lNTRODUCTlON

Hepatic artery aneurysm(HAA)is the second most common visceral aneurysm[1].The incidence rate of HAA in 2091965 patients who visited the Mayo Clinic between 1980 and 1986 was 0.002%[2].A total of 77% HAAs are isolated in the proximal part of the liver,of which 20% are combined with parenchymal and extraparenchymal invasion and 3% are confined to the liver[3].Excluding traumatic aneurysms,patients most commonly suffer from HAAs during their sixth decade of life[4].Lesions in the hepatic circulation show a ratio of approximately 3:2 in terms of sex with male predominance[2].Risk factors for HAA include atherosclerosis,medial degeneration,infection,trauma,and vasculitis[4].A large majority of HAAs are diagnosed incidentally

computed tomography(CT)scan[3].Most patients with symptomatic aneurysms present with one or more of Quincke's classic triad of biliary bleeding(jaundice,biliary colic,and gastrointestinal bleeding)[4].Diagnosis can be made by ultrasound scan,CT angiography(CTA),and digital subtraction angiography.CTA is recommended as the diagnostic tool of choice in patients who are thought to have HAA[5].Despite recent advances in therapeutic techniques and diagnostic tools,the management of a visceral artery aneurysm remains clinically challenging.Rupture is the most emergent and life-threatening situation in HAA.Lumsden

[4]pointed out that the HAA-related early incidence of rupture and mortality was 9.1% and 22.7%,respectively.Fibromuscular dysplasia and polyarteritis nodosa increase the risk of HAA rupture and account for 50% of HAA ruptures[5].The majority of these lesions rupture when they are ＞ 2 cm in diameter[3].

When the kids came in, he took them for walks along the pier21 near their office. Often she went along and watched Eric, who was becoming a master of sign language, talk and laugh with her boys as no one else had before.

The guideline,named“the Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms”,states that all hepatic artery pseudoaneurysms regardless of cause(Grade 1A)and all symptomatic HAAs regardless of size(Grade 1A)should be repaired as soon as possible;in asymptomatic patients without significant comorbidity,repair is recommended if the true HAA is ＞ 2 cm(Grade 1A)or if the aneurysm enlarges at the rate of ＞ 0.5 cm per year(Grade 1C);in patients with significant comorbidities,repair is recommended if the HAA is ＞ 5.0 cm(Grade 1B);furthermore,the repair of HAA in patients with vasculopathy or vasculitis regardless of size(Grade 1C)or with positive blood cultures(Grade 1C)is recommended[5].The clinical practice guidelines on the management of visceral aneurysms set by the Society for Vascular Surgery indicate that treatment approaches mainly include endovascular repair with covered stents,open repair,and coil embolization.The endovascular approach represents a minimally-invasive alternative with low mortality and morbidity[6].Given the abundant collateral supply of the liver,the incidence of hepatic necrosis after disruption of the common hepatic artery is low.Percutaneous embolization is of special value in patients with intrahepatic aneurysms[5].Endovascular therapy has become the mainstream approach.However,open repair remains a therapeutic option with definite efficacy and is mostly chosen under the conditions of HAA rupture,infeasible endovascular approach and for symptomatic patients with fibromuscular dysplasia or polyarteritis nodosa and lesions in the proper hepatic and proximal right or left hepatic branches[5].

CASE PRESENTATlON

Chief complaints

A 66-year-old woman was admitted to our hospital with the chief complaint of severe abdominal pain with vomiting.Four hours before admission,the patient had a sudden onset of sharp pain in the upper and middle abdomen with no obvious cause.The pain was unbearable and persistent without relief,which involved back pain and was accompanied by vomiting the contents of the stomach,without dizziness,headache,chest tightness,chest pain,acid reflux,heartburn,chills,fever and other symptoms.

History of present illness

The patient was found to have hypertension for more than 20 years,with the highest blood pressure reaching 220/160 mmHg.She was taking nimodipine tablets(30 mg tid)regularly,and her blood pressure was controlled at approximately 140/75 mmHg,usually without dizziness and headache.

History of past illness

The patient had no other previous illnesses.

Personal and family history

Her personal and family history was unremarkable.

Physical examination

Diagnosing huge hepatic aneurysms in time and choosing the best treatment are very challenging.When other serious diseases,such as Stanford type B aortic dissection,are found at the same time,the complexity of the patient's condition and the difficulty of treatment double.Although endovascular therapy is the first choice in most cases,open surgery still has a unique role.We should not only strictly understand the indications of various surgical procedures,but also make clinical decisions in accordance with the specific conditions of patients.

Laboratory examinations

Open repair was performed six days later.A right subcostal incision was made,and the surgical approach was

the small omental sac.Intraoperative findings showed the following: the proper hepatic artery,which was approximately 6 cm × 6 cm in size,was located between the medial side of the descending duodenum and the anterior of the pancreatic head and bile duct(Figure 2A).We then mobilized the inflow and outflow of the proper hepatic artery.After systemic heparinization,the inflow and outflow of the HAA was clamped,and the aneurysm was directly opened.An aneurysm break approximately 2 mm in size and slight mural thrombus(Figure 2B)were found.No collateral vessel was detected in the aneurysm.The proximal part of the proper hepatic artery was anastomosed end to end with the right hepatic artery as the adjacent orifice location,and the left hepatic artery was anastomosed end to side with the proper hepatic artery(Figure 2C).The hepatic artery clamp time was 31 min.After anastomosis,ultrasound revealed the patency of the anastomotic site and the distal hepatic artery branches.The operation was performed without difficulties.

Imaging examinations

CT revealed:(1)A giant aneurysm of the proper hepatic artery(maximum diameter approximately 56 mm);and(2)Dissection of the lower abdominal aorta(single break)(Figure 1A and B).

In this case,deploying the covered stent was difficult considering the tortuosity of the delivery route.Therefore,the proper hepatic artery was anastomosed end to end with the right hepatic artery,and the left hepatic artery was anastomosed end to side with the proper hepatic artery without an artificial blood vessel or saphenous vein.This approach was riddled with the considerations discussed above.First,we anastomosed the blood vessels directly because the ends were highly adjacent,and the tension was low after direct anastomosis with no need for the use of artificial blood vessels or saphenous veins,so that the patient could reduce the subsequent anticoagulant burden.Second,we did not first anastomose the left and right hepatic arteries and then anastomose them with the proper hepatic artery as during the operation,we found that the patient’s right hepatic artery was thick and large,so that we could prevent complications in one of the left and right hepatic arteries from affecting the other artery to the greatest extent.Moreover,we did not completely isolate the whole aneurysm,thus reducing the damage to the surrounding tissue and the incidence of postoperative complications.During the entire operation,the hepatic artery occlusion time was 31 min,which reduced the probability of hepatic ischemia.

FlNAL DlAGNOSlS

The patient was diagnosed with abdominal aortic dissection,hepatic artery aneurysm,and hypertension grade 3(very high risk).

TREATMENT

After receiving blood pressure control,sedation and related symptomatic treatment from the coronary heart disease center of our cardiology department,the patient's symptoms disappeared and her vital signs stabilized.The patient was transferred to our department on the same day of admission due to CT findings of abdominal aortic coarctation and a hepatic aneurysm.We performed angiography,which showed that the HAA had a maximum diameter of approximately 5.6 cm and that it originated from the proper hepatic artery and was located approximately 1.5 cm from the involved bifurcation of the left and right hepatic arteries with no collaterals.Prolonged angiography revealed no communication between the HAA and superior mesenteric artery(Figure 1C).Considering the complexity of the patient's condition,the aortic dissection was repaired with a Endurant II stent graft(Medtronic,Inc.)at the first stage,and the HAA was scheduled for surgical repair at the second stage.Postoperatively,the patient was treated with antiplatelet,lipid-lowering and blood pressure control therapy.

Her blood test results showed no special abnormalities.

OUTCOME AND FOLLOW-UP

Oh, how Gerda s heart beat with anxiety and longing29! It seemed as if she were going to do something wrong, but she only wanted to know if it were little Kay

DlSCUSSlON

Visceral aneurysms,despite their rare incidence of 0.01%-0.2%,are of clinical importance,especially if we consider their natural history which is characterized by their propensity to rupture,with HAA accounting for approximately 20% of visceral aneurysms and a rupture rate of 44%[5].They are usually asymptomatic and difficult to detect until they rupture and cause abdominal pain and hypovolemic shock.As a result,most visceral aneurysms are found incidentally.The mortality rate following ruptured visceral aneurysms remains high(30% reported in the last decade)[7].

The timing of the intervention for hepatic aneurysms has been mentioned above.The treatment of a hepatic aneurysm is mainly as follows: Covered stent,open repair,and embolization[2,3,5].The ideal surgical option should be to remove the aneurysm while maintaining the hepatic circulation.Therefore,the primary treatment of hepatic aneurysms varies by site.The main treatments for common HAAs include open surgical ligation,endovascular embolization,resection/reconstruction,aneurysmorrhaphy,and a covered stent;those for the proper hepatic artery are resection with arterial reconstruction and endovascular repair with a covered stent;those for the proximal right or left hepatic branches are resection with arterial reconstruction and endovascular stent grafting;and finally,those for anintrahepatic aneurysm are endovascular embolization and resection of the lobe in which the aneurysm is located[5,8].However,the specific choice of treatment should be based on the patient's specific circumstances.

In this case,we did not select coil embolization mainly for the following reasons: First,the endovascular repair of extrahepatic HAA depends on the collaterals and location of the HAA.Given that the maintenance of distal organ perfusion is important,embolization is usually discouraged in patients with HAAs in the proper hepatic artery due to the risk of liver ischemia[5].Furthermore,in this case,the location of the HAA in the proper hepatic artery involved the bifurcation of the left and right hepatic arteries with no collateral circulation and thus increased the risk.Second,the HAA was so large that a large parenchymal lesion would be created if we performed embolization;this lesion might compress the biliary tract and duodenum and thus cause jaundice,gastrointestinal obstruction,and even duodenum fistula[5,9].

Another main option for HAA repair is endovascular stent grafting.The endovascular repair of visceral aneurysms with stent implantation can simultaneously enable aneurysm exclusion and vascular preservation,and therefore minimize the risk of ischemic complications[10].Nearly all retrospective case series have shown that although the outcomes for visceral artery aneurysms after open or endovascular repair share similar long-term results,morbidity is significantly worse with open repair than with the endovascular approach[5,8].The scope of aneurysm morphology suitable for endovascular repair is expanding with the accumulation of experience and improvements in equipment.The anatomical complexity of aneurysms is generally believed to affect the technical difficulty of repair with the development of the application of endovascular covered grafts;this belief is the main reason why we did not choose the approach of endovascular covered grafting.The main complications of endovascular stent grafting include occlusion[9,11].However,the patency rate of hepatic artery stenting is rarely reported.Künzle

[12]reported that the 2-year patency of the endovascular stent grafting of visceral artery aneurysms is approximately 81%.

Postoperatively,the patient experienced no specific discomfort.Antiplatelet,blood pressure control,and lipid-lowering treatments were maintained.Eleven days later,the patient was successfully discharged without surgery-related complications.The important times and events during the patient's hospitalization are shown in Table 1.The patient’s 3-mo follow-up checkup did not reveal any late complications(Figure 3).She reported no specific discomfort on review and was very satisfied with her treatment.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

The main methods of vascular reconstruction include direct vascular anastomosis and bypass of the artificial vascular or saphenous vein and vascular patch[11].The main complications of open surgical revascularization are infection and occlusion.Erben

[11]reported that in open surgical revascularization,the incidence of occlusion is 12%,with saphenous veins and artificial vessels sharing 6% and 6% equally,and the incidence of infection is 6%.

I think he is not in his right senses! said the Princess, and walked on, butwhen she had gone a little way, she stopped again. One must encourage art, said she, I am the Emperor s daughter. Tell him he shall, as on yesterday,have ten kisses from me, and may take the rest from the ladies of the court.

CONCLUSlON

Physical examination showed slight tenderness in the upper abdomen and no rebound pain;blood pressure of 214/139 mmHg;pulse of 64 beats/min;and temperature of 36.4°C.

FOOTNOTES

Wen X was responsible for collecting the information and writing the article;Yao ZY was involved in surgery and communication with the patient;Zhang Q participated in surgery and data collection;Wei W participated in surgery;Chen XY revised the article;Huang B designed the surgical plan and participated in the surgery;all authors have read and approved the final manuscript.

After making perennial2（，） efforts to measure my exact height, I reached the inescapable conclusion that I was permanently3 handicapped. Back in those days, I was a callow（） young chap（） vastly capable of darling and foolhardiness（） , and determined4 to wrestle5 with this prejudice against men s lack of height. So by hook or by rook, I married a girl who 1.74 meters in height. Such an astonishing tour de force（，） thus achieved greatly bolstered6 the morale7（，） and esteem8 of those of us who were handicapped .

The patient provided informed written consent prior to study enrollment.

This article is not supported by funding and has no conflict of interest.

1.Last evening of the year: New Year s Eve, as mentioned specifically later in the story. The Christmas and New Year holidays are known for great times of charitable giving. This story has become one of the most popular tales for inspiring charitable donations, especially during the Christmas holidays. It s also a reminder29 that this little girl, like so many others in poverty, needs help every day of the year, not just Christmas.Return to place in story.

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

Open surgery,which is usually known as open surgical revascularization,is another common method for the treatment of HAA.Considering the possibility of central liver necrosis despite adequate collateral flow by endovascular exclusion,open repair is recommended in low-risk patients if endovascular stent graft exclusion is not possible[5].In addition,open surgery has its unique role in aneurysm rupture.

“But the book in which I have read this account,” said the emperor, “was sent to me by the great and mighty emperor of Japan, and therefore it cannot contain a falsehood. I will hear the nightingale, she must be here this evening; she has my highest favor; and if she does not come, the whole court shall be trampled upon after supper is ended.”

China

Xi-Yang Chen 0000-0002-4108-1869;Bin Huang 0000-0003-4767-0629.

He sent for his Grand Wazeer and told him that he was going on one of his lonely expeditions, and that the Wazeer must invent some excuse to account for his absence

Wu YXJ

One fine morning, a hunter was getting ready to go hunting. Before departing1, he went to see his little baby. His baby was awake in a baby crib. He looked at his baby’s blanket and thought the blanket might not be thick enough for the coming winter.

Webster JR

Wu YXJ

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