Active Contrast Extravasation Research Articles

Comparative analysis among therapeutic modalities in ruptured hepatocellular carcinoma and identification of imaging predictors for survival

BackgroundSpontaneous rupture of hepatocellular carcinoma (rHCC) poses a life-threatening complication with a mortality rate of 25–75%. Treatment aims at achieving hemostasis and includes options such as trans-arterial embolization, perihepatic packing, and hepatic resection. The optimal treatment remains a subject of debate. Our retrospective review evaluates these treatments and investigates imaging’s role in prognosis for rHCC patients.PurposeWe aimed to compare survival outcomes among rHCC patients who received transarterial embolization (TAE), surgery (perihepatic packing, hepatectomy), or best supportive care (BSC), while also identifying predictive imaging factors in these patients.Materials and methodsAll patients diagnosed with rHCC and admitted to Maharaj Nakorn Chiangmai Hospital between January 2012 and December 2021 were included. We reviewed clinical features, imaging results, treatment modalities, and outcomes. In order to balance pretreatment confounders, inverse probability treatment weighting (IPTW) was employed. Flexible parametric survival regression was utilized to compare survival outcomes and identify imaging factors predicting the survival of rHCC patients. Hazard ratios (HR) and the difference in restricted mean survival time (RMST) were reported.ResultAmong the 186 rHCC patients included, we observed 90-day and 1-year mortality rates of 64% and 84%, respectively. Both the TAE and surgery groups exhibited significantly lower 1-year mortality rates compared to BSC. The HR were 0.56 (95% CI 0.33–0.96) for TAE and 0.52 (95% CI 0.28–0.95) for surgery compared to BSC. Both the TAE and surgery also significantly extended the 1-yeaar life expectancy post-initial treatment when compared to BSC, with an RMST difference of + 55.40 days (95% CI 30.18–80.63) for TAE vs. BSC and + 68.43 days (95% CI 38.77–98.09) for surgery vs. BSC. The presence of active contrast extravasation and bleeding in both lobes were independent prognostic factors for 1-year survival.ConclusionsTAE and surgical treatments provide comparable survival benefits for rHCC patients, extending survival time by approximately 2 months compared to best supportive care. We strongly recommend active management for all rHCC patients whenever possible.

Predictors and pathways of in-hospital mortality in active vascular contrast extravasation detected on abdominopelvic CT

ObjectivesThis study aimed to identify factors influencing in-hospital mortality in adult patients with active vascular contrast extravasation (AVCE) on abdominopelvic computed tomography (CT).MethodsAll consecutive patients with AVCE detected on CT between January 2019 and May 2022 were retrospectively included. Their data were compared through uni- and multivariable analyses between patients with and without in-hospital mortality. Path analysis was utilized to clarify the relationships among factors affecting mortality.ResultsThere were 272 patients (60.2 ± 19.4 years, 150 men) included, of whom 70 experienced in-hospital mortality. Multivariable analysis revealed nonsurgery, chronic kidney disease (CKD) stage 4–5 or dialysis, prolonged partial thromboplastin time (PTT), minimum AVCE length > 8 mm, and a lower rate of packed red cell (PRC) transfusion were identified as independent predictors of in-hospital mortality (p = 0.005–0.048). Path analysis demonstrated direct influences of CKD4-5 or dialysis, prolonged PTT, and minimum AVCE length on mortality (coefficients 0.525–0.616; p = 0.009 to < 0.001). PRC transfusion impacted mortality through nonsurgery (coefficient 0.798, p = 0.003) and intensive care unit (ICU) admission (coefficients 0.025, p = 0.016), leading to subsequent death. Three AVCE spaces (free, loose, and tight) defined on CT were not directly associated with in-hospital mortality.ConclusionIn adults with AVCE on CT, AVCE size had a direct independent influence on mortality, highlighting the critical role of radiologists in detecting and characterizing this finding. Additionally, CKD4-5 or dialysis and prolonged PTT also directly influenced mortality, while the lower rate of PRC transfusion impacted mortality through nonsurgery and ICU admission.Clinical relevance statementIn patients with active vascular contrast extravasation (AVCE) on abdominopelvic CT, larger AVCE directly increased in-hospital mortality. Radiologists’ detection and characterization of this finding is crucial, along with recognizing factors like CKD4-5, dialysis, and prolonged PTT to improve patient outcomes.Key PointsSeveral factors independently predicted in-hospital mortality in patients with abdominopelvic AVCE.Extravasation length > 8 mm was the only imaging marker predictive of in-hospital mortality.Non-imaging factors correlated with in-hospital mortality, and PRC transfusion impacted mortality through nonsurgery and ICU admission pathways.Graphical

Spontaneous rupture of a mycotic splenic artery pseudoaneurysm secondary to histoplasmosis: a case report

BackgroundA splenic artery pseudoaneurysm is a rare pathology that occurs mainly secondary to pancreatitis, abdominal trauma, peptic ulcers, pancreatic and gastric cancers, and infections. It is best diagnosed using computed tomography angiography and typically treated using endovascular embolization and, in some cases, open or laparoscopic surgery. In this report, we present a case of a ruptured mycotic splenic artery pseudoaneurysm containing Histoplasma capsulatum, which to our knowledge is the first case to report a mycotic splenic artery pseudoaneurysm of this nature.Case presentationWe report a case of a 42-year-old white male with past medical history of Hepatitis C and IV drug abuse who presented to the Emergency Department with a 24-h history of severe diffuse abdominal pain. He was tachycardic and peritonitic on exam. Work-up demonstrated leukocytosis and lactic acidosis. Computed tomography of the abdomen and pelvis with intravenous contrast showed hemoperitoneum and active extravasation of contrast from the splenic artery into the splenic hilum, associated with a surrounding hematoma measuring 5.3 × 5.0 cm, concerning for ruptured splenic artery pseudoaneurysm. The patient was taken emergently for exploratory laparotomy, where a large intraperitoneal hematoma was evacuated. A ruptured splenic artery pseudoaneurysm was identified, isolated, and controlled, followed by completion splenectomy. Final pathology demonstrated a 3.0 × 1.3 × 0.3 cm pseudoaneurysm wall and a 14 × 9.5 × 5.5 cm spleen containing multiple necrotizing granulomata positive for the presence of Histoplasmosis species. The patient recovered appropriately and was discharged on post-operative day five.ConclusionsThis case demonstrates a successful approach to a ruptured mycotic splenic artery pseudoaneurysm resulting in a positive outcome. It is a unique case as it highlights, to our knowledge, the first report of splenic artery aneurysm secondary to Histoplasma capsulatum infection. This report helps further the understanding of the pathophysiology as well as the natural history of mycotic splenic pseudoaneurysms.

ANGIOEMBOLISATION OF CREMASTERIC ARTERY FOR SCROTAL HAEMATOMA FOLLOWING HERNIAL REPAIR

Cremasteric artery is a branch of inferior epigastric artery supplying the cremaster muscle and coverings of the cord. The possible consequence of injury to this artery is scrotal haematoma. We present a case of haemorrhage from unexpected cresmastric artery injury post-hernioplasty treated with angioembolisation. To the best of our knowledge, this has not been reported in literature.&#x0D; A 66-year-old gentleman with left indirect inguinal hernia underwent a left inguinal hernioplasty in our institution with no immediate complications. However he presented to the emergency department the day after the procedure with complaints of rapidly worsening painful left scrotal swelling accompanied with symptoms of intestinal obstruction. Emergency laparotomy and re-do left hernioplasty was performed, revealing a strangulated inguinoscrotal hernia. Post-operatively, there was non-resolving scrotal swelling with a drop in the haemoglobin level; from 11.9g/dl to 8.5g/dl requiring packed cell transfusion. CT angiogram revealed active contrast extravasation from the left cremasteric artery. Angiographic run confirmed the finding and the left cresmatric artery was superselectively cannulated with a 1.9Fr microcatheter and embolization done with 0.5mm microcoil. Ultrasound scan 24-hour post-procedure showed patent proximal vessel. Clinically there was a reduction of the left scrotal swelling and the haemoglobin remained stable. &#x0D; Cremasteric artery courses laterally deep into the fascia transversalis entering the cord deep to the internal spermatic fascia to supply the cremaster muscle and coverings of the cord. This course renders the artery to be prone for injury during procedure such as hernioplasty; one of the possible consequences is scrotal haematoma. This artery is usually small in caliber and its identification is important for efficient and effective treatment.&#x0D; Angioembolisation is able to treat this injury with superior precision owing to its ability for localization and selective cannulation of the offending vessel.

Unusual Cause of Acute Stroke in a Young Woman with Patent Foramen Ovale - Duplicated Inferior Vena Cava and May-Thurner Syndrome.

The etiology of acute ischemic stroke (AIS) may often remain uncertain despite diligent work-up, especially in young people. Although patent foramen ovale (PFO) is a frequent association during such work-up, the actual source of thromboembolism, like deep vein thrombosis (DVT), may not be found. Such associative pathology makes it challenging to prescribe anticoagulation for secondary stroke prevention. We describe a young woman with a known history of PFO who presented with AIS and underwent endovascular reperfusion therapy. Post-thrombectomy, she developed hypoxic respiratory failure due to pulmonary embolism. Initiation of therapeutic anticoagulation was complicated by a retroperitoneal bleed necessitating imaging studies for etiological work-up. Computed tomographic angiography and venogram showed no active contrast extravasation but demonstrated duplication of the inferior vena cava with DVT in the right iliofemoral vein (RIFV). The proximity of the right common iliac artery compressing RIFV against the pelvic inlet is described as May-Thurner syndrome (MTS). Afterward, the patient was successfully treated with anticoagulation and PFO closure. MTS is a rare and underdiagnosed cause of iliofemoral DVT. In patients with known PFO, MTS is a possible cause that needs consideration. Hence, appropriate diagnostic tests are necessary to initiate appropriate management and to prevent AIS recurrence.

Early Experience of Transarterial Therapy in Ruptured Hepatocellular Carcinoma

Introduction: Hepatocellular carcinoma (HCC) is the 3rd leading cause of cancer-related mortality. Ruptured HCC carries a high mortality if untreated. Peripherally located HCC has a higher risk of rupture. However, most of the ruptured HCCs on presentation are in an advanced stage and, hence are unresectable. Henceforth treatment options available are conservative and transcatheter embolization. Methods: Retrospectively, 8 patients with ruptured HCC who underwent trans arterial embolization were studied for hemostasis and 30-day mortality. Clinical history and laboratory data were obtained from the medical records of the patients, and radiological images were extracted from picture archiving and communication systems and studied. Results: The age ranged between 31 to 78 years and 7 were male. In patients presenting with sudden onset pain abdomen, ruptured HCC was suspected if there was a hemoperitoneum with or without extravasation of contrast adjacent to peripherally located HCC on CT angiography. Angiography revealed tumour blush with sentinel vessels in all. Two showed active contrast extravasation. Seven patients with relatively preserved liver function (Child A and B) attained both radiological and clinical hemostasis. One patient with Child C status died due to MODS on day 3 of embolisation. Three patients survived more than a year with additional liver-directed therapies. Two patients were lost to follow-up after discharge and two after six months. Conclusions: Transarterial embolization for ruptured HCC is an effective method of hemostasis and helps in achieving better survival by the additional benefit of tumor control and poor functional status of the liver predicts lower survival.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience

PurposeTo retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH).Materials and methodsRetrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed.ResultsPre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms.ConclusionEmbolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury.

Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention. In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BackgroundHere, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.Case presentationA 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.ConclusionsIntercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Spontaneously Ruptured Hepatocellular Carcinoma: Computed Tomography-Based Assessment

Spontaneously ruptured hepatocellular carcinoma (SRHCC) is an uncommon and life-threatening complication in patients with hepatocellular carcinoma (HCC). It is usually associated with chronic liver disease and has a poor prognosis with a high mortality rate during the acute phase. SRHCC can cause a severe and urgent condition of acute abdomen disease and requires a correct diagnosis to achieve adequate treatment. Clinical presentation is related to the presence of hemoperitoneum, and abdominal pain is the most common symptom (66-100% of cases). Although the treatment approach is not unique, trans-arterial (chemo)embolization (TAE/TACE) followed by staged hepatectomy has shown better results in long-term survival. A multi-phase contrast-enhanced CT (CECT) scan is a pivotal technique in the diagnosis of SRHCC due to its diagnostic accuracy and optimal temporal resolution. The correct interpretation of the main CT findings in SRHCC, such as active contrast extravasation and the sentinel clot sign, is fundamental for a prompt and correct diagnosis. Furthermore, CT also plays a role as a post-operative control procedure, especially in patients treated with TAE/TACE. Therefore, a multi-phase CECT scan should be the diagnostic tool of choice in SRHCC since it suggests an immediate need for treatment with a consequent improvement in prognosis.

Abstract No. 177 Quantification of Lower Gastrointestinal Bleed Characteristics on Computed Tomography and Relationship with Findings During Catheter Angiography

Many patients who present with lower gastrointestinal (LGI) bleeding and active contrast extravasation on computed tomography angiography (CTA) do not demonstrate active bleeds during catheter angiography (CA). Bleeding stops spontaneously in many patients, and CA represents an unnecessary procedural risk. The purpose of this study is to determine whether a subset of patients with slow extravasation on CTA are unlikely to have positive catheter angiography. Retrospective review of 100 sequential patients from November 3, 2018, to August 30, 2022, who presented with LGI bleeding and positive CTA and underwent CA from was performed. Volume of extravasated contrast on arterial and portal venous phases was measured by a senior resident and attending abdominal radiologist using 3-dimensional segmentation in Visage Client version 7.1.17. Volume and time between imaging phases was used to calculate hemorrhage rate. Extravasation volume and rate were correlated with active contrast extravasation during CA. Patient age, bleed etiology, blood transfusion volume, hemoglobin, and time from CTA to CA were included for multivariate analysis. Majority of patients in our cohort were males presenting with diverticular bleeds. 55% of patients were found to have active extravasation on CA and of those 63% underwent coil embolization. Using a binary cutoff of bleed rate less than or greater than 0.5 mL/min, there was a significantly greater rate of positive CA with calculated hemorrhage rates greater than 0.5 mL/min than less than 0.5 mL/min (61% vs 25%, P = 0.008). For absolute hemorrhage rate, there was a trend toward more likely positive CA with greater hemorrhage rate which was not statistically significant (P = 0.1). Percent increase of bleed volume between arterial and portal venous phase for patients with positive CA was 297% versus 146% for patients with negative CA (P < 0.05). Additionally, decreased time between CTA and CA approached statistical significance in a multivariate analysis (P = 0.08). While patients with a bleed rate less than 0.5 mL per minute were less likely to have positive CA, 25% of these patients still had a positive CA, suggesting that even patients with a slow bleed by CTA may warrant intervention. There was no correlation between absolute hemorrhage rate and positive CA. Interestingly, percentage increase in extravasated volume between arterial and venous phase was a predictor of CA. These findings may assist in identifying patients likely to have ceased bleeding by the time of CA and would benefit from conservative management rather than intervention.

EUS-directed transgastric endoscopy for upper gastrointestinal bleeding.

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips Figure 3. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient’s anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2,3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.Figure 1: EUS gastro-gastric fistulaFigure 2: LAMS ballon dilatationFigure 3: Conventional endoscopic treatmentDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

N-butyl 2-Cyanoacrylate (NBCA) in Nephron Sparing Superselective Embolization of Iatrogenic Renovascular Injuries: A Single Centre Experience.

Purpose To evaluate the safety and efficacy of N-butyl-2-cyano-acrylate (NBCA) for endovascular management of iatrogenic renal-vascular injuries and effects on renal function. Material & Methods Fifteen patients with diagnosed or suspected iatrogenic renal vascular injuries, following percutaneous procedures formed the study group. All the patients were having retroperitoneal hemorrhage or hematuria, with hemodynamic instability at the time of presentation. Pseudoaneurysms, active extravasation of contrast, and the arteriovenous fistula were identified as the cause of bleeding on digital subtraction angiography. Patients underwent trans arterial super-selective embolization. Renal function was monitored using serum creatinine, estimated glomerular filtration rate (eGFR), and mean blood pressure of all the patients at immediate post-procedure and two months intervals. Results Technical and clinical success was achieved in all the cases using NBCA alone. Patients improved hemodynamically. None of the patients required repeat embolization. No derangement in renal function was observed immediately after the procedure and at interval follow-up. Conclusion NBCA can be used as a safe embolizing agent to provide a quick and effective cure for iatrogenic renovascular injuries. Renal parenchymal loss can be minimized by super selective technique.

Predictors of need for endovascular intervention in hepatic trauma.

Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma. The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE. In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE. In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.

The Role of Renal Artery Embolisation in the Management of Blunt Renal Injuries: A Review

Renal injuries are the most common urinary tract injury secondary to external abdominal trauma. They are caused by blunt, penetrating and iatrogenic mechanisms. Despite the high number of blunt renal injuries, little evidence is available to guide management, especially with the evolution of embolisation as a minimally invasive treatment. Consequently, clinical practice is driven by results of observational studies and anecdote. We have reviewed the current trends in practice when using renal artery embolisation in the management of blunt renal injuries. Three key principles are highlighted. First, high-grade blunt renal injuries can be successfully managed with embolisation. Second, embolisation should be considered when there is radiological evidence of active contrast extravasation, pseudoaneurysm or arteriovenous fistula. Third, embolisation can be used to manage blunt renal injuries in haemodynamically unstable patients. Beyond this, evidence regarding optimal technique, CT indications, clinical status, comorbidities and complications are inconclusive. We discuss the implications for clinical practice and how these findings should define the agenda for future clinical research.

Abstract 11104: Percutaneous Embolization of Extensive Collateral Vessels for Hemoptysis in Pulmonary Aspergilloma

Introduction: Pulmonary aspergillomas form due to fungal colonization in patients with immunocompromise and underlying cavitary lung disease. They can present with hemoptysis due to erosion of pulmonary vessels and formation of collaterals. Arterial embolization of bronchial vessels is considered first line treatment due to effectiveness and minimal invasiveness. We present one patient with need for extensive embolization treatment for persistent hemoptysis. Case: 53yo woman with pulmonary sarcoidosis and bilateral pulmonary aspergilloma presented to our institution for lung transplant evaluation. She had persistent hemoptysis for years after being diagnosed. She previously had bronchial artery embolization at outside hospital but had persistent symptoms severely limiting her functional status. She continued to have active hemoptysis during the admission, including on arrival to procedure. Angiography demonstrated extensive collateral vessels from systemic arterial to pulmonary circulation including several large branches originating from the subclavian arteries, internal mammary arteries and dorsal scapular arteries. There was leak through multiple previously embolized arteries, with active extravasation of contrast. Initial large collaterals were embolized using Medtronic MVP micro-vascular plugs (3Q, 5Q, 7Q) and smaller collaterals from intercostal arteries embolized using Penumbra Ruby Coil. She had improvement following the first procedure, but had persistent hemoptysis requiring repeat procedures to address more collateral and native vessels prior to resolution of symptoms. Conclusions: This patient with bilateral pulmonary aspergilloma had previous unsuccessful coil embolizations and complex collateral vessel system that resulted in severe recurrent bleeds. We successfully treated this patient’s persistent massive hemoptysis after extensive embolizations during multiple challenging procedures.

Pseudoaneurysm as a differential for the computed tomography angiography "spot sign" in atypical presentations of intracerebral hemorrhage: illustrative case.

The computed tomography angiography (CTA) "spot sign" is a well-recognized radiographic marker in primary intracerebral hemorrhage (ICH). Although it has been demonstrated to represent an area of active hemorrhage or contrast extravasation, the exact pathophysiology remains unclear. Vascular mimics of the spot sign have been identified; however, those representing pseudoaneurysm and small vessel aneurysm have rarely been reported. A 57-year-old female with a past medical history of hypertension and diabetes mellitus presented with 2 weeks of acute-onset, worsening headache. Computed tomography scanning showed a right interior frontal lobe intraparenchymal hemorrhage. CTA demonstrated a punctate focus of hyperattenuation within the hematoma, consistent with a spot sign, which corresponded to a distal anterior cerebral artery pseudoaneurysm on a cerebral angiogram. The patient subsequently underwent emergent resection of the pseudoaneurysm and hematoma evacuation without complications. Her postoperative course was unremarkable without acute concerns or residual symptoms at the 4-month follow-up. The authors present a unique case of a distal anterior cerebral artery pseudoaneurysm presenting as a spot sign in a relatively young patient without underlying vascular disease. Given the need for emergent intervention, intracranial pseudoaneurysm is an important diagnosis to consider in the presence of a spot sign in atypical clinical presentations of primary ICH.

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

S3162 Subcapsular Hepatic Hematoma: A Rare Complication of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome in Pregnancy

Introduction: Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is seen in 0.1-1.0% of pregnant people overall, with the risk increased by preeclampsia. Common complications of HELLP include bleeding, disseminated intravascular coagulation (DIC), and abruptio placentae. Here we present a rare case of subcapsular liver hematoma that occurs in only 1% of HELLP patients. Case Description/Methods: A 29-year-old woman, gravida 4, para 3 with a history of preeclampsia during prior pregnancies presents with acute onset epigastric and pelvic pain for one day at 27th-week gestation. The severe, intermittent epigastric pain radiates laterally down to the pelvis and is aggravated with laying down. The review of systems and vitals were normal. Mild tenderness in the right upper quadrant (RUQ) was noted. Labs showed high ALT 233 U/L, AST 378 U/L, low platelet 108,000/microL, and high LDH 519 IU/L. The rest of the labs were normal. She underwent an emergent C-section at admission for HELLP syndrome. An ultrasound showed two complex hypoechoic hepatic mass-like areas measuring 9.3cm and 3.5 cm in the setting of hepatomegaly and diffuse hepatic steatosis suggestive of focal fatty sparing or cavernous hemangioma. Biliary sludge without cholecystitis or cholelithiasis was also noted. An MRI with IV contrast with the liver mass protocol was obtained which showed hepatic subcapsular hematoma of dimensions 24 cm x 9.2 cm x 3.9 cm at the level of the right hepatic lobe. The pain continued to worsen with a drop in hemoglobin from 12.8 gm/dl at admission to 7.1 gm/dl on day 4. IR was consulted for rupture concern and recommended CT angiography of abdomen and pelvis with and without arterial/venous phase that showed similar appearing subcapsular hematoma without an active bleed. Underwent image-guided hepatic angiography that showed large perihepatic hematoma along the right lateral abdominal wall without active contrast extravasation. Right hepatic artery embolization was done with a reduction in peripheral hepatic arterial blood flow by 25%. Later hemoglobin stabilized, liver enzymes improved, and the patient was discharged home 6 days later in a clinically stable state (Figure). Discussion: Early diagnosis of subcapsular hematoma is challenging due to nonspecific signs and symptoms but crucial for improved outcomes. Physicians should evaluate for a subcapsular hematoma in patients with HELLP and RUQ pain or hypotension. Therapeutic options for ruptured hematomas include laparotomy and hepatic artery embolization.Figure 1.: Coronal section of MRI with IV contrast (Liver mass protocol) of abdomen and pelvis demonstrates subcapsular hepatic hematoma involving the hepatic dome and right hepatic lobe approximately measuring 24 cm in craniocaudal dimension.

S1954 An Unusual Location of Pseudoaneurysm in the Setting of Acute Severe Pancreatitis

Introduction: Acute pancreatitis (AP) is one of the most common gastroenterological causes of hospital admissions. The mortality rate of AP is around 10% despite medical advancements. Around 4-17% of cases of acute pancreatitis are complicated by the formation of pseudoaneurysms. The most commonly involved arteries are splenic artery (60-65%), gastroduodenal (20-25%), pancreaticoduodenal (10-15%), hepatic (5-10%) and left gastric arteries (2-5%). We present a case of superior mesenteric artery (SMA) pseudoaneurysm secondary to acute severe pancreatitis. Case Description/Methods: A 33-year-old male patient with a past medical history of alcohol abuse presented to the hospital for abdominal pain after an alcohol binge. He was found to have significant acute kidney injury, metabolic acidosis, and leukocytosis to 24 K/uL. CT showed acute pancreatitis and a large peripancreatic collection consistent with hemorrhage with posterolateral extension into the left iliopsoas space. He was found to have staphylococcus aureus bacteremia thus he was initially treated with fluid resuscitation and cefazolin. Several days into the admission he had an episode of hemodynamic instability with a CT showing a 7 mm pseudoaneurysm seen within the collection with active contrast extravasation. His hemoglobin dropped 2g during this episode requiring pRBC transfusion. He underwent IR coil embolization of the middle colic branch of the SMA (Figure). During a subsequent admission, he had worsening abdominal pain and distension with radiographic evidence of enlarging collections so a drain was placed into the peripancreatic collection by IR with improvement in symptoms. Discussion: Pseudoaneurysm formation is an uncommon but life-threatening complication of pancreatitis. Pancreatic enzymes released in the setting of pancreatic inflammation leak into vessel walls causing destruction. The majority develop in the splenic artery given the proximity to the pancreas. Those in the SMA account for just 5% of cases. CT angiography is the best diagnostic modality for assessing pseudoaneurysm arterial bleeding. Treatment in the past was primarily surgical but with endovascular advancements, embolization with coils or glue is now first line. However, many patients may still require surgery if embolization fails or if hemodynamically unstable. Despite the rarity of pseudoaneurysm formation, it is important to have knowledge of the appropriate diagnostic workup and treatment given the potentially high mortality rate.Figure 1.: IR coil embolization of the middle colic branch of the SMA