Endovascular Reconstruction of the Hepatic Arterial System for the Management of Mycotic Pseudoaneurysm in a Liver Transplant Patient Jackie Zhang, 1 Ali Khalifeh, 1 Rafael Santini-Dominguez, 1 Rolf N. Barth, 2 David Bruno, 2 Sarasijhaa Desikan, 1 Anuj Gupta, 3 and Shahab Toursavadkohi, 1 Baltimore, Maryland Background: Hepatic artery pseudoaneurysm is a rare but very morbid complication after liver transplant. Treatment options include ligation or endovascular embolization, followed by revas- cularization. We describe a new endovascular approach by stent exclusion in a high-risk patient. Results: A 62-year-old male who received a second liver transplant after failed allograft pre- sented with hemobilia and was diagnosed with a hepatic artery pseudoaneurysm in the setting of infection. Given his hostile abdomen, an endovascular approach was sought. We excluded the mycotic pseudoaneurysm with multiple covered stent grafts extending from the common he- patic artery to the right and left hepatic arteries. He was discharged with long-term antibiotics. On his 6-month follow-up visit, his stent was patent and hepatic function was stable. Conclusions: Endovascular stent-graft placement for management of hepatic artery pseudoa- neurysm after liver transplant should be considered as a lower morbidity alternative to surgical repair, even in the setting of infection. INTRODUCTION Vascular complications of the hepatic artery account for about 7e10% of graft losses after orthotropic liver transplantation. 1,2 Hepatic artery thrombosis represents the main cause, but a smaller percentage of graft failure is attributed to the formation of a he- patic artery pseudoaneurysm (PSA). 3 Although rare, with an incidence reported between 0.3% and 1.3%, it is a detrimental complication due to the high risk of rupture with an overall mortality of 69%. 4 Most he- patic artery PSAs occur in the first 2 months after transplantation and are attributed to infection. 5,6 Current management options include exclusion of the PSA with either ligation or endovascular coil embolization to control the risk of rupture and hem- orrhage. This is followed by revascularization with arterial bypass or re-transplantation. 4,7 Conse- quently, an open approach in a hostile abdomen in- creases the risk of complication and graft loss. 8,9 Endovascular approaches have been reported for main common hepatic artery (CHA) PSA, however, with risk of in-stent thrombosis. We present a unique case for endovascular man- agement of PSA of common, right, and left hepatic arteries after a second liver transplant. CASE Our patient is a 62-year-old male with a history of end- stage liver disease secondary to hepatitis C, treated with HARVONI Ò (Foster City, CA), who underwent a right Conflict of interest: The authors have no conflicts of interest to declare. Funding: There was no funding provided for the publication of this project. 1 Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD. 2 Division of Organ Transplant, Department of Surgery, University of Maryland Medical Center, Baltimore, MD. 3 Department of Cardiology, University of Maryland Medical Center, Baltimore, MD. Correspondence to: Ali Khalifeh, MD, University of Maryland Med- ical Center, 22S Greene Street S8B02 Baltimore, MD 21201; E-mail: akhalifeh@som.umaryland.edu Ann Vasc Surg 2019; 61: 473.e7–473.e11 https://doi.org/10.1016/j.avsg.2019.05.060 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: April 21, 2019; manuscript accepted: May 29, 2019; published online: 5 August 2019 473.e7