Clin J Gastroenterol (2013) 6:169–172 DOI 10.1007/s12328-013-0372-3
CASE REPORT
Hepatic artery aneurysm in a patient with hepatitis C liver cirrhosis: report of a case Yu Saito • Tomoharu Yoshizumi • Noboru Harada • Hiroto Kayashima • Koji Yamasaki • Noriaki Sadanaga Hiroshi Matsuura • Kenichiro Okadome
•
Received: 7 December 2012 / Accepted: 18 February 2013 / Published online: 9 March 2013 Ó Springer Japan 2013
Abstract Visceral artery aneurysms are rare, with an incidence rate of only 0.01–0.2 % in routine autopsies, and hepatic artery aneurysms account for approximately 20 % of these aneurysms. Despite recent advances in therapeutic techniques and diagnostic tools, the management of visceral artery aneurysms remains clinically challenging. We report a case of hepatic artery aneurysm with liver cirrhosis due to hepatitis C in an 81-year-old woman. A computed tomography scan demonstrated a hepatic artery aneurysm 4.4 cm in diameter. She underwent successful aneurysmectomy with vascular anastomosis. A computed tomography scan on postoperative day 7 demonstrated patent hepatic artery. The patient was followed-up for 1 year after surgery and died owing to progressive liver failure. However, she did not show any hepatic artery problem such as hepatic arterial thrombosis or occlusion. We discuss the risk factors of atherosclerosis in patients with liver cirrhosis, and present an overview of the treatment of hepatic artery aneurysms.
Y. Saito Department of Surgery, The University of Tokushima, Tokushima 770-8501, Japan Y. Saito T. Yoshizumi N. Harada H. Kayashima K. Yamasaki N. Sadanaga H. Matsuura K. Okadome Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka 810-0001, Japan T. Yoshizumi (&) N. Harada Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan e-mail: [email protected]
Keywords Hepatic artery aneurysm Atherosclerosis Hepatitis C Abbreviations CT Computed tomography HBs Hepatitis B surface HCV Hepatitis C virus CHA Common hepatic artery GDA Gastroduodenal artery PHA Proper hepatic artery RHA Right hepatic artery LHA Left hepatic artery
Introduction Visceral artery aneurysms are rare, with an incidence rate of only 0.01–0.2 % in routine autopsies, and hepatic artery aneurysms account for approximately 20 % of these aneurysms [1]. Historically, most aneurysms had ruptured at presentation or were incidentally discovered at autopsy. The recent advances and rapid spread of cross-sectional imaging have enabled the identification of hepatic artery aneurysms earlier in their natural history. Over the past two decades the treatment options for ruptured or symptomatic hepatic artery aneurysm have evolved. However, because of the rarity of these aneurysms, optimal management of asymptomatic hepatic artery aneurysm remains controversial. We report a case of successful aneurysmectomy with arterial anastomosis for an atherosclerotic hepatic artery aneurysm complicated with hepatitis C liver cirrhosis. We also review the literature pertaining to the treatment of hepatic artery aneurysms.
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Clin J Gastroenterol (2013) 6:169–172
Fig. 1 Preoperative computed tomography (CT). a Demonstrates axial dynamic CT images. Aneurysm (arrow heads) with a diameter of 4.4 cm is shown with pooling of contrast medium. b Shows volume-rendered threedimensional (3-D) CT images demonstrating an saccular aneurysm (arrow heads) of 4.4 9 3.5 cm located where the common hepatic artery (CHA) bifurcated to the gastroduodenal artery (GDA) and proper hepatic artery (PHA)
Fig. 2 Intraoperative view of the aneurysm: CHA, PHA, and right (RHA) and left hepatic artery (LHA) are encircled
Case report The patient was an 81-year-old woman with liver cirrhosis due to hepatitis C and esophageal varix followed in another clinic. Computed tomography (CT) in 2004 demonstrated a hepatic artery aneurysm 2.5 cm in diameter, but the patient did not undergo any treatment at that time because of her poor liver function. After 4 years, a CT scan revealed that the aneurysm had increased to 4.4 cm in diameter, therefore, she was transferred to our hospital. The patient was 148 cm tall and weighed 60 kg. Her body mass index was 26.2 kg/m2. Physical examination revealed a pulsatile mass in her right upper abdomen; she had no ascites and no encephalopathy. Laboratory data were as follows: platelet count 8.5 9 104/ll, serum albumin 3.6 g/dl, serum total bilirubin 1.0 mg/dl, prothrombin time 92 %, indocyanine green retention rate at 15 min (ICGR15) 43 %, serum total cholesterol 145 mg/dl, serum triglyceride 156 mg/dl and blood sugar 132 mg/dl.
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Fig. 3 Postoperative volume-rendered three-dimensional (3-D) CT images on postoperative day 7 demonstrating patent hepatic arteries. Arrowheads show the anastomosis site between CHA and PHA
Hepatitis B surface (HBs) antigen was negative and hepatitis C virus (HCV) antibody was positive. Her liver function was classified as Child-Pugh grade A. A CT scan demonstrated a saccular aneurysm with intramural thrombus with a diameter of 4.4 9 3.5 cm, located, where the common hepatic artery (CHA) bifurcated to the gastroduodenal artery (GDA) and the proper hepatic artery (PHA) (Fig. 1). We opted for surgical treatment because the diameter of the aneurysm was increasing, and there was a risk of rupture. The surgical findings were as follows: The surface of the liver was rough and cirrhosis was identified. A pulsatile aneurysm 5.0 cm in diameter was identified in the hepatoduodenal ligament. After the CHA,
Clin J Gastroenterol (2013) 6:169–172
Fig. 4 Pathological picture of resected aneurysm. The figure shows the wall of the resected aneurysm (H&E stain, 9200). The section shows atherosclerosis with calcification
PHA, and right and left hepatic artery (RHA and LHA) were exposed (Fig. 2), they were ligated and divided under clamping. The wall of the aneurysm was calcified. The aneurysm was incised, and the GDA was closed within the aneurysm with a running suture of 4-0 Prolene. Finally, the CHA and PHA were anastomosed in an end-to-end fashion using a 5-0 Prolene running suture. Anticoagulant therapy was not administered after surgery. A CT scan on postoperative day 7 demonstrated a patent hepatic artery (Fig. 3). Histological examination of the wall of the aneurysm revealed atherosclerosis with calcification (Fig. 4). The patient was followed-up for 1 year after surgery and died owing to progressive liver failure. However, she did not show any hepatic artery problem such as hepatic arterial thrombosis or occlusion.
Discussion In general, patients with cirrhosis have a lower frequency of atherosclerosis than those without cirrhosis. Kawakami et al. [2] have reported that vascular sclerosis decreases with severity of cirrhosis, through hypotension and hyperbilirubinemia. In contrast, the cause of the aneurysm in our case was atherosclerosis with calcification. We speculate that one of the risk factors for atherosclerosis in our patient was HCV infection, which has been associated with atherosclerosis [3– 5]. HCV infection facilitates the occurrence of carotid atherosclerotic lesions [3], and moreover, HCV and hepatitis B virus are strongly associated with early atherosclerosis and are independent classical risk factors for insulin resistance and metabolic syndrome [4]. Recently, Miyajima et al. [5] have reported that chronic HCV infection is associated with
171
mild carotid atherosclerosis. However, as far as we are aware, there have been no reports of a direct association between HCV infection and hepatic artery aneurysm. Further study is needed to elucidate how HCV infection influences the occurrence of arterial aneurysm. There are several possible treatments for hepatic artery aneurysms, including endovascular intervention, hepatic artery ligation with exclusion, complete excision of the aneurysm with or without vascular replacement, and arterial bypass [6–8]. Endovascular intervention provides compatible and even better early postoperative outcomes than surgery for visceral artery aneurysms [6]. In contrast, elective open surgery is safe and effective, and offers satisfactory early and long-term results [8]. Although endovascular intervention and surgical ligation are effective techniques when collateral vessels through the liver develop, there were no collateral vessels in our case and the aneurysm extended to the GDA and PHA, so that endovascular intervention or surgical ligation had a risk of liver infarction [9]. Therefore, we selected surgical aneurysmectomy with vascular anastomosis. Reconstruction of the hepatic artery is a safe and reliable technique in the liver transplantation era [10, 11], although surgical complications, such as hepatic artery thrombosis, kinking or stenosis may occur in 3–8 % of cases [12, 13]. Direct arterial anastomosis without vascular graft, as in present case is a rare treatment option. Abbas et al. [14] have reported 10 cases of vascular reconstruction for hepatic artery aneurysm: saphenous vein graft was used in seven cases and Dacron graft in three. They reported 30 % graft occlusion during follow-up. Whether the vascular graft is necessary for reconstruction depends on aneurysm size and location [6]. Moreover, a preoperative three-dimensional CT scan can demonstrate aneurysms and branches of the hepatic artery, as shown in Fig. 1. Therefore, the operative procedure can be planned accurately beforehand. In conclusion, we performed a successful aneurysmectomy with vascular anastomosis for an atherosclerotic hepatic artery aneurysm complicated with hepatitis C cirrhosis. Hepatitis C cirrhosis could be associated with atherosclerosis of the hepatic artery. In patients with no collateral pathway, we recommend surgical aneurysmectomy with vascular anastomosis for the treatment of a hepatic artery aneurysm. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Rokke O, Sondenaa K, Amundsen S, Bjerke-larssen T, Jensen D. The diagnosis and management of splanchnic artery aneurysms. Scand J Gastroenterol. 1996;31:737–43.
123
172 2. Kawakami M, Koda M, Murawaki Y. The prevalence of atherosclerosis in cirrhotic patients: assessment of two aspects of atherosis and sclerosis. Hepatol Res. 2007;37:152–7. 3. Boddi M, Abbate R, Chellini B, Giusti B, Solazzo V, Soft F, et al. HCV infection facilitates asymptomatic carotid atherosclerosis: preliminary report of HCV RNA localization in human carotid plaques. Dig Liver Dis. 2007;39:S55–60. 4. Targer G, Bertolini L, Padovani R, Rodella S, Arcaro G, Day C. Differences and similarities in early atherosclerosis between patients with non-alcoholic steatohepatitis and chronic hepatitis B and C. J Hepatol. 2007;46:1126–32. 5. Miyajima I, Kawaguchi T, Fukami A, Nagao Y, Adachi H, Sasaki S, et al. Chronic HCV infection was associated with severe insulin resistance and mild atherosclerosis: a population-based study in an HCV hyperendemic area. J Gastroenterol. 2013; 48:93–100. 6. Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Surg. 2007;33:293–301. 7. Chirica M, Alkofer B, Sauvanet A, Vullierme MP, Levy Y, Belghiti J. Hepatic artery ligation: a simple and safe technique to treat extrahepatic aneurysms of the hepatic artery. Am J Surg. 2008;196:333–8. 8. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg. 2008;48:334–42.
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Clin J Gastroenterol (2013) 6:169–172 9. Kitagawa T, Iriyama K. Hepatic infarction as complication of gastric cancer surgery: report of four cases. Surg Today. 1998; 28:542–6. 10. Matsuda H, Yagi T, Sadamori H, Matsukawa H, Shinoura S, Murata H, et al. Complications of arterial reconstruction in living donor liver transplantation: a single-center experience. Surg Today. 2006;36:245–51. 11. Yoshizumi T, Taketomi A, Uchiyama H, Harada N, Kayashima H, Yamashita Y, et al. Graft size, donor age, and patient status are the indicators of early graft function after living donor liver transplantation. Liver Transpl. 2008;14:1007–13. 12. Pakosz-Golanowsha M, Lubikowski J, Post M, Jarosz K, ZasadaCedro K, Milkiewicz P, et al. The arterial anastomosis in liver transplantation: complications, treatment and outcome. Hepatogastroenterology. 2010;57:1477–82. 13. de Jong KP, Bekker J, van Laarhoven S, Ploem S, van Rheenen PF, Albers MJ, et al. Implantable continuous Doppler monitoring device for detection of hepatic artery thrombosis after liver transplantation. Transplantation. 2012;94:958–64. 14. Abbas MA, Fowl RJ, Stone WM, Panneton JM, Oldenburg WA, Bower TC, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg. 2003;38:41–5.
CASE REPORT
Hepatic artery aneurysm in a patient with hepatitis C liver cirrhosis: report of a case Yu Saito • Tomoharu Yoshizumi • Noboru Harada • Hiroto Kayashima • Koji Yamasaki • Noriaki Sadanaga Hiroshi Matsuura • Kenichiro Okadome
•
Received: 7 December 2012 / Accepted: 18 February 2013 / Published online: 9 March 2013 Ó Springer Japan 2013
Abstract Visceral artery aneurysms are rare, with an incidence rate of only 0.01–0.2 % in routine autopsies, and hepatic artery aneurysms account for approximately 20 % of these aneurysms. Despite recent advances in therapeutic techniques and diagnostic tools, the management of visceral artery aneurysms remains clinically challenging. We report a case of hepatic artery aneurysm with liver cirrhosis due to hepatitis C in an 81-year-old woman. A computed tomography scan demonstrated a hepatic artery aneurysm 4.4 cm in diameter. She underwent successful aneurysmectomy with vascular anastomosis. A computed tomography scan on postoperative day 7 demonstrated patent hepatic artery. The patient was followed-up for 1 year after surgery and died owing to progressive liver failure. However, she did not show any hepatic artery problem such as hepatic arterial thrombosis or occlusion. We discuss the risk factors of atherosclerosis in patients with liver cirrhosis, and present an overview of the treatment of hepatic artery aneurysms.
Y. Saito Department of Surgery, The University of Tokushima, Tokushima 770-8501, Japan Y. Saito T. Yoshizumi N. Harada H. Kayashima K. Yamasaki N. Sadanaga H. Matsuura K. Okadome Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka 810-0001, Japan T. Yoshizumi (&) N. Harada Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan e-mail: [email protected]
Keywords Hepatic artery aneurysm Atherosclerosis Hepatitis C Abbreviations CT Computed tomography HBs Hepatitis B surface HCV Hepatitis C virus CHA Common hepatic artery GDA Gastroduodenal artery PHA Proper hepatic artery RHA Right hepatic artery LHA Left hepatic artery
Introduction Visceral artery aneurysms are rare, with an incidence rate of only 0.01–0.2 % in routine autopsies, and hepatic artery aneurysms account for approximately 20 % of these aneurysms [1]. Historically, most aneurysms had ruptured at presentation or were incidentally discovered at autopsy. The recent advances and rapid spread of cross-sectional imaging have enabled the identification of hepatic artery aneurysms earlier in their natural history. Over the past two decades the treatment options for ruptured or symptomatic hepatic artery aneurysm have evolved. However, because of the rarity of these aneurysms, optimal management of asymptomatic hepatic artery aneurysm remains controversial. We report a case of successful aneurysmectomy with arterial anastomosis for an atherosclerotic hepatic artery aneurysm complicated with hepatitis C liver cirrhosis. We also review the literature pertaining to the treatment of hepatic artery aneurysms.
123
170
Clin J Gastroenterol (2013) 6:169–172
Fig. 1 Preoperative computed tomography (CT). a Demonstrates axial dynamic CT images. Aneurysm (arrow heads) with a diameter of 4.4 cm is shown with pooling of contrast medium. b Shows volume-rendered threedimensional (3-D) CT images demonstrating an saccular aneurysm (arrow heads) of 4.4 9 3.5 cm located where the common hepatic artery (CHA) bifurcated to the gastroduodenal artery (GDA) and proper hepatic artery (PHA)
Fig. 2 Intraoperative view of the aneurysm: CHA, PHA, and right (RHA) and left hepatic artery (LHA) are encircled
Case report The patient was an 81-year-old woman with liver cirrhosis due to hepatitis C and esophageal varix followed in another clinic. Computed tomography (CT) in 2004 demonstrated a hepatic artery aneurysm 2.5 cm in diameter, but the patient did not undergo any treatment at that time because of her poor liver function. After 4 years, a CT scan revealed that the aneurysm had increased to 4.4 cm in diameter, therefore, she was transferred to our hospital. The patient was 148 cm tall and weighed 60 kg. Her body mass index was 26.2 kg/m2. Physical examination revealed a pulsatile mass in her right upper abdomen; she had no ascites and no encephalopathy. Laboratory data were as follows: platelet count 8.5 9 104/ll, serum albumin 3.6 g/dl, serum total bilirubin 1.0 mg/dl, prothrombin time 92 %, indocyanine green retention rate at 15 min (ICGR15) 43 %, serum total cholesterol 145 mg/dl, serum triglyceride 156 mg/dl and blood sugar 132 mg/dl.
123
Fig. 3 Postoperative volume-rendered three-dimensional (3-D) CT images on postoperative day 7 demonstrating patent hepatic arteries. Arrowheads show the anastomosis site between CHA and PHA
Hepatitis B surface (HBs) antigen was negative and hepatitis C virus (HCV) antibody was positive. Her liver function was classified as Child-Pugh grade A. A CT scan demonstrated a saccular aneurysm with intramural thrombus with a diameter of 4.4 9 3.5 cm, located, where the common hepatic artery (CHA) bifurcated to the gastroduodenal artery (GDA) and the proper hepatic artery (PHA) (Fig. 1). We opted for surgical treatment because the diameter of the aneurysm was increasing, and there was a risk of rupture. The surgical findings were as follows: The surface of the liver was rough and cirrhosis was identified. A pulsatile aneurysm 5.0 cm in diameter was identified in the hepatoduodenal ligament. After the CHA,
Clin J Gastroenterol (2013) 6:169–172
Fig. 4 Pathological picture of resected aneurysm. The figure shows the wall of the resected aneurysm (H&E stain, 9200). The section shows atherosclerosis with calcification
PHA, and right and left hepatic artery (RHA and LHA) were exposed (Fig. 2), they were ligated and divided under clamping. The wall of the aneurysm was calcified. The aneurysm was incised, and the GDA was closed within the aneurysm with a running suture of 4-0 Prolene. Finally, the CHA and PHA were anastomosed in an end-to-end fashion using a 5-0 Prolene running suture. Anticoagulant therapy was not administered after surgery. A CT scan on postoperative day 7 demonstrated a patent hepatic artery (Fig. 3). Histological examination of the wall of the aneurysm revealed atherosclerosis with calcification (Fig. 4). The patient was followed-up for 1 year after surgery and died owing to progressive liver failure. However, she did not show any hepatic artery problem such as hepatic arterial thrombosis or occlusion.
Discussion In general, patients with cirrhosis have a lower frequency of atherosclerosis than those without cirrhosis. Kawakami et al. [2] have reported that vascular sclerosis decreases with severity of cirrhosis, through hypotension and hyperbilirubinemia. In contrast, the cause of the aneurysm in our case was atherosclerosis with calcification. We speculate that one of the risk factors for atherosclerosis in our patient was HCV infection, which has been associated with atherosclerosis [3– 5]. HCV infection facilitates the occurrence of carotid atherosclerotic lesions [3], and moreover, HCV and hepatitis B virus are strongly associated with early atherosclerosis and are independent classical risk factors for insulin resistance and metabolic syndrome [4]. Recently, Miyajima et al. [5] have reported that chronic HCV infection is associated with
171
mild carotid atherosclerosis. However, as far as we are aware, there have been no reports of a direct association between HCV infection and hepatic artery aneurysm. Further study is needed to elucidate how HCV infection influences the occurrence of arterial aneurysm. There are several possible treatments for hepatic artery aneurysms, including endovascular intervention, hepatic artery ligation with exclusion, complete excision of the aneurysm with or without vascular replacement, and arterial bypass [6–8]. Endovascular intervention provides compatible and even better early postoperative outcomes than surgery for visceral artery aneurysms [6]. In contrast, elective open surgery is safe and effective, and offers satisfactory early and long-term results [8]. Although endovascular intervention and surgical ligation are effective techniques when collateral vessels through the liver develop, there were no collateral vessels in our case and the aneurysm extended to the GDA and PHA, so that endovascular intervention or surgical ligation had a risk of liver infarction [9]. Therefore, we selected surgical aneurysmectomy with vascular anastomosis. Reconstruction of the hepatic artery is a safe and reliable technique in the liver transplantation era [10, 11], although surgical complications, such as hepatic artery thrombosis, kinking or stenosis may occur in 3–8 % of cases [12, 13]. Direct arterial anastomosis without vascular graft, as in present case is a rare treatment option. Abbas et al. [14] have reported 10 cases of vascular reconstruction for hepatic artery aneurysm: saphenous vein graft was used in seven cases and Dacron graft in three. They reported 30 % graft occlusion during follow-up. Whether the vascular graft is necessary for reconstruction depends on aneurysm size and location [6]. Moreover, a preoperative three-dimensional CT scan can demonstrate aneurysms and branches of the hepatic artery, as shown in Fig. 1. Therefore, the operative procedure can be planned accurately beforehand. In conclusion, we performed a successful aneurysmectomy with vascular anastomosis for an atherosclerotic hepatic artery aneurysm complicated with hepatitis C cirrhosis. Hepatitis C cirrhosis could be associated with atherosclerosis of the hepatic artery. In patients with no collateral pathway, we recommend surgical aneurysmectomy with vascular anastomosis for the treatment of a hepatic artery aneurysm. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Rokke O, Sondenaa K, Amundsen S, Bjerke-larssen T, Jensen D. The diagnosis and management of splanchnic artery aneurysms. Scand J Gastroenterol. 1996;31:737–43.
123
172 2. Kawakami M, Koda M, Murawaki Y. The prevalence of atherosclerosis in cirrhotic patients: assessment of two aspects of atherosis and sclerosis. Hepatol Res. 2007;37:152–7. 3. Boddi M, Abbate R, Chellini B, Giusti B, Solazzo V, Soft F, et al. HCV infection facilitates asymptomatic carotid atherosclerosis: preliminary report of HCV RNA localization in human carotid plaques. Dig Liver Dis. 2007;39:S55–60. 4. Targer G, Bertolini L, Padovani R, Rodella S, Arcaro G, Day C. Differences and similarities in early atherosclerosis between patients with non-alcoholic steatohepatitis and chronic hepatitis B and C. J Hepatol. 2007;46:1126–32. 5. Miyajima I, Kawaguchi T, Fukami A, Nagao Y, Adachi H, Sasaki S, et al. Chronic HCV infection was associated with severe insulin resistance and mild atherosclerosis: a population-based study in an HCV hyperendemic area. J Gastroenterol. 2013; 48:93–100. 6. Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Surg. 2007;33:293–301. 7. Chirica M, Alkofer B, Sauvanet A, Vullierme MP, Levy Y, Belghiti J. Hepatic artery ligation: a simple and safe technique to treat extrahepatic aneurysms of the hepatic artery. Am J Surg. 2008;196:333–8. 8. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg. 2008;48:334–42.
123
Clin J Gastroenterol (2013) 6:169–172 9. Kitagawa T, Iriyama K. Hepatic infarction as complication of gastric cancer surgery: report of four cases. Surg Today. 1998; 28:542–6. 10. Matsuda H, Yagi T, Sadamori H, Matsukawa H, Shinoura S, Murata H, et al. Complications of arterial reconstruction in living donor liver transplantation: a single-center experience. Surg Today. 2006;36:245–51. 11. Yoshizumi T, Taketomi A, Uchiyama H, Harada N, Kayashima H, Yamashita Y, et al. Graft size, donor age, and patient status are the indicators of early graft function after living donor liver transplantation. Liver Transpl. 2008;14:1007–13. 12. Pakosz-Golanowsha M, Lubikowski J, Post M, Jarosz K, ZasadaCedro K, Milkiewicz P, et al. The arterial anastomosis in liver transplantation: complications, treatment and outcome. Hepatogastroenterology. 2010;57:1477–82. 13. de Jong KP, Bekker J, van Laarhoven S, Ploem S, van Rheenen PF, Albers MJ, et al. Implantable continuous Doppler monitoring device for detection of hepatic artery thrombosis after liver transplantation. Transplantation. 2012;94:958–64. 14. Abbas MA, Fowl RJ, Stone WM, Panneton JM, Oldenburg WA, Bower TC, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg. 2003;38:41–5.
