True hepatic artery aneurysm (HAA) is a rare, but clinically important entity. Mortality following spontaneous rupture has been reported to be from 5.9-40%[1-5]. Treatment is challenging due to the variability of aneurysm location and the importance of maintaining arterial circulation to the liver. There are few publications involving more than 20 cases of true HAAs from a single institution[1-3]. Current treatment guidelines are based on low level of evidence from meta-analysis of case reports and small observational studies[5-7]. The aim of this study was to evaluate patient characteristics and the outcome of open technique (OT) and endovascular technique (ET) in the treatment of HAA.

A retrospective cohort study was performed on patients who underwent treatment for HAAs between 2002 to 2022. The approach to each HAA was decided by a team of interventional radiologists and abdominal transplant surgeons. Endovascular repair was the first choice of treatment whenever technically possible. Clinical presentation, risk factors, and operative approach were reviewed. Severity of complications was graded according to the CCI grading system. Primary outcome was postoperative morbidity and mortality. Secondary outcomes were patency of the vascular reconstruction and long-term survival.

A total of 84 patients were included. Median age was 63 years [IQR 55-79], and 75% of the patients were men. Common risk factors included history of tobacco (69%), hypertension (65%), hyperlipidemia (32%) and diabetes (15%). Fifty-one patients (61%) were asymptomatic, 15 (18%) presented with abdominal pain, 10 (12%) patients presented with rupture, and five (6%) presented with sepsis. Seventy-five (89%) aneurysms were extrahepatic. The most common locations were the common hepatic artery (35%) and the celiac trunk (25%). All nine intrahepatic aneurysms (11%) had an identifiable infectious etiology (endocarditis n=3, cholangitis n=3, liver abscess n=2, infected pancreatic cyst n=1). Multiple synchronous aneurysms were detected in 22 patients (26%), most commonly in the aortoiliac region (12%), followed by the superior mesenteric artery (5%), renal artery (4%) and splenic artery (2%). Fifty patients (60%) underwent endovascular treatment with either covered stent placement (n=30) or coil occlusion (n=20). Thirty-four patients (40%) were treated with open surgery. Vascular reconstruction and bypass was performed using allogenic iliac artery (n=15), autologous saphenous vein (n=15) or GoreTex graft (n=2). Two patients underwent ligation of the aneurysm as the only treatment. Postoperative complications occurred in 13 patients (38%) in the OT group (pleural effusion n=4, pneumonia n=3, pulmonary embolism n=3, hemorrhage n=2, hepatic artery graft thrombosis n=2, bile leak n=2, abdominal abscess n=1, bowel perforation n=1). Ten patients (20%) undergoing endovascular treatment had complications or technical failure (failed attempt n=3, endoleak n=2, hemorrhage n=2, liver necrosis n=1, stent dislocation n=1, aortic dissection n=1, pseudoaneurysm in the common femoral artery n=1). A significantly higher short-term morbidity was found in the OT group (mean CCI 21.9 vs 8.1, p<0.01). Mean follow-up was 73±49 months. Overall postoperative mortality was 1 patient (1.2%) undergoing OT for ruptured HAA. Overall 5-year survival was 81.2%. Five graft occlusions were observed during follow-up (stent graft n=1, autologous n=2, allogenic n=2). Overall graft patency evaluated by CT angiography (n=44) or Doppler ultrasound (n=13) was 85.6% at 5 years. No long-term re-interventions were performed.

ET is the preferred approach for HAA whenever technically feasible, with good short-term and long-term results. Despite notable morbidity and mortality, OT with autologous or allogenic bypass shows comparable long-term outcomes when ET is not technically possible.

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