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

Renal bleeding: imaging and interventions in patients with tumors

In patients with cancer, spontaneous renal bleeding can stem from a range of underlying factors, necessitating precise diagnostic tools for effective patient management. Benign and malignant renal tumors are among the primary culprits, with angiomyolipomas and renal cell carcinomas being the most common among them. Vascular anomalies, infections, ureteral obstructions, and coagulation disorders can also contribute to renal-related bleeding. Cross-sectional imaging techniques, particularly ultrasound and computed tomography (CT), play pivotal roles in the initial detection of renal bleeding. Magnetic resonance imaging and CT are preferred for follow-up evaluations and aid in detecting underlying enhancing masses. IV contrast-enhanced ultrasound can provide additional information for active bleeding detection and differentiation. This review article explores specific disorders associated with or resembling spontaneous acute renal bleeding in patients with renal tumors; it focuses on the significance of advanced imaging techniques in accurately identifying and characterizing renal bleeding in these individuals. It also provides insights into the clinical presentations, imaging findings, and treatment options for various causes of renal bleeding, aiming to enhance the understanding, diagnosis, and management of the issue.

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.

Embolization of multiple splenic artery aneurysms in a patient with hypersplenism due to portal hypertension: a case report

Aneurysms of the splenic artery are the third most common type of intra-abdominal aneurysms and the most common type of visceral aneurysms. Portal hypertension is a significant risk factor for development of these aneurysms. We report the case of a white, female, 52-year-old patient with multiple splenic artery aneurysms and hypersplenism secondary to portal hypertension and cirrhosis. Abdominal angiotomography identified six splenic aneurysms. In this scenario, an endovascular intervention was scheduled to conduct embolization using controlled release coils and Onyx™ embolization agent. The three largest aneurysms were treated. Control angiographs showed good exclusion of the aneurysms. The endovascular technique therefore proved to be a good choice considering the patient's comorbidities and blood disorders. In this case, the procedure was successful. There were no immediate or long-term complications. The patient recovered well and is in clinical follow-up.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms

BACKGROUND

Endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms is an effective, minimally invasive treatment that has been successfully used since the early 1990s, with refined and expanded techniques and tools currently offering excellent outcomes. Due to increased detection of such lesions in recent years, many of which are asymptomatic, revision of the indications for intervention and the correct endovascular treatment approaches has become essential.

PURPOSE

This document will presume that the indication for treatment is clear and approved by the multidisciplinary team and will define the standards required for the performance of each intervention, as well as their relative advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of the endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in endovascular treatments. The writing group reviewed the existing literature on visceral and renal artery aneurysms and pseudoaneurysms, performing an evidence search using PubMed to identify publications in English and relating to human subjects from 1990 to 2022. The final recommendations were formulated through consensus.

RESULTS

Endovascular treatment has an established role in the successful management of visceral and renal artery aneurysms and pseudoaneurysms, and this Standards of Practice document provides up-to-date recommendations for its safe performance.

Endovascular treatment of chronic mesenteric ischaemia secondary to a superior mesenteric artery pseudoaneurysm: a modified neurointerventional technique

A man in his late 60s presented with intermittent abdominal pain, nausea, vomiting and approximately 40 pounds of weight loss over the course of a year, most concerning for chronic mesenteric ischaemia. Given a prior negative workup, a CT angiogram was performed and revealed a wide neck mid-superior mesenteric artery pseudoaneurysm (PSA). As PSAs are susceptible to thrombus formation and distal emboli, this incidental finding was considered a possible explanation for his intermittent symptoms and thus required treatment. Anatomical constraints precluded traditional coiling or covered stent placement, so the interventional radiology team used a neurointerventional technique and performed a successful balloon-assisted coil embolisation of the PSA with subsequent resolution of the patient's symptoms. More than 3 years postprocedure, the patient remains asymptomatic with no complications.

Wunderlich Syndrome: Comprehensive Review of Diagnosis and Management

Wunderlich syndrome (WS), which was named after Carl Wunderlich, is a rare clinical syndrome characterized by an acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces, without a history of antecedent trauma. Patients may present with a multitude of symptoms ranging from nonspecific flank or abdominal pain to serious manifestations such as hypovolemic shock. The classic symptom complex of flank pain, a flank mass, and hypovolemic shock referred to as the Lenk triad is seen in a small subset of patients. Renal neoplasms such as angiomyolipomas and clear cell renal cell carcinomas that display an increased proclivity for hemorrhage and rupture contribute to approximately 60%-65% of all cases of WS. A plethora of renal vascular diseases (aneurysms or pseudoaneurysms, arteriovenous malformations or fistulae, renal vein thrombosis, and vasculitis syndromes) account for 20%-30% of cases of WS. Rare causes of WS include renal infections, cystic diseases, calculi, kidney failure, and coagulation disorders. Cross-sectional imaging modalities, particularly multiphasic CT or MRI, are integral to the detection, localization, and characterization of the underlying causes and facilitate optimal management. However, large-volume hemorrhage at patient presentation may obscure underlying causes, particularly neoplasms. If the initial CT or MRI examination shows no contributary causes, a dedicated CT or MRI follow-up study may be warranted to establish the cause of WS. Renal arterial embolization is a useful, minimally invasive, therapeutic option in patients who present with acute or life-threatening hemorrhage and can help avoid emergency radical surgery. Accurate diagnosis of the underlying cause of WS is critical for optimal patient treatment in emergency and nonemergency clinical settings. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography

Splenic artery aneurysm (SAAs) rupture is associated with a high mortality rate. Regular surveillance with imaging before and after intervention is crucial to guide best evidence treatment. The following study aimed to determine the efficacy of color Doppler ultrasound imaging (DUS) compared to digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) as a follow-up modality after selective coil embolization of true SAAs. We analyzed data from 20 patients, 15 females (48.1 ± 16.1 years) undergoing selective SAA coil embolization using detachable fibered embolization coils. Imaging using DUS, MRA, and DSA was performed 3 months after the initial embolization or the consequent re-embolization procedure. Primary clinical success, defined as Class I aneurysm occlusion, on 3-month follow-up was seen in 16 (80.0%) patients. DUS had a sensitivity of 94.4% and a specificity of 42.9% when compared to DSA and 92.3% and 30%, respectively, when compared to MRA in identifying Class I aneurysm occlusion. The positive predictive value (PPV) of DUS in identifying the need for re-embolization was 75.0%, while the NPV of DUS in these terms was 90.5%. DUS showed a high sensitivity in detecting aneurysm occlusion and clinical success, simultaneously exhibiting poor specificity. Still, with caution, this follow-up modality could be used for monitoring select low-risk patients after selective embolization of SAAs. DUS could provide a higher cost-to-benefit ratio, enabling more systematic post-procedural follow-up, as it is far more commonly used compared to MRA and non-invasive compared to DSA.

Eighteen cases of renal aneurysms: Clinical retrospective analysis and experience of endovascular interventional treatment

Background

Development of endovascular interventional techniques gradually replaced traditional open surgery and has become the preferred treatment for renal aneurysms. This study aimed to analyze the clinical characteristics of renal artery aneurysm (RAA) and the safety and efficacy of intravascular interventional treatment.

Materials and Methods

We retrospectively analyzed the clinical characteristics and imaging data of 23 aneurysms in 18 patients with RAA. The technical success rate, complication rate, mortality rate, reintervention rate, and use of embolization materials were evaluated.

Results

In 18 patients with RAA (age, 32-72 years, average age, 52.2 ± 11.2 years), a total of 23 aneurysms were found (diameter 0.5-5.5 cm, average diameter 2.2 ± 1.4 cm). Among them, 11 cases (61.1%) were discovered accidentally, and the remaining patients were diagnosed due to the following major complaints: four cases (22.2%) presented low back pain, two (11.1%) were due to high blood pressure, and one (5.5%) had low back pain with gross hematuria. A total of 14 aneurysms in 13 patients received endovascular interventional therapy. The technical success rate of 13 patients with renal aneurysms was 100%. Three of the 18 patients were lost to follow-up, and the remaining were followed up for 4-89 months. There was no recurrence of the aneurysm or displacement of the stent or coil.

Conclusion

Endovascular treatment for RAA has a high success rate, low complication rate, and low reintervention rate. It has the advantage of less trauma and is flexible and more targeted for different types of renal aneurysms.

Renal Artery Aneurysm Mimicking Nephrolithiasis: A Case Report and Review of Literature

While originally described in the 18th century, the incidental detection of renal artery aneurysms (RAAs) has increased significantly with the advent and increased usage of modern cross-sectional imaging. Although the incidence remains low, RAAs are clinically important, especially if measuring greater than 2 cm in diameter. Therefore, ultrasonographers and radiologists alike should be aware of its features on multiple imaging modalities as well as imaging pitfalls. Renal duplex sonography is widely used for the evaluation of renal arteries stenosis, fibromuscular dysplasia, renal veins patency, and for the status of renal transplants. RAA is another, albeit rare, indication for renal arteries duplex examination. Furthermore, RAAs may be an incidental finding on abdominal or renal ultrasound. Therefore, familiarity with the sonographic presentation of a RAA is important. Diagnosing RAAs with duplex ultrasound may become exceptionally difficult when the aneurysm has peripheral calcification, even more so when the aneurysm is situated by the renal hilum. Those calcified arterial walls may produce strong acoustic shadowing, mimicking a renal calculus.

Imaging of renal emergencies: Review of infectious, hemorrhagic, vascular, and traumatic etiologies

Diagnostic imaging allows for accurate and early recognition of acute renal pathologies, thus allowing for appropriate clinical triage, life-saving treatments, and preservation of renal function. In this review, we discuss the clinical presentation and imaging findings of renal emergencies with infectious, hemorrhagic, vascular, and traumatic etiologies.

Endovascular interventions in main renal artery pathologies: an overview and update

Renal arteries are involved in a wide spectrum of pathologies including atherosclerosis, fibromuscular dysplasia, Takayasu arteritis, aneurysms, and aortic type B dissections extending into main renal arteries. They manifest as renovascular hypertension, renal ischemia, and cardiovascular dysfunction. The location of the renal arteries in relation to the abdominal aortic aneurysm is a critical determinant of interventional options and long-term prognosis. This article provides a comprehensive review of the role of interventional radiologists in transcatheter interventions in various pathologies involving the main renal arteries with analysis of epidemiology, pathophysiology, newer interventional techniques, and management options.

Two Cases of Duodenal Ulcers That Developed after Transcatheter Procedures for Unruptured Visceral Artery Aneurysms

Herein, we report two cases of duodenal ulcers that developed after transcatheter procedures for the treatment of unruptured artery aneurysms. Both patients recovered after the administration of nothing by mouth, intravenous fluids, and proton-pump inhibitors. Notably, the duodenal ulcer was unchanged in one patient six days after endovascular treatment and improved in the other patient 13 days after angiography. These cases suggest that conservative treatment is acceptable in patients with duodenal ischemia that develops as an adverse effect of endovascular procedures. The usefulness of esophagogastroduodenoscopy in such patients has also been highlighted.

Endovascular repair of visceral artery aneurysms and pseudoaneurysms in 159 patients: twelve years' experience of clinical technique

OBJECTIVES

The purpose of this study was to evaluate the therapeutic efficacy and safety of endovascular treatment for patients with visceral and renal artery aneurysms (VRAAs). Twelve years of experience with interventional procedures and treatment options in our center were also worth discussing.

METHODS

From January 2009 to December 2020, clinical data of 159 consecutive patients with VRAAs were retrospectively analyzed. Patients' demographic and clinical data were recorded, and the safety and efficacy of endovascular therapy were evaluated. In addition, interventional procedures were also described.

RESULTS

A total of 159 patients underwent angiography, and 154 patients were successfully treated with endovascular therapy, with a technical success rate of 96.9%. Of the 154 patients with successful endovascular therapy, 3 patients died within 30 days of treatment, with a 30-day mortality rate of 1.9%, and the remaining patients were clinically successful, with a clinical success rate of 98.1%. Fifty-seven patients underwent emergency interventional treatment due to ruptured aneurysm. There were statistically significant differences in hemoglobin before and after emergency treatment (78.5 ± 22.0 g/dL vs. 93.8 ± 15.0 g/dL, P = 0.00). No other serious complications occurred except death in 3 patients.

CONCLUSION

Endovascular treatment of VRRAs is safe and effective and can significantly improve the symptoms of patients, especially those with ruptured aneurysms.

Visceral artery aneurysmal lesion of the omentum - a rare cause of spontaneous fatal intra-abdominal hemorrhage

We report unexpected death of a 72-year-old man due to a hemoperitoneum (1.9 L of blood in the abdominal cavity). Postmortem examination revealed that the cause of the hemorrhage was an arterial aneurysmal lesion in the greater omentum. The lesion measured 4 × 4 × 6 cm with a generally smooth wall, but with a focal area of rupture within a hemorrhagic region measuring 1 × 2 cm. There was a substantial feeding artery. Histological examination revealed features in keeping with a pseudoaneurysm, but also with some features of a true aneurysm. There was no history of trauma and the rupture of the aneurysmal lesion that had caused the hematoperitoneum was considered to be spontaneous. Prior to his death the deceased had attended hospital for epigastric pain, which was attributed to dyspepsia, but otherwise he had not had symptoms prior to his death.

Endovascular Oriented Classification and Treatment of Celiac Trunk Aneurysms: 10 Years Experience

OBJECTIVE

To propose an endovascular-oriented classification of celiac trunk aneurysms (CTa) and discuss single center results of this rare pathology.

METHODS

Data of all patients admitted to our institution for CTa from 2011 to 2021 were prospectively collected. Of them, those who underwent endovascular treatment were retrospectively analyzed. All preoperative CT scans were reviewed and CTa were classified in 4 different configurations based on progressive distal landing zone. We excluded from the classification all cases with median arcuate ligament syndrome (MALS), patients with coexistent aortic dilation or no endovascular proximal neck. Preoperative demographics, intraoperative data and post-operative complications were recorded. All-cause late mortality and complications were identified through a review of office charts and telephone assessment.

RESULTS

During the study period 19 patients were referred to our Institution for CTa. Ten patients underwent endovascular treatment (ET). In 6 cases a watchful waiting strategy was adopted, 2 (10.5 %) patients refused ET and one patient without suitable proximal landing zone (< 10 mm) was not proposed to open surgical repair for surgical contraindication but is followed by strict instrumental and clinical evaluation. Six (60%) patients presented type 2 CTa; all of them underwent ET requiring positioning of covered stent-graft and SA embolization. Three (30%) patients presented type 3 CTa; all of them underwent ET with covered stent-graft deployment over the GDA with preliminary embolization. One (10%) patient presented type 4 CTa that was treated by means of covered stent-graft deployment along the right hepatic artery with left hepatic artery embolization. Overall, no major complications and perioperative mortality was observed.

CONCLUSION

Celiac trunk aneurysms are rare, and no classifications have still been presented. Stent-graft exclusion provides excellent short-term outcome with no significant morbidity and mortality rate when technically feasible.

Evolving Diagnostic and Therapeutic Options for Visceral Artery Aneurysms

BACKGROUND

Visceral artery aneurysms (VAAs) are associated with a very high mortality rate when ruptured and may present as a surgical emergency. Due to their rarity and varying pathophysiology, literature concerning the optimal management of VAAs is limited. This review evaluates the evolving management options for VAAs with a focus on open and endovascular repair.

METHODS

A combination of databases including OVID, PubMed and Medline were used to perform a literature search. Search terms employed include 'visceral artery aneurysms', 'angiography', '3D-volumetric rendering', 'management', 'open repair' and 'endovascular repair', amongst others.

RESULTS

3D modelling in conjunction with existing diagnostic techniques, such as computed tomography and angiography, may improve diagnostic sensitivity. The literature surrounding operative management of VAAs highlights the effectiveness of endovascular repair for anatomically suitable aneurysms. Advances in endovascular technologies may expand the type and number of aneurysms amenable to catheter-based treatment approaches. For aneurysms not amenable to endovascular treatment, or those with an emergency indication, open repair remains an appropriate management choice.

CONCLUSION

Although rare, VAAs pose a high mortality risk, especially when ruptured. Practical limitations that restrict current operative approaches may be overcome by recent developments including novel neurointerventional techniques that have been applied in VAA management.

Morbidity and mortality associated with open repair of visceral aneurysms

BACKGROUND

The Society for Vascular Surgery (SVS) recently published clinical practice guidelines on the management of visceral aneurysms. However, studies investigating the perioperative outcomes of open repair of visceral aneurysms have been limited to single-center experiences with variable results that span multiple decades. In the present study, we sought to detail the morbidity and mortality associated with open repair of visceral aneurysms using a national database in the contemporary era.

METHODS

National Surgical Quality Improvement Program data from 2013 to 2019 were queried for patients who had undergone open repair of visceral aneurysms, which had been classified as mesenteric, renal, or splenic using Current Procedural Terminology and International Classification of Diseases codes. The primary endpoint was the composite of major complications (cardiovascular, pulmonary, progressive renal failure, deep wound infection, return to operating room, sepsis) and 30-day mortality. Logistic regression was used to identify the predictors of the primary endpoint for nonruptured aneurysm cases.

RESULTS

Of the 304 aneurysms, 263 were nonruptured (137 mesenteric, 66 renal, 60 splenic) and 41 were ruptured (24 mesenteric, 1 renal, 16 splenic) and had undergone open repair. For those with nonruptured aneurysms, their mean age was 59.4 ± 14.7 years and 48.3% were women. For those with nonruptured aneurysms, the 30-day mortality was 1.9% and the major complication rate was 12.9%. A return to the operating room (5.3%) and prolonged ventilator support (3.8%) were especially common. As expected, rupture was associated with significantly greater mortality (22.0%; P < .001) and major complications (34.1%; P = .001). The use of postoperative transfusion was common in the elective group but was significantly greater in the ruptured group (24.3% vs 80.5%; P < .001). The predictors of the primary outcome for nonruptured aneurysms included male sex (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.28-6.7; P = .011), anticoagulation (not discontinued before surgery) or bleeding disorder (OR, 4.52; 95% CI, 1.37-14.7; P = .012), and albumin <3.0 g/dL (OR, 4.66; 95% CI, 1.17-18.6; P = .029). Neither age nor aneurysm location were significant risk factors.

CONCLUSIONS

Open repair of visceral aneurysms was associated with acceptable morbidity and mortality, although these risks are significantly greater once ruptured. Male sex, bleeding risk, and low albumin were all risk factors for adverse events and should be considered for operative planning and postoperative care.

Endovascular treatment of wide-necked aneurysms of the visceral and renal arteries using the double microcatheter technique via a single access route

PURPOSE

We aimed to evaluate the utility of and complications associated with the double microcatheter technique for the treatment of wide-necked visceral and renal artery aneurysms (VRAAs).

METHODS

Nine patients (mean age, 58 years; age range, 42-69 years; 4 men, 5 women) with wide-necked VRAAs who underwent treatment with the double microcatheter technique from January 2016 to July 2018 were included in the study. For all patients, anatomical features were confirmed using cone-beam computed tomography (CT) with rotational angiography. The aneurysmal location, size, volume, neck-to-dome ratio, number of coils used, and coil packing density were investigated. Technical success, complications (coil migration and organ ischemia), changes in the complete blood count or serum creatine level, and recurrence were also evaluated.

RESULTS

Three renal artery aneurysms and 6 splenic artery aneurysms were treated by the double microcatheter technique. The mean size of the aneurysms was 26.09±4.76 mm, mean volume was 6.19±3.69 cm3, and mean neck-to-dome ratio was 1.53±0.24. The number of coils used ranged from 7 to 16. The mean packing density was 11.32%±3.72%. Technical success was achieved in all 9 patients. Renal ischemia occurred in two patients with renal artery aneurysm, one of whom showed minimal scar formation on follow-up CT after infarction. No coil migrations or disease recurrences were observed.

CONCLUSION

The double microcatheter technique for the treatment of wide-necked VRAAs appears to be relatively safe and useful. However, complex renal artery aneurysm should be carefully managed in order to prevent infarction.

The Minimally Invasive Treatment of Visceral Artery Pseudoaneurysms: A Retrospective Observational Single Centre Cohort Study on Glue Embolization

OBJECTIVE

The objective is to report a single centre experience in the embolization of visceral artery pseudoaneurysms with N-butyl-cyanoacrylate-methacryloxy sulfolane (NBCA-MS).

METHODS

A retrospective observational cohort study was conducted on data about all consecutive patients treated for visceral artery pseudoaneurysms in the Interventional Radiology Unit of SS Annunziata Hospital, in Taranto (Italy) between January 2016 and July 2020. Only patients treated with NBCA-MS embolization were included. Clinical and technical outcomes were evaluated during in-hospital stay and at 3-month follow-up by computed angiotomography (CTA).

RESULTS

Among 89 patients undergoing treatment for visceral artery pseudoaneurysm, a total of 58 (65.2%) patients (n = 32, 55.2% men; median age 45.8 years, range: 35-81) treated with NBCA-MS only were enrolled. Pseudoaneurysms were located in the renal artery (n = 18 cases, 31%), in the splenic artery (n = 27, 46.6%), in the intra-parenchymal hepatic artery (n = 3, 5.2%), in the common hepatic artery (n = 4, 6.9%) or in the pancreatic artery (n = 6, 10.3%). N-butyl-cyanoacrylate was diluted 1:1 with Lipiodol ultra-fluid, and mean volume injected was 0.6 ± 0.3 mL (range: 0.2-2.8 mL). Embolization was technically and clinically successful in all patients (n = 58, 100%) with an immediate total thrombosis of the pseudoaneurysm at the completion angiography. No systemic complications were noted in all cases. Five cases (8.6%) of non-target vessel embolization occurred without any clinical complication. No pseudoaneurysm recurrence was detected at the CTA control 1 day postoperatively. In one case (1.7%), a recurrence was detected 4 days after the initial treatment and successfully managed by a repeated NBCA-MS embolization. During the hospital stay, 56 patients recovered well but 2 (3.4%) died from multi-organ failure not related to the embolization. No recurrences were detected at the 3-month postoperative CTA in the remaining patients.

CONCLUSIONS

In properly selected patients affected with visceral artery pseudoaneurysms, NBCA-MS represents a definitive and safe embolization agent.

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.

An Undiagnosed Case of Chronic Pancreatitis With Multiple Visceral Arteries Pseudoaneurysm

Visceral artery aneurysms, which could be either true or pseudo, are abnormal focal dilations of vessels supplying the abdominal organs. True aneurysms, by definition, suggest dilation of the vessel in response to increased blood flow, ultimately causing a blood-filled sac to form. Pseudoaneurysm, however, is the pooling of blood in surrounding tissues secondary to trauma or rupture. A 43-year-old woman G9 P9, known hypertensive was admitted electively for investigation of melena, hematemesis, hematochezia for one week along with weight loss and epigastric pain. Laboratory studies showed mild anemia with a hemoglobin level of 9.6 g/dL, hematocrit 29.5%, mean corpuscular hemoglobin (MCH) 26.7, upon which she was transfused two pints of blood and commenced at Injectable Vitamin K, injectable transamine, and infusion omeprazole. Two days later her levels improved to HB 12.4 g/dL, hematocrit 37.5%, MCH 26.7 pg, RBC 4.64 × 10*12/L. while being on treatment, a computed tomography (CT) mesenteric angiography was also conducted that showed multiple splanchnic pseudoaneurysms involving celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing significant mass effect on the second part of duodenum. On the basis of such findings, it was advised to perform coiling and embolization of the corresponding arteries. Multiple other small aneurysms with secondary arteriovenous malformations (AVM) were also seen. The whole circuit of flow retrograde and antegrade along with the aneurysm sac was blocked with multiple coils of variable sizes. An angiogram was repeated that revealed a good outcome. Pseudoaneurysms of the visceral arteries are very rare and affect mainly the splenic artery. The rarest of which is gastroduodenal artery (1.5%), pancreaticoduodenal artery (2%), and coeliac truck (4%). Therefore, this can be an incidental finding. The diagnosis is usually made with an angiography combined with clinical presentation. Variable treatment options are available depending on the patient’s fitness and hemodynamic stability. The endovascular approach, however, is mostly used in such cases.

Mid-term Results of Coil Embolization Alone and Stent-assisted Coil Embolization for Renal Artery Aneurysms

BACKGROUND

Coil embolization (CE) alone and stent-assisted coil embolization (SCE) are two major endovascular techniques to treat renal artery aneurysms (RAAs). This study aimed at providing safety and efficacy data of CE and SCE for RAAs.

METHODS

Between August 2015 and June 2019, 40 RAA patients treated with CE or SCE were included in the retrospective study. Patients' demographics, clinical manifestations, aneurysm characteristics, treatment strategies, and follow-up results were collected and analyzed.

RESULTS

There were 26 and 14 patients in the CE and SCE group, respectively. The mean aneurysm diameter was 2.5 ± 1.5 cm and 2.2 ± 0.8 cm (CE versus SCE, P = 0.52). The neck width of the aneurysm was 0.63 ± 0.37 cm and 1.07 ± 0.42 cm (CE versus SCE, P = 0.021). Technical success was achieved in 97.5% patients. No death or aneurysm rupture occurred. During the perioperative period, 12% and 7.1% patients suffered partial renal infarction (CE versus SCE, P = 0.45). The mean duration of follow-up was 8.8 ± 9.4 months and 16.1 ± 16.3 months (CE versus SCE, P = 0.158) by imaging and 20.8 ± 11.3 and 22.7 ± 16.5 months by visit/telephone (CE versus SCE, P = 0.703). During the follow-up, 17.4% patients in the CE group and 30.8% patients in the SCE group suffered partial renal infarction, while their overall renal function remained normal. In addition, there was no aneurysm recurrence, sac enlargement, or death in both groups.

CONCLUSIONS

Both CE and SCE were safe and effective to treat RAAs. In addition, SCE may prevent coil migration in the wide neck aneurysm in selected patients.

Endovascular management of a large hepatic artery aneurysm related to type B aortic dissection

Management of visceral artery aneurysms can be challenging: there is limited evidence to determine size thresholds for intervention and it is often technically difficult to exclude the aneurysms while preserving visceral perfusion.

We present the case of a 68-year-old male with a rapidly enlarging hepatic artery aneurysm related to type B aortic dissection extending into the coeliac axis, which presented unique difficulties due to its morphology and filling via the false lumen. Endovascular treatment involved stent–graft placement from the coeliac axis into the splenic artery with the intention of excluding the coeliac supply to the common hepatic artery. Despite early stent–graft occlusion, the aneurysm was successfully excluded and adequate hepatic and splenic perfusion was maintained. The patient made a good recovery.

Application of interventional embolization in the treatment of iatrogenic pseudoaneurysms

The present study aimed to investigate the clinical effectiveness and safety of endovascular embolization for the treatment of pseudoaneurysm secondary to previous abdominal and pelvic surgery or radiological percutaneous abdominal procedure. A retrospective review was performed on all patients with abdominal and pelvic pseudoaneurysm confirmed by CT angiography or digital subtraction angiography and treated with endovascular embolization. Different techniques of embolization with coils were applied and the outcomes, including clinical effectiveness and safety, were assessed. A total of 31 patients with a total of 32 pseudoaneurysms were included in the present study. Of these pseudoaneurysms, 23 were from the main trunks and branches of the gastroduodenal artery, 5 were from the splenic artery, 2 were from the common hepatic artery, 1 was from the right hepatic artery and 1 was from the right internal iliac artery. There were no serious complications observed and there was no occurrence of re-bleeding following embolization. The embolization of the pseudoaneurysms was successful in all patients. In conclusion, endovascular embolization is a safe and effective method for the treatment of secondary iatrogenic pseudoaneurysm in the abdomen and pelvis.

[Embolization of splenic artery aneurysms: Treatment of choice. About a case and review of the literature]

Splenic artery aneurysms constitute 60% of digestive artery aneurysms. They are often discovered incidentally and by imaging. Currently, endovascular treatment is considered the first-line treatment, as it is less invasive with less morbidity and mortality than surgery. An aggressive approach in their management is certainly justified because the overall mortality of ruptured splenic aneurysms is 25%. False splenic aneurysms have a greater potential for rupture than true aneurysms because they grow faster. Endovascular treatment is generally indicated for aneurysms larger than 2cm or with an increase in size of more than 0.5cm/year. Embolization is rarely associated with an infarction of the spleen due to the good supply of short gastric vessels. Embolization is performed using different materials including coils, which can be used alone or with other embolic agents. Post-embolization syndrome can be seen with persistent pain, fever and other systemic symptoms. Endovascular treatment compared to open surgery is associated with better quality of life and appears to be the most cost-effective strategy. Endovascular treatment and especially coil embolization are starting to be the standard treatment. Surgical and laparoscopic treatment are reserved for ruptured aneurysms which are burdened with significant mortality, especially in pregnant women. We report the case of a 66-year-old female patient in whom a splenic artery aneurysm was discovered incidentally during an ultrasound for an ovarian cyst.

Surgical Treatment of Celiacomesenteric Trunk Aneurysm: Report of 2 Cases

BACKGROUND Celiac artery aneurysm is very rare, and even is more uncommon in patients with celiacomesenteric trunks. With recent developments in diagnostic imaging, the detection of asymptomatic abdominal visceral aneurysms has increased. However, some abdominal visceral aneurysms are still first discovered after a rupture. An abdominal visceral aneurysm rupture can occur suddenly and lead to shock due to intraperitoneal hemorrhage. Two cases of celiac artery aneurysms that involved common celiacomesenteric trunks are presented. CASE REPORT Case 1 was a 63-year-old man who was referred to our facility for further study after a routine abdominal ultrasound identified an aneurysm in the superior mesenteric artery. Contrast-enhanced computed tomography (CT) scan revealed a 39-mm aneurysm in the celiacomesenteric trunk and its branches. Case 2 was a 32-year-old man who was referred to our facility after an abdominal ultrasound performed during a physical examination revealed a celiac artery aneurysm. Contrast-enhanced CT revealed a 31-mm aneurysm in the celiacomesenteric trunk and its branches. In both patients, the aneurysms were proximally located, and the distinctive anatomy of the celiacomesenteric trunk made endovascular treatment difficult. Open replacement and reconstructive surgery was performed to repair the aneurysms with grafts from the great saphenous vein. Both patients had uneventful postoperative courses. CONCLUSIONS The optimal treatment for the patients described was open surgical repair because the lower risk of occlusion of the visceral branch made it safer and more reliable than an endovascular approach.

Role of imaging in visceral vascular emergencies

Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen.

Management of distal aneurysm of the superior mesenteric artery by percutaneous ultrasound-guided Onyx injection: A case report

OBJECTIVES

The aim of this article is to report an alternative approach for the management of a distal aneurysm of superior mesenteric artery using direct percutaneous ultrasound-guided Onyx injection.

METHODS

We report a rare case of symptomatic superior mesenteric artery aneurysm. A 78-year-old man presents with pain and pulsating mass in the right umbilical region of the abdomen. The patient was treated by percutaneous ultrasound-guided Onyx injection after several failing transarterial embolization attempts.

RESULTS

The procedure was successful without any complication, and the patient wasdischarged to home the day after procedure. Follow-up at 60 months confirmed the complete thrombosis of the aneurysm sac. Ultrasound-guided Onyx injection for distal superior mesenteric artery aneurysm could provide an alternative to transcatheter arterial embolization or open surgery. Anatomical assessment of collaterals and knowledge of abdomen anatomy could play important roles in preventing bowel ischemia and minimizing the risk of procedural complication.

CONCLUSION

Ultrasound-guided Onyx injection of superior mesenteric artery aneurysm is a feasible, effective, and cost-saving technique that can be used when endovascular approach is not possible or has failed.

"Renal emergencies: a comprehensive pictorial review with MR imaging"

Superior soft-tissue contrast and high sensitivity of magnetic resonance imaging (MRI) for detecting and characterizing disease may provide an expanded role in acute abdominal and pelvic imaging. Although MRI has traditionally not been exploited in acute care settings, commonly used in biliary obstruction and during pregnancy, there are several conditions in which MRI can go above and beyond other modalities in diagnosis, characterization, and providing functional and prognostic information. In this manuscript, we highlight how MRI can help in further assessment and characterization of acute renal emergencies. Currently, renal emergencies are predominantly evaluated with ultrasound (US) or computed tomography (CT) scanning. US may be limited by various patient factors and technologist experience while CT imaging with intravenous contrast administration can further compromise renal function. With the advent of rapid, robust non-contrast MRI, and magnetic resonance angiography (MRA) imaging studies with short scan times, free-breathing techniques, and lack of ionization radiation, the utility of MRI for renal evaluation might be superior to CT not only in diagnosing an emergent renal process but also by providing functional and prognostic information. This review outlines the clinical manifestations and the key imaging findings for acute renal processes including acute renal infarction, hemorrhage, and renal obstruction, among other entities, to highlight the added value of MRI in evaluating the finer nuances in acute renal emergencies.

High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know

The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ^©RSNA, 2019.

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.

Tratamento de aneurismas de artéria esplênica e renal no mesmo tempo operatório: relato de caso e revisão

Resumo Aneurismas de artérias viscerais e renais são raros (0,01 a 2%) e seu risco de ruptura varia entre os diferentes tipos e de acordo com sua anatomia e contexto do paciente (comorbidades, gravidez e histórico de transplante hepático). A mortalidade decorrente da ruptura desses aneurismas é em torno de 25%. Novas técnicas e materiais derivados da neurointervenção parecem alternativas promissoras para o tratamento desses aneurismas. Neste contexto, relatamos um caso de paciente submetida a tratamento endovascular no mesmo procedimento de aneurisma de artéria esplênica e de artéria renal com a utilização de stent Solitaire® (Medtronic, Minneapolis, EUA) e molas de liberação controlada Ruby® (Penumbra, Alameda, EUA). A paciente apresentou boa evolução com ambos aneurismas tratados de forma adequada. Em conclusão, o tratamento endovascular de aneurismas de artéria esplênica e renal no mesmo tempo operatório é exequível e demonstrou segurança e efetividade no caso relatado.

Visceral artery aneurysms: review on indications and current treatment strategies

Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.

A hybrid procedure for middle colic artery aneurysm complicated by chronic juxtarenal segmental aortic occlusion

Here we describe a hybrid procedure, that is, a combination of open isolation and coil embolization, to treat a saccular middle colic artery aneurysm deep behind the pancreas. The middle colic artery provided the collateral blood flow necessary to bypass a chronic segmental aortic occlusion. For preservation of the collateral vessels, we surgically excluded and bypassed the aneurysm and then performed endovascular embolization of the pancreaticoduodenal arteries flowing into the aneurysm, resulting in complete isolation of the aneurysm without jeopardizing blood flow. This hybrid procedure for visceral artery aneurysms can be effective when the collateral vessels need to be preserved.

Maximizing Deceased-Donor Allograft Utilization: Management of a Celiac Artery Aneurysm in a Deceased-Donor Liver

As the scarcity of transplantable organs continues to rise, compounded with an aging donor population, transplant surgeons are increasingly confronted with organ offers from less than ideal donors. The presence of a celiomesenteric aneurysm involving the vascular supply of a donor allograft may predispose to vascular complications in the transplanted liver. We present a 61-year-old brain-dead donor who was discovered to have a celiac artery aneurysm during organ recovery. After gross atherosclerotic or mycotic involvement was ruled out and after careful consideration of the vascular reconstructive options, the donor common hepatic artery was divided distal to the aneurysmal dilatation and anastomosed to the recipient bifurcation of the left and right hepatic artery in an end-to-end beveled anastomosis. The postoperative course was unre-markable, with normal blood flow through the anastomosis and no significant com-plications. The recipient is doing well 6 months after transplant. The presence of a celiomesenteric aneurysm should not discourage the use of an otherwise adequate liver graft. Careful vascular reconstruction is encouraged to increase the rate of marginal graft utilization and minimize vascular complications. Liberal postoperative imaging can enable early detection of vascular com-plication and prompt intervention. Through this case, we demons-trate the remarkable potential of less-than-ideal grafts with acceptable posttransplant outcomes.

Endovascular treatment of true renal artery aneurysms: a single center experience

PURPOSE

We aimed to report a single center's experience on endovascular treatment of true renal artery aneurysms (TRAAs), including treatment techniques and outcomes.

METHODS

This retrospective study was designed to evaluate the treatment and follow-up of TRAAs treated by a variety of endovascular interventional techniques over a period of 6 years. Six patients with nine TRAAs were identified; seven of the TRAAs were treated using different combinations of coil embolization and flow diverter stents. The clinical findings, aneurysm characteristics, endovascular methods and treatment outcomes were reported.

RESULTS

Seven TRAAs of six patients were treated, with a median aneurysm size of 20 mm. Three TRAAs were treated with primary sac occlusion (one with primary coil embolization, one with balloon and stent assisted coil and glue embolization, and one with amplatzer vascular occlusion device and coil embolization). The remaining four TRAAs of three patients were treated with flow diverter stents (Cardiatis, Silk, Pipeline, and Surpass). Immediate clinical success was achieved in patients treated with primary sac embolization (95% CI, 29.2%-100%). Among patients treated with flow diverter stents, one patient required an additional flow diverter at 6-month follow-up. The occlusion time in flow diverters ranged from 1 month to 12 months (median, 3.5 months) taking the repeat procedure into account. In patients treated with flow diverters, the clinical success rate was 100% (95% CI, 29.2%-100%) at one-year follow-up. Long-term follow-up ranged from 3 to 52 months. One intraprocedural complication was encountered with a flow diverter during deployment, which required additional stenting and tirofiban infusion. No other major complication was seen.

CONCLUSION

Endovascular treatment is an effective and safe method offering high success rates and low morbidity in the treatment of TRAAs and may supplant surgery as the primary therapy. Current experience in the use of flow diverter stents in TRAAs is limited to individual case reports with one brand of flow diverter device. Our small numbered series of four TRAAs shows our experience regarding endovascular treatment with different flow diverter brands.

Percutaneous Embolization of an Inferior Mesenteric Artery Aneurysm in a Patient With Type IV Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) refers to a group of genetic disorders involving the connective tissues. Type IV EDS impairs type III collagen that is responsible for vessel integrity. Patients with type IV EDS are susceptible to vascular and visceral complications, including aortic aneurysms, pseudoaneurysms, dissections, and spontaneous rupture of internal organs. Treating aneurysms with open surgery versus endovascular techniques each carry a unique risk-to-benefit ratio that must be applied to each individual carefully. We present a patient with type IV EDS who presented with a rapidly growing inferior mesenteric artery aneurysm. The patient was treated with a percutaneous endovascular technique using coils and n-butyl-cyanoacrylate glue.

Clinical treatment strategy for post pancreatectomy hemorrhage

Hemorrhage is the most serious complication after pancreatic surgery and is also the main cause of clinical death. With the progress of surgical methods and the rapid development of minimally invasive techniques, surgeons have more technical means to deal with postoperative hemorrhage. It is still inconsistent in terms of taking effective therapeutic measures according to different causes of bleeding. And this has long plagued every pancreatic surgeon. This article reviews the location, causes, preventive measures, and treatment of hemorrhage after pancreatectomy, in order to provide some guidance to clinicians.

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.

Endoscopic ultrasound-guided coil and glue for treatment of splenic artery pseudo-aneurysm: new kid on the block!

BACKGROUND AND STUDY AIMS

 Pseudoaneurysm most commonly involves the splenic artery and is conventionally treated with angioembolization or surgery. Herein we describe six patients with splenic artery pseudoaneurysm who were treated using a new technique of endoscopic ultrasound (EUS)-guided glue and coil injection.

PATIENTS AND METHODS

 Six patients (median age 36.7, range: 19 - 60, M: F = 5:1) with splenic artery pseudoaneurysm who had failed angiographic embolization underwent EUS-guided transgastric injection of coil and glue injection between July 2016 and September 2017.

RESULTS

The diameter of the splenic artery pseudoaneurysms varied from 2.5 cm to 6.5 cm . The size (8, 14 and 16 mm) and number (1 to 5) of coils and amount of glue (1 - 2 mL) injected all were greater in larger aneurysm. All six patients had complete occlusion of the pseudoaneurysm as determined by using computed tomography at 4 weeks and EUS at 12 weeks. No complication was encountered.

CONCLUSION

EUS-guided coil and glue injection for obliteration of splenic artery pseudoaneurysm is a feasible, highly effective and safe technique.

Endovascular management of pancreatitis-related pseudoaneurysms: A review of techniques

Objectives

To present the various techniques used in the management of pancreatitis-related pseudoaneurysms of visceral vessels.

Methods

The retrospective clinical study was carried out at the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. The fifteen patients included in the study were diagnosed with pseudoaneurysms of visceral arteries, as a complication of chronic pancreatitis. The diagnosis was made using contrast-enhanced computed tomography, followed by angiography. On admission, all patients were symptomatic, with varying degrees of abdominal pain. One patient was haemodynamically unstable. Treatments with endovascular techniques were analysed, along with their efficacy and outcomes. Coil embolisation was performed in 5 patients. Stent graft was used in 1 patient. Liquid embolic agents were used in 7 cases, of which 5 patients were treated with thrombin injection and 2 with Squid. A combination of techniques was used in 2 patients.

Results

The most common artery affected by pseudoaneurysm formation was the splenic artery (7/15; 46.7%), and the size of the pseudoaneurysms ranged from 27 mm to 85 mm. Primary technical success was achieved in 14 out of 15 patients (93.3%). One patient required reintervention. Two patients required splenectomy after embolisation due to splenic ischemia. No recanalisation was present at the follow-up computed tomography performed after 1 to 3 weeks, and no mortality was observed within 30 days.

Conclusion

Vascular complications of pancreatitis require accurate diagnosis and immediate treatment. Endovascular intervention is highly effective and is the preferred treatment option. The technique used is determined based on vascular anatomy and the patient’s haemodynamic status.