Transhepatic Arterial Stent-Graft Placement for a Pseudoaneurysm after Liver Transplant

Although there are many reports of transhepatic access for hepatic and portal venous procedures, there are very few reports (1Bulman J.C. Weinstein J.L. Moussa M. Ahmed M. Transsplenic arterial embolization for splenic artery steal following liver transplant.J Vasc Interv Radiol. 2021; 32: 474-475Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Wagner A. Kim S.K. Transsplenic splenic artery embolization for persistent pseudoaneurysm after proximal splenic artery embolization.J Vasc Interv Radiol. 2022; 33: 870-871Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 3Oguslu U. Uyanik S.A. Gümüş B. Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature.CVIR Endovasc. 2019; 2: 39Crossref PubMed Scopus (5) Google Scholar, 4Yu M. Lewandowski R.J. Ibrahim S. et al.Direct hepatic artery puncture for transarterial therapy in liver cancer.J Vasc Interv Radiol. 2010; 21: 394-399Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar) of transhepatic access for arterial intervention. Transhepatic arterial access for stent placement is particularly rare but represents a potential option when traditional femoral, radial, or brachial access is impossible because of technical factors or patient anatomy. This is a report of a case of transhepatic, hepatic arterial stent-graft placement to treat a persistent hepatic artery pseudoaneurysm. The Beth Israel Deaconess Institutional Review Board has exempted this report from review. A 39-year-old man with a history of deceased donor liver transplant, deceased donor kidney transplant, right hepatic artery anastomosis, and proper hepatic artery drug-eluting stent placement for high-grade stenosis presented to the emergency department after 3 episodes of hematemesis. Imaging revealed a transplant hepatic artery pseudoaneurysm in proximity to the bowel (Fig 1). Stent-graft placement was not possible because of small-caliber vessels and tortuosity. This was initially treated with relining of the previously placed stents with stent-assisted coil embolization (Concerto; Medtronic, Minneapolis, Minnesota) using a left brachial artery approach (Fig 2a). When the pseudoaneurysm was still present on follow-up imaging, a second attempt of stent-assisted coil embolization of the pseudoaneurysm through the interstices of the existing stents was performed (Fig 2b). The patient was brought back for a third intervention to try to use a coronary stent-graft off-label (Papyrus; Biotronik, Lake Oswego, Oregon) to cover the neck of the pseudoaneurysm. Because of the previous stent placement and vessel tortuosity, the stent-graft could not be delivered using the radial approach. The decision was made to gain percutaneous, transhepatic, retrograde access to the right hepatic artery to deliver the stent using a retrograde approach distal to the tortuosity.Figure 2(a) Digital subtraction angiography of the common hepatic artery using brachial access revealed the presence of a pseudoaneurysm (arrow) arising from the right hepatic artery. (b) An unsubtracted image portrays the pseudoaneurysm (white arrow) arising from the right hepatic artery with a previously placed stent (black arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Transhepatic arterial access was gained under real-time ultrasound and direct fluoroscopic guidance with a 21-gauge needle advanced into a peripheral right hepatic arterial branch (Fig 3a). The position within the chosen branch was confirmed with angiography, and a 5-F Slender sheath (Terumo, Somerset, New Jersey) was placed over a 0.014-inch microwire. A 0.018-inch microwire was passed through the transhepatic access retrograde through the area of tortuosity and snared from the radial access to achieve through-and-through access (Fig 3b). Because the transhepatic approach was the least tortious path to the pseudoaneurysm, a 5-mm × 3-mm balloon expandable stent-graft (PK Papyrus) was advanced via the transhepatic sheath through the right hepatic artery, positioned over the neck of the pseudoaneurysm, and deployed. Postprocedural angiography revealed no endoleak or further filling of the pseudoaneurysm. The transhepatic arterial access was closed using a combination of microcoils and thick gelatin sponge paste in the parenchymal tract. A final hepatic arteriogram showed no evidence of active contrast medium extravasation or pseudoaneurysm (Fig 4). Follow-up duplex ultrasound and magnetic resonance imaging at 3 months revealed patency of the artery distal to the stents without evidence of pseudoaneurysm.Figure 4Final hepatic arteriography confirmed no extravasation or pseudoaneurysm at the site of new stent deployment.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Although not for this purpose, transvisceral arterial access has been described previously (1Bulman J.C. Weinstein J.L. Moussa M. Ahmed M. Transsplenic arterial embolization for splenic artery steal following liver transplant.J Vasc Interv Radiol. 2021; 32: 474-475Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Wagner A. Kim S.K. Transsplenic splenic artery embolization for persistent pseudoaneurysm after proximal splenic artery embolization.J Vasc Interv Radiol. 2022; 33: 870-871Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 3Oguslu U. Uyanik S.A. Gümüş B. Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature.CVIR Endovasc. 2019; 2: 39Crossref PubMed Scopus (5) Google Scholar, 4Yu M. Lewandowski R.J. Ibrahim S. et al.Direct hepatic artery puncture for transarterial therapy in liver cancer.J Vasc Interv Radiol. 2010; 21: 394-399Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar). Oguslu et al (3Oguslu U. Uyanik S.A. Gümüş B. Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature.CVIR Endovasc. 2019; 2: 39Crossref PubMed Scopus (5) Google Scholar) reported a case of transhepatic arterial access when transfemoral access was not feasible to treat an arterioportal fistula. Bulman et al (1Bulman J.C. Weinstein J.L. Moussa M. Ahmed M. Transsplenic arterial embolization for splenic artery steal following liver transplant.J Vasc Interv Radiol. 2021; 32: 474-475Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar) reported successful transsplenic arterial access for embolization of the mid- and lower-pole splenic arteries for splenic reduction in a patient with splenic artery steal syndrome and previous proximal splenic artery ligation who underwent liver transplant. Wagner et al (2Wagner A. Kim S.K. Transsplenic splenic artery embolization for persistent pseudoaneurysm after proximal splenic artery embolization.J Vasc Interv Radiol. 2022; 33: 870-871Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar) reported successful transsplenic embolization of a persistent splenic artery pseudoaneurysm that could not be treated with anterograde splenic artery embolization. This report adds support for the concept that transhepatic retrograde arterial access represents an additional advanced access option when traditional antegrade hepatic arterial access is not feasible.