Isolated Left Hepatic Artery Transection In Blunt Abdominal Trauma: Case Report

Abstract

Turkish Abstract

Introduction

Although injury to the liver is a common finding after blunt abdominal trauma, injuries to the anatomic structures of the porta hepatis are rare and the morbidity and mortality rates of such injuries are high ¹. Pseudoaneurysm of the hepatic artery after blunt trauma is a very rare complication, which may cause delayed hemorrhage and hemobilia. Symptoms of hepatic artery pseudoaneurysm may vary from clinical stability to intraperitoneal hemorrhage or gastrointestinal, venous, portal, biliary system rupture ². Vascular injuries on the porta may result in hemorrhage  and need to be controlled. In extrahepatic arterial injuries, the vessel may also need to be ligated ³.

The case is here presented of a patient with isolated left hepatic artery transection seen after blunt trauma, and the findings are discussed in the light of relevant  literature.

Case Report

A 17-year-old male patient was admitted to the Emergency Department of Bitlis State Hospital after a traffic accident. The patient was conscious and co-operative on admission. Blood pressure was 120/70 mmHg, and pulse was 114/min. At the time of admission hemoglobin, AST and ALT values were 13.6 g/dl, 219 U / L and 191 U / L, respectively. Plain pulmonary and abdominal radiographs were normal. Brain CT, cervical spine CT and thorax CT were normal. CT angiography showed a pseudoaneurysm in the left hepatic artery and contrast extravasation in the posterior of the artery (Figure 1A).

Figure 1A CT angiography showed a pseudoaneurysm in the left hepatic artery and contrast extravasation in the posterior of the artery

On the portal vein phase CT, the right hepatic artery was seen to be normal and the left hepatic artery was not detected. Parenchymal hematoma and non-contrasted laceration areas were observed in the left lobe (Figure 1B).

Figure 1B Parenchymal hematoma and non-contrasted laceration areas were observed in the left lobe

With the development of hypotension and tachycardia, the patient was admitted for surgery. In the exploration of the abdomen there was found to be hemorrhage of nearly 2 liters of blood and left hepatic artery transection. The left hepatic artery was ligated to provide hemostasis and no other intraabdominal pathology was observed. The patient was stabilized and followed up in the intensive care unit. During the follow-up, the patient had no active drainage, and hemogram monitoring remained stable. On postoperative day 1, the patient was referred to a tertiary level hospital as it was thought that sufficient follow-up of the patient could not be applied in a secondary hospital.

Discussion

Many changes have been observed in the follow-up of blunt liver trauma in the last two decades. Non-operative observation is the standard treatment for hemodynamically stable patients with low-grade injuries ⁴. Indication for emergent surgery can be considered in hemodynamically unstable patients ⁵.

Hepatic artery injury due to blunt trauma is rare, but reported mortality rates in adults are up to 50% ^6,7. In a review of 118 cases with porta hepatis injury, the hepatic artery was determined to be the least injured structure (23%) ⁸. Hepatic artery injury following blunt trauma is often seen as pseudoaneurysm. Occlusion, partial and complete transection are seen less frequently. Severe blood loss occurs when partial or full transection is observed and the patient is hemodynamically unstable. Patients with pseudoaneurysms also do not have apparent clinical symptoms ⁶. In the current case, complete transection was observed in the left hepatic artery, the patient was hemodynamically unstable and underwent emergent surgery.

According to the theory of Bunt et al. it has been shown that due to the flexibility of the proper hepatic artery, injuries are more frequent, and due to the fixed structure of the left hepatic artery, injuries to this are rare ⁹. In the current case, left hepatic artery transection was observed.

Current treatment options for hepatic artery injuries are listed as repair of the artery with end to end anostomosis, lateral arteriorraphy, graft interposition, vascular transposition, embolization and endovascular stenting. The hemodynamic status of the patient plays an important role in the treatment plan ⁶. In the majority of patients with hepatic artery injuries, bleeding is controlled by artery ligation. Most patients tolerate hepatic artery ligation without any sequelae, which is possible because of collaterals from the phrenico-abdominal and intercostal arteries ³. In another previous study of 16 patients with hepatic artery injury, 75% were determined to have occurred by blunt trauma and only one case was treated with hepatic artery ligation ⁸. The current patient had unstable hemodynamic status and was stabilised with hepatic artery ligation.

In conclusion, isolated left hepatic artery transection is rarely seen after blunt trauma and can be fatal. Arterial ligation is the most commonly used treatment option in hemodynamically unstable patients.

References

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