Type:
Educational Exhibit
Keywords:
Aneurysms, Stents, Embolisation, Fluoroscopy, Catheter arteriography, Interventional vascular
Authors:
F. Sacconi, R. Pozzi Mucelli, F. Pozzi Mucelli, S. Cernic, M. Braini, M. A. Cova; trieste/IT
DOI:
10.26044/ecr2019/C-0822
Findings and procedure details
Case description:
Case n.
1.
Female,
65 yo.
An abdominal CT examination identified a 5 cm aneurysm of the pancreatic-duodenal artery (Fig.1) probably due to an occlusion of the origin of the celiac trunk caused by Dunbar Syndrome.
Follow-up CT demonstrated a mild enlargement of the aneurysm and for this reason an endovascular treatment was proposed.
Considering that coiling of the aneurysm was not an option due to the risk of occlusion of the efferent vessel feeding the gastroduodenal,
hepatic and splenic arteries we considered to treat the aneurysm by deploying a flow-diverter stent.
Procedure was done in local anesthesia with a brachial approach.
After superior mesenteric artery catheterization a 6F guiding catheter (Envoy Cardinal Health) was advanced at the origin of the pancreatic-duodenal artery close to the aneurysm (Fig.2).
After multiple attempts a .014 guidewire (V14 Boston) was advanced distally to the aneurysm.
However this wire did a large “loop” inside the aneurysm (Fig.
3).
For this reason,
a second .014 guidewire was advanced parallel to the first one (Fig.
4) and a rapid exchange balloon 6 mm (Sterling Boston) was inflated close to the distal end of the first wire (Fig.
5).
The first guidewire was gently retracted until the “loop” disappeared.
Also the second guidewire could be straightened and the guiding catheter was advanced distal to the aneurysm (Fig.
6).
In this way the flow diverter stent easily advanced in the correct position and was deployed (Fig.
7).
CT follow-up after 3 months shows the correct position of the flow diverter and the exclusion of the aneurysmatic sac (Fig 8-9).
Case 2.
Male,
75 yo.
An asymptomatic iuxtarenal abdominal aortic aneurysm was detected during abdominal US performed for unrelated pathology.
CT-angiography confirmed a 6.5 cm aneurysm starting just below the origin of the superior mesenteric artery (SMA) and involving both renal arteries.
An EVAR treatment was planned with “parallel” stenting of both renal arteries and SMA.
After surgical cutdown of the axillary artery two long introducer-sheaths were advanced in SMA and left renal artery.
Right renal artery was approached from one of two femoral accesses however advancement of stiff guidewire (Amplatz Superstiff- Boston) was problematic due to unfavourable angle.
For this reason we decided to inflate an occlusion balloon (Medtronic) while advancing the stiff wire in the right renal artery (Fig.
10) and after this,
with the same modality,
a long introducer sheath was introduced inside the artery (Fig.11-12).
In this way the deployment of the covered stent could be done easily.
Thus EVAR treatment was completed as usual with a good result (Fig.13-14).
Case 3.
Male 68 yo.
History of HCC treated with multiple chemoembolization procedures.
At CT follow-up an incomplete response was detected in a nodule of the 7th segment and a feeding artery supplied by right diaphragmatic artery was suspected.
Selective angiography of celiac trunk was done,
but visualization of right diaphragmatic artery was faint (Fig.
15).
In order to increase the caliber of the small diaphragmatic artery and improve its visibility, we inflated a balloon distally to the origin of the artery,
this way occluding the parent artery (Fig.
16).
This manouver allowed an easier catheterization by enhancing the visibility of the feeding artery and the small HCC nodule (Fig 17-18).