Type:
Educational Exhibit
Keywords:
Interventional vascular, Vascular, Emergency, CT-Angiography, Catheter arteriography, Diagnostic procedure, Embolisation, Stents, Haemorrhage
Authors:
F. Carchesio1, R. Iezzi2, A. Posa1, R. Manfredi2; 1Roma/IT, 2Rome/IT
DOI:
10.1594/ecr2018/C-2537
Findings and procedure details
We present cases of iatrogenic pseudoaneurysms of splancnic vessels following surgical procedures,
and their endovascular treatment options.
First case:
58 years-old woman,
who underwent duodeno-cephalo-pancreasectomy (DCP),
in 5th postoperative day; he presents hypotension and hematic material from the drainage on the left hypochondrium; basal CT exam demonstrates the presence of hyperattenuating material in the gastro-splenic ligament,
referring to hematic material; CT-angiography shows a pseudoaneurysm of the splenic artery (Fig. 1a,
1b) confirmed on DSA (Fig. 2) and treated by placing a covered stent.
At the end of the procedure,
pseudoneurysm's sac is completely excluded from the flow (Fig. 3).
Second case:
Acute anemization in a 73 years-old male patient in 2nd postoperative day after enucleation of renal neoplasm on left kidney; CT exam shows the presence of an hyperattenuating subcapsular hematoma and the presence of a “pseudobulging” of the profile of a vessel of the III upper kidney,
referring to a pseudoaneurysm (Fig.
4).
DSA confirms the finding and also shows the presence of a second pseudoaneurism of a branch of the same artery (Fig.
5).
The branches of the upper polar artery are then embolized: the first one with 2 coils,
and the second one with glue and a coil.
The post-procedural check demonstrates a complete resolution (Fig.
6).
Third case:
A 67 years-old woman who underwent DCP,
in 7th postoperative day; hematic material from the epigastric drainage; CT exam (Fig.
7) shows an irregular profile of the left hepatic artery - that originates from celiac trunk,
whereas the right hepatic artery arises from the superior mesenteric artery- related to the presence of multiple stenosis and multiple pseudoaneurysms.
DSA ( Fig.
8) confirms these findings.
To prevent ischemic damage and,
at same time,
to prevent a recanalization of the vessel,
at first a coil is positioned in the distal tract of the vessel,
upstream to its segmentary bifurcation and thereafter an embolization with glue (Cianoacrylate) is performed.
At the end of the procedure,
an angiography (Fig.
9) shows the left hepatic artery occlusion with a retrograde perfusion of the segmentary vessels sustained by an accessory left hepatic artery that arises from left gastric artery.
Fourth case:
A 57 years-old male patient who underwent partial gastric resection for a GIST; CT exam shows two pseudoaneurysms of a branch of the pancreatic-duodenal arcade (Fig.
10),
the presence of two pseudoaneurysms is confirmed at the DSA after selective catheterization of the superior mesenteric artery (Fig.11); the cranial one is embolized at first by placing two coils and then glue,
without a complete resolution (Fig.
12a; Fig.12b); the second aneurysm is excluded with glue ( Fig.
13).
Because of the persistence of the first pseudoaneurysm treated,
two coils are positioned in a collateral vessel feeding the sac; angiography at the end of the procedure shows a technical success (Fig.14)