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Although liver lacerations are relatively common following blunt trauma, hepatic artery injuries are rare, with only a few cases of hepatic artery dissection caused by blunt trauma reported to date. Due to its rarity, no standardized treatment protocol exists for managing such injuries. We report the case of a 22-year-old female patient referred with a suspected pancreatic injury and liver laceration following blunt trauma. Upon arrival, she presented severe abdominal pain, and a physical examination revealed significant epigastric tenderness. Emergency laparotomy confirmed pancreatic contusion and liver laceration, for which peritoneal irrigation and wide drainage were performed. On postoperative day 17, hepatic artery dissection was incidentally diagnosed with computed tomography, although the patient remained asymptomatic and laboratory tests were within normal limits. Conservative management with an antiplatelet agent was initiated. A follow-up computed tomography scan performed 4 months post trauma demonstrated complete resolution of hepatic artery dissection.
Liver laceration following blunt trauma is relatively common; however, injury to the common hepatic artery is rare. Hepatic artery dissection (HAD) has been reported after liver transplantation or intra-arterial radiologic intervention; however, HAD following blunt trauma is uncommon [1–3]. It can lead to serious complications, such as bleeding due to rupture of the injured blood vessel or ischemic insult resulting from thrombosis. Due to the rarity of HAD, treatment guidelines are not well established. Here, we report a case of HAD after blunt trauma treated conservatively due to its delayed presentation.
CASE REPORT
Ethics statement
This study was approved by the Institutional Review Board of Pusan National University Hospital, with a waiver of informed consent (No. 2407-011-140).
Patient information
A 22-year-old female patient was transferred to our emergency room from another hospital. The patient had been assaulted 3 days prior to admission and complained of severe epigastric pain. She had no relevant medical history.
Clinical and diagnostic findings
Her initial vital signs were stable except for tachycardia at 136 beats per minute. A chest computed tomography (CT) scan showed multiple rib fractures, a sternal fracture, and pneumothorax. An abdominal CT scan revealed a liver laceration and a possible pancreatic injury (Fig. 1). Physical examination showed remarkable epigastric tenderness. Initial serum amylase and lipase levels were 1,438.2 and 897.1 U/L, respectively, and her white blood cell count was elevated at 30.28×103/µL. Endoscopic retrograde cholangiopancreatography was unavailable within 24 hours of admission because it was the weekend.
Therapeutic intervention
We performed exploratory laparotomy. During surgery, we found a pancreatic contusion and a grade III liver laceration but no significant hepatic artery injury, pancreatic laceration, saponification, or bile leakage. Therefore, we performed peritoneal irrigation and wide drainage.
Follow-up and outcomes
On postoperative day (POD) 3, minor pancreatic leakage was detected through analysis of fluid from the peripancreatic drain, although the fluid appeared serous-sanguineous rather than turbid. On POD 6, sips of water were initiated, and a soft diet was introduced on POD 8. During diet progression, the patient reported no specific symptoms other than postoperative pain, and drain output gradually decreased. On POD 17, before removing the peripancreatic drains, we performed a follow-up CT scan to evaluate any residual peripancreatic fluid collection. The abdominal CT scan revealed no peripancreatic fluid collection, but incidentally detected a proper HAD extending into the right and left main hepatic arteries (Fig. 2A). At that time, liver function tests were within normal limits (aspartate aminotransferase, 26 U/L [reference range, 0–40 U/L]; alanine aminotransferase, 23 U/L [reference range, 0–40 U/L]; total bilirubin, 0.51 mg/dL [reference range, 0.1–1.2 mg/dL]), and vital signs remained stable. Interventional radiology recommended follow-up CT rather than angiography due to bilateral hepatic artery involvement and small distal vessels, which increased the risk of stent occlusion. Surgical reconstruction was deemed infeasible because of the long dissection segment and difficulty accessing the intrahepatic arteries. We opted for close monitoring with short-term follow-up CT scans and chemoprophylaxis for thrombosis using acetylsalicylic acid (100 mg once daily).
Throughout her hospital stay, the patient was closely monitored with serial CT scans for potential complications such as bleeding or thrombosis while receiving conservative treatment. On POD 23, abdominal CT angiography showed proper hepatic artery and bilateral hepatic artery dissections with aneurysmal dilatation (Fig. 2B). The peripancreatic drains were removed on POD 24. On POD 36, abdominal CT angiography showed no significant changes compared with the imaging performed 2 weeks earlier (Fig. 2C). She was discharged on POD 38 without any hepatic artery-related complications.
A follow-up abdominal CT scan performed 4 months post trauma demonstrated complete resolution of HAD (Fig. 2D). The patient remained symptom-free without any hepatic artery-related complications.
DISCUSSION
Hepatic artery injury is rare, and HAD is even rarer. Due to this rarity, the exact prevalence of HAD remains undetermined. Reported etiologies include fibromuscular dysplasia, medical degeneration, cystic medial necrosis, anoxic medial damage, pancreatitis, iatrogenic injury, and trauma; however, in nearly half of reported cases, the etiology was unknown [1–6].
About 30% of patients with HAD present with symptoms such as epigastric pain, upper gastrointestinal hemorrhage, and jaundice [4]. However, these symptoms are nonspecific to HAD and do not always occur, making them unreliable diagnostic aids. This is particularly true in patients with multiple trauma, in whom abdominal pain may not be a clear indicator due to pain from fractures and contusions or sedation related to ventilator management. Similarly, abnormal liver function tests are not specific, as they are commonly associated with liver lacerations or contusions.
HAD can be diagnosed using contrast-enhanced abdominal CT, and CT angiography is particularly useful when HAD is suspected. CT images can accurately identify the location, size, and extent of lesions. Angiography, which offers even greater diagnostic accuracy, may be utilized and allows simultaneous therapeutic interventions [7,8].
In this case, the initial abdominal CT scan after trauma did not reveal significant HAD (Fig. 1B). However, an abdominal CT scan performed on POD 17 revealed HAD (Fig. 2A). Because the liver laceration in the left lobe extended deeply near the hilum, the initial intimal injury to the hepatic artery might not have been prominent but could have existed initially. This delayed manifestation allowed identification of HAD at a later stage. Therefore, we recommend considering the possibility of porta hepatis injury when liver injuries near the hilum are identified.
Due to the rarity of HAD, there are no well-established treatment guidelines for asymptomatic and hemodynamically stable patients. In contrast, superior mesenteric artery dissections have been studied more extensively, with conservative and endovascular approaches successfully applied in asymptomatic cases [7–10]. Bang et al. [5] reported successful conservative management, including anticoagulation with low molecular weight heparin, in two patients with spontaneous HAD.
The role of anticoagulation during conservative management remains a matter of debate. Some studies advocate anticoagulation therapy for symptomatic patients [7,11], whereas other studies have suggested no significant benefit from anticoagulation therapy [8,12]. Thus, the benefits and risks of anticoagulation therapy must be carefully assessed before initiation. In this case, as the patient exhibited no evident thrombus or hepatic artery-related symptoms, we administered only acetylsalicylic acid (100 mg once daily).
In our case, the patient remained asymptomatic, normotensive throughout hospitalization, and had normal liver function tests at the time of HAD diagnosis. The dissection was incidentally discovered during a follow-up abdominal CT scan. The dissection extended from the proper hepatic artery into the right and left main hepatic arteries, with intact distal flow. Considering the small diameter of distal hepatic arteries and the potential for thrombotic complications following surgical or radiologic intervention, we opted for conservative treatment using antiplatelet therapy. A contrast-enhanced abdominal CT scan performed 4 months after trauma showed complete resolution of HAD (Fig. 2D). In a case report describing two patients with spontaneous HAD, follow-up CT scans were performed at 9 and 4 months, respectively [5]. Another report of HAD associated with acute pancreatitis documented radiologic resolution at 8 months [6].
When complications such as bleeding from arterial rupture or ischemic injury due to thrombosis occur, emergent surgical treatment must be considered. If the patient's condition allows, bypass surgery using a graft can be performed. Bushkin et al. [3] reported successful treatment of traumatic HAD through an aorto-common hepatic artery bypass using an artificial graft. Müller and Kim [4] successfully treated spontaneous HAD using a saphenous vein graft. Hepatic artery ligation may be necessary when a patient is hemodynamically unstable and bleeding cannot be controlled through other methods. Hepatic artery ligation typically results in minimal complications because arterial blood flow to the liver is often compensated through collateral circulation [13]. However, the risk of hepatic necrosis and abscess formation after ligation increases significantly in cases with substantial underlying hepatic impairment or severe parenchymal injury from trauma [14,15].
Angiography can also be performed in patients with active bleeding. This allows precise identification of injured vessels, visualization of collateral arteries, and assessment of portal vein flow in the delayed venous phase. This method enables both diagnosis and direct control of bleeding, including stent placement if necessary. Furthermore, angiography can be conducted under local anesthesia, making it advantageous for patients at high anesthetic risk. Taslakian et al. [16] reported a case in which angiography with embolization successfully treated isolated hepatic artery injury presenting with upper gastrointestinal bleeding.
Considering the risks associated with surgical or intravascular interventions for HAD and their potential complications, conservative management with anticoagulation therapy may serve as an appropriate initial approach for selected patients.
ARTICLE INFORMATION
Author contributions
Conceptualization: all authors; Funding acquisition: CIP; Investigation: JHK, CWK; Methodology: JHK, CWK; Project administration: CIP; Resources: CIP; Supervision: CIP; Visualization: JHK, CWK; Writing–original draft: SBL, CIP; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
This study was supported by a clinical research grant from Pusan National University Hospital in 2022.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.
Computed tomography (CT) scans of the patient following blunt trauma. (A) Initial contrast-enhanced abdominal CT showed grade III liver laceration on the left lobe (arrow). (B) Initial CT showed no significant hepatic artery injury (arrow).
Fig. 2.
Follow-up computed tomography (CT) scans. (A) On postoperative day (POD) 17, contrast-enhanced abdominal CT showed posttraumatic arterial dissection initially presented as smooth fusiform dilatation, indicating early mural weakening or dissecting hematoma (arrow). (B) On POD 23, abdominal CT angiography showed proper hepatic artery and bilateral hepatic artery dissection with aneurysmal dilatation (arrow). (C) On POD 36, abdominal CT angiography demonstrated no significant interval change (arrow), with irregular tapering and wall remodeling of the dissected segment. (D) Four months after trauma, follow-up CT revealed radiographic resolution of the hepatic artery dissection (arrow).
REFERENCES
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2. Miranda LE, Leitão L, Jucá N, Lacerda CM. Dissection of the hepatic artery: a rare cause of late ischemia after liver transplant. Exp Clin Transplant 2020;18:641–4.
5. Bang JH, Choi JB, Lee BC, Kim DH, Jung HJ. Conservative treatment in two patients with spontaneous hepatic artery dissection. Vasc Endovascular Surg 2023;57:60–3.
7. Ullah W, Mukhtar M, Abdullah HM, et al. Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circ J 2019;49:400–18.
9. Jia Z, Tu J, Jiang G. The classification and management strategy of spontaneous isolated superior mesenteric artery dissection. Korean Circ J 2017;47:425–31.
12. Luan JY, Li X, Li TR, Zhai GJ, Han JT. Vasodilator and endovascular therapy for isolated superior mesenteric artery dissection. J Vasc Surg 2013;57:1612–20.
16. Taslakian B, Ghaith O, Al-Kutoubi A. Isolated hepatic artery injury in blunt abdominal trauma presenting as upper gastrointestinal bleeding: treatment with transcatheter embolisation. BMJ Case Rep 2012;2012:bcr2012007464.
Conservative treatment in a patient with hepatic artery dissection following blunt trauma in Korea: a case report
Fig. 1. Computed tomography (CT) scans of the patient following blunt trauma. (A) Initial contrast-enhanced abdominal CT showed grade III liver laceration on the left lobe (arrow). (B) Initial CT showed no significant hepatic artery injury (arrow).
Fig. 2. Follow-up computed tomography (CT) scans. (A) On postoperative day (POD) 17, contrast-enhanced abdominal CT showed posttraumatic arterial dissection initially presented as smooth fusiform dilatation, indicating early mural weakening or dissecting hematoma (arrow). (B) On POD 23, abdominal CT angiography showed proper hepatic artery and bilateral hepatic artery dissection with aneurysmal dilatation (arrow). (C) On POD 36, abdominal CT angiography demonstrated no significant interval change (arrow), with irregular tapering and wall remodeling of the dissected segment. (D) Four months after trauma, follow-up CT revealed radiographic resolution of the hepatic artery dissection (arrow).
Fig. 1.
Fig. 2.
Conservative treatment in a patient with hepatic artery dissection following blunt trauma in Korea: a case report
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