Hepatic Artery Aneurysms in Infective Endocarditis: Report of 10 Cases and Literature Review

BACKGROUND

Hepatic artery aneurysms (HAAs), albeit rare in infective endocarditis (IE), are associated with a life-threatening morbidity.

METHODS

Retrospective review of 10 HAA-IE patients based on a total of 623 IE patients managed in 2 institutions (2008-2020) versus 35 literature cases.

RESULTS

In our patient population, HAAs (10 males, mean age 48) were incidentally found during IE workup. All were asymptomatic. IE involved mitral (n = 6), aortic (n = 3), or mitral-aortic valve (n = 1). Predisposing factors for IE were as follows: prosthetic valve (n = 6), previous IE (n = 2), IV drug user (n = 1). Streptococcus species (spp.) were predominant (n = 4), then staphylococcus spp (n = 2) and E. faecalis (n = 2). All patients presented associated lesions: infectious aneurysms (n = 5), emboli (n = 9), abscesses (n = 5), and spondylitis/spondylodiscitis (n = 2). HAA patterns on abdominal CT angiography (CTA) were solitary (70%), mean diameter 11.7 mm (range 2-30), intrahepatic location (100%) involving the right HA in 9 out of 10 (90%) patients. In 2 patients, HAAs were complicated (rectorragia and hemobilia in 1, cholestasis in the other). Six patients underwent endovascular hepatic embolization (2 with multiple HAAs). Three HAA-IEs <15 mm resolved under antibiotherapy on abdominal CTA follow-up. All patients underwent cardiac surgery. Late outcome was favorable in all followed patients (5/10). Literature review showed the preponderance of Streptococcus spp., of right lobe and intrahepatic HAA localization. Complications revealed HAAs in patients under antibiotic therapy and/or after cardiac surgery in 17 literature cases of delayed diagnosis.

CONCLUSIONS

Abdominal CTA was pivotal in the initial IE workup. Small aneurysms (≤15 mm) resolved under antibiotherapy. The usual treatment modality was HAA embolization and endovascular embolization before valve surgery was safe.

Middle Rectal Artery Pseudoaneurysm: A Case of Massive Lower Gastrointestinal Bleeding Managed With Coil Embolization

Pseudoaneurysms of the middle rectal artery are rare. When encountered, these have the potential for significant morbidity and mortality due to bleeding and potential rupture. Endovascular embolization is a feasible option in the management of these pseudoaneurysms. The present report describes a case of a 43-year-old male presenting with hemorrhagic shock secondary to lower gastrointestinal bleeding one day after undergoing excision of an external perineal condyloma, incision and drainage of a perirectal abscess, and biopsy of a perianal mass. Angiographic imaging revealed a right middle rectal artery pseudoaneurysm. Selective embolization of the right middle rectal artery and bilateral superior rectal arteries was successfully performed. At the two-week post-embolization follow-up, hemoglobin was stable, and the patient reported normal bowel movements with no episodes of bleeding per rectum.

Spontaneous Subdiaphragmatic Hemorrhage From an Aneurysm of Inferior Phrenic Artery

Inferior phrenic artery (IPA) aneurysms are the rarest type of visceral aneurysms. It usually occurs secondary to trauma, surgery, or as a complication of pancreatitis. In addition, it can be a manifestation of underlying systemic pathology such as vasculitis, collagen vascular disorders, sepsis, or segmental arterial mediolysis. It can be associated with hypertension in 43% of cases. The presentation of IPA aneurysm is nonspecific with abdominal pain, melena, hematochezia, and anemia. The ruptured and actively bleeding aneurysm can lead to hemorrhagic shock, and immediate management is required with angiography and endovascular embolization with coil or gel foam or stent etc. Inaccessible locations are reached with surgical intervention, but it is associated with high morbidity and mortality. We here report a rare case of spontaneously ruptured IPA pseudoaneurysm extending from the posterior mediastinum to the subdiaphragmatic area and managed with coil and gel foam embolization.

Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review

BACKGROUND

To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE).

METHODS

We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020).

RESULTS

Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone.

CONCLUSIONS

SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

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.

A large common hepatic artery pseudo aneurysm: A case report

INTRODUCTION & IMPORTANCE

The Hepatic Artery Aneurysms (HAAs) are rare and asymptomatic with a high rate of rupture. The management is mandatory and depends on the size and the location of the aneurysm.

CASE PRESENTATION

We reported a case of 50 years old male, admitted to sharp epigastric pain. Radiological investigations confirmed a common hepatic artery aneurysm. We indicated an open surgery to repair the aneurysm, the postoperative course finished without any complications.

CLINICAL DISCUSSION & CONCLUSION

HAAs are considered the second most common type of splanchnic aneurysms. Although from the rare occurrence, HAAs have a high rate of rupture. Open repair of the HAAs remains the treatment of choice of degenerative HAAs, to preserve the arterial flow to the liver.

Value of contrast-enhanced ultrasound for vascular diseases of the liver - current indications and open questions

Contrast-enhanced ultrasonography (CEUS) is a widely available and well-tolerated technique that can expand the diagnosis of a variety of vascular liver diseases. This paper presents an overview of the current possibilities of the use of CEUS in vascular liver diseases. Particularly where Doppler sonography has technical limitations, CEUS provides additional opportunities to visualize vascular thrombosis and other obstructions restricting blood flow. When CT or MRI contrast agents cannot be used because of severe allergy or renal insufficiency, CEUS can be a valuable diagnostic alternative and has demonstrated comparable diagnostic performance in at least some vascular liver diseases, such as portal vein thrombosis. In addition, CEUS works without radiation and, therefore, might be particularly suitable for young patients and children. This may be useful, for example, in congenital disorders such as persistent umbilical vein or preduodenal portal vein. Vascular liver disease is rare and comprehensive data are still lacking, but the available literature provides promising insights into potential new ways to study vascular liver disease. Although most studies are based on small sample sizes or even case reports, the high diagnostic utility is undisputed.

Endovascular coil-embolization of an unruptured, true UAA during early pregnancy- a case report

BACKGROUND

True uterine artery aneurysms, especially during pregnancy, are a rare entity and not well understood. Clinical symptoms are unspecific pelvic pain and pressure. Diagnosis can be confirmed by transvaginal color-coded-sonography and/or magnetic resonance imaging. Because of potential risk of rupture, immediate interdisciplinary discussion and treatment planning in the best interests of both mother and child is crucial.

CASE PRESENTATION

We present a 31-year-old pregnant woman with increasing pelvic pain and pressure. Diagnosis of an unruptured uterine artery aneurysm was confirmed by color-coded-sonography and magnetic resonance angiography. After interdisciplinary consultation, successful endovascular super-selective coil-embolization was performed by using X-ray fluoroscopy. Thus, fetal radiation dose during treatment with 4.33 mGy (VirtualDoseTM) was as low as possible with no immediate harm to the fetus.

CONCLUSIONS

Unruptured true uterine artery aneurysms can be successfully treated by endovascular super-selective coil-embolization during early pregnancy with no immediate harm to the fetus.

Endovascular Treatment of a Giant Aneurysm of the Aberrant Right Hepatic Artery in a Patient with Osler-Weber-Rendu Syndrome: A Case Report

Osler-Weber-Rendu syndrome (OWR) is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous or visceral telangiectasias, and arteriovenous malformations in the lungs, liver, brain, and gastrointestinal tract. Hepatic artery aneurysms (HAAs) can also occur in OWR patients. HAAs are the second most common type of visceral artery aneurysm, and mortality rates are high owing to the lack of a tamponade effect. Anatomical variations of the celiacomesenteric vasculature are common, and the most common variation is that of the right hepatic artery originating from the superior mesenteric artery (SMA). We present the endovascular treatment of a patient with OWR and an aberrant right HAA originating from the SMA, with coil embolization and stent grafting. Giant HAAs can be treated endovascularly. However, stent graft placement should be reconsidered because of the need for antithrombotic medication, which may increase the incidence of epistaxis attacks in that patient group.

Intraperitoneal Haemorrhage Secondary to Rupture of Right Colic Artery Pseudoaneurysm: A Case Report and Literature Review

This article presents the case of a 58-year-old woman who presented feeling unwell with pain in the right upper abdomen for three days. She had a history of splenic infarcts, was on lifelong warfarin and had recently returned from a trip to Gambia. She was admitted to the hospital under suspicion of sepsis of unknown origin, and a CT scan later revealed haemoperitoneum along with a pseudoaneurysm of the right colic artery. After initially responding to resuscitation, the patient deteriorated haemodynamically, and a decision was made to perform a laparotomy, revealing a ruptured right colic artery pseudoaneurysm. In this article, the authors highlight the challenges of managing a complex unwell patient with a ruptured right colic artery pseudoaneurysm, emphasising the importance of a multi-disciplinary team approach and shared decision-making and reviewing the available literature.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.

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.

Endovascular embolization of visceral artery aneurysm: a retrospective study

To assess the safety and efficacy of endovascular embolization techniques, we compared the short- to medium-term prognosis of coil embolization for symptomatic visceral aneurysms (SVAA) and asymptomatic visceral aneurysms (ASVAA) to identify risk factors associated with 30-day mortality. Explore the symptom profile and intrinsic associations of SVAA. A retrospective study of 66 consecutive patients at two tertiary care hospitals from 2010 to 2020 compared the short- to mid-term outcomes of 22 symptomatic VAAs and 44 asymptomatic VAAs treated with coil embolization. Univariate and log-rank tests were used to analyze the prognostic impact of SVAA and ASVAA. SVAA group had significantly higher 30-day mortality than ASVAA group (2(9.1%) vs 0, P = 0.042), both patients who died had symptomatic pseudoaneurysms. Perioperative complications such as end-organ ischemia (P = 0.293) and reintervention (P = 1) were similar in both groups. No difference in event-free survival was identified between the two groups (P = 0.900), but we found that the majority of pseudoaneurysms were SVAA (4/5) and that they had a much higher event rate than true aneurysms. In addition, dyslipidemia may be an influential factor in the development of VAA (P = 0.010). Coil embolization is a safe and effective method of treatment for VAA. Most pseudoaneurysms have symptoms such as abdominal pain and bleeding, and in view of their risk, more attention should be paid to symptomatic patients and the nature of the aneurysm should be determined as soon as possible to determine the next stage of treatment.

N-butyl-2-cyanoacrylate Packing of a Gastroduodenal Artery Pseudoaneurysm due to Distal Pancreatectomy After Subtotal Esophagectomy

We describe the successful n-butyl cyanoacrylate (NBCA) packing of a large gastroduodenal artery pseudoaneurysm after distal pancreatectomy in a patient with a history of subtotal esophagectomy and gastric tube reconstruction. The pseudoaneurysm was considered to be caused by direct injury to the gastroduodenal artery (GDA). However, embolization of the GDA was not possible in this case because due to prior esophageal surgery, the main blood vessel supplying the gastric tube was the right epigastric artery from the GDA. Packing a pseudoaneurysm with NBCA is a treatment option when preservation of the parent artery is required.

Coil Embolization of True, Common and Proper, Hepatic Artery Aneurysms: Technique, Safety and Outcome

PURPOSE

To retrospectively assess the safety and efficacy of coil embolization for catheter-directed true common and proper hepatic artery aneurysm exclusion.

MATERIALS AND METHODS

Nine consecutive patients (2005-2021) in two university centers presenting with true common and proper hepatic artery aneurysms (> 2 cm in diameter) were treated with 'frontdoor-backdoor' coil embolization. Patients presenting with a hepatic artery pseudoaneurysm, mycotic aneurysm or patients with small (< 2 cm diameter) aneurysms and followed up by imaging were excluded. Technical and clinical success was defined as complete coil-exclusion of the aneurysm on completion angiography and absence of post-embolization adverse events, in particular mass effect or hemorrhage, respectively. Patient characteristics, technical and clinical success, liver function tests and follow-up results were assessed based on the patients' electronic medical records.

RESULTS

Technical and 30-day clinical success was achieved in all procedures (100%). No major procedural complications were reported. Liver function test values were available in 6/9 patients, showing transient elevation of bilirubin in one patient. No end organ ischemia was reported. The mean clinical follow-up period of the study patients was 72 months (12-168 months). Long-term stable occlusion of the hepatic aneurysms was achieved in 9/9 patients (100%). One patient showed late complication (3 years) with coil migration into a bulbar ulcer, without aneurysm recanalization, however with fatal outcome.

CONCLUSION

Coil embolization for the endovascular exclusion of true common and proper hepatic artery aneurysms is safe and effective.

Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: A multicenter cohort study in the pediatric population

BACKGROUND

Little guidance exists for the treatment of pseudoaneurysm (PA) following pediatric blunt liver and/or spleen injuries (BLSIs). We aimed to describe the incidence of delayed PA development and the subsequent clinical course of PA in pediatric BLSIs.

METHODS

This multicenter retrospective cohort study from Japan included pediatric patients (16 years and younger) who sustained BLSIs from 2008 to 2019. The cohort was divided into four groups based on hemostatic intervention within 48 hours of admission, namely, nonoperative management (NOM), NOM with interventional radiology (IR), operative management (OM), and combined IR/OM. Descriptive statistics were used to describe the incidence of delayed PA among the groups and to characterize the clinical course of any PAs.

RESULTS

A total of 1,407 children (median age, 9 years) from 83 institutions were included. The overall number (incidence) of cases of delayed PA formation was 80 (5.7%), and the number with delayed PA rupture was 16 cases (1.1%) in the entire cohort. Patients treated with NOM (1,056), NOM with IR (276), OM (53), and combined IR/OM (22) developed 43 (4.1%), 32 (12%), 2 (3.8%), and 3 (14%) delayed PAs, respectively. Among patients who developed any PAs, 39% of patients underwent prophylactic IR for unruptured PA, while 13% required emergency angioembolization for delayed PA rupture, with one ruptured case requiring total splenectomy. At least 45% of patients experienced spontaneous resolution of PA without any interventions.

CONCLUSION

Our results suggest that the risk of delayed PA still exists even after acute phase IR as an adjunct to NOM for BLSIs in children, indicating the necessity of a period of further observation. While endovascular interventions are usually successful for PA management, including rupture cases, given the high incidence of spontaneous resolution, the ideal management of PA remains to be investigated in future studies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Endovascular management of iatrogenic arterial injury post bone marrow biopsy: A report of 3 cases

Bone marrow biopsy is an important tool for the evaluation of malignant and benign hematologic disorders. Performed blindly, usually with a Jamshidi biopsy needle penetrating the posterior iliac crest bone, the procedure is generally considered safe but rarely complications are observed; vascular complications associated with bleeding are the most serious and potentially life-threatening. We describe 3 cases of arterial injury following a bone marrow biopsy procedure, all treated successfully with minimal invasive endovascular management, and emphasize the need for clinical awareness and recognition of this rare complication in order to facilitate rapid diagnostic and minimal invasive therapeutic interventions, when appropriate, for successful outcomes.

Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience

Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.

Splenic artery aneurysm masked as a gastroenterology complication: A case report and literature review

INTRODUCTION AND IMPORTANCE

Splenic artery aneurysm has an insidious onset, and low incidence, most of which have no specific manifestations on the early onset and remains the most common visceral aneurysm and third most common splanchnic aneurysm as it still remains a challenge to deal with clinically by many clinicians.

CASE PRESENTATION

We report a single case of a young 21 years old girl who had no potential risk of splenic artery aneurysm on clinical presentation, for gastroenterology disease only assessment and attention in our facility. The patient born and raised on a tropical island in Southern China was clinically diagnosed with splenic artery aneurysm-associated gastroenterological complications which was presented earlier as hematemesis. The patient was considered to have received optimal critical care by our multidisciplinary team and classical features displayed within the clinical settings are worth documenting and contribute perfectly to medical literature as the patient on follow-up is now back to normal life.

CLINICAL DISCUSSION

Our patient recovered excellently on critically close follow-up since the patient had special gastroenterology associated complication features which masked the splenic artery aneurysm with very encouraging post-operative parameters or results.

CONCLUSION

The patient was considered to have received optimal multidisciplinary quaternary medical care for SAAs with gastroenterology-associated complications in our interventional cardiovascular and gastroenterology medicine department.

Ruptured ileocolic artery pseudoaneurysm after laparoscopic appendectomy for acute appendicitis

Background

A pseudoaneurysm of the splanchnic vessels is considered to be rare, and in particular, very few cases of pseudoaneurysm in the ileocolic artery are reported. Here, we report a case of rupture of a pseudoaneurysm of the appendicular branch of the ileocolic artery after laparoscopic appendectomy.

Case presentation

A 52-year-old man was diagnosed as having phlegmonous appendicitis, and an emergency laparoscopic appendectomy was performed. Bleeding from the inter-appendicular ligament during detachment of adhesions was stopped by white coagulation and Z-suture, and the inter-appendicular ligament was treated. The postoperative course was uneventful, and there were no adverse events or findings suggestive of abscess formation. On postoperative day 30, he presented with a ruptured pseudoaneurysm of the appendicular branch of the ileocolic artery. A definitive diagnosis was made by computed tomography, and emergency interventional radiology was performed with hemostasis achieved by coiling. The patient’s postprocedure course was favorable, and he was discharged with no adverse events, such as intestinal ischemia.

Conclusions

We experienced a case of delayed pseudoaneurysm rupture after laparoscopic appendectomy. Care must be taken when handling the appendicular artery during the procedure, and the potential for pseudoaneurysm formation should be considered at postoperative follow-up.

Renal pseudoaneurysm after rigid ureteroscopic lithotripsy: A case report

BACKGROUND

Ureteroscopic lithotripsy (URSL) is a common surgical treatment for ureteral stones. Although flexible ureteroscopy can be used to treat ureteral and renal stones in a single procedure, rigid ureteroscopy can only be used to treat ureteral stones; nonetheless, rigid ureteroscopy remains mainstream in Taiwan owing to its late introduction and flexible ureteroscopy is not covered by national health insurance. Hematuria is a common complication that occurs when the scope passes through stricture sites or when mucosal damage occurs during lithotripsy, but this is usually self-limited. Prolonged hematuria requiring intervention is termed persistent hematuria. Persistent hematuria is less common and few studies have reported the development and etiology of renal pseudoaneurysm after flexible ureteroscopy for renal stones. Herein, we present the first reported case of renal pseudoaneurysm after rigid URSL for ureteral stone.

CASE SUMMARY

The patient was a 57-year-old man who developed renal pseudoaneurysm with active bleeding after rigid ureteroscopy. He presented with gross hematuria and intolerable left flank pain after left URSL. Severe anemia was noted (hemoglobin level, 6.8 g/dL). Contrast enhanced computed tomography revealed one pseudoaneurysm each in the upper and lower renal cortex. He was managed via transcatheter arterial embolization with microcoils, which relieved the symptoms.

CONCLUSION

To the best of our knowledge, ours is the first case report on renal pseudoaneurysm after rigid URSL. Because renal pseudoaneurysms are difficult to access, underlying hypertension, clinical signs such as refractory flank pain, and gross hematuria should be carefully monitored following similar endourological procedures.

Percutaneous N-Butyl-Cyanoacrylate Embolization for Treating Ruptured Pancreaticoduodenal Aneurysm: A Case Report

Background and Objectives: Pancreaticoduodenal artery aneurysms are rare visceral artery aneurysms. Interventional treatments, including transcatheter embolization, have an acceptable success rate. We report a case of ruptured pancreaticoduodenal aneurysm that was successfully treated with percutaneous N-Butyl-cyanoacrylate (NBCA) embolization after failed transcatheter embolization. Materials and Methods: A 53-year-old man presented to the emergency department with abdominal pain. Computed tomography (CT) revealed a ruptured aneurysm in the inferior pancreaticoduodenal artery (IPDA) with retrohemoperitoneum. The patient underwent percutaneous NBCA embolization after transcatheter embolization failure. Results: On CT, the pancreaticoduodenal aneurysm was completely embolized. No additional bleeding events occurred. Conclusions: Percutaneous NBCA embolization is safe and effective for treating patients with ruptured pancreaticoduodenal aneurysms after failed transcatheter embolization.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients: A case report and review of literature

BACKGROUND

The rupture of a splenic artery aneurysm (SAA) in pregnancy is an uncommon condition. However, it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment. Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases, the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.

CASE SUMMARY

We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy. After emergent initial resuscitation, the patient was diagnosed with a ruptured SAA through digital angiography. Immediately upon diagnosis, she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot. Next, surgery was performed to remove the hematoma under stable conditions. Although the fetus was found to be dead during resuscitation, the woman recovered without complications and was discharged 15 d postoperatively.

CONCLUSION

Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Lichtenstein and Total Extraperitoneal Techniques in Inguinal Hernia Surgery: A Comparison of the Intraoperative and Early Postoperative Complications Between the Two Approaches

Background and objective

The Lichtenstein technique (LSt) and total extraperitoneal technique (TEPt) are the most frequently performed surgical procedures for inguinal hernia (IH). This study aimed to compare LSt and TEPt in terms of intraoperative and postoperative complications as well as recurrence rates.

Methods

This retrospective study involved patients hospitalized for IH repair. The study included a total of 262 patients (LSt group: n=125; TEPt group: n=137). 

Results

The follow-up period of the patients ranged between 16 and 30 months (mean: 22.3 months). While intraoperative complications were more commonly reported in the TEPt group, postoperative complications were more common in the LSt group (2.9% vs. 1.6%). Postoperative bleeding/hematoma developed in three (2.4%) patients in the LSt and three (2.2%) in the TEPt group. One of the patients in the LSt group was reoperated due to persistent bleeding. Two patients in the LSt and two in the TEPt group were reoperated for postoperative recurrence (1.6% vs. 2.4%). One patient was reoperated due to chronic persistent pain. Seroma was aspirated in three (2.4%) patients in the LSt and two (1.5%) in the TEPt group.

Conclusion

This study revealed no significant difference between TEPt and LSt groups regarding intraoperative and postoperative complications. We propose that both TEPt and LSt could be safely performed in cases of primary and complex IH by selecting the appropriate method based on the hernia type and patient and with sufficient surgical experience.

Splenic Artery Pseudoaneurysm—A Concern for the Anesthesiologist

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

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

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

Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning

Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.

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.

Laparoscopic transabdominal preperitoneal and totally extraperitoneal in inguinal hernia surgery: comparison of intraoperative and postoperative early complications of two techniques

Purpose

Methods

Results

Conclusion

Splenic artery aneurysm in obstetric patients: a series of four cases with different clinical presentation and outcome

OBJECTIVE

To describe four consecutive cases of splenic artery aneurysm with different clinical patterns of presentation among obstetric patients.

METHOD

A series of four cases of splenic artery aneurysm diagnosed in pregnant or post-partum women at our University center between January 1998 and December 2020. Clinical and radiological data were retrospectively obtained by reviewing paper and electronic medical records after acquiring patient's consent.

RESULTS

One case was completely asymptomatic and incidentally identified at the beginning of pregnancy, thus allowing for multidisciplinary treatment. The other three cases were unknown: two manifested with maternal collapse due to aneurysm rupture in the third trimester of gestation, whereas one presented with acute abdominal pain during the post-partum period and was successfully managed before rupture occurred.

CONCLUSION

Although being extremely rare, SAA rupture in obstetric patients can be associated with dramatic consequences. Since early suspicion and prompt intervention are essential to avoid fatal outcomes, promotion of knowledge of all the potential clinical patterns of presentation of SAA rupture among obstetric patients is mandatory.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery

An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.

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.

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.

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.

Superior Mesenteric Artery Pseudoaneurysm Induced by Accidental Ingestion of a Foreign Body: Case Report

Background

Superior mesenteric artery (SMA) pseudoaneurysm is a very rare condition, typically associated with trauma, inflammation, and infection, and as a post-operative complication. If left untreated it can lead to serious consequences such as rupture and fatal haemorrhage.

Report

A 17 year old male presented to the emergency department with a history of intermittent progressive epigastric pain with no preceding significant symptoms of a possible cause. He was initially treated conservatively until the intensity of pain was so severe an abdominal computed tomography (CT) scan was justified. A pseudoaneurysm of the SMA was found. Full inflammatory and immunological workup was unremarkable. Repeat CT scan showed the SMA pseudoaneurysm was larger, mandating surgical intervention; the vascular surgeon suggested an exploratory laparotomy. Intra-operatively, unexpectedly, a wooden foreign body measuring 5.0 × 0.3 × 0.5 cm was seen once the aneurysm sac was opened. The pseudoaneurysm was repaired and the abdomen closed after ascertaining that all other organs were intact. The patient had a simple recovery with no complications and was discharged home. The follow up CT scans were unremarkable.

Conclusion

Pseudoaneurysm of the SMA in the paediatric age group is an extremely rare and life threatening phenomenon. The clinical presentation may be subtle, leading to delayed diagnosis. Early surgical intervention may be lifesaving and prevent further complications.

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Pseudoaneurysm due to swallowed foreign body is an extremely rare pathology.

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Visceral artery pseudoaneurysm are usually silent but potentially fatal.

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Surgical intervention is mainstay treatment of visceral artery pseudoaneurysm.

Learning from mistakes when reporting urgent and emergency vascular studies

The majority of out-of-hours cases relate to neurological, chest, and gastrointestinal pathologies with acute vascular cases being encountered less commonly. Trainees and exposure of non-vascular/interventional radiology (IR) consultants to angiographic imaging is often limited in working hours and this may lead to reporting on-call cases outside of normal daytime practice. In a recent local review, a number on-call vascular studies were found to contain a number of vascular-related discrepancies. Vascular reporting is a complex subspecialty, which comprises many clear diagnoses (large vessel occlusions, large vessel aneurysms, or dissections); however, also several subtle and complex abnormalities. These more subtle abnormalities, at times, require dedicated vascular specialist review to ensure subtle findings are communicated appropriately to the clinical team. The recent increased complexity of endovascular treatments and their complications has also provided further challenge for the non-specialist reporter. Similarly, improved imaging techniques have allowed for non-obvious but significant findings that may require urgent management, such as small aneurysms and dissection flaps. We will review a range of key vascular findings that demonstrate learning opportunities, particularly within the acute and on-call settings. These will include gastrointestinal haemorrhage, subtle aortic pathologies, head and neck vascular emergencies, small to mid-sized vessel injuries and imaging of post-procedural complications. Educational hints and tips will be provided to enable learning from mistakes encountered by trainees and non-vascular specialist radiologists in the on-call or urgent reporting settings, and these will be reviewed with reference to the literature.

Pseudoaneurysm of the uterine artery with presentation of haematuria; a rare case report

Introduction

Pseudoaneurysm of the uterine artery is a condition in which extra luminal collection of blood with a turbulent flow that communicates with flowing blood of uterine artery through a defect in its arterial wall. As per literature uterine artery pseudoaneurysm is a very rare condition and its incidence is 2–3/1000 deliveries. Clinical diagnosis is very challenging and in the index case haematuria was the presenting complaint which in fact is the extremely rare presenting complaint. Angioembolization is the ideal treatment modality for such a rare condition.

Case presentation

A 25-year old female presented in a shock state with history of massive haematuria two months after delivering a baby. She was resuscitated with fluid, blood and blood products. A computed tomography angiogram was done which showed a large pseudoaneurysm of the left uterine artery so consequently angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.

Discussion

A post-partum massive haematuria could be due to pseudo aneurysm of uterine artery. The presentation of haematuria may occur due to communication of aneurysm with urinary bladder and which further get ruptured. Aggressive resuscitation and angioembolization of the pseudoaneurysm is employed to treat such patients.

Conclusion

Pseudoaneurysm of uterine artery is rare condition which may present as haematuria. Once clinical diagnosis is suspected it's better to first resuscitate and plan for angioembolization for better outcome.

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Pseudoaneurysm of uterine artery presented with haematuria is the first case to be reported in the leterature.

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Clinically the pseudoaneurysm of uterine artery should be considered in mind in patients with massive haematuria after caesarean/normal deliveries.

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Aggressive resuscitation and definitive management with embolization is the ideal treatment for such cases.

Endovascular therapy choices for different sites of delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery: a retrospective study

Background

Angiography and subsequent endovascular therapy is an effective technique for delayed postoperative arterial hemorrhage (PAH) after hepatobiliary pancreatic surgery. In this research, we aimed to evaluate endovascular therapy choices for different sites of delayed PAH after hepatobiliary pancreatic surgery.

Methods

A total of 85 patients with delayed PAH who underwent endovascular therapy at the Department of Radioactive Intervention of Eastern Hepatobiliary Surgery Hospital were retrospectively enrolled. According to the hemorrhage site, participants were divided into 3 groups, all of whom then received embolization, covered stent placement, or a combination of both. Ongoing or recurrent hemorrhages, intervention times, complications associated with intervention, and mortality rate were documented. The chi-squared (χ²) test was used for statistical analysis.

Results

A total of 22 participants with arterial branch hemorrhage underwent superselective embolization. Overall, 81.8% (18/22) of patients underwent embolization once. The successful hemostasis rate was 77.3% (17/22), and the mortality rate was 13.6% (3/22). A total of 53 participants with arterial trunk hemorrhage underwent embolization or covered stent placement. The rate of multi-time intervention, failure to achieve hemostasis, complications associated with intervention, and mortality was lower in the stent group than in the embolization group, and there was a significant difference in complications between the 2 groups (χ²=4.93, P=0.026). Among a total of 10 patients with multisite hemorrhage who underwent embolization, covered stent placement, or a combination, the successful hemostasis rate was 20%; and the mortality rate was 70%.

Conclusions

Superselective embolization is a safe treatment method for arterial branch hemorrhage, and covered stent placement may be a better choice for arterial trunk hemorrhage. Verification of these findings is required via additional large population studies.

The value of systematic follow-up imaging for assessing pseudoaneurysm formation after blunt and penetrating liver injury: A level 1 trauma centre experience

Introduction

Hepatic pseudoaneurysm (HPA) is a rare but potentially life-threatening sequelae of blunt or penetrating liver trauma. At our institution, an imaging protocol for liver injury patients has been developed, with repeat computed tomographic (CT) angiography of the liver 48–72 h post-admission to assess for HPA. The purpose of this study was to evaluate the utility of this imaging pathway in liver trauma for the detection of HPAs.

Methods

A retrospective analysis was performed on patients who were admitted to our institution between January 2014 and January 2018, found to have either blunt or penetrating liver injury on initial CT imaging. Data collection included mechanism of injury, injury severity score (ISS), American Association for the Surgery of Trauma (AAST) liver injury score, initial and follow-up CT findings and secondary intervention.

Results

During the study period, 149 major trauma patients were admitted with liver injuries (mean age 35.6 years; 72% male, 28% female). Seventy two percent of patients suffered blunt (median ISS = 29; median AAST = 2.89) and 28% patients suffered penetrating injuries (median ISS = 16; median AAST = 2.88). The mean time to follow-up CT was 46.1 h. Follow-up CT identified 8 (5.4%) HPAs. 5 (62.5%) of these patients were treated with embolization. ISS and AAST were not associated with pseudoaneurysm formation according to logistic regression analysis; however, ISS (OR 1.06 [1.02, 1.09; p < 0.05]) and AAST (OR 2.24, [1.31, 3.83; p < 0.05]) were associated with requirement for embolization.

Conclusion

Our experience indicates a role for early detection of HPAs using a dedicated trauma imaging pathway.

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.

A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre

INTRODUCTION

Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management.

METHODS

Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020).

RESULTS

There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention.

CONCLUSION

In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.

Focal hepatic intrinsically hyperattenuating lesions at unenhanced CT: Not always calcifications

Due to the growing use of CT, there has been an increase in the frequency of detecting focal liver lesions. Intrinsically hyperattenuating hepatic lesions or pseudolesions are not uncommon at unenhanced CT. Hyperattenuating hepatic lesions can be divided into non-calcified and calcified. Causes of intrinsic hyperattenuation include hemorrhage, thrombosis, and calcifications. Focal liver lesions can show hyperattenuation on unenhanced CT in case of severe liver steatosis. Recognition of etiologies associated with hyperattenuation on unenhanced CT can help the radiologist in characterizing focal liver lesions and pseudolesions. In this paper, we describe the spectrum of intrinsically hyperattenuating focal liver lesions and pseudolesions at unenhanced CT.

Analysis of outcomes of endovascular embolisation: A cross-sectional two-center study on 46 visceral artery pseudoaneurysms

Purpose

Visceral artery pseudoaneurysms (VAPAs) are uncommon in clinical practice but may have serious clinical outcomes up to death. Endovascular management is a safe effective alternative option to traditional surgical procedures. This study assesses the outcome of different embolic materials and techniques used in the endovascular management of VAPAs.

Materials and methods

This is a two-center retrospective analysis of endovascular embolisation of 46 VAPAs, with a mean pseudoaneurysm size of 13 ± 11.35 mm, that were urgently managed between July 2018 and March 2020. Patients’ presentations were GIT hemorrhage, intrabdominal hemorrhage, hematuria, and abdominal pain in 34.78%, 30.43%, 23.91%, and 10.87% respectively. Management using coils only was done in 28/46 patients (60.87%), NBCA glue only in 16/46 patients (34.78%), combined coils and NBCA glue in 1/46 patient (2.17%), and Amplatzer plugs only in 1 patient (2.17%). The management techniques were sac packing in 9/46 patients (19.57%), inflow occlusion in 28/46 patients (60.87%) and trapping in 9/46 patients (19.57%). All patients were followed-up for 1 year after the procedure.

Results

The overall clinical success and periprocedural complication rates were 93.48%, and 15.22% respectively, and 30-day mortality was zero. Clinical success was 92.86% in the coil subgroup (n = 28), and 93.75% in the NBCA glue subgroup (n = 16). The technical success rate was 100%. Effectiveness of the procedures during the follow-up was 97.83%. Target lesion re-intervention rate was 2.17%.

Conclusion

Transarterial embolisation can provide high technical and clinical success rates with low periprocedural complication and re-intervention rates, as well as satisfactory procedure effectiveness in the management of VAPAs.

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.

Percutaneous Trans-Hepatic Embolization of an Iatrogenic Extra-Hepatic Pseudoaneurysm of the Right Hepatic Artery in a Patient With Previous Occlusion of the Proper Hepatic Artery: An Endovascular Procedure to Avoid a Difficult Surgical Repair

We report a case of successful percutaneous transhepatic, embolization of an iatrogenic extra-hepatic pseudoaneurysm (PsA) of the right hepatic artery (RHA) under combined fluoroscopic and ultrasonographic guidance. A 73-year-old man underwent percutaneous transhepatic biliary drainage placement in another hospital, complicated by haemobilia and development of a RHA PsA. Endovascular embolization was attempted, resulting in coil embolization of the proper hepatic artery, and persistence of the PsA. At this point, the patient was referred to our hospital. Computed tomography and direct angiography confirmed the iatrogenic extra-hepatic PsA of the RHA, refilled by small collaterals from the accessory left hepatic artery (LHA) and coil occlusion of the proper hepatic artery. Attempted selective catheterization of these vessels was unsuccessful due to the tortuosity and very small caliber of the intra-hepatic collaterals, the latter precluding endovascular treatment of the PsA. Percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA was performed with Lipiodol® and cyanoacrylate-based glue (Glubran®2). Real time fluoroscopic images and computed tomography confirmed complete occlusion of the pseudoaneurysm. Surgical repair, although feasible, was considered at high risk. In our patient, we decided to perform a percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA using a mix of Lipiodol® and Glubran®2 because of the fast polymerization time of the glue allowing the complete occlusion of the PsA in few seconds, thus eliminating the risk of coil migration, reducing the risk of PsA rupture and avoid a difficult surgical repair.

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.