Visceral artery aneurysms are a rare cause for abdominal pain and require prompt referral to a vascular surgeon for review, as rupture is associated with significant morbidity and mortality [1]. We present a case of an 87-year-old man with an extremely large aneurysmal dilation of the common hepatic artery, which was missed on prior radiologic examination, and discuss the various management options for common hepatic artery aneurysms.

An 87-year-old male was transferred to our tertiary center for management of sepsis secondary to cervical discitis with intravenous antibiotics. He was an ex-smoker, with type two diabetes, heart failure with cardiomyopathy, chronic obstructive pulmonary disease, and stage 4 chronic kidney disease. On arrival he had a short episode of acute abdominal pain without radiation and was hemodynamically stable. He had a diffusely tender abdomen with no other remarkable clinical findings. Laboratory investigations revealed an elevated white cell count of 19.9 × 109 g/L, a macrocytic anemia with a hemoglobin of 121 mg/dL, and a creatinine of 323 umol/L in keeping with an acute on chronic kidney injury.

The patient was sent for abdominal computed tomography (CT), which revealed a 62 × 54 mm aneurysm originating at the common hepatic artery (CHA) bifurcation, with involvement of the gastroduodenal artery (Figure 1) and (Figure 2), which was felt to be the cause of the patient’s abdominal pain. There was no evidence of aneurysm rupture or features of an inflammatory or infective process. Retrospective review of abdominal imaging 2-years prior to presentation revealed that the aneurysm had grown significantly from 42 × 37 mm. He had not previously been referred to a vascular unit for opinion.

Extensive discussion was regarding management of the aneurysm, with consideration for both open repair and endovascular coiling. The patient was not fit for open surgery due to advanced age and multiple active medical problems, and was not a candidate for dialysis, precluding an endovascular approach.

The patient was discharged to a high-level care nursing home and managed expectantly, without further vascular follow-up.

Visceral artery aneurysms are an uncommon but potentially fatal condition and require urgent diagnostic evaluation and vascular surgery consultation. When rupture occurs mortality rate can be between 25% and 70%, hence timely referral to a vascular unit for evaluation and management is essential [1]. Common hepatic artery aneurysms are responsible for approximately 20% of visceral artery aneurysms [2].

Risk factors for CHA aneurysms include atherosclerosis, hypertension, coeliac axis stenosis, and a multitude of connective tissue disorders [3]. Pseudoaneurysm formation is most commonly caused by inflammation or trauma, such as in pancreatitis, prior vascular intervention, or hepatobiliary surgery [4]. Specific risk factors for CHA aneurysm rupture are yet to be established, and there is no clear association between size and rupture risk [5].

Diagnosis prior to rupture of CHA aneurysms is often incidental through abdominal imaging. Ruptured aneurysms commonly present with abdominal pain, accompanied by nonspecific gastrointestinal symptoms, such as vomiting, diarrhea, hematemesis, and melena [3]. Diagnosis can be confirmed with visceral angiography, CT, magnetic resonance imaging angiography, and ultrasonography [6],[7]. Visceral angiography is the gold-standard for diagnosis offers, the potential for therapeutic intervention, however CT is often the initial mode of investigation, as it is noninvasive and gives 3D representation of the aneurysm and its relationship to surrounding structures.

Common hepatic artery aneurysms can be managed surgically, endovascularly, or conservatively. Intervention is indicated for symptomatic aneurysm, pseudoaneurysm, and aneurysms greater than 2 cm in size [3]. Open surgical access is commonly through midline laparotomy, with aneurysm repair with or without patch angioplasty or ligation of the aneurysm with or without bypass. Limited case series have shown endovascular repair to be a safe alternative to open surgery, especially in patients unfit for open repair [8].

This case report describes a CHA aneurysm at the extremes of size. Common hepatic artery aneurysms are rare, with description limited to case reports and small retrospective cohort studies. It is important for clinicians to realize the significance of visceral artery aneurysms and the potential for timely lifesaving intervention. Due to the relative rarity of visceral artery aneurysms, under-recognition may result in delay to diagnosis, surgical referral, and management.