Overview
Definition:
Hepatic artery reconstruction refers to the surgical repair or bypass of an injured hepatic artery, essential for restoring adequate blood flow to the liver
Injuries can be iatrogenic, traumatic, or secondary to other pathologies.
Epidemiology:
Hepatic artery injuries are relatively uncommon but can occur during abdominal surgeries (e.g., liver resection, transplantation, pancreaticoduodenectomy) or as a result of blunt or penetrating abdominal trauma
Incidence varies widely based on surgical procedures and trauma mechanisms.
Clinical Significance:
The hepatic artery is the sole arterial supply to the liver, crucial for its metabolic functions and oxygenation
Injury can lead to hepatic ischemia, infarction, liver failure, and potentially life-threatening hemorrhage, making timely and accurate reconstruction vital for patient survival and organ function.
Clinical Presentation
Symptoms:
Hemodynamic instability and shock
Acute abdominal pain, often severe and diffuse
Hematemesis or melena if associated gastrointestinal injury
Jaundice may develop later
Signs of liver dysfunction like encephalopathy or coagulopathy.
Signs:
Hypotension and tachycardia
Abdominal distension and tenderness
Palpable pulsatile mass in the upper abdomen (rare)
Signs of peritoneal irritation
Decreased urine output.
Diagnostic Criteria:
Diagnosis is often made intraoperatively or based on imaging findings suggestive of arterial injury
Clinical suspicion in the setting of trauma or post-abdominal surgery is paramount
No specific diagnostic criteria exist
it is a diagnosis of exclusion or direct visualization.
Diagnostic Approach
History Taking:
Detailed history of trauma mechanism (blunt vs
penetrating)
History of recent abdominal surgery, type of procedure, and any intraoperative complications
Past medical history including bleeding disorders or anticoagulant use
Symptoms of pain, bleeding, or organ dysfunction.
Physical Examination:
Thorough abdominal examination for tenderness, guarding, rigidity, masses, and signs of peritonitis
Assess for hemodynamic stability
Examine for external signs of trauma
Digital rectal examination for evidence of GI bleeding.
Investigations:
Complete blood count (CBC) to assess for anemia and coagulopathy
Liver function tests (LFTs) to assess hepatic function
Type and crossmatch for blood transfusion
Angiography (CT angiography or conventional angiography) is the gold standard for diagnosis and localization of arterial injury
Ultrasound with Doppler can be useful for initial assessment but is less definitive for arterial lesions.
Differential Diagnosis:
Other causes of intra-abdominal hemorrhage (e.g., splenic rupture, mesenteric artery injury, aortic injury)
Non-arterial causes of abdominal pain or shock
Hepatic vein injury
Biliary tree injury.
Management
Initial Management:
Immediate resuscitation with intravenous fluids and blood products to stabilize hemodynamics
Control of external hemorrhage if present
Prompt surgical exploration is indicated for suspected significant arterial injury and hemodynamic instability.
Surgical Management:
Surgical exploration via laparotomy or laparoscopy
Control of bleeding proximal and distal to the injury
Hepatic artery reconstruction options include direct repair (suture), interposition graft using autologous vein (e.g., saphenous vein), or prosthetic graft if necessary
Ligation of the hepatic artery is considered only if reconstruction is not feasible and the liver has adequate collateral supply (e.g., through portal vein or contralateral hepatic artery)
Embolization via angiography can be a temporizing or definitive measure for selected injuries.
Supportive Care:
Intensive care unit (ICU) monitoring for hemodynamic stability, fluid balance, and organ function
Nutritional support, often parenteral initially
Close monitoring of liver function tests and coagulation profile
Management of pain and potential complications like sepsis or coagulopathy.
Complications
Early Complications:
Hemorrhage from the repair site or unrepaired injury
Hepatic ischemia or infarction, leading to liver failure
Sepsis
Biliary complications (e.g., fistula, stricture).
Late Complications:
Hepatic pseudoaneurysm formation at the repair site
Hepatic artery stenosis or occlusion
Portal vein thrombosis
Chronic liver dysfunction or cirrhosis.
Prevention Strategies:
Meticulous surgical technique, careful dissection to avoid inadvertent injury
Preoperative assessment of liver anatomy and collateral circulation
Intraoperative Doppler ultrasound to confirm patency of repairs
Liberal use of angiography for diagnosis and potential endovascular intervention for subtle injuries.
Prognosis
Factors Affecting Prognosis:
Severity of the injury (e.g., degree of vessel disruption, associated organ damage)
Timeliness of diagnosis and intervention
Adequacy of hepatic blood flow post-reconstruction or alternative supply
Patient's underlying health status and pre-existing liver disease.
Outcomes:
Successful reconstruction with adequate flow generally leads to good outcomes
However, significant ischemia or infarction can result in graft failure, liver failure, or death
The liver has remarkable regenerative capacity, but severe insult can be irreversible.
Follow Up:
Regular clinical assessment and laboratory monitoring of LFTs and coagulation profile
Follow-up imaging, including angiography or CT angiography, to assess the patency of the reconstruction and detect late complications like stenosis or pseudoaneurysm formation
Lifelong monitoring may be required for complex repairs or significant parenchymal damage.
Key Points
Exam Focus:
Hepatic artery supplies oxygenated blood
portal vein supplies nutrient-rich blood
Injury can be iatrogenic or traumatic
Angiography is diagnostic
Reconstruction options include direct repair, autologous vein graft, or prosthetic graft
Ligation is a last resort
Complications include ischemia, infarction, pseudoaneurysm, and stenosis.
Clinical Pearls:
Always suspect hepatic artery injury in hemodynamic instability post-abdominal surgery or trauma
Intraoperative Doppler is invaluable for assessing arterial patency
Consider portal vein supply as a compensatory mechanism for hepatic artery sacrifice, but it is not a complete substitute
Early angiography can save lives by identifying and treating injuries.
Common Mistakes:
Delayed diagnosis or surgical intervention
Inadequate control of proximal and distal bleeding
Inappropriate ligation of the hepatic artery without assessing collateral flow
Failure to monitor for post-operative complications like pseudoaneurysm or stenosis.