Successful interventional treatment of huge hepatic haemangioma in a neonate following failed medical approach

An outborn male term neonate presented with a complaint of respiratory distress since birth on day 9 of life. On examination, baby was having tachypnoea, tachycardia and hepatomegaly. The baby was delivered at term gestation and cried immediately after birth. The chest X-ray showed cardiomegaly. The abdomen ultrasound showed a complex cystic vascular lesion suggestive of hepatic haemangioma. The echocardiography showed an atrial septal defect. The baby was initially treated conservatively along with specific treatment (steroids and propranolol) for haemangioma for 6 weeks. However, the symptoms persisted and there was non-resolution, therefore, particle embolisation of the right hepatic artery was performed. Subsequently, it resulted in complete resolution of the lesion.

Variant origins of the middle colic artery from the coeliac trunk and its branches

The middle colic artery usually arises from the superior mesenteric artery, but in rare cases it may arise from the coeliac trunk or its branches. The aim of this study was to investigate variant origins of the middle colic artery on computed tomography and anatomical dissection. Variant middle colic arteries were identified on computed tomography as part of an ongoing study investigating anatomical variations of vessels of the upper abdomen. Three-dimensional reconstructions were made to demonstrate the variant findings. Cadaveric dissections were performed as part of a routine dissection course. We report five cases of rare variant origins of the middle colic artery arising from the coeliac axis. Among these sites of origin were the coeliac trunk, the gastrosplenic trunk, the splenic artery, and the common hepatic artery. Four cases were identified on multi-detector computed tomography and one in a cadaver. In all cases, the vessels passed posterior to the body of the pancreas before entering the transverse mesocolon. Knowledge of middle colic artery variations is important to prevent inadvertent injury in digestive surgery, especially in the hepatopancreatic area. Variant origins of the middle colic artery are rare, and their knowledge is crucial to prevent unnecessary iatrogenic injury during abdominal surgery.

The involvement of the hepatic artery is a risk factor for unresectability after neoadjuvant treatment in borderline pancreatic adenocarcinoma

INTRODUCTION

Borderline Resectable Pancreatic Ductal Adenocarcinoma (BR-PDAC) benefits from neoadjuvant treatment (NAT) with the intent of surgical salvage in the absence of disease progression during chemotherapy (CT) or chemoradiotherapy (CRT). Scarce literature exists about prognostic factors of resectability at the time of diagnosis or during neoadjuvant treatment, especially regarding vascular relationships.

MATERIALS

We reviewed our prospective BR-PDAC cohort to determine resectability predictors. We collected data about clinical baseline characteristics, vessels' involvement, type of NAT, CA19-9 evolution, and radiological outcome. We performed a descriptive analysis and a logistic regression model to define resectability predictors; we finally compared overall survival (OS) and progression-free survival (PFS) for those predictors.

RESULTS

One hundred patients started NAT, with a resection rate of 44 % (40 pancreaticoduodenectomies, 4 distal pancreatectomies). The most frequent vessel relationship was the abutment of the superior mesenteric artery (44 %), and 26 patients had ≥2 vessels involved. Prognostic factors of resectability were CA19-9 response >10 % (OR 3.07, p = 0.016) and Hepatic Artery involvement (OR 0.21, p = 0.026). Median overall survival was better for CA19-9 responders than for non-responders (20.9 months and 11.8 months respectively, p < 0.001), and similar to normalized CA19-9 (25.0 months, p = 0.48). There were no differences in terms of OS or PFS with the involvement of the HA (17.7 vs 17.1 months, p = 0.367; and 8.7 vs 12.0 months, p = 0.267).

CONCLUSION

The involvement of the Hepatic Artery seems to confer a worse prognosis regarding resectability. A decrease of only >10 % of CA19-9 is a predictive factor for resectability and better overall and progression-free survival.

Safety and efficacy of biliary stenting combined with iodine-125 seed strand followed by hepatic artery infusion chemotherapy plus lenvatinib with PD-1 inhibitor for the treatment of extrahepatic cholangiocarcinoma with malignant obstructive jaundice

Objectives

To evaluate the efficacy and safety of biliary stenting implantation with iodine-125 seed strand (SI) followed by hepatic artery infusion chemotherapy (HAIC) plus lenvatinib (Len) with programmed death-1 (PD-1) inhibitor for patients diagnosed with extrahepatic cholangiocarcinoma (ECC) and malignant obstructive jaundice (MOJ).

Methods

In this single-center retrospective study, the data of ECC patients with MOJ from March 2015 to January 2023 was assessed. Using probability score matching (PSM), the selection bias of patients was reduced. Primary study outcomes included overall survival (OS) and progression-free survival (PFS). The OS and PFS were performed using the Kaplan-Meier method and evaluated with the log-rank test.

Results

A total of 104 patients were enrolled finally, including 52 patients treated with interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor (SI+HAIC+Len+P group) and 52 patients treated with interventional therapy (SI+HAIC) plus lenvatinib (SI+HAIC+Len group). 26 pairs of patients were matched after PSM analysis. After PSM analysis, the median OS and PFS in the SI+HAIC+Len+P group were significantly longer compared to those in the SI+HAIC+Len group (OS:16.6 vs. 12.3 months, P = 0.001; PFS:12.6 vs 8.5 months, P = 0.004). The DCR was significantly different between groups (P = 0.039), while ORR not (P = 0.548). The addition of PD-1 inhibitor was generally well tolerated without treatment-associated mortality.

Conclusion

Interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor was effective for ECC patients accompanied by MOJ with a manageable safety profile.

Hepatic artery branch perforation with hemoperitomeum: A rare complication of pericardiocentesis

A 58-year-old male patient presented with anterior myocardial infarction after 36 hours of symptom onset.

Effects of Preservation of Donor Liver Gastroduodenal Artery on Post-Transplant Biliary Complications in 187 Liver Transplant Recipients: A Retrospective Study

BACKGROUND This retrospective study aimed to evaluate the effects of preservation of the donor liver gastroduodenal artery on post-transplant biliary complications in 187 liver transplant recipients. MATERIAL AND METHODS The clinical data of 187 liver transplantation recipients were retrospectively analyzed. Recipients were divided into conventional and modified groups. The technical point of the modified group is to preserve at least 2 cm of the distal gastroduodenal artery, and pay special attention to preserve the superior pancreaticoduodenal artery to ensure the distal blood supply to the common bile duct. RESULTS The modified group had significantly shorter operative time (7.17 vs 7.98) h (P<0.001) and less intraoperative blood loss (2715.40 vs 3434.93) ml (P=0.003) than the conventional group. The incidence of postoperative biliary complications (including anastomotic biliary leakage, ischemic bile duct stenosis, and anastomotic bile duct stenosis) in the modified group (4/114, 4.1%) was significantly lower (15/73, 20.5%) (P<0.001). There was no significant difference in the intraoperative cold and warm ischemia time and postoperative hospital stay length between the 2 groups. In addition, there was no significant difference in the effect of cardiac-death and brain-death sources on perioperative biliary complications, while the peak postoperative transaminase and total bilirubin were higher in patients receiving the donor liver of cardiac death (P<0.05). CONCLUSIONS Preserving the integrity of the donor gastroduodenal artery and surrounding tissue is beneficial to protect the blood supply of the extrahepatic bile duct, and can reduce the incidence of biliary complications.

Surgical Versus Image-Guided Interventions in the Management of Complications After Liver Transplantation

Liver transplantation is a technically demanding surgical procedure with known complications, and the optimal approach to addressing vascular and biliary complications requires a coordinated effort between surgical and interventional radiology teams. Vascular complications involving the hepatic artery, portal vein, or hepatic veins can be characterized by their mechanism, chronicity, and timing of presentation. These factors help determine whether the optimal therapeutic approach is surgical or endovascular. Very early presentation in the perioperative period favors surgical revision, while later presentation is best addressed endovascularly. Biliary complications can be categorized as leaks or strictures, and coordinated surgical, endoscopic, and percutaneous management is needed to address these types of complications. Through advances in technique and the management of complications, outcomes after liver transplantation continue to improve.

[Study on the comparison of postoperative liver injury caused by hepatic arterial perfusion chemotherapy combined with targeted immunotherapy with hepatic arterial chemoembolization combined with targeted immunotherapy for intermediate-and advanced-stage liver cancer]

Objective: To compare the postoperative liver function injury condition in patients with intermediate-and advanced-stage hepatocellular carcinoma (HCC) treated with hepatic artery infusion chemotherapy (HAIC) and hepatic artery chemoembolization (TACE) combined with immune checkpoint inhibitors (ICIs) and multi-target tyrosine kinase inhibitors (TKIs). Methods: Patients with intermediate-and advanced-stage HCC who were admitted and treated with HAIC/TACE+ICIs+TKIs therapy at Nanfang Hospital of Southern Medical University from January 2019 to November 2021, with follow-up up to July 2023, were retrospectively enrolled. The results of liver function tests within one week before interventional surgery and on the first day after surgery were recorded. The degree of postoperative liver injury was graded according to the common terminology criteria for adverse events 5.0 (CTCAE 5.0). The treatment efficacy was evaluated according to RECIST 1.1 criteria. Measurement data were compared between groups using a t-test or a non-parametric rank sum test. Enumeration data were compared between the groups using the χ(2) test or Fisher's exact probability method. The survival condition differences were analyzed by the log-rank method. Results: This study included 82 and 77 cases in the HAIC and TACE groups. There were no statistically significant differences between the two groups of patients in terms of gender, age, physical condition score, number of tumors, presence or absence of liver cirrhosis, Child-Pugh grade, albumin-bilirubin (ALBI) grade, and combined ICIs and TKIs . The HAIC group had later tumor staging, a greater tumor burden, poorer liver reserve function, and a larger proportion of patients in stage C (81.7% vs. 63.6%), χ(2)=6.573, P = 0.01). There were 53 cases (64.6% vs. 32.5%) with a maximum tumor diameter of ≥ 10cm, χ(2)=16.441, P < 0.001), and more patients had a retention rate of ≥ 10% for indocyanine green (ICG) at 15 minutes (68.3% vs. 51.9%, P = 0.035). The postoperative incidence rate of increased levels of alanine aminotransferase, aspartate aminotransferase, and total bilirubin was significantly lower in the HAIC group than that in the TACE group (28.0% vs. 63.6%, χ(2)=20.298, P < 0.001, 54.9% vs. 85.7%, χ(2)=17.917, P < 0.001;40.2% vs. 55.8%, χ(2)=3.873, P = 0.049). The number of patients with postoperative ALBI grade 3 was significantly lower in the HAIC group than that in the TACE group (6.1% vs. 16.9%, χ(2)=4.601, P = 0.032). There was no statistically significant difference in the incidence rate of postoperative hypoalbuminemia, activated partial thromboplastin time, or increased international standardized ratio between the two groups of patients. There was no statistically significant difference in median progression-free survival (7.3 months vs. 8.2 months, P = 0.296) or median overall survival (16.5 months vs. 21.9 months, P = 0.678) between the two groups of patients. Conclusion: The incidence rate of postoperative liver injury is higher in patients with intermediate-and advanced-stage HCC treated with TACE combined with ICIs and TKIs than in patients with HAIC combined with ICIs and TKIs.

A Prospective Study of the Effect of Gastroduodenal Artery Reconstruction on Duodenal Oxygenation and Enzyme Content After Pancreas Transplantation

BACKGROUND

Whole pancreas transplantation provides durable glycemic control and can improve survival rate; however, it can carry an increased risk of surgical complications. One devastating complication is a duodenal leak at the site of enteroenteric anastomosis. The gastroduodenal artery (GDA) supplies blood to the donor duodenum and pancreas but is commonly ligated during procurement. Since we have not had expressive changes in pancreatic back table surgical techniques in the recent decades, we hypothesized whether back table GDA reconstruction, improving perfusion of the donor duodenum and head of the pancreas, could lead to fewer surgical complications in simultaneous pancreas-kidney (SPK) transplants.

MATERIAL AND METHODS

Between 2017 and 2021, we evaluated demographic information, postoperative complications, intraoperative donor duodenum, recipient bowel O2 tissue saturation, and patient morbidity through the Comprehensive Complication Index (CCI®).

RESULTS

A total of 26 patients were included: 13 underwent GDA reconstruction (GDA-R), and 13 had GDA ligation (GDA-L). There were no pancreatic leaks in the GR group compared to 38% (5/13) in the GDA-L group (p = 0.03913). Intraoperative tissue oxygen saturation was higher in the GDA-R group than in the GDA-L (95.18 vs.76.88%, p < 0,001). We observed an increase in transfusion rate in GDA-R (p < 0.05), which did not result in a higher rate of exploration (p = 0.38). CCI® patient morbidity was also significantly lower in the GDA-R group (s < 0.05).

CONCLUSIONS

This study identified improved intraoperative duodenal tissue oxygen saturation in the GDA-R group with an associated reduction in pancreatic leaks and CCI® morbidity risk. A larger prospective multicenter study comparing the two methods is warranted.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

The arterial anatomy of the posterior duodenum - A computed tomography angiography analysis with implications for abdominal surgery

The main objective of the present study was to clarify the anatomical characteristics of the GDA. In order to fulfill this objective, novel classification systems of both the origin and branching pattern of the said vessel were created. Being aware of the variable anatomy of the GDA is of great importance when performing hepatopancreaticobilliary procedures. The results of 75 consecutive patients who underwent abdomen computed tomography angiography (CTA) were analyzed. A total of 74 GDA were analyzed. Of these, 42 were from women (56.8%) and 32 were from men (43.2%). The most common direction of origin of the GDA was inferior (n = 38; 51.4%). The origin variation of each GDA was deeply analyzed. Initially, eight types of origin variations were evaluated, of which types 1-3 constituted 83.8%. Furthermore, analogously, branching pattern types were also established. Initially, 11 branching variations were evaluated, of which types 1-3 constituted 87.8%. The GDA is subject to numerous variations, both in the origin and in the branching pattern of the vessel. In order to clarify the anatomical characteristics of this vessel, novel classifications of the origin and branching patterns were made, presenting the most frequent patterns. Our results may be of great use for surgeons performing hepatopancreaticobilliary surgeries, such as the Whipple procedure or vascular reconstructions after cholangiocarcinoma resections. Being aware of the anatomical variations of relevant structures associated with a surgical procedure may help reduce potential intraoperative and/or postoperative complications.

Refining Auxiliary Orthotopic Liver Transplantation (AOLT) Improves Outcomes in Adult Patients With Acute Liver Failure

OBJECTIVE

To investigate whether and how experience accumulation and technical refinements simultaneously implemented in auxiliary orthotopic liver transplantation (AOLT) may impact on outcomes.

BACKGROUND

AOLT for acute liver failure (ALF) provides the unique chance of complete immunosuppression withdrawal after adequate native liver remnant regeneration but is a technically demanding procedure. Our department is a reference center for ALF and an early adopter of AOLT.

METHODS

This is a single-center retrospective before/after study of a prospectively maintained cohort of 48 patients with ALF who underwent AOLT between 1993 and 2019. In 2012, technical refinements were implemented to improve outcomes: (i) favoring the volume of the graft rather than that of the native liver, (ii) direct anastomosis of graft hepatic artery with recipient right hepatic artery instead of the use of large size vessels, (iii) end-to-side hepaticocholedocostomy instead of bilioenteric anastomosis. Early experience (1993-2011) group (n=26) and recent experience (2012-2019) group (n=22) were compared. Primary endpoint was 90-day severe morbidity rate (Clavien-Dindo≥IIIa) and secondary endpoints were overall patient survival and complete immunosuppression withdrawal rates.

RESULTS

Compared with the earlier experience group, the recent experience group was associated with a lower severe complication rate (27% vs 65%, P <0.001), as well as less biliary (18% vs 54%, P =0.017) and arterial (0% vs 15%, P =0.115) complications. The 1-, 3-, and 5-year patient survival was significantly improved (91%, 91%, 91% vs 76%, 61%, 60%, P =0.045). The rate of complete immunosuppression withdrawal increased to 94% vs 70%, ( P =0.091) with no need of long-term graft explant.

CONCLUSION

These technical refinements favoring the liver graft and reducing morbidity may promote AOLT implementation among LT centers.

The Portal Vein: A Comprehensive Review

Radiologists are familiar with the appearances of a normal portal vein; variations in its anatomy are commonplace and require careful consideration due to the implications for surgery. These alterations in portal vein anatomy have characteristic appearances that are clearly depicted on CT, MR, and US images. Similarly, there are numerous congenital and acquired disorders of the portal vein that are deleterious to its function and can be diagnosed by using imaging alone. Some of these conditions have subtle imaging features, and some are conspicuous at imaging but poorly understood or underrecognized. The authors examine imaging appearances of the portal vein, first by outlining the classic and variant anatomy and then by describing each of the disorders that impact portal vein function. The imaging appearances of portal vein abnormalities discussed in this review include (a) occlusion from and differentiation between bland thrombus and tumor in vein and the changes associated with resultant hepatic artery buffer response changes, cavernous transformation of the portal vein, and portal biliopathy; (b) ascending thrombophlebitis of the portal vein (pylephlebitis); (c) portal hypertension and its causes and sequelae; (d) the newly described disease entity portosinusoidal vascular disorder; and (e) intra- and extrahepatic shunts of the portal system, both congenital and acquired (including Abernethy malformations), and the associated risks. Current understanding of the pathophysiologic processes of each of these disorders is considered to aid the approach to reporting. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Detection of arterial phase hyperenhancement of small hepatocellular carcinoma with MRI: Comparison between single arterial and multi-arterial phases and between extracellular and hepatospecific contrast agents

PURPOSE

The purpose of this study was to compare the detection rate of arterial phase hyperenhancement (APHE) in small hepatocellular carcinoma (HCC) between single arterial phase (single-AP) and triple hepatic arterial (triple-AP) phase MRI and between extracellular (ECA) and hepato-specific (HBA) contrast agents.

MATERIALS AND METHODS

A total of 109 cirrhotic patients with 136 HCCs from seven centers were included. There were 93 men and 16 women, with a mean age of 64.0 ± 8.9 (standard deviation) years (range: 42-82 years). Each patient underwent both ECA-MRI and HBA (gadoxetic acid)-MRI examination within one month of each other. Each MRI examination was retrospectively reviewed by two readers blinded to the second MRI examination. The sensitivities of triple- and single-AP for the detection of APHE were compared, and each phase of the triple-AP sequence was compared with the other two.

RESULTS

No differences in APHE detection were found between single-AP (97.2%; 69/71) and triple-AP (98.5%; 64/65) (P > 0.99) at ECA-MRI. No differences in APHE detection were found between single-AP (93%; 66/71) and triple-AP (100%; 65/65) at HBA-MRI (P = 0.12). Patient age, size of the nodules, use of automatic triggering, type of contrast agent, and type of sequence were not significantly associated with APHE detection. The reader was the single variable significantly associated with APHE detection. For triple-AP, best APHE detection rate was found for early and middle-AP images compared to late-AP images (P = 0.001 and P = 0.003). All APHEs were detected with the combination of early-AP and middle-AP images, except one that was detected on late-AP images by one reader.

CONCLUSION

Our study suggests that both single- and triple-AP can be used in liver MRI for the detection of small HCC especially when using ECA. Early AP and middle-AP are the most efficient phases and should be preferred for detecting APHE, regardless of the contrast agent used.

Extreme hepatectomy with modified ALPPS in a rat model: gradual portal vein restriction associated with hepatic artery restriction

BACKGROUND & AIM

Associating liver partition and portal vein ligation (PVL) for staged hepatectomy (ALPPS) is a creative strategy for enlarging the future liver remnant (FLR) and increasing the tumor resectability rate. However, the indications for ALPPS must have a certain limit when the FLR is too small. We aimed to establish a modified ALPPS model with more widen applicability in rats.

METHODS

An extreme ALPPS model was established in rodents with only a 6.5% FLR. The portal vein (PV) was subjected to restriction to different degrees, then the portal vein pressure (PVP) was measured. Then, different modifications of ALPPS, including hepatic artery restriction (HAR), gradual portal vein restriction (GPVR), and GPVR-associated HAR (HAR+GPVR), were applied in the extreme ALPPS models.

RESULTS

PVL or PVR provoked an immediate increase in the PVP. The PVP in the PVR -1.28 mm, PVR -0.81 mm, PVR -0.63 mm, and PVL groups was 11.05±1.57 cmH2O, 16.18±1.92 cmH2O, 20.66±1.99 cmH2O, and 24.10±3.33 cmH2O, respectively, and the corresponding 3-day survival rate was 100%, 90.09%, 36.33% and 0, respectively. Then, in the extreme ALPPS model, the growth ratio of the FLR in the control, HAR, GPVR, and HAR+GPVR groups was 0.43±0.21, 0.50±0.16, 4.80±0.86, and 7.40±2.56, and as a consequence, the corresponding 30-day survival rate was 9.09%, 15.38%, 84.61% and 92.90%, respectively.

CONCLUSION

ALPPS itself has a limit, and high PVP after PVL contributes to postoperative death in the extreme ALPPS model. Furthermore, a modified method for extreme ALPPS is proposed, i.e., GPVR+HAR in place of PVL, which significantly improves the survival rate of extreme hepatectomy in rat models.

Relationship Between Perioperative Factors and Splenic Artery Steal Syndrome After Orthotopic Liver Transplant: A Retrospective Clinical Study

OBJECTIVES

After orthotopic liver transplant, ischemia of biliary tract and graft loss may occur due to impaired hepatic arterial blood flow. This situation with hypersplenism and impaired hepatic arterial blood flowis defined as splenic artery steal syndrome.The aim of this study was to investigate the relationship between perioperative factors and splenic artery steal syndrome in orthotopic liver transplant patients.

MATERIALS AND METHODS

Forty-five patients who underwent orthotopic liver transplant between 2014 and 2022 were included in the study. The data for the patients were obtained from the hospital database, including the intraoperative anesthesiology and postoperative intensive care records.

RESULTS

Eleven patients were diagnosed with splenic artery steal syndrome. Patients with splenic artery steal syndrome had higher need for intraoperative vasopressor agents (P = .016) and exhibited lower intraoperative urine output (P = .031). In the postoperative intensive care follow-up, patients with splenic artery steal syndrome had higher levels of C-reactive protein during the first 48 hours (P = .030).

CONCLUSIONS

Intraoperative administration of vasopressor drugs, low urine output, and early postoperative high C-reactive protein levels were associated with the development of splenic artery steal syndrome in patients undergoing orthotopic liver transplant. Future studies should focus on investigation of biomarkers associated systemic hypoperfusion that may contribute to the development of splenic artery steal syndrome.

SerpinB3 as hepatic marker of post-resective shear stress

Post-resective liver failure is a frequent complication of liver surgery and it is due to portal hyperperfusion of the remnant liver and to arterial vasoconstriction, as buffer response of the hepatic artery. In this context, splenectomy allows a reduction of portal flow and increases the survival chance in preclinical models. SerpinB3 is over-expressed in the liver in oxidative stress conditions, as a mechanism of cell defense to provide survival by apoptosis inhibition and cell proliferation. In this study, the expression of SerpinB3 was assessed as predictor of liver damage in in vivo models of major hepatic resection with or without splenectomy. Wistar male rats were divided into 4 groups: group A received 30% hepatic resection, group B > 60% resection, group C > 60% resection with splenectomy and group D sham-operated. Before and after surgery liver function tests, echo Doppler ultrasound and gene expression were assessed. Transaminase values and ammonium were significantly higher in groups that underwent major hepatic resection. Echo Doppler ultrasound showed the highest portal flow and resistance of the hepatic artery in the group with > 60% hepatectomy without splenectomy, while the association of splenectomy determined no increase in portal flow and hepatic artery resistance. Only the group of rats without splenectomy showed higher shear-stress conditions, reflected by higher levels of HO-1, Nox1 and of Serpinb3, the latter associated with an increase of IL-6. In conclusion, splenectomy controls inflammation and oxidative damage, preventing the expression of Serpinb3. Therefore, SerpinB3 can be considered as a marker of post-resective shear stress.

Axon guidance genes control hepatic artery development

Earlier data on liver development demonstrated that morphogenesis of the bile duct, portal mesenchyme and hepatic artery is interdependent, yet how this interdependency is orchestrated remains unknown. Here, using 2D and 3D imaging, we first describe how portal mesenchymal cells become organised to form hepatic arteries. Next, we examined intercellular signalling active during portal area development and found that axon guidance genes are dynamically expressed in developing bile ducts and portal mesenchyme. Using tissue-specific gene inactivation in mice, we show that the repulsive guidance molecule BMP co-receptor A (RGMA)/neogenin (NEO1) receptor/ligand pair is dispensable for portal area development, but that deficient roundabout 2 (ROBO2)/SLIT2 signalling in the portal mesenchyme causes reduced maturation of the vascular smooth muscle cells that form the tunica media of the hepatic artery. This arterial anomaly does not impact liver function in homeostatic conditions, but is associated with significant tissular damage following partial hepatectomy. In conclusion, our work identifies new players in development of the liver vasculature in health and liver regeneration.

Low hepatic artery resistive index on Doppler ultrasound performed on the first post-liver transplant day is associated both with hepatic artery thrombosis and decreased graft survival

PURPOSE

Although liver transplantation (LT) outcomes have improved significantly over the last decades, early vascular complications are still associated with elevated risks of graft failure. Doppler ultrasound (DUS) enables detection of vascular complications, provides hepatic artery Resistive Index (RI). The aim of our study was to evaluate the association of the RI parameters of DUS performed in the first post-transplant week with post-transplant outcomes.

METHODS

All consecutive patients undergoing a first LT between 2001 and 2019 at a single center were included. Patients were divided into two groups: RI < 0.55 and RI ≥ 0.55. Patients were also divided according to the presence or absence of hepatic artery thrombosis (HAT). Graft survival was compared between groups.

RESULTS

Overall, 338 patients were included. HAT occurred in 23 patients (6.8%), of which 7 were partial and 16, complete. Biliary complications were more common in patients with HAT (10 [43.5%]) vs. 38 [12.1%] [p < 0.001]). Graft survival was lower for patients with HAT (p = 0.047). Also, RI < 0.55 was associated with increased incidence of HAT (p < 0.001). Additionally, patients with RI < 0.55 on post-operative day 1 had decreased graft survival as compared to patients with RI > 0.55 (p = 0.041). RI on post-operative day 3 and 5 was not predictive of inferior graft outcomes.

CONCLUSIONS

Intensive use of DUS in the early post-LT period offers the possibility of early diagnosis of vascular complications, guiding medical and surgical management of HAT. Additionally, according to our data, low RI (< 0.55) on the first postoperative day also is a predictor of HAT and decreased graft-survival.

Morphological characteristics of the left gastric, common hepatic and splenic arteries. A descriptive study in human cadaveric specimens

OBJECTIVE

to evaluate the morphology of the branches of celiac trunk (CT), left gastric (LGA), common hepatic (CHA), and splenic (SA) arteries in cadaveric specimens from a sample of a Colombian population.

METHODS

descriptive cross-sectional study of 26 blocks from the abdominal upper segment of human cadavers who underwent forensic autopsies at the Instituto de Medicina Legal at Bucaramanga, Colombia. The vascular beds of the celiac trunk were, subsequently, perfused with a semi-synthetic resin.

RESULTS

the diameters of LGA, CHA, and SA were 3.6±0.8mm, 5,2±1.2mm, and 5.9±1.0mm, respectively. Statistically, LGA and SA were different (p=<0.001). SA followed a linear trajectory in 8 (31%) samples, slightly tortuous in 4 (15%), and tortuous in 14 (54%). The tortuosity index was 1.25±0.18. Of the branches of CHA, the proper hepatic artery (PHA) had 4.8±1.2mm in diameter and 18.8±9.1mm in length, whereas the gastroduodenal artery (GDdA) had 4.1±0.8mm. In 2 cases (7.7%), an accessory hepatic artery from the LGA was found to supply perfusion to the left hepatic lobe. Finally, in 2 cases (7.7%) the SA came independently from the abdominal aorta.

CONCLUSION

the observed emergence incidence of the CT branches from the same level as reported in the literature is lower. The characterization, along with their variants, of LGA, CHA, and SA must be considered in surgical procedures in the upper abdominal segment, to avoid iatrogenic complications.

Hepatic artery pseudoaneurysm caused by chronic pancreatitis: Case report and literature review

RATIONALE

Visceral artery pseudoaneurysm is a rare complication of chronic pancreatitis (CP), all pancreatic or peripancreatic arteries have been reported to be involved, while hepatic artery is less common.

PATIENT CONCERNS

This case report illustrated a 42-year-old man with CP who developed right hepatic artery pseudoaneurysm (HAP), and finally he was treated with intravascular embolization.

DIAGNOSES

The patient suffered from HAP due to acute attack of CP.

INTERVENTIONS

The pseudoaneurysm located in a fine branch of right hepatic artery was embolized.

OUTCOMES

The HAP of the patient was cured. He had no recurrent bloody stool or abdominal pain. The symptoms gradually relieved.

CONCLUSION

Herein, we report a patient with CP who developed right HAP causing infected hematoma, gastrointestinal bleeding, and obstructive jaundice, and a literature review is also presented. HAP caused by CP is a rare disease in the clinic, but rupture of pseudoaneurysm is fatal. Careful evaluation, early detection, and prompt treatment should be performed when the patient is admitted and followed up.

[Global trends in endovascular treatment of patients with malignant neoplasms and metastatic liver damage]

OBJECTIVE

To analyze the results of endovascular embolization of malignant tumors and liver metastases.

MATERIAL AND METHODS

We analyzed international studies on the treatment of patients with neoplastic liver lesions and complications after regional endovascular embolization following leakage of chemotherapeutic drugs from the target vessel and negative systemic effects. The results of embolization of liver arteries without chemotherapeutic drugs were also analyzed. We reviewed the PubMed, The Cochrane Library, Web of Science databases, as well as Russian scientific and practical journals.

CONCLUSION

Literature data indicate high clinical effectiveness of interventional treatment of patients with malignant neoplasms and metastatic liver damage.

Intra-arterial hepatic bevacizumab and systemic chemotherapy in hepatic metastasis of colorectal cancer: A phase II multicentric trial in second-line treatment

INTRODUCTION

Intra-arterial hepatic (IAH) treatment has shown promising results in the management of patients with unresectable colorectal liver metastases (CRLM) the prognosis of which is poor. Bevacizumab adjunction to standard chemotherapy has been shown to improve survival of this patient population. This prospective study was conducted to assess the efficacy and safety of IAH bevacizumab combined to systemic chemotherapy after first-line treatment failure in patients with CRLM.

METHODS

Included patients had dominant or isolated unresectable CRLM progressing after standard first-line treatment for metastases of colorectal cancer. Three patients had less than 30% liver invasion, three patients between 30 and 50%, two more than 50% and data was missing in two patients. An intra-hepatic catheter was implanted surgically or percutaneously. Bevacizumab 7.5 mg/kg was administered once every 3 weeks in combination with capecitabine 2000 mg/m² per day for 2 weeks and oxaliplatin 130 mg/m² or irinotecan 200 mg/m² once every 3 weeks. The primary end-point was the objective response rate.

RESULTS

Between June 2013 and February 2015, 10 patients were included. The trial was prematurely closed because of the lack of financial support and poor accrual. The patients had a median of 6 [1-9] cycles of treatment. Partial response was achieved in 2 patients (20%) and a R0 liver metastases resection in one another. All patients died of disease progression. The median overall and progression-free survival rates were respectively 14.0 (95% IC [4.8 - 25.8] and 5.4 months (95% IC [1.6 - 6.2]). Four patients had severe side effects but no toxic death occurred.

CONCLUSION

IAH bevacizumab combined to systemic chemotherapy is feasible and safe in patients with unresectable isolated or dominant CRLM progressing after a first-line systemic treatment. Based on the low number of patients included in our study, our results suggest that this treatment does not increase dramatically the response rate versus an adapted systemic treatment. However, considering the safety data provided in this study, arterial infusion of bevacizumab in adjunction to chemotherapeutic agents could be evaluated in the future.

[Hemodynamics in the right gastroepiploic artery and its practical application]

OBJECTIVE

To study functional anatomy of the right gastroepiploic artery (RGEA), its gastric and omental branches and practical significance of these anatomical features.

MATERIAL AND METHODS

We analyzed 20 cadaveric organ complexes (11 men and 9 women, aged 49-85 years) between 2018 and 2019. The organ complexes consisted of the stomach, proximal duodenum and large omentum. RGEA catheterization at the level of pylorus was followed by selective real time angiography. We assessed the following parameters of RGEA: total length, diameter at the level of pylorus, number and diameter of gastric and omental branches. To objectify the study, we visually divided RGEA into 5 equal segments between pylorus and the last branch arising from this artery.

RESULTS

The RGEA looks like a gradually and evenly narrowing tube. Mean diameter of the artery at the level of pylorus was 2.2±0.68 mm, mean length - 23.6±3.7 cm. Mean number of gastric and omental branches was 16.2±4.8 and 8.6±2.6, respectively. The number of gastric branches in the distal part of the RGEA increased, while the diameters of the gastric branches did not significantly differ. The number of gastric branches in distal RGEA increased, while diameters of gastric branches were similar. The greatest number of omental branches with the largest diameter was observed in the 2nd and 3rd segments of the artery. Considering these data, we formulated the equation for RGEA hemodynamics and developed the technique for optimal blood supply to proximal part of the gastric transplant during esophagogastroplasty.

CONCLUSION

Anatomical features of the right gastroepiploic artery can be used in reconstructive surgery of abdominal cavity and chest.

Large gastroduodenal artery pseudoaneurysm, arterioportal fistula and portal vein stenosis in chronic pancreatitis treated using combined transarterial embolization and transportal stenting: A case report

RATIONALE

Chronic pancreatitis is an ongoing fibroinflammatory disease of the pancreas characterized by irreversible damage to the pancreatic parenchyma and ductal system. Besides, chronic pancreatitis can present with a variety of life-threatening complications.

PATIENT CONCERNS

The patients visited our hospital due to abdominal pain and anemia, and had chronic pancreatitis as an underlying disease.

DIAGNOSES

Computed tomography showed a large gastroduodenal artery pseudoaneurysm, arterioportal vein fistula, and portal vein stenosis.

INTERVENTIONS

We would like to report the successful use of the coils, and N-butyl cyanoacrylate glue for the therapeutic embolization of the pseudoaneurysm and fistula between the gastroduodenal artery and the portal vein, and stenting for portal vein stenosis.

OUTCOMES

On the day following the endovascular management, the patient reported remission of abdominal pain, and hemoglobin level returned to normal after transfusion. It was confirmed that it was still well maintained in the follow-up examination after 1 month.

LESSONS

Although chronic pancreatitis causes many vascular complications, simultaneous occurrence of these lesions is extremely rare. Herein, we share our experience with a unique case of an extrahepatic arterioportal fistula induced by the rupture of gastroduodenal artery pseudoaneurysm with concomitant portal vein stenosis. In these complex cases, combined transarterial embolization and transportal stenting can be helpful.

Fasudil inhibits hepatic artery spasm by repressing the YAP/ERK/ ETA/ETB signaling pathway via inhibiting ROCK activation

OBJECTIVE

To explore the effect of Fasudil on HA spasm and its underlying mechanism.

METHODS

Rabbits were divided into Sham, Fasudil, and Model groups for experiments. Fasudil was injected into the left medial lobe of the rabbit liver using a 16G lumbar puncture needle through the laparotomic route. The spasm model was established by inserting the catheter sheath into the femoral arteries of rabbits, followed by celiac artery angiography and left HA catheterization with a micro-catheter. Next, the GSE60887 and GSE37924 datasets concerning Fasudil treatment were analyzed. Moreover, immunofluorescence staining was conducted for YAP1 and α-SMA. Finally, Western blotting was performed to examine the expressions of YAP1, ROCK, ERK1/2, ETA, and ETB.

RESULTS

Fasudil could relieve HA spasm. The Go and KEGG pathway analyses revealed that the MAPK signaling pathway and the Hippo signaling pathway were enriched in vasospasm. Besides, GSEA revealed that ROCK was functionally enriched in the MAPK and Hippo signaling pathways. Co-expression analysis revealed that MAPK1 was significantly correlated with YAP1 and MYC, and YAP1 was significantly correlated with ETA and ETB. It was manifested in the results of immunofluorescence staining that the YAP1-positive fluorescence area was significantly decreased after Fasudil treatment. Moreover, Western blotting results showed that Fasudil decreased the expressions of YAP1, RhoA, ROCK, ETA, ETB, and p-ERK1/2. In addition, in-vitro Western blotting revealed that Fasudil suppressed the YAP/ERK/ETA/ETB signaling pathway in the case of HA spasm by inhibiting ROCK activation.

CONCLUSIONS

Fasudil ameliorates HA spasm through suppressing the YAP/ERK/ETA/ETB signaling pathway and the ROCK activation.

Fluid mechanics approach to perfusion quantification: vasculature computational fluid dynamics simulation, quantitative transport mapping (QTM) analysis of dynamics contrast enhanced MRI, and application in nonalcoholic fatty liver disease classification

OBJECTIVE

We quantify liver perfusion using quantitative transport mapping (QTM) method that is free of arterial input function (AIF). QTM method is validated in a vasculature computational fluid dynamics (CFD) simulation and is applied for processing dynamic contrast enhanced (DCE) MRI images in differentiating liver with nonalcoholic fatty liver disease (NAFLD) from healthy controls using pathology reference in a preclinical rabbit model.

METHODS

QTM method was validated on a liver perfusion simulation based on fluid dynamics using a rat liver vasculature model and the mass transport equation. In the NAFLD grading task, DCE MRI images of 7 adult rabbits with methionine choline-deficient diet-induced nonalcoholic steatohepatitis (NASH), 8 adult rabbits with simple steatosis (SS) were acquired and processed using QTM method and dual-input two compartment Kety's method respectively. Statistical analysis was performed on six perfusion parameters: velocity magnitude [Formula: see text] derived from QTM, liver arterial blood flow [Formula: see text], liver venous blood flow [Formula: see text], permeability [Formula: see text], blood volume [Formula: see text] and extravascular space volume [Formula: see text] averaged in liver ROI.

RESULTS

In the simulation, QTM method successfully reconstructed blood flow, reduced error by 48% compared to Kety's method. In the preclinical study, only QTM |u| showed significant difference between high grade NAFLD group and low grade NAFLD group.

CONCLUSION

QTM postprocesses DCE-MRI automatically through deconvolution in space and time to solve the inverse problem of the transport equation. Comparing with Kety's method, QTM method showed higher accuracy and better differentiation in NAFLD classification task.

SIGNIFICANCE

We propose to apply QTM method in liver DCE MRI perfusion quantification.

Unravelling the mystery of porta hepatis for surgical benefit

BACKGROUND

Hepatobilliary surgery is nowadays growing with increasing popularity throughout the world with advent of newer liver imaging modalities. Anticipating a wide range of morphological variations of porta hepatis (PH), a precise understanding is pertinent to preoperative diagnosis, operative procedure and post-operative outcome of hepatobiliary disease.

MATERIALS AND METHODS

Considering recent interest, present study was undertaken. One-hundred and ten isolated adult cadaveric livers of unknown age and sex were dissected to explore detail morphology and morphometry of PH.

RESULTS

Classical picture of PH was observed in 20% liver. The standard representation of structures was highest in hepatic artery (59.1%) followed by portal vein (55.5%) and hepatic duct (51.8%). On the basis of structural distribution PH was described as 16 types. Maximum variable number was found in hepatic artery followed by portal vein and hepatic duct. In morphometric analysis, transverse diameter of PH was more than antero-posterior diameter, indicated that PH was slightly oval in transverse plane. Position of PH was more towards posterior and slightly right in inferior surface of liver.

CONCLUSIONS

Variations of portal anatomy regarding circulatory and biliary dynamics is worth knowing in successful planning of hepatobiliary surgeries with least complications.

Pseudoaneurysm of the cystic artery after acute necrotizing pancreatitis

A 35-year-old woman, chronic alcoholic, was admitted for an attack of acute, necrotizing pancreatitis. Antibiotics and percutaneous drainage failed to control the septic status and the pancreatic collection. Open surgery allowed a successful necrosectomy and drainage. However, a control CT scan before removal of drains showed a 1 cm diameter pseudoaneurysm of the cystic artery, not present at previous abdominal imaging. A redo laparotomy was performed followed by cholecystectomy with en bloc resection of the pseudoaneurysm and a second look of the peripancreatic area. The patient made an uneventful recovery and was discharged on postoperative day 5. Pseudoaneurysms of the cystic artery after acute necrotizing pancreatitis are very rare. Percutaneous embolization is effective in controlling the pseudoaneurysm, but requires subsequent cholecystectomy within a short delay, due to the risk of gangrene of the gallbladder requiring a further, emergency surgical treatment. Open resection of the pseudoaneurysm en bloc with cholecystectomy appears, therefore, an appropriate treatment of this rare condition. KEY WORDS: Cystic artery, Pancreatitis, Pseudoaneurysm.

Post-Cholecystectomy Right Hepatic Artery Pseudoaneurysm Induced by Generalized Seizure: A Case Report

Pseudoaneurysm is a rare complication of laparoscopic cholecystectomy (LC). In most cases, the patient presents with gastrointestinal bleeding or hemoperitoneum. Here, we present a case with a post-cholecystectomy right hepatic artery pseudoaneurysm (PSA) induced by a generalized seizure. A 39-year-old male was sent to the emergency room with a generalized seizure and a loss of consciousness for approximately 5 min. Diffuse abdominal pain was complained of after consciousness returned. The surgical history of LC 13 days prior was mentioned. Abdominal computer tomography (CT) revealed a lobulated fluid accumulation in the gallbladder fossa with prominent fatty stranding and suspected biloma formation. After admission for one week, sharp abdominal pain was observed. Abdominal CT angiography revealed a right hepatic artery pseudoaneurysm. Transcatheter arterial embolization was performed with a total of seven platinum coils. In conclusion, it is important for doctors to take pseudoaneurysm into consideration in the patient who presents with seizure attack after receiving LC. Late discovery of PSA when it is ruptured can lead to fatal conditions, such as severe hemoperitoneum.

[Liver manifestation of circulatory disorders]

The liver is abundant in blood supply and receives 25% of the cardiac output via the hepatic artery and portal vein. Circulatory disorders may cause hepatic injury, resulting in congestive hepatopathy(CH) and ischemic hepatitis(IH). Hepatic congestion arising from increased hepatic venous pressure and decreased cardiac output is the common pathophysiological basis of both CH and IH. In addition, extensive arteriovenous shunts affect portal pressure and cardiac function, leading to alterations of hepatic blood supply. The current review summarizes the pathophysiology, clinical manifestations and therapeutic interventions of the above diseases, in order to provide reference for clinical practice.

Splenic artery steal syndrome in patients with orthotopic liver transplant: Where to embolize the splenic artery?

Purpose

This study compared proximal and distal embolization of the splenic artery (SA) in patients with splenic artery steal syndrome (SAS) after orthotopic liver transplantation (OLT) regarding post interventional changes of liver function to identify an ideal location of embolization.

Methods and materials

85 patients with SAS after OLT treated with embolization of the SA between 2007 and 2017 were retrospectively reviewed. Periinterventional DSA was used to assess treatment success and to stratify patients according to the site of embolization. Liver function was assessed using following laboratory values: bilirubin, albumin, gamma-glutamyl transferase, glutamat-pyruvat-transaminase (GPT), glutamic-oxaloacetic transaminase (GOT), Alkaline Phosphatase (ALP), aPTT, prothrombin time and thrombocyte count. Descriptive statistics were used to summarize the data. Median laboratory values of pre, 1- and 3-days, as well as 1-week and 1-month post-embolization were compared between the respective embolization sites using linear mixed model regression analysis.

Results

All procedures were technically successful and showed an improved blood flow in the hepatic artery post-embolization. Ten Patients were excluded due to re -intervention or inconsistent image documentation. Pairwise comparison using linear mixed model regression analysis showed a significant difference between proximal and distal embolization for GPT (57.0 (IQR 107.5) vs. 118.0 (IQR 254.0) U/l, p = 0.002) and GOT (48.0 (IQR 48.0) vs. 81.0 (IQR 115.0) U/l, p = 0.008) 3-days after embolization as well as median thrombocyte counts 7-days after embolization (122 (IQR 108) vs. 83 (IQR 74) in thousands, p = 0.014). For all other laboratory values, no statistically significant difference could be shown with respect to the embolization site.

Conclusion

We conclude that long-term outcomes after embolization of the SA in the scenario of SAS after OLT are irrespective of the site of embolization of the SA, whereas a proximal embolization potentially facilitates earlier normalization of liver function. Choice of technique should therefore be informed by anatomical conditions, safety considerations and preferences of the interventionalist.

The effect of end-ischaemic normothermic machine perfusion on donor hepatic artery endothelial integrity

BACKGROUND

Ex vivo normothermic machine liver perfusion (NMLP) involves artificial cannulation of vessels and generation of flow pressures. This could lead to shear stress-induced endothelial damage, predisposing to vascular complications, or improved preservation of donor artery quality. This study aims to assess the spatial donor hepatic artery (HA) endothelial quality downstream of the cannulation site after end-ischaemic NMLP.

METHODS

Remnant HA segments from the coeliac trunk up to the gastroduodenal artery branching were obtained after NMLP (n = 15) and after static cold storage (SCS) preservation (n = 15). Specimens were fixed in 10% neutral buffered formalin and sectioned at pre-determined anatomical sites downstream of the coeliac trunk. CD31 immunohistostaining was used to assess endothelial integrity by a 5-point ordinal scale (grade 0: intact endothelial lining, grade 5: complete denudation). Endothelial integrity after SCS was used as a control for the state of the endothelium at commencement of NMP.

RESULTS

In the SCS specimens, regardless of the anatomical site, near complete endothelial denudation was present throughout the HA (median scores 4.5-5). After NMLP, significantly less endothelial loss in the distal HA was present compared to SCS grafts (NMLP vs. SCS: median grade 3 vs. 4.5; p = 0.042). In NMLP specimens, near complete endothelial denudation was present at the cannulation site in all cases (median grade: 5), with significantly less loss of the endothelial lining the further from the cannulation site (proximal vs. distal, median grade 5 vs. 3; p = 0.005).

CONCLUSION

Loss of endothelial lining throughout the HA after SCS and at the cannulation site after NMLP suggests extensive damage related to surgical handling and preservation injury. Gradual improved endothelial lining along more distal sites of the HA after NMLP indicates potential for re-endothelialisation. The regenerative effect of NMLP on artery quality seems to occur to a greater extent further from the cannulation site. Therefore, arterial cannulation for machine perfusion of liver grafts should ideally be as proximal as possible on the coeliac trunk or aortic patch, while the site of anastomosis should preferentially be attempted distal on the common HA.

Gastrointestinal bleeding due to pseudoaneurysms in children

Radiological embolization is the treatment of choice in adults with visceral artery pseudoaneurysm (PSA) and gastrointestinal bleeding, but pediatric data is scanty. We analyzed the etiology, clinical presentation, and outcome of radiological intervention in children with PSA of celiac (CA) or superior mesenteric artery (SMA) branches. Electronic records of children with PSA of CA or SMA branches were reviewed and data on clinical and laboratory profile, radiological intervention, and outcome was recorded. Eleven children with PSA (5 boys, 11 [7-17] years) were studied. Etiology was liver abscess (n 4), abdominal trauma (n 3), pancreatitis (n 3), and indeterminate in 1 case. Ten (91%) patients were symptomatic: abdominal pain (10, 91%), hematemesis/melena (9, 81%), and Quincke's triad (1, 9%). One child with pancreatic pseudocyst was diagnosed incidentally on imaging. Doppler ultrasound identified PSA only in 3 cases, while computed tomography angiography (CTA) picked all cases. Children with liver abscess, trauma, and unknown etiology had PSA from CA (right hepatic artery 7, left hepatic artery 1). Of the 3 pancreatitis cases, 2 had PSA from SMA (inferior pancreatico-duodenal artery and ileal branch) and 1 from CA (left gastric artery). Radiological embolization was done in 9 (81%) cases (coil 6, glue 2, both 1), without any complications or failure. One case resolved spontaneously and 1 died pre-intervention. Nine intervened cases were asymptomatic in follow-up [6 (1-24) months].Conclusion: Liver abscess, trauma, and pancreatitis are causes of PSA of CA and SMA branches in children. A majority present with gastrointestinal bleeding and are identified on CTA. Radiological embolization was safe with 100% success. What is Known: • Pseudoaneurysm of visceral artery is an uncommon cause of gastrointestinal bleeding. • Endoluminal intervention is an established and efficacious treatment modality in adults and preferred over surgery. What is New: • Liver abscess, abdominal trauma and pancreatitis are common causes of celiac artery and superior mesenteric artery branch pseudoaneurysm in children and computed tomography angiography has high sensitivity in identifying these pseudoaneurysms. • Minimally invasive radiological angio-embolization, in the hands of trained radiologists, is a safe and successful modality of treatment in children.