Background: Hepatic artery pseudoaneurysm (HAP) is a rare entity, potentially life threatening and associated with high mortality. The aim of this study was to evaluate Mayo Clinic enterprise’s clinical experience with HAP occurrence, clinical features and outcome in the last 20 years, and to compare our results with what the literature.

Methods: This retrospective analysis included patients diagnosed with HAP at three Mayo Clinic sites (Florida, Minnesota and Arizona) from September 1998 to June 2022. Initial data identified a total number of 37 cases, of which 10 were excluded from the study for not meeting inclusion criteria. The final analysis included 27 patients. This study analyzed: demographics, presenting symptoms, location of HAP, etiology, complications and mortality.

Results: Of 27 patients, 17 (63%) were male and median age was 57 years (range: 25-87 years). Presenting symptoms were gastrointestinal (GI) bleeding (29.6%), bleeding other than GI bleed (11.1%), abdominal pain (14.81%), and in 18.52% HAP was incidentally found. The right hepatic artery (RHA) was the predominant location for pseudoaneurysms (70.4%), and in 23 cases (85.2%) HAP were intrahepatic. Malignancy was found in 52% of these cases, while 26% of patients had liver transplant. Procedures associated with HAP development were balloon angioplasty and TIPS (11.1%), liver transplant (14.8%), liver biopsy (11.1%), laparoscopic cholecystectomy (3.7%), ERCP and biliary drain placement (14.8%), cryoablation and the Whipple procedure (11.1%) and trauma (14.8%). 11.1% were considered spontaneous. Known HAP (p=0.381), HAP rupture (p=0.382), anticoagulation (p=0.856), hemorrhagic shock (p=0.25), liver cirrhosis (0.143), GI bleed (0.879), hepatobiliary abscess (p=0.079), liver transplant (p=0.738), spontaneous HAP (p=0.381) and malignancy (p=0,163) were features not associated with mortality. We have identified four categories connected with mortality which are transfusion (p=0,021), tumor invasion (p=0,023), Poral vein thrombosis (PVT) (p=0,02) and liver necrosis (p=0,02). The infection rate was 3%.

Conclusions: HAP most commonly presents as bleeding following rupture, but mortality was not associated with it. HAP can be incidentally found, mostly in post liver transplant period. Hepatobiliary procedures were highly associated with occurrence of HAP, but they were not associated with mortality (liver transplantation, hepatic resection, biliary stent placement, any abdominal surgery). Risk factors associated with mortality were transfusion, tumor invasion PSA, PVT and liver necrosis. The infection rate in all HAP was 3% compared to the previously published infection rate in posttransplant cases from 85% (Marshall). While previous studies reported high mortality associated with HAP, we found that in Mayo Clinic overall mortality was 18.5%. Improvement in diagnostic modalities, early diagnosis and treatment in tertiary academic hospital in the last 20 years probably contributed to this improvement in mortality and infection rate.