Dealing with hepatic artery traumas: A clinical literature review

ARTICLE HIGHLIGHTS

Research background

The hepatic artery (HA) has been used more and more for diagnosis and treatment in recent years. Besides, HA is one of the most threatened vascular structures during hepatopancreatobiliary (HPB) surgeries and interventional procedures. The incidence of HA injury is not precisely known.

Research motivation

There are many studies reporting that more than half of the cases died in the case of HA trauma or involuntary ligation until the last 3-4 decades. There is still a risk of serious morbidity and mortality as a result of injury to the HA during an increasing number of interventional procedures and HPB surgeries in recent years. There is a need for algorithmic approaches to HA-related problems and their solutions, which can be encountered for many different reasons.

Research objectives

Most of the studies related to HA in the literature are in the form of case reports. There are no algorithms developed for solving HA problems that surgeons, internists, gastroenterologists, hepatologists, and interventional radiologists often encounter sporadically. There is no consensus established for the solution of the problems encountered. Since there are no experimental studies in humans, there is a need for the analysis of data from case reports and a limited number of clinical series.

Research methods

The authors have reviewed 100 years of MEDLINE (PubMed) literature. The clinical approach algorithm was tried to define by reviewing the papers, including cases and series of HA injuries. The study researched keywords containing "hepatic artery" AND (trauma OR injury OR resection OR ligation OR avulsion OR transection OR reconstruction) and their various combinations. Approaches that have evolved in recent years in managing patients with HA injury (laceration, transection, ligation, resection) with severe morbidity and mortality risk are reviewed in the light of current literature.

Research results

The authors found 6314 articles as a result of the MEDLINE research. While one to two articles were published annually in the first 50 years, this number has increased gradually in the last 50 years and reached 109-237 articles per year. There are 1555 articles with the keywords "hepatic artery injury" or "hepatic artery trauma" and 468 articles with the word "hepatic artery ligation". In the first half of the century, we detected that HA traumas were applied mainly with unintentional ligations during gallbladder and stomach surgeries and patients who underwent planned ligation for HA aneurysm. We have identified 57 studies with the word "HA resection", and "HA embolization" was the subject of 406 studies; most of them have been published in the previous 2 decades. Articles on HA transection and reconstruction, a challenging stage of liver transplantation, ligation, resection, and reconstructions for HA aneurysms were also discussed. HA embolization has found many more clinical applications with the developing technological applications, and more studies have been reported in recent years. Here, HA pathologies, therapeutic procedures, and also HA embolization will be shortly described in the paper.

Research conclusions

With the technological developments in the last 2-3 decades and their contribution to diagnosis and treatment, positive developments have been identified in the prevention and management of HA trauma and related complications. The risk of HA injury increases during cholecystectomies and pancreatoduodenectomies, among the most common operations. HA anatomy shows anomalies in approximately 15%-25% of the cases, further increasing this risk. Complications and deaths due to HA injury are less common today. The risk of complications increases in patients with hemodynamic instability, jaundice, and cholangitis. Revealing the variations in the preoperative radiological evaluation will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to maintain with primary anastomosis, arterial transpositions, or grafts. In cases where bile duct injury develops, patients should be directed to HPB surgery centers, considering the possibility of accompanying HA injury.

Research perspectives

Due to the high risks it contains, the inability to conduct prospective studies in humans remains a problem. However, experimental studies in animals are needed regarding identified pathological processes. Besides, large-scale and multicentric clinical prospective studies are needed to understand better the early and long-term results of HA ligation and determine preventive procedures.