Role of Interventional Radiology as the First-line Management in Unruptured Giant Hepatic Hemangiomas

Dear Editor, Giant hepatic hemangiomas are rare entities and management protocols are still evolving.[1] Often, they may be diagnosed incidentally or during evaluation for vague pain abdomen or anemia. We report the case of one young adult who underwent investigation for anemia. He was found to have a giant liver hemangioma. It measured 15 cm in the largest dimension. The patient was referred by gastrointestinal surgeon for feasibility of embolization. After reviewing the images and doing ultrasound and computed tomography, the diagnosis was confirmed [Figure 1]. Procedure was planned to be performed under sedation.Figure 1: Portal venous and delayed phase of computed tomography showing typical imaging appearance of haemangiomaAfter right groin common femoral artery puncture, hepatic angiogram was performed which revealed vascular lesion almost completely replacing the right lobe of the liver. It showed peripheral puddling of contrast and gradual centripetal filling in. Bleomycin and lipiodol embolization were performed in two sittings 6 weeks’ apart. The hemangioma showed marked reduction in volume [Figures 2-4] and patient got rid of dull dragging pain which he used to have earlier.Figure 2: Post 1st sitting of embolization follow up computed tomography. Note the hyperdense lipiodol bleomycin mixture previously used for embolizationFigure 3: Angiogram and negative road map intraprocedure showing percolation into the haemangioma supplied by right hepatic arteryFigure 4: Final angiogram revealing near total obliteration of haemangioma blush. Patent right main hepatic artery. Bleomycin and lipiodol embolization was donePreviously, bland embolization used to be done with Poly Vinyl Alcohol particles or other particulate materials. Now bleomycin has emerged as the first choice embolic agent.[2-7] Our patient had nil complications and got discharged after a few days both times. Transient increase in liver enzymes is expected and happened in our case too, which came to normal within a week. The procedure was performed in staged manner to allow the hemangioma to shrink in size and also to avoid lung toxicity of bleomycin. The case highlights the role of Interventional Radiology in unruptured giant hepatic hemangiomas. Open surgery would have been a nightmare in these types of cases with significant risk of morbidity and mortality. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.