Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms

Clinical Characteristics and Management of Peripancreatic Arterial Aneurysms: A 20-year Experience

Pancreaticoduodenal and gastroduodenal artery aneurysms (PDAAs and GDAAs) are rare visceral aneurysms. Considering the rupture risk regardless of size, treatment should be provided promptly. We reviewed the characteristics and management of peripancreatic aneurysms in a retrospective, single-center review of consecutive patients with PDAAs and GDAAs between 2000 and 2022. Demographics, clinical characteristics, radiologic features, treatment, and outcomes were recorded. Nineteen PDAAs and seven GDAAs were identified in 24 patients. The median sizes of the PDAAs and GDAAs were 21 mm (range: 8-50 mm) and 14 mm (range: 11-32 mm), respectively. There were 4 ruptured cases (15.4%). Ten aneurysms (38.5%) had concomitant visceral aneurysms, and 16 (61.6%) were associated with celiac pathology. Aneurysms were managed using endovascular in 12 (46.2%), surgical in 4 (15.4%), and combined methods in 3 (11.5%) cases; 7 patients (26.9%) were lost to follow-up or refused treatments. During a median 13.8-month follow-up (range: 1-147.6), two complications (7.7%) occurred including pancreatitis and coil migration into the superior mesenteric artery after embolization within 30 days. After 30 days, aorto-common hepatic artery bypass graft stenosis was identified in one PDAA. Depending on the characteristics of peripancreatic aneurysms, endovascular, surgical, and hybrid approaches might all be practical treatment options.

Infective native visceral artery aneurysm (INVAA): A systematic review of etiology, treatment, and outcomes

The present review introduces the term 'infective native visceral artery aneurysm (INVAA)' and provides a systematic review of the literature on this topic. The terms 'mycotic' and 'infected' have been replaced by the term 'infective native' to more accurately describe aneurysms of this type. A systematic search of MEDLINE, Embase, Google Scholar, and Scopus databases was performed to identify articles reporting on INVAAs to April 2024. Inclusion criteria encompassed studies describing 'mycotic' or 'infected' primary visceral aneurysms, excluding patients with concurrent aneurysms in the aorta. The search yielded 356 articles, with 161 meeting the inclusion criteria, covering 175 patients. The median age was 48 years (IQR: 33-60 years), predominantly men (n = 127, 72.6%). INVAA was most frequently reported in the superior mesenteric artery (37.5%, n = 65), followed by the hepatic (22.9%, n = 40) and splenic arteries (14.3%, n = 25). Endocarditis was the predominant etiology in 67.4% (n = 118) of cases. Gram-positive pathogens were identified in 58.8% (n = 103) of cases. Treatment modalities included open surgery (49.7%, n = 87), endovascular interventions (37.7%, n = 66), and medical management (12.0%, n = 21). The overall proportion of patients who died was 13.7% (n = 24). In multivariable modeling, cerebral aneurysms (OR: 4.0, 95% CI 1.17, 12.8; p = 0.02), gastrointestinal bleed (OR: 5.79, 95% CI 1.86, 17.6; p < 0.01), and chronic kidney disease (OR: 16.0, 95% CI 2.3, 136; p < 0.01) were associated with increased odds of death. The optimal treatment for INVAA remains undefined, highlighting the need for standardization of reporting and prospective registries to enhance the understanding and management of this complex disease.

Interventional treatment of peripancreatic aneurysms: can one strategy fit all?

PURPOSE

To identify the frequency and association of visceral arterial (VA) stenosis in peripancreatic aneurysms (PPAs) and to develop a uniform, more detailed treatment strategy for PPAs in case of accompanying VA stenosis, as current guidelines do not adequately address this constellation.

MATERIALS AND METHODS

Patients with PPAs diagnosed at a tertiary care hospital were retrospectively analyzed. In case of multiple PPAs, the aneurysm with the highest aneurysm-to-vessel ratio (AVR) within the celiac-mesenteric collateral circulation was classified as the primary aneurysm and categorized as "critical" or "non-critical" based on the risk of organ ischemia. Celiac artery and superior mesenteric artery stenoses were graded as low (< 50%), high (> 50%), or total occlusion. Treatment strategies were based on VA stenosis severity, aneurysm classification, and morphology. Treatment strategies included endovascular, surgical and watch-and-wait management.

RESULTS

Thirty-one patients with PPAs were included with a total of 53 aneurysms; mean aneurysm size: 12.5 ± 7.9 mm (range 5-38 mm), AVR: 3.5 ± 2.1 (range 1-11.3). The superior and inferior pancreaticoduodenal arteries as well as the pancreaticoduodenal arcade were affected in most cases (67.9%). AVR was significantly higher in cases of aneurysm rupture (6.2 ± 2.8; p = 0.031). Celiac artery stenosis was present in 87.1%. Aneurysm size and occurrence of active bleeding did not correlate (p = 0.925). 11 patients presented with critical aneurysms, with 10 patients requiring individually tailored treatment. Non-critical aneurysms were treated with coil embolization in most cases.

CONCLUSION

CA stenosis, aneurysm position, and AVR significantly influence treatment decisions. Individualized approaches based on anatomical and hemodynamic factors are needed in PPA treatment.

Gastroduodenal artery aneurysm degeneration after coiling necessitating open repair

A 77-year-old male presented for an incidental 5-cm gastroduodenal artery aneurysm (GDAA). He underwent an endovascular GDAA coil embolization with 6 months of no aneurysmal growth on surveillance imaging. His 12-month scan revealed aneurysmal growth from 5 cm to 7.5 cm involving the hepatic confluence. He underwent successful open aneurysm resection and primary anastomosis of the hepatic artery. Although less invasive interventions are recommended for GDAAs, many vascular surgeons prefer to proceed with an open repair. Continued GDAA enlargement after perceived endovascular success demonstrates the importance of long-term surveillance and viability of open intervention, sparing patients from a potentially fatal rupture.

Ultra-short Echo-time MR Angiography Combined with a Modified Signal Targeting Alternating Radio Frequency with Asymmetric Inversion Slabs Technique to Assess Visceral Artery Aneurysm after Coil Embolization

Contrast-enhanced CT and MR angiography are widely used for follow-up of visceral artery aneurysms after coil embolization. However, potential adverse reactions to contrast agents and image deterioration due to susceptibility artifacts from the coils are major drawbacks of these modalities. Herein, we introduced a novel non-contrast-enhanced MR angiography technique using ultra-short TE combined with a modified signal targeting alternating radio frequency with asymmetric inversion slabs, which could provide a serial hemodynamic vascular image with fewer susceptibility artifacts for follow-up after coil embolization.

Trans-Arterial Balloon-Assisted Embolization of Traumatic Giant Hepatic Pseudoaneurysm With Thrombin

Giant hepatic pseudoaneurysms are rare after injury. We report a case of a 20-year-old male, post gunshot injury to his right upper quadrant of the abdomen with delayed blood loss. CTA of the abdomen demonstrated a 6.5 cm right hepatic artery pseudoaneurysm. This was successfully embolized with balloon assisted trans-arterial thrombin injection.

Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review

BACKGROUND

Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs.

MATERIALS AND METHODS

A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications.

RESULTS

We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups.

CONCLUSIONS

Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.

Endovascular Treatment of Visceral Artery Pseudoaneurysms with Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs)

Background and Objectives: Treatment of visceral artery pseudoaneurysms (VAPs) is always indicated regardless of their diameters, as their risk of rupture is significantly higher than that of visceral artery aneurysms. The invasiveness of surgery and its associated complications have led to a shift in favor of radiological interventions as the initial treatment of choice. However, there are still some unanswered questions on endovascular treatment of VAPs regarding the optimal endovascular technique and the efficacy and safety outcomes. The purpose of this multicenter study was to retrospectively evaluate the effectiveness and safety of endovascular treatment of visceral pseudoaneurysms using Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs). Materials and Methods: Consecutive patients who underwent endovascular embolization with EVOH-based NALEAs for visceral artery pseudoaneurysms between January 2018 and June 2023 were retrospectively evaluated. Results: 38 embolizations were performed. Technical success was achieved in all patients. The clinical success rate was high (92.1% overall), with no significant differences between ruptured and unruptured VAPs (p = 0.679). Seven patients (18.4%) experienced procedure-related complications, related to one case of non-target embolization, four splenic abscesses due to end-organ infarction, and two femoral pseudoaneurysms. The rates of procedure-related complications, end-organ infarction, and vascular access-site complications did not significantly differ between ruptured and unruptured VAPs (p > 0.05). Conclusions: Both ruptured and unruptured visceral pseudoaneurysms can be effectively and safely treated with NALEA-based endovascular embolization. We suggest considering the use of NALEAs, particularly in specific clinical cases that highlight their advantages, including patients with coagulopathy, fragile vessels, and embolization targets that are located at a considerable distance from the microcatheter tip and are otherwise difficult to reach.

Surgical repair of a symptomatic celiac artery aneurysm with resection and end-to-end anastomosis

A true aneurysm of the celiac artery is a rare form of a visceral aneurysm, constituting ∼4% of visceral aneurysms. Mortality in ruptured cases is high; thus, early recognition and treatment are crucial. Recent guidelines suggest endovascular therapy; however, numerous complications are associated with endoluminal treatment. Open repair in select cases, using an individualized strategy fit for the patient's anatomy still provides excellent early and long-term results. Our patient was treated with open surgical resection and end-to-end anastomosis of the celiac and common hepatic arteries. A 43-month follow-up computed tomography angiogram revealed excellent hepatic artery patency and no pseudoaneurysm formation.

Clinical Profile, Management, and Outcome of Visceral Artery Pseudoaneurysms: 5-Year Experience in a Tertiary Care Hospital

Visceral artery pseudoaneurysms are potentially lethal lesions and tend to rupture in a high proportion of cases, thereby warranting an immediate and active intervention. We present our experience of splanchnic visceral artery pseudoaneurysms in a university hospital over a 5-year time interval with emphasis on etiology, clinical presentation, management (endovascular/surgical), and final outcome. This was a retrospective study in which we searched our image database for pseudoaneurysms of visceral arteries over a period of 5 years. The clinical and operative details were retrieved from the medical record section of our hospital. The lesions were analyzed for the vessel of origin, size, etiology, clinical features, mode of treatment, and outcome. Twenty-seven patients with pseudoaneurysms were encountered. Pancreatitis (8) was the most common cause, followed by previous surgery (7) and trauma (6). Fifteen were managed by the interventional radiology (IR) team, 6 by surgery, and in 6 no intervention was done. Technical and clinical success was achieved in all patients in the IR group with few minor complications. Surgery and no intervention carry a high mortality in such a setting (66 and 50%, respectively). Visceral pseudoaneurysms are potentially fatal lesions, commonly encountered after trauma, pancreatitis, surgeries, and interventional procedures. These lesions are easily salvageable by minimally invasive interventional techniques (endovascular embolotherapy), and surgeries carry a lot of morbidity and mortality in such cases and a prolonged hospital stay.

Splenic Artery Pseudoaneurysm—A Concern for the Anesthesiologist

Pseudoaneurysms as compared with aneurysms lack a true wall and have a higher propensity of rupture. Visceral artery pseudoaneurysms are uncommon and are life-threatening. We, hereby, report anesthetic management of a rare case of splenic artery pseudoaneurysm that accompanied the dilatation of aorta from its origin extending up to its bifurcation.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

Percutaneous direct puncture and embolization of vascularly inaccessible abdominal visceral pseudoaneurysms: A single-center experience and literature review

BACKGROUND

To evaluate the techniques, efficacy, and safety for treating vascularly inaccessible abdominal visceral pseudoaneurysms by direct puncture and embolization.

METHODS

A retrospective study of 5 consecutive patients who underwent percutaneous direct puncture embolization for intra-abdominal pseudoaneurysms in our institution between January 2009 and December 2016. Technical aspects, success, clinical outcome, and complications were discussed.

RESULTS

Four patients (80%) were men, and the mean age of all five patients was 57.2 years (range, 47-72 years). The mean diameter of the pseudoaneurysms was 2.5 cm (range, 1.9-3.4 cm). All the pseudoaneurysms were punctured under the imaging guidance of fluoroscopy, ultrasound, or computed tomography. Coils and glue were used in four of the patients, the remaining one with coil only. The mean injected glue volume was 1.5 (range, 0.8-2) mL. The overall technical and clinical success rate was 100% without major complications or mortality.

CONCLUSION

Our single-center experience and the literature review demonstrate that percutaneous direct puncture embolization is feasible and effective to serve as an alternative for treating abdominal vascular pseudoaneurysms when the traditional endovascular embolization fails. In this approach, fluoroscopy is the most needed guidance technique.

A Large Series of True Pancreaticoduodenal Artery Aneurysms

INTRODUCTION

True pancreaticoduodenal artery aneurysms (PDAA) are rare and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health-system from 2004-2019 with true PDAA, with a focus on risk factors, interventions, and patient outcomes.

METHODS

Patients were identified by querying a single health-system PACS database for radiographic reports noting a PDAA. Retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests.

RESULTS

A total of 59 true PDAA were identified. Forty aneurysms (68%) were intact (iPDAA) and 19 (32%) were ruptured (rPDAA) at presentation. Mean size of ruptured PDAA was 16.4 mm (median size 14.0 mm; range 10 - 42 mm) and mean size of intact PDAA was 19.4 mm (median size 17.5mm; range 8 - 88 mm), this difference was not statistically significant (P = 0.95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%, P=0.017), and less likely to have aneurysmal wall calcifications (6% vs 53%, P=0.002). Thirty-seven patients underwent intervention (63%); with eight (22%) undergoing concomitant hepatic revascularization (2 stents and 6 bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAA experienced an aneurysm related mortality of 10.5% while those with iPDAA experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. Ruptured PDAA showed a trend towards increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%, P=0.13).

CONCLUSIONS

These findings support previous reports that the rupture risk of PDAA is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both intact and ruptured PDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review

BACKGROUND

Visceral artery aneurysms (VAA) are rare with an incidence of up to 0.2% and mortality of up to 40%. Aneurysms larger than 5 cm are referred to as giant visceral artery aneurysms (GVAA). We present a case of a celiac artery aneurysm of 14 cm which required endovascular and surgical management. A review of the literature with focus on treatment is also provided.

CASE PRESENTATION

In this case report, a 76-year-old male presented with postprandial nausea and vomitus. An ultrasound and computed tomography scan showed an aneurysm of the celiac artery of approximately 14 cm. Initial treatment was conducted with coiling. Despite this treatment, patient presented again with the same complaints, most likely due to gastric outlet syndrome caused by the aneurysm sac. Partial open removal of the aneurysm sac was performed with release of the duodenum. Due to recurring dysphagia and postprandial nausea, a gastroenterostomy was created, which was later supplemented with a Roux-en-Y anastomosis due to gastroparesis. Patient recovered uneventful after the Roux-en-Y and was discharged from the hospital.

CONCLUSION

Giant visceral artery aneurysms sometimes need multimodal treatment. We showed that an endovascular first approach of a giant visceral artery aneurysm is not only technically feasible, but it also facilitates subsequent open surgery due to limiting blood loss and reducing the need for extensive mobilisation of the viscera to gain arterial control.

Complex endovascular treatment of a celiac trunk artery aneurysm with splenic artery rescue: Santini et al.: Celiac trunk artery aneurysm treatment - endovascular approach

Visceral arterial aneurysms are uncommon pathologies, with an uncertain ethology and no clear treatment guidelines. As in our case, where we treated a 70 y.o. male patient, who came to us for un unspecific abdominal pain. So, he practiced a CT total body with contrast, presenting a celiac trunk aneurysm with involvement of the hepatic and splenic artery and therefore the team decided for an endovascular treatment, successfully obtained. Our experience is about the description of a case in its most practical and technical aspect, especially in complicated or rare conditions.

Small saccular aneurysms in the coronary and right epigastric arteries: A case report

Small saccular aneurysm in the right gastroepiploic artery is a sporadic disease accounting for approximately 0.4% of abdominal visceral aneurysms rarely observed during routine examination of other illnesses; however, it has been reported following rupture. The right gastroepiploic artery is a common alternative to the internal thoracic artery in coronary artery bypass grafting. We report a case of small aneurysms in the left anterior descending artery, diagonal branch artery, and right gastroepiploic artery and a pseudoaneurysm in right gastroepiploic artery. Coronary artery bypass grafting was performed using the left internal thoracic artery and right gastroepiploic artery, and a 5-mm aneurysm was observed in the right gastroepiploic artery. The resected 5-mm right gastroepiploic artery aneurysm was saccular. Pathological investigation revealed media loss and adventitial thinning, indicating the possibility of an aneurysm rupture. Thus, preoperative three-dimensional computed tomography is beneficial for patients with coronary arterial aneurysms and preoperative evaluation of right gastroepiploic artery to help achieve good clinical outcomes in patients undergoing coronary artery bypass grafting with another arterial aneurysm.

Endovascular interventions in management of renal artery aneurysm

Renal artery aneurysm (RAA) is a rare disease. With modern non-invasive imaging modalities, the disease is being increasingly diagnosed. It is a slow-growing aneurysm with high mortality in the event of rupture; especially in pregnant females for in which case patients were treated surgically. With advances in endovascular therapy, numerous techniques have been employed to manage complex RAA in artery bifurcation, branch and segmental arteries with excellent technical and clinical success. The various recent techniques include the use of flow diverter stents, remodelling with stent-assisted coil embolization (SACE), balloon-assisted coil embolization (BACE), selective embolization with coils-sac packing, inflow occlusion and coil trapping and selective embolization with liquid embolic agents-hystroacril and onyx. A combination of stent-graft with liquid embolization and liquid with microcoil embolization has been advocated with success. The most common complication encountered is renal infarction. This is mostly without impairment of renal function and secondary to embolization. Endovascular therapy has shorter operative time, less blood loss, shorter intensive care stay, done under conscious sedation and is associated with lesser postoperative morbidity compared to surgery. Reduction in hypertension, improvement of renal function and symptoms has been seen in most studies. Endovascular management of RAA has become the management of choice even with complex anatomy and technically challenging lesions.

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

Visceral artery aneurysms (VAAs) are rare, usually asymptomatic and incidentally discovered during a routine radiological examination. Shared guidelines suggest their treatment in the following conditions: VAAs with diameter larger than 2 cm, or 3 times exceeding the target artery; VAAs with a progressive growth of at least 0.5 cm per year; symptomatic or ruptured VAAs. Endovascular treatment, less burdened by morbidity and mortality than surgery, is generally the preferred option. Selection of the best strategy depends on the visceral artery involved, aneurysm characteristics, the clinical scenario and the operator's experience. Tortuosity of VAAs almost always makes embolization the only technically feasible option. The present narrative review reports state of the art and new perspectives on the main endovascular and other interventional options in the treatment of VAAs. Embolization techniques and materials, use of covered and flow-diverting stents and percutaneous approaches are accurately analyzed based on the current literature. Visceral artery-related considerations and targeted approaches are also provided and discussed.

Common hepatic artery pseudoaneurysm: A rare complication following total gastrectomy: A case report

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Common Hepatic Artery pseudoaneurysm after total gastrectomy is uncommon and can be devastating.

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We report a case of a ruptured common hepatic artery pseudoaneurysm who presented with massive gastrointestinal bleeding.

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Early assessment with CT angiography followed by early appropriate treatment is life-saving.

Introduction and importance

Common Hepatic Artery (CHA) Pseudoaneurysm is a rare entity, attributed to infections, trauma, and upper abdominal surgery. Most cases occur after biliary and pancreatic surgery. CHA pseudoaneurysm after total gastrectomy is uncommon and can be devastating.

Case presentation

A 58-years male who underwent D2 total gastrectomy for gastric carcinoma ten days ago, presented with hematemesis, epigastric pain, and a history of melaena. After admission, upper gastrointestinal endoscopy showed a clot at the jejunojejunostomy site. Computed tomography with angiography was diagnostic of pseudoaneurysm of CHA located inferiorly. Coil embolization of CHA was done and the patient improved.

Clinical discussion

Pseudoaneurysm of the common hepatic artery is a serious complication after abdominal surgery. Only a few cases have been reported with similar symptoms related to gastrointestinal bleeding following various upper abdominal surgeries. Coil embolization is a gold standard technique with a high success rate.

Conclusion

CHA pseudoaneurysm is a dreadful potential complication of abdominal surgery including gastrectomy. Early recognition and emergency management of CHA pseudoaneurysm are crucial for a favorable outcome for patients with bleeding from CHA aneurysm.

Endovascular management of giant visceral artery aneurysms

Endovascular management of small visceral artery aneurysms is an established treatment with satisfactory outcomes. However, when size exceeds 5 cm visceral aneurysms are considered as “giant” (giant visceral artery aneurysms or GVAAs) and management is significantly more complex. Between August 2007 and June 2019 eleven cases of GVAAs that were endovascularly treated were retrospectively reviewed and included in this single center study. Mean size was 80 mm (± 26.3 mm) x 46 mm (+ \-11.8 mm). Nine of the lesions were true aneurysms, and two were pseudoaneurysms. In 8 patients, the lesion was causing compression symptoms in the surrounding organs, one patient developed a contained rupture while 2 patients were completely asymptomatic. However, all patients were hemodynamically stable at the time of treatment. Technical success was defined as immediate complete exclusion of the aneurysmal sac, and clinical success as complete relief from clinical symptoms. Follow-up was performed with CT angiography, ultrasound and clinical examination. Mean follow-up was 45 months (range 6–84). Technical and clinical success were both 91%. Complications were one lack of control of contained rupture that was subsequently operated, one case of self-limiting non-target spleen embolization and one case of splenic abscess. Three patients died, one due to the contained rupture 15 days after procedure, the other two for other causes and occurred during the long-term follow-up. This series suggests that endovascular treatment of giant visceral artery aneurysms and pseudoaneuryms is a valid minimally invasive solution with very satisfactory immediate and long-term outcomes unless the aneurysm is already ruptured. A variety of endovascular tools may be required for successful treatment.

Transcirculation microballoon-assisted coil embolization for dorsal pancreatic artery aneurysm due to celiac artery dissection: A case report

The dorsal pancreatic artery is a part of peripancreatic arcade connecting celiac artery to transpancreatic artery. A dorsal pancreatic artery aneurysm derived from dissection of celiac artery is a rare pathology, and it sometimes requires ingenious strategy in an endovascular surgery. Hereby, we report a case of a patient who underwent coil embolization for dorsal pancreatic artery aneurysm due to celiac artery dissection by applying transcirculation approach of a balloon catheter through the peripancreatic arcade, which was successfully achieved.

Direct Percutaneous Puncture and Embolization of Visceral Pseudoaneurysm: Safety and Clinical Efficacy

Purpose The aim of the study is to assess the safety and clinical effectiveness of direct percutaneous embolization of visceral artery pseudoaneurysms.

Materials and Methods Retrospective analysis of patients who had undergone direct percutaneous embolization of visceral artery pseudoaneurysms between January 2012 and May 2017 was performed. The study included 26 patients with a mean age of 36 years (range 10–71 years). The indications for direct percutaneous embolization included the inability to catheterize endovascularly (n = 24) or prior embolization (n = 2) of the feeding artery. Patient demographics, details of the procedure, complications, and outcomes were evaluated. Patients were followed for a mean of 15 months to assess for recurrence of the pseudoaneurysms on ultrasound.

Results Splenic artery (n = 13), gastroduodenal artery (n = 4), right hepatic artery (n = 3), pancreaticoduodenal arteries (n = 3), left gastric artery (n = 2), and left hepatic artery (n = 1) were the embolized arteries. Etiology for pseudoaneurysm were pancreatitis (n = 20), trauma (n = 2), postoperative (n = 2), and few were incidentally detected (n = 2). N-butyl cyanoacrylate (NBCA) with lipiodol was used in 23 (88.4%) patients, coil in one (3.8%), and both coil and NBCA in two patients (7.7%). Embolization of the pseudoaneurysm was successful in all cases. No procedure-related complication was observed. Follow-up showed no recurrence of the pseudoaneurysm. Self-limiting splenic infarct was seen in six patients. Self-limiting abdominal pain was seen in all the patients with embolization with NBCA. One patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage.

Conclusion Direct percutaneous embolization is safe and effective in the treatment of visceral artery pseudoaneurysms and should be considered as an alternative in patients with a failed endovascular approach.

Unusual case of upper gastrointestinal haemorrhage secondary to a ruptured gastroduodenal artery pseudoaneurysm: case presentation and literature review

Pseudoaneurysm rupture of the gastroduodenal artery (GDA) is life-threatening and can present as an acute upper gastrointestinal haemorrhage. Here, we present a case of upper gastrointestinal haemorrhage arising from a ruptured GDA pseudoaneurysm. A 56-year-old woman presented acutely with haematemesis. She reported ongoing upper epigastric pain for a few weeks. Laboratory evaluation revealed severe microcytic hypochromic anaemia (haemoglobin, 69 g/L; normal, 120-140 g/L) and a mildly raised serum amylase level. Upper gastrointestinal endoscopy revealed dark blood collection between the rugae of the distal stomach. An abdominal CT scan detected a homogeneously enhancing rounded lesion arising from the GDA adjacent to the second part of the duodenum. The median arcuate ligament was causing stenosis of the coeliac axis origin. The diagnosis of haematemesis secondary to a ruptured GDA pseudoaneurysm was confirmed by mesenteric angiography, and aneurysmal embolisation was done. The haemoglobin level stabilised after aneurysmal embolisation.

A case of endovascular therapy for treating idiopathic arterial deteriorations of unknown etiology

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A 50-year-old patient presented with multiple idiopathic arterial deteriorations.

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He had a renal artery tear and a pseudoaneurysm of the left internal iliac artery.

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Previous direct intervention failed and we suspected vascular fragility.

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The two lesions were treated by simultaneously placing endografts.

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Endovascular treatment is a desirable option in the case of vascular fragility.

Introduction

Peripheral artery pseudoaneurysm as a consequence of arterial deterioration is relatively rare in young populations, who typically lack an atherosclerotic background. Such pseudoaneurysms are known to pose a risk of rupture, which is correlated with high mortality and morbidity rates. Pseudoaneurysms are more prone to rupture than true aneurysms are, as their vessel walls tear more easily. We present the case of a 50-year-old patient who had multiple arterial deteriorations.

Case presentation

The patient experienced backache, and computed tomography revealed a tear of the right renal artery, and a pseudoaneurysm of the left internal iliac artery. He had a history of graft replacement for the right superficial artery pseudoaneurysm, which had been occluded. Although various tests were performed for differential diagnosis, the etiology was unidentified. Considering the suspected vascular fragility and failure of previous direct intervention, these 2 lesions were treated by placing endografts simultaneously.

Discussion

We investigated various diseases causing vascular fragility in the reported case, such as vascular Behçet disease, vascular Ehlers-Danlos syndrome, fibromuscular dysplasia, and segmental arterial mediolysis. However, these were all excluded and the etiology remains unclear. Progress in endovascular techniques enables the use of minimally invasive treatment in patients with vascular fragility.

Conclusion

When vascular fragility may exist, endovascular treatment is a desirable option, as it can be performed repetitively and is less invasive.

Inferior epigastric artery pseudoaneurysm secondary to port placement during a robot-assisted laparoscopic radical cystectomy

Pseudoaneurysm occurs when the artery wall is damaged and the blood is contained by the surrounding tissues with the eventual formation of a fibrous sac communicating with the artery. We report a case of a 74-year-old man with inferior epigastric artery (IEA) pseudoaneurysm secondary to an 8-mm port placement during a robot-assisted laparoscopic radical cystectomy with ureteroileocutaneostomy. The pseudoaneurysm was initially diagnosed by contrast-enhanced ultrasound (CEUS); subsequently, a computed tomography (CT) scan and an angiography test were performed. The pseudoaneurysm was then treated successfully with embolization of the inferior epigastric artery. Awareness of this rare complication is of clinical importance to avoid excessive morbidity of affected individuals.

Frequency and causes of delayed diagnosis of visceral artery pseudoaneurysms with CT: Lessons learned

Objective

Visceral artery pseudoaneurysms (VAPA) are associated with a high morbidity and mortality, but sometimes are missed in initial computed tomography (CT) examinations. The aims of this study were to determine the frequency and causes of misdiagnoses of VAPA with CT.

Materials and Methods

We retrospectively identified 77 patients with VAPA in our database who underwent contrast-enhanced CT. The frequency of delayed diagnosis was determined and the reasons were noted. We identified the etiology of VAPA, measured size, and noted the affected vessels.

Results

Forty-five of the 77 patients (58 %) had a delayed diagnosis of VAPA. There was no difference in the rate of missed VAPA in symptomatic compared to asymptomatic patients (p = 0.255). The majority of VAPA were associated with previous surgery or interventions (n = 48/62 %). The major affected vessel was the hepatic (n = 31) followed by the splenic artery (n = 17). The main reasons for misdiagnosis were a missed arterial phase in CT (n = 16/36 %), artifacts masking the aneurysm (n = 9/20 %), overlooked pseudoaneurysm (n = 19/42 %), and misinterpretation by attending radiologists (n = 1/2 %). Missed VAPA were smaller (median 8 mm) than those VAPA that were initially diagnosed (median 13 mm, p < 0.01), but occurred with a similar frequency in larger and smaller visceral arteries (p = 0.601).

Conclusions

Our study showed that 58 % of VAPA were diagnosed with delay, with the following four reasons for misdiagnosis: Lack of an arterial contrast phase in CT, no techniques for artifact reduction, and lack of awareness of the radiologists. Avoiding delayed diagnosis will most probably improve outcome of patients with VAPA.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Left Gastroepiploic Artery True Aneurysm: Case Report and Review of the Literature

Although the aneurysm of the splenic artery represents the third most common abdominal arterial aneurysm next to the aortic and iliac aneurysms, the aneurysm of the gastroepiploic artery is extremely rare occurring at a frequency of 3-4% of all visceral arteries' aneurysms; only 17 cases have been reported in the English literature. We present the case of a 65-year-old woman with an asymptomatic visceral artery aneurysm, which was an incidental ultrasonography finding. Magnetic resonance imaging showed an arterial aneurysm close to the peripheral splenic artery with intense tortuosity of the celiac and splenic artery. Abdominal computed tomography angiography confirmed the existence of an arterial aneurysm with a diameter of 2.3 cm near the splenic hilus without identifying the involved vessel. Endoluminal treatment was considered cumbersome due to anticipated anatomic obstacles; the patient underwent an elective open surgery in which the tortuosity of the celiac and splenic arteries and the aneurysm of the left gastroepiploic artery were revealed. The aneurysm was resected after proximal and distal ligation of the gastroepiploic artery; the flow of the splenic artery was intact. Histologically, it was a true aneurysm. The patient left the hospital on the fourth postoperative day without any complication. Historically, most aneurysms of the gastroepiploic arteries have been observed in men in the sixth decade of their life and after rupture; in modern times, their early incidental apocalypse is frequent due to the widespread use of imaging studies. Diagnostic approach and preoperative planning is of paramount importance to avoid complications. Current therapeutic modalities include catheter-based techniques or laparoscopic surgery.

Percutaneous Embolization of a Saccular Omental Artery Aneurysm

Omental artery aneurysms are a unique subset of splanchnic artery aneurysms that are associated with intraperitoneal hemorrhage and high mortality rates. Detecting omental artery aneurysms prior to rupture is especially challenging; as such there are limited data surrounding unruptured aneurysms. Various methods of treating ruptured omental artery aneurysms have been previously described including omentectomy and transcatheter arterial embolization. Because of the mortality rate associated with ruptures, elective intervention in unruptured splanchnic artery aneurysms is recommended regardless of their size. This report details the successful embolization of an unruptured omental artery aneurysm utilizing a percutaneous approach.

Covered stenting and transcatheter embolization of splenic artery aneurysms in diabetic patients: A review of endovascular treatment of visceral artery aneurysms in the current era

Diabetes mellitus is associated with both microvascular and macrovascular complications, which can result in visceral aneurysms as for example splenic artery aneurysms: in their management, an endovascular treatment, less invasive than surgery, is generally preferred. Endovascular treatment of splenic artery aneurysms can be based either on covered stenting (CS) or transcatheter embolization (TE). CS generally allows aneurysm exclusion with vessel preservation, while TE usually determines target artery occlusion with potential risk of distal ischemia. We performed a review of the existing literature on endovascular treatment of visceral artery aneurysms (VAAs) and psudoaneurysms (VAPAs) in the current era.

Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: case report and literature review

Pseudoaneurysm of the splenic artery is a rare entity, with little more than 150 cases described in the literature. Pancreatitis is the most common etiology, followed by trauma. In contrast with true aneurysms, pseudoaneurysms are frequently symptomatic, with a 47% risk of rupture and 90% mortality if left untreated. We describe the case of a 48-year-old female patient who suffered a gastrointestinal hemorrhage associated with acute-on-chronic pancreatitis. During workup, endoscopy revealed signs of recent bleeding and magnetic resonance angiography of the abdomen showed a large pseudoaneurysm of the splenic artery. The patient underwent endovascular treatment with microcoil embolization and no further bleeding episodes occurred. Endovascular treatment is now an effective option with low morbidity and mortality and success rates in the range of 79-100%, making it a viable technique for patients with active abdominal inflammation. We conducted a review of endovascular techniques and embolization agents used to treat this pathology.

Splenic Artery Aneurysm Treated With Endovascular Stent Grafting: A Case Report and Review of Literature

INTRODUCTION:

Although endovascular therapy is becoming an alternative to open surgical repair of splenic artery aneurysms (SAAs), reports on the use of stent grafts for SAA repair are limited. We present our experience of endovascular therapy using a stent graft for the treatment of an SAA that had ruptured into the gastric lumen. We also reviewed 18 cases of stent graft repair for SAAs, including the present case.

CASE REPORT:

A 43-year-old man was admitted due to hematemesis. Endoscopic examination and contrast-enhanced computed tomography (CT) revealed a dissecting SAA that had ruptured into the stomach. Two 10 × 100 mm Viabahn (W.L. Gore, Flagstaff, Arizona) stent grafts were used to exclude the aneurysm. No complications occurred during the procedure. Although postoperative CT showed complete exclusion of the aneurysm, endoscopic examination showed a discharge of purulent matter from the aneurysm. Therefore, surgical debridement and omental implantation were added to avoid stent graft infection. Follow-up CT obtained 1 year later showed the residual aneurysm almost disappeared without any evidence of infection.

LITERATURE REVIEW:

A literature search in the PubMed database returned 17 cases with sufficient data. Review of these cases, together with the present case, revealed a 100% technical success rate, 11% splenic infarction rate, 94% graft patency rate, and 0% reintervention rate.

CONCLUSION:

Endovascular repair of SAAs using stent grafts appears to be safe and effective. In terms of preserving the blood flow and avoiding splenic infarction, it may be superior to coil embolization. Even in a case with aneurysm infection, stent graft repair may be an acceptable method to minimize invasion of concomitant surgical intervention.

Duplex Ultrasound-guided Direct Percutaneous Management of Pseudoaneurysm of Branch of Segmental Renal Artery: Technique and Its Outcome

OBJECTIVE

To describe the role of duplex ultrasound imaging (DUI) in prompt diagnosis of pseudoaneurysm (PSA) of a branch of the segmental renal artery (b-SRA) and to evaluate outcomes of DUI directed percutaneous embolization.

MATERIALS AND METHODS

Forty-five patients were referred to us for the management of intractable renal hematuria. A total of 20 cases (44.44%) had developed PSA after nephrolithotomy, 12 cases (12.66%) had developed PSA after guided renal biopsies, 6 cases (13.33%) had developed PSA following road side trauma, and 2 cases (4.44%) of the tuberous sclerosis complex had developed PSA. Three cases (6.66%) of arteriovenous and 2 cases (4.44%) of arteriocalyceal fistulae had been excluded from the study. DUI-guided direct percutaneous management (DPM) was done as a 4-step process. First is the identification of PSA sac in the neck and offending b-SRA. Second is the puncture of PSA sac with 18 g puncture needle under DUI. Subsequently, manual injection of temporary embolic agent was done followed by N-butyl cyanoacrylate glue. Thrombosis of the PSA sac was confirmed by absent flow on DUI.

RESULTS

Forty cases of b-SRA were managed successfully in a single session and followed up by clinical findings, DUI, and computed tomography angiography. There was no need for the second session of DPM, transarterial embolization, or surgery in this cohort. Twelve cases (30%) had developed a mild fever and were managed conservatively. All 40 cases had no evidence of renal hematuria after follow-up of 3 months.

CONCLUSION

DUI-guided DPM is a safe, feasible, cost-effective, and nephron-sparing promising alternative to TAE or surgery for management of PSA of b-SRA.

Endovascular Repair of 40 Visceral Artery Aneurysms and Pseudoaneurysms with the Viabahn Stent-Graft: Technical Aspects, Clinical Outcome and Mid-Term Patency

PURPOSE

Endovascular repair of true visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) with stent-grafting (SG) can simultaneously allow aneurysm exclusion and vessel preservation, minimizing the risk of ischemic complications. Our aim was to report a single-center experience on SG of visceral aneurysms, focusing on technical aspects, clinical outcome and mid-term patency.

MATERIALS AND METHODS

Consecutive patients affected by VAAs-VAPAs and submitted to endovascular treatment were retrospectively reviewed, and SG cases with the self-expandable peripheral Viabahn stent-graft were analyzed (2003-2017). Aneurysm type, patient number, SG clinical setting, procedural data, peri-procedural complications, technical success, 30-day clinical success, 30-day mortality and follow-up period (aneurysm exclusion, stent-graft patency, ischemic complications) were analyzed.

RESULTS

SG was performed in 40 patients (24 VAPAs/16 VAAs) and in 44 procedures (25 in emergency, 19 in elective treatments), via transfemoral in 37 cases (transaxillary in 7 cases). One peri-procedural complication was recorded (a splenic artery dissection successfully converted to transcatheter embolization). The overall technical and clinical success rates were, respectively, 96 and 84%, with excellent trend in elective treatments (both 100%). Overall 30-day mortality was 12.5% (septic shock after pancreatic surgery). Stent-graft thrombosis occurred in 2 patients within 3 months, with aneurysm exclusion and without ischemic complications. Stent-graft patency and aneurysm exclusion were confirmed at 6, 12 and 36 months in 18, 12 and 7 patients, respectively.

CONCLUSION

SG of VAAs and VAPAs was safe and effective, particularly in elective treatments. The Viabahn stent-graft, flexible and without shape memory, is suitable for endovascular repair of tortuous visceral arteries.

Comparison of CTA and DSA in the diagnosis of superior mesenteric artery dissecting aneurysm

Objective

To compare computed tomography arteriography (CTA) and digital subtraction arteriography (DSA) in the diagnosis of superior mesenteric artery dissecting aneurysm (SMADA).

Methods

All SMADA patients who underwent CTA and DSA at one of two medical centers between May, 2007 and April, 2017 were identified. The accuracy of CTA and DSA for the depiction of morphologic characteristics of SMADA was analyzed.

Results

Fourteen patients (12 men; mean age, 55.1 ± 6.4 years) were included in this study. The mean diameter of the dissecting aneurysm was 3.78 ± 1.53 mm on CTA and 3.81 ± 1.54 mm on DSA ( p = 0.96). The luminal stenosis was 0.52 ± 0.27 on CTA and 0.35 ± 0.23 on DSA ( p = 0.09). The thrombosed false lumen was visualized on CTA in 79% (11/14) of patients but in no patients on DSA ( p < 0.001). The entry points of the dissection were visualized on CTA in 64.3% (9/14) of patients and on DSA in 100% (14/14) of patients ( p = 0.041); CTA and DSA did not visualize re-entry points in any patients. The intimal flap was visualized on CTA in 71.4% (10/14) of patients and on DSA in 78.6% (11/14) of patients ( p > 0.05). Branch vessel involvement was visualized in 7.1% (1/14) of patients on CTA but in no patients on DSA ( p > 0.05).

Conclusions

CTA can be used in place of DSA for the diagnosis of SMADA. Although CTA may exaggerate the degree of luminal stenosis and is weak in depicting the entry points of SMADA, this modality more accurately depicts the thrombosed false lumen and branch vessel involvement.

Pancreatitis: Preventing catastrophic haemorrhage

Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.

Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms in 100 Patients: Covered Stenting vs Transcatheter Embolization

Purpose: To retrospectively report a large single-center experience of visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) treated with covered stenting (CS) as the first therapeutic option vs transcatheter embolization (TE). Methods: One hundred patients (mean age 59±14 years; 58 men) underwent 59 elective and 41 emergent endovascular procedures to treat 51 VAAs and 49 VAPAs. Seventy patients had TE and 30 received CS (27 Viabahn and 3 coronary stent grafts). Both TE and CS were performed in 10 cases. Results: Technical success was 96% (97% CS, 96% TE), and 30-day clinical success was 83% (87% CS, 81.4% TE). Four major complications occurred; 30-day mortality was 7%, mainly due to septic shock following pancreatic surgery. The midterm follow-up was 20.8 months in the total population and 32.8 months in the CS group. More than 6 months after CS all aneurysms remained excluded; stent patency was achieved in 88%. Twelve CS patients with >3 years’ follow-up had maintained stent patency. Conclusion: In endovascular treatment of visceral aneurysms, covered stenting was feasible in 30%. CS showed a slightly better efficacy than TE and good midterm patency. The Viabahn covered stent seems to be suitable for endovascular repair of tortuous visceral arteries affected by true or false aneurysms.

Endovascular treatment of visceral artery aneurysms and pseudoaneurysms with stent-graft: Analysis of immediate and long-term results

INTRODUCTION

The aim of this study is to analyze the safety and efficacy of stent-graft endovascular treatment for visceral artery aneurysms and pseudoaneurysms.

METHODS

Multicentric retrospective series of patients with visceral aneurysms and pseudoaneurysms treated by means of stent graft. The following variables were analyzed: Age, sex, type of lesion (aneurysms/pseudoaneurysms), localization, rate of success, intraprocedural and long term complication rate (SIR classification). Follow-up was performed under clinical and radiological assessment.

RESULTS

Twenty-five patients (16 men), with a mean age of 59 (range 27-79), were treated. The indication was aneurysm in 19 patients and pseudoaneurysms in 6. The localizations were: splenic artery (12), hepatic artery (5), renal artery (4), celiac trunk (3) and gastroduodenal artery (1). Successful treatment rate was 96% (24/25 patients). Intraprocedural complication rate was 12% (4% major; 8% minor). Complete occlusion was demonstrated during follow up (mean 33 months, range 6-72) in the 24 patients with technical success. Two stent migrations (2/24; 8%) and 4stent thrombosis (4/24; 16%) were detected. Mortality rate was 0%.

CONCLUSION

In our study, stent-graft endovascular treatment of visceral aneurysmns and pseudoaneurysms has demonstrated to be safe and is effective in the long-term in both elective and emergent cases, with a high rate of successful treatment and a low complication rate.

Catheter-directed endovascular application of thrombin: Report of 3 cases and review of the literature

PURPOSE

To report 3 new cases of catheter-directed endovascular application of thrombin and explore trends by analysis of published case series.

MATERIALS AND METHODS

Institutional Review Board approved this retrospective study. All cases of non-tumoral arterial embolization performed from January 2003 to January 2015 at our institution were retrospectively reviewed. Thrombin was used in 7 of 589 cases. In 3 cases intra arterial thrombin was injected via catheter to treat active hemorrhage. Four cases were excluded due to percutaneous injection into visceral pseudoaneurysms (n=3) and making ex vivo autologous clot to be injected via catheter (n=1). Fisher's exact and the Wilcoxon rank sum tests were used to assess for association with acute nontarget thrombosis.

RESULTS

Catheter-directed thrombin was used in 3/589 (0.5%) cases at our institution. All three cases were technically successful with no further bleeding (100%). Nontarget thrombosis of proximal branches occurred in 2 patients (67%) with no significant clinical consequences. Including our 3 cases, a total of 28 cases were reviewed. Of the variables examined-location (p=0.99), size (p=0.66) and etiology of vascular lesion (p=0.92), pseudoaneurysm neck anatomy (p=0.14), thrombin units (p=0.47), volume (p=0.76) or technique of use of small doses (p=0.99), use of other embolic material (p=0.67) and use of adjunct techniques (p=0.99)-none were found to be significantly associated with acute nontarget thrombosis. Technical success was 96% with no reports of reperfusion after treatment.

CONCLUSIONS

Catheter-directed endovascular thrombin can be an additional tool to treat pseudoaneurysms not amenable to conventional embolization. Further studies are required to optimize technique and outcomes.

Visceral aneurysms: Old paradigms, new insights?

True visceral artery aneurysms (VAAs) are a rare entity with an incidence of 0.01-2%. The risk of rupture varies amongst the different types of VAAs and is higher for pseudo aneurysms compared with true aneurysms. Size, growth, symptoms, underlying disease, pregnancy and liver transplantation have all been associated with increased risk of rupture. Mortality rates after rupture are around 25%. The splenic artery is most commonly affected and the etiology is predominantly atherosclerosis. Open repair can be done by simple ligation or reconstruction of the artery, while endovascular options include embolization or using a stent graft. Location, collateral circulation and medical condition of the patient should all be taken into account when an intervention is planned. We compared types of treatment and searched for risk factors for rupture but unfortunately, the level of evidence found in the literature is low. Therefore, deciding when and how to treat a patient with a VAA based on the current literature, remains challenging for clinicians.

Rebleeding of a Splenic Artery Aneurysm after Coil Embolisation

Background. Splenic artery aneurysm (SAA) is an uncommon and difficult diagnosis. SAA is more common in females. Only 20% of SAA is symptomatic and may present as a rupture. A ruptured SAA is associated with a 25% mortality rate. Case Presentation. We present a case of a male patient with a bleeding SAA that rapidly increased in size. Distal coiling was technically impossible and despite proximal coil embolisation the SAA continued to bleed. A laparotomy including splenectomy and partial pancreatectomy was performed with an uneventful patient recovery. Discussion. Endovascular management is currently considered the optimal treatment of SAA. However, careful monitoring and follow-up is needed after embolisation as rapid recanalization of the SAA may possibly occur, especially when distal coiling of the aneurysm is unsuccessful. Conclusion. Endovascular treatment of an SAA is not necessarily effective. Surgeons must be prepared to perform open procedures to further reduce mortality rates.

Late Migration of a Covered Stent into the Stomach after Repair of a Splenic Artery Pseudoaneurysm

We would like to report our experience of a rather rare complication that occurred in a 76-year old patient tree years after endovascular repair of a splenic artery pseudoaneurysm with a covered stent. Three years after stent insertion, the patient complained of mild abdominal pain and melena; it was revealed endoscopically that the covered stent has eroded the stomach wall and migrated into the stomach. The splenic artery is the most common location among the spectrum of potential presentation sites of visceral arteries aneurysms and pseudoaneurysms. Endovascular treatment with the use of coils or stents is the first option due to lower morbidity and mortality than open surgery. Endovascular repair may also lead to complications and patients need to be followed up in order to confirm aneurysm sealing, and exclude late complication. Minor stent graft migration may occur in the long term, however extra vascular migration is extremely rare.

Embolization of a Jejunal Artery Pseudoaneurysm via Collateral Vessels

Visceral artery pseudoaneurysms are rare and only few cases have been reported. They are considered to be life threatening in case of rupture. Rapid treatment is mandatory and endovascular procedure is recommended as the treatment of choice. Occasionally, endovascular approach is difficult to achieve, owing to unusual vascular anatomy. Whenever it is the case, an alternative method has to be considered. We report the case of a jejunal artery pseudoaneurysm that required an access via collateral vessels to accomplish complete occlusion in a 34-year-old woman who presented with a sudden epigastric pain 14 days after a cephalic duodenopancreatectomy.

An insidious case of hepatic artery pseudoaneurysm secondary to acalculus cholecystitis

A 68-year-old man with expressive dysphasia presented with upper gastrointestinal haemorrhage, jaundice and abdominal pain. He was unable to tolerate ultrasound tranducer pressure. His oesophagogastroduodenoscopy (OGD) showed large blood clots in the stomach with blood trickling from the ampulla. An urgent CT angiogram demonstrated a 32 mm pseudoaneurysm within the gallbladder fossa. The patient subsequently underwent an endovascular embolisation of the pseudoaneurysm performed by the interventional radiology team.