Although hepatic artery aneurysms (HAAs) are uncommon, they have a high mortality rate if they rupture [1]. The current treatment indications are as follows [2]: (1) presence of symptoms; (2) size >2 cm; (3) growth rate >0.5 cm/y; (4) presence of vasculopathy or vasculitis; or (5) positive blood culture. In terms of therapy, endovascular treatments (e.g., coil embolization and endograft placement) are preferred owing to their low morbidity; however, open surgical repair is required if the aneurysm cannot be excluded while maintaining hepatic circulation [2].

Right gastroepiploic artery (RGEA) transposition to the proper hepatic artery (PHA) was introduced in 2007 to restore hepatic arterial blood flow after aneurysm resection [3]. However, this surgery has not been reported since. Here, we present a case of RGEA transposition in a patient with HAA. The study was approved by the Institutional Review Board of the Kyungpook National University Hospital (IRB no. 2023-01-012-001), which waived the requirement for written informed consent.

A 53-year-old ex-smoker man was referred to our hospital with an incidentally found pancreatic head mass-like lesion on a screening abdominal ultrasound. The patient was asymptomatic, and his medical history was significant for hypertension and dyslipidemia. He was on a calcium channel blocker, angiotensin-converting enzyme inhibitor, and statin. He had no history of abdominal surgery or trauma. Computed tomography angiography (CTA) revealed a HAA with a mural thrombus from the common hepatic artery (CHA) to the PHA (Fig. 1). The aneurysm was scaphoid in shape. Its maximum diameter and length were 4 and 4.5 cm, respectively. Because the aneurysm involved the entire PHA and gastroduodenal artery (GDA), endovascular treatment was not an option. CTA revealed stenosis of the celiac artery and good collateral circulation to the GDA via the pancreaticoduodenal artery from the superior mesenteric artery. To preserve the hepatic arterial flow after aneurysm resection, we decided to use the RGEA.

Figure 1. Preoperative computed tomography angiography. (A- C) An aneurysm with mural thrombus from the common hepatic artery to the proper hepatic artery bifurcation (arrows) was demonstated on axial images. (D) The right gastroepiploic artery (RGEA) originated from the gastroduodenal artery in a maximum intensity projection image. (E) A stenosis of the celiac artery was noted in a volume rendering image. CA, celiac artery; CHA, common hepatic artery; GDA, gastroduodenal artery; IPDA, inferior pancreaticoduodenal artery; LHA, left hepatic artery; PHA, proper hepatic artery; RGA, right gastric artery; RHA, right hepatic artery; SA, splenic artery; SMA, superior mesenteric artery.

Elective surgery was performed via an abdominal midline incision. The HAA and branch arteries connecting to it were dissected (Fig. 2A). The RGEA was mobilized after omentectomy (Fig. 2B). To prevent spasms, the RGEA was wrapped in papaverine-soaked gauze; milrinone was not used. The aneurysm was excised after branch arteries were controlled. The proximal CHA, GDA, and right gastric artery were ligated before anastomosis of the RGEA to the PHA bifurcation (Fig. 2C). Total clamping time for the PHA was 45 minutes.

Figure 2. (A) An aneurysm involving the proper hepatic artery (arrow). (B) Mobilized right gastroepiploic artery (arrowheads). (C) Gastroepiploic artery was anastomosed to the proper hepatic artery bifurcation (circle). CHA, common hepatic artery; LHA, left hepatic artery; RGA, right gastric artery.

Aspartate transaminase, alanine transaminase, alkaline phosphatase, amylase, and lipase levels were normal after surgery. The patient was discharged without any complications on postoperative day 8 and the transposed RGEA was patent at 6-month postoperative CTA (Fig. 3). Schematic configuration of preoperative and postoperative anatomy is illustrated in Fig. 4.

Figure 3. (A, B) Postoperative computed tomography angiography. The right gastroepiploic artery (RGEA) was anastomosed to the proper hepatic artery bifurcation (arrow). IPDA, inferior pancreaticoduodenal artery; LHA, left hepatic artery; RHA, right hepatic artery.

Figure 4. Illustration of preoperative (A) and postoperative (B) anatomic configurations. CA, celiac artery; CHA, common hepatic artery; GDA, gastroduodenal artery; IPDA, inferior pancreaticoduodenal artery; LGA, left gastric artery; LHA, left hepatic artery; PHA, proper hepatic artery; RGA, right gastric artery; RGEA, right gastroepiploic artery; RHA, right hepatic artery; SA, splenic artery; SMA, superior mesenteric artery.

HAAs can be treated surgically using various techniques, including ligation, aneurysmorrhaphy, and aneurysm resection with or without arterial reconstruction [4]. The type of open surgical repair depends on the shape of the aneurysm (fusiform or saccular), location of the aneurysm, diameter of the hepatic artery, and collateral circulation status. Owing to the collateral circulations from the GDA and right gastric artery, most HAAs localized within the CHA can be treated with ligation without arterial reconstruction [5]. For HAAs involving the PHA or the GDA, additional procedures, such as patch angioplasty [6] and bypass with autologous or prosthetic graft [1,7], are required to avoid hepatic ischemia after aneurysm removal, as well as transposition of the splenic artery or the RGEA [8,9].

Transposition of the splanchnic artery other than the hepatic artery has the advantages of being an autologous artery, easy to access without additional incision, having sufficient length for reconstruction, and requiring only one anastomosis [9].

The most commonly used artery for transposition is the splenic artery; however, RGEA can be used as an alternative [3]. Following en bloc resection of advanced hepatobiliary and pancreatic (HBP) malignancies [10] and during coronary artery bypass grafting (CABG) [11], RGEA has been used as a conduit for reconstruction. However, the main disadvantage of RGEA is its small diameter compared with that of the splenic artery. It is suggested that a splenic artery with a larger inflow vessel diameter is better suited for hepatic artery reconstruction [8]. Hence, during surgery for HBP malignancy, the RGEA is usually anastomosed to the right or left hepatic artery rather than to the PHA [10].

Nonetheless, in our case, the RGEA could be an appropriate conduit given the diameters of the right and left hepatic arteries were small, and there was no size discrepancy between the PHA bifurcation and the RGEA. Additionally, owing to celiac artery stenosis, there is a risk of splenic artery flow impairment. Therefore, RGEA could be a better conduit candidate than the splenic artery. Moreover, it is simple to use and does not require pancreatic dissection, thus reducing risk of pancreatitis. Moreover, there is no risk of splenic infarction [3].

As there are only two reported cases of RGEA transposition, including this one, we cannot comment on long-term patency. However, given the outcomes of CABG with the RGEA graft, this would be acceptable [11]. In conclusion, RGEA transposition may be a viable option in select patients who require hepatic arterial flow restoration following HAA resection.

None.

The authors have nothing to disclose.

Concept and design: WSY, SH. Analysis and interpretation: DH, WSY, HJK. Data collection: DH, HJK. Writing the article: DH, WSY. Critical revision of the article: DH, WSY, HKK, SH. Final approval of the article: all authors. Overall responsibility: WSY.