Discussion

Blunt injuries to the porta hepatis remain rare. Hepatic artery injuries account for 21% to 44% of all splanchnic artery aneurysms and the majority are intrahepatic when they occur after traumatic injury.1 2 Presentation is typically delayed weeks to months and gold standard for diagnosis remains imaging with arteriography. A high degree of suspicion is required as these may not be readily apparent on the first imaging studies. Rupture may occur into the peritoneum, biliary tract, or gastrointestinal tract.3 4 Mortality rates are highest in those with intraperitoneal rupture with one study reporting a 33% mortality rate.2 The most common interventions include embolization, hepatic artery ligation, no intervention, and hepatic resection in cases of intrahepatic pseudoaneurysm.

Gaining proximal control of the common hepatic artery is often difficult as it often exists deep to multiple important structures. Ligation of the celiac is a known option for controlling significant hemorrhage from any of its many branches, though our literature search did not reveal prior examples of this maneuver to control a bleeding extrahepatic pseudoaneurysm. Certainly, this would not have been feasible had our patient not had good collateral flow from the gastroduodenal artery. Pseudoaneurysms of the proper hepatic artery may prove a more challenging entity in that ligation and embolization may completely take out the hepatic arterial vasculature, despite the proper hepatic artery being in a more anatomically amenable position.

This case highlights the urgency needed in diagnosing and treating these pseudoaneurysms. In this case, placement of REBOA was crucial to temporize the arterial hemorrhage and this demonstrates an example of how this device may be used outside the trauma bay. Treatment of these pseudoaneurysms remains difficult and multiple strategies should be considered including operation, endovascular techniques, or a combination of both. Hybrid operating rooms may be especially useful in these scenarios, though these remain a scarce resource. In our case, our trauma center does not currently use a hybrid OR, otherwise this would have likely been the best place for our patient as he eventually required both angiographic and open surgical procedures. No one method has proven superior for treatment and patient history, hemodynamic stability, associated injuries, hospital resources, and operator abilities should all be considered when making treatment decisions.