souza, NFA; Fernandes, ESM.

Abstract

Hepatic artery aneurisms are infrequent and most are asymptomatic. Clinical presentation

is variable but the most frequent form is rupture, complicated by hemoperitoneum and

shock. We present the case of a deceased donor who had a right hepatic artery aneurism

detected during the organ procurement, and because of the difficulty to guarantee the right

lobe perfusion with the preservation solution, the liver graft was not used for transplantation.

Introduction



Although rare, hepatic artery aneurism (HAA) is the second most common type of visceral

aneurysm after splenic artery aneurysm. (1,2,3) The true incidence of HAA is unknown.

Recent advances in and rapid proliferation of cross-sectional imaging has enabled early

identification in their natural history. (4) This aneurysm is more common in men. (2,5,6) and

most HAA are extrahepatic and solitary. (1,3,4)

Several conditions have been associated with HAA, including atherosclerosis, arterial

fibrodysplasia, vasculitis, polyarteritis nodosa, systemic lupus erythematosus and others

rheumatic diseases . (1,2,4) Historically, mycotic aneurysms were the most common cause

of HAA, although they now account for only 4% cases.(7,8) Atherosclerosis is present in up

to 30% of such lesions, although it continues to be viewed as a secondary process. Less

common are, periarterial inflammation caused by either cholecystitis or pancreatitis. HAA´s

are found also as anastomotic complications of liver transplantation, and recently has been

one of the most common causes. HAAs have also followed hepatic tumor embolization,

where it is speculated that the main cause of aneurysm formation was the embolic agent.

(9,10)

Diagnose could be suspected when on abdominal films, rim calcifications appears on liver

topography (11,12). Doppler ultrasound can localize the aneurysm and study the blood

flow. CT angiography are useful in demonstrating the nature of the aneurysm, adjacent

structures and evidence of rupture (12). However, angiography is considered gold standard

for diagnose, as it provides the size, shape and location of the aneurysm with possibility for

intervention (11,12,13).

The purpose of this report is to discuss the importance of hepatic hilum dissection

during the procurement to indentify the possible anatomic variations of the liver vesselsand also potential unusual problems that can contraindicated the organ implant such as,

aneurisms, tumors or vascular thrombosis.

Case report

L.V., 65 years, hospitalized for 7 days, cause of death myocardium infarction,



Laboratory with Alanine Amino Transferasis 19; Aspartate Amino Transferasis 20; Gamma

Glutamil Transferasis 53; Total Bilirubin 0,7; Direct Bilirubin 0,4; Indirect Bilirubin 0,3;

Albumin 2,5; Creatinine 1,2; Sodium 182

Procurement initiated and identified a mass in the hepatic hilum, in a first site, was suspect

of a large lymphonode, continuing the dissection, was identified an aneurism of the righthepatic artery, just after the gastroduodenal artery origin (Figure 1). The right hepatic artery

did not have pulse or flow, so the perfusion with the preservation solution for the right lobe

would be jeopardized.

Figure 1: A Hepatic artery; B Right hepatic artery with an aneurism; C Left hepatic

artery; D Middle hepatic artery; E Cystic artery

ABCDE



The vascular structures were dissected and ressected for study. When opening the

specimen was identified total thrombosis of the aneurism (Figure 2).

Figure 2: A Aorta; B Celiac artery; C Splenic artery; D Left gastric artery; E Hepaticartery; F Gastroduodenal artery; G Left hepatic artery; H Middle hepatic artery; I

Right hepatic artery with a thrombosed aneurism; J Cystic artery.

E

I

G

H J

F C

D

B

A



Discussion

Hepatic artery aneurisms are infrequent and most of the times are asymptomatic .The

diagnose is made as an incidental finding on image studies or in the event of complications,

such as rupture or acute liver infarction.

Most of the potential cadaveric donors do not undergo through detailed images studies of

the abdominal vessels routinely. Few transplant surgeons do not dissect the liver hilum

during the procurement and prefer to dissect it during the bench time but the great

majority of the centers use the Starzl technique that involve extensive dissection of the

celiac artery and main branches to facilitated the bench time and recognize all the potential

problems and anatomic variations.

Here we´ve presented a case where the complication was an aneurism of the right hepatic

artery totally thrombosed, with no flow for the right segments of the liver. Theoretically, it

could be a chronic disease with collateral flow inside the parenchyma? Would the infusionof preservation fluid be satisfactory if injected in the right hepatic artery just after the

aneurism? Or the right liver might be suffering for a long period with a low pO2 level? And,

since the biliary tree after liver transplant is dependent on the arterial blood supply, biliary

complications could be a expected problem in such cases.

Considering all the doubts mentioned and the pale aspect of the right liver lobe and the lack

of arterial pulse above the aneurism, the team decided to abort the liver procurement. In

Rio de Janeiro, we recently report a high mortality at the waiting list related to donor

scarcity (14) and the use of very high risk donor would be a problem for re-transplantation.

References



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hepatic artery aneurism in deceased donor

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