Ann Hepatobiliary Pancreat Surg.  2021 Feb;25(1):126-131. 10.14701/ahbps.2021.25.1.126.

Application of resuscitative endovascular balloon occlusion in post-transplant mycotic hepatic artery pseudoaneurysm rupture in the setting of Aspergillus Constellatus bacteremia

• Stephenson K
• Kalkwarf K
• Giorgakis E

• KMID: 2513186
• DOI: http://doi.org/10.14701/ahbps.2021.25.1.126

Abstract

Hepatic artery pseudoaneurysm (HAP) is a rare, highly morbid and frequently fatal complication of liver transplantation. Most are a mycotic mediated weakness of the arterial wall, with associated bacterial or fungal infection of ascitic fluid. As it is usually asymptomatic prior to rupture, the majority present in acute hemorrhagic shock and dire extremis. Resuscitative endovascular balloon occlusion (REBOA) was initially developed for the management of noncompressible hemorrhagic shock in trauma; however, remains underutilized and understudied in the non-trauma setting. We present the case of a mycotic hepatic artery pseudoaneurysm rupture due to Streptococcus constellatus and Klebsiella pneumoniae post directed donor orthoptic liver transplant, in which REBOA was employed in the setting of impending exsanguination as a bridge to definitive surgical intervention. Although this patient passed away of multiorgan system failure prior to re-transplant, this case demonstrates the importance of a heightened suspicion of this devastating complication, especially in the setting of bilioenteric reconstruction and perihepatic fluid collection, as well as the benefit of utilizing resuscitative techniques such as REBOA prior to definitive surgical or endovascular therapy to mitigate the high morbidity and mortality of this condition.

Keyword

Hepatic artery pseudoaneurysm; Streptococcus constellatus; REBOA; Resuscitative endovascular balloon occlusion; Liver transplantation

Figure

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  Fig. 1 REBOA catheter placement involves cannulation of the common femoral artery, insertion of an introducer sheath with Seldinger technique over a guidewire, and placement of the device by either landmark or radiologic guidance into an aortic zone. Zone 1 inflation, located between the left subclavian artery and the celiac trunk, is used for abdominal hemorrhage control.

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  Fig. 2 Computed tomography revealing a main HA pseudoaneurysm with active extravasation and an associated hemoperitoneum.

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