Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms

Left colic artery pseudoaneurysm from pancreatitis presenting as upper gastrointestinal hemorrhage

Visceral pseudoaneurysms resulting from pancreatitis occur in approximately 10% of cases. The present report describes a left colic artery pseudoaneurysm from pancreatitis presenting with active duodenal bleeding. Based on the clinical and endoscopic demonstration of duodenal bleeding, celiac and superior mesenteric arteriograms were initially obtained, and their findings were negative. Repeat arteriography, including an inferior mesenteric artery injection, demonstrated a left colic pseudoaneurysm with rupture into the pancreatic duct and retrograde flow into the duodenum. Because of inconsistent diagnostic yields for arteriography performed for pancreatitis-related bleeding, the authors recommend disciplined interrogation of all three major mesenteric vessels, unbiased by initial endoscopic findings, to reduce false-negative examination results and empiric embolization.

Imaging appearances and endovascular management of uncommon pseudoaneurysms

Pseudoaneurysms are uncommon and their aetiology is varied. They occur in numerous anatomical locations and present with a multitude of clinical presentations sometimes life-threatening. This review describes the causes, sites, and presentations of uncommon pseudoaneurysms, as well as illustrating their diagnostic appearances and endovascular management.

Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization

PURPOSE

To describe our experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and to propose indications for treating VAA by this method.

METHODS

We treated 22 patients with VAA by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. All nine splenic artery aneurysms patients presented with chronic hepatitis-C; four had hepatocellular carcinoma. Of the seven renal artery aneurysms patients, four were hypertensive and three had rheumatoid arthritis. Both pancreaticoduodenal arcade artery aneurysms patients manifested severe stenosis of the celiac axis. Our transcatheter coil embolization procedure includes coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation.

RESULTS

Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7%) of the 22 patients and the native arterial circulation was preserved. Postprocedure angiograms confirmed complete disappearance of the VAA. In four of the nine splenic artery aneurysm patients, the native arterial circulation was not preserved. In one renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in one splenic- and two renal artery aneurysms patients; the latter developed flank pain and fever after the procedure.

CONCLUSIONS

Transcatheter coil embolization is an effective alternative treatment for patients with saccular and proximal VAA. In particular, the isolation technique using coil embolization is advantageous in splenic artery aneurysm patients.

Partial splenic embolization

Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.

Transcatheter coil embolization of splenic artery aneurysm

The purpose of this study was to evaluate clinical results and technical problems of transcatheter coil embolization for splenic artery aneurysm. Subjects were 16 patients (8 men, 8 women; age range, 40-80 years) who underwent transcatheter embolization for splenic artery aneurysm (14 true aneurysms, 2 false aneurysms) at one of our hospitals during the period January 1997 through July 2005. Two aneurysms (12.5%) were diagnosed at the time of rupture. Multiple splenic aneurysms were found in seven patients. Aneurysms were classified by site as proximal (or strictly ostial) (n = 3), middle (n = 3), or hilar (n = 10). The indication for transcatheter arterial embolization was a false or true aneurysm 20 mm in diameter. Embolic materials were fibered coils and interlocking detachable coils. Embolization was performed by the isolation technique, the packing technique, or both. Technically, all aneurysms were devascularized without severe complications. Embolized aneurysms were 6-40 mm in diameter (mean, 25 mm). Overall, the primary technical success rate was 88% (14 of 16 patients). In the remaining 2 patients (12.5%), partial recanalization occurred, and re-embolization was performed. The secondary technical success rate was 100%. Seven (44%) of the 16 study patients suffered partial splenic infarction. Intrasplenic branching originating from the aneurysm was observed in five patients. We conclude that transcatheter coil embolization should be the initial treatment of choice for splenic artery aneurysm.

Endovascular ligature of splenic artery aneurysm with Amplatzer Vascular Plug: a case report

Splenic artery aneurysm (SAA) is a rare disease that is asymptomatic for a long time and is often only incidentally discovered during imaging performed for other reasons. The natural history of SAA is a progressive increase in size until rupture. Therefore, treatment is recommended in symptomatic patients and for aneurysms larger than 2 cm in diameter. Using different techniques, endovascular treatment is feasible in nearly all SAAs. In this report, we describe a technique using Amplatzer Vascular Plug in endovascular ligature to exclude an SAA of the middle tract of the splenic artery.

Emergency endovascular treatment with stent graft of a gastric artery aneurysms (GAA)

The purpose of this paper is to present a case of emergency endovascular treatment of a symptomatic gastric artery aneurysm (GAA) with stent graft. A symptomatic aneurysm of a "gastro-hepatic" trunk in a 63-year-old patient was excluded with stent graft. Treatment was successful and without complications. Follow-up computed tomography-angiography confirmed the exclusion of the aneurysm after 6 months. Endovascular therapy with stent graft can be considered a feasible and effective approach for the treatment of GAAs in patients with suitable anatomy.

Visceral and renal artery aneurysms: a pictorial essay on endovascular therapy

Visceral artery aneurysms (VAAs), which were once considered uncommon, are now being diagnosed with increasing frequency, a fact that reflects the routine use of computed tomography (CT), magnetic resonance imaging, and ultrasonography. Diagnostic radiology plays a major role in the detection and characterization of VAAs. Cross-sectional imaging can help exclude aneurysm rupture, which requires emergent treatment. CT angiography or catheter angiography can clearly depict the aneurysm and help identify other aortic, visceral, or peripheral aneurysms. Most important, radiologic examination can help determine the adequacy of the collateral blood supply to the vascular bed distal to the aneurysm, information that is essential prior to the initiation of endovascular treatment. Advances in endovascular therapy have allowed interventional radiologists to contribute to the management of VAAs. Coil embolization or covered stent placement can now be used to treat patients with aneurysms whose size or location would make a surgical approach problematic, as well as patients in whom surgery is considered to pose considerable risk.