Embolization Of Pseudoaneurysm Research Articles

Covid-19-related pulmonary artery pseudoaneurysm managed with endovascular intervention

BackgroundPulmonary pseudoaneurysm (PAP) is a fatal complication of severe acute respiratory syndrome caused by coronavirus 2 infections in the lungs. Other causative agent such as fungal and tubercular also responsible for this entity. Early detection and treatment can save a patient’s life.Case presentationHere we describe a case of a left pulmonary artery pseudo aneurysm in a 54-year-old patient with COVID-19 pneumonia who presented with massive hemoptysis and which was treated with endovascular embolization.ConclusionIt is caused by vasculopathy due to immunosuppression /immune dysregulation in COVID-19. Minimally invasive endovascular embolization of pseudoaneurysm carries less mortality and morbidity.

Postpercutaneous nephrolithotomy pseudoaneurysm embolization – Immediate endovascular coil migration into the pelvicalyceal system causing obstruction

ABSTRACT Bleeding is the most dreaded complication after percutaneous nephrolithotomy (PCNL). We report a case of post PCNL hematuria managed with selective angioembolization of the pseudoaneurysm. During the embolization, the emolization coil along with the glue migrated into the pelvicalyceal system from the pseudoaneurysmal cavity. The pseudoaneurysm was again embolized using cyanoacrylate glue and a screening computed tomography was immediately performed which showed the migrated coil along with the glue into the pelvicalyceal system resulting in pelviureteric junction obstruction. The coil was retrieved endoscopically, after the patient was stabilized. To our knowledge, this is the first reported case of an immediate migration of the coil and the urologists should be aware of it.

Coil Embolization of Isolated Gastroduodenal Artery Pseudoaneurysm

Abstract Gastroduodenal artery (GDA) aneurysm is very rare, and it comprises around 1.5% of all visceral artery aneurysms. More common in male (male:female = 4:1) patients attributed to increased alcoholism and incidence of pancreatitis. In this case report, we describe a successful coil embolization of GDA pseudoaneurysm.

Pseudoaneurysms embolization with glue via percutaneous direct puncture: a multicenter experience on 54 patients

BackgroundThis retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach.ResultsFifty-four patients data were collected from five centers.All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable.True aneurysms and lesions treated with embolics other than glue were excluded.Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT.Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization.Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions.Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass.Mean lesions diameter was 19.3 mm (range: 7–30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%).Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy.In 16.6% the percutaneous approach followed previous treatments failure.The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%).Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization.Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome).ConclusionsIn this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Abstract 169: Antiplatelet regimens after pseudoaneurysm embolization with phosphorylcholine coated flow diverters: a series of 180 cases

Introduction Indications for flow diversion for the treatment of cerebral aneurysms have increased remarkably in recent years.1 This has been particularly useful for aneurysms that are difficult to treat via endosaccular or open approaches, such as pseudoaneurysms.2 Flow diversion, however, typically requires dual antiplatelet therapy (DAPT), which can contribute to greater morbidity particularly in patients with ruptured aneurysms or other comorbidities.3 The third‐generation iteration of the Pipeline Embolization Device (PED) incorporates Shield technology, a phosphorylcholine coating designed to reduce thrombogenicity via mimicry of native cell membranes.4 In light of this reduced thrombogenicity, there have been reports of early transition to single antiplatelet therapy (SAPT), or other variations on DAPT, in patients treated with PED Shield. We therefore aim to characterize the antiplatelet regimens, and associated thromboembolic/hemorrhagic outcomes, utilized in patients with aneurysms treated with PED Shield. Methods Factors including demographics, comorbidities, rupture status, devices placed, and antiplatelet regimen, among others, were collected. Follow‐up data including aneurysm thromboembolic complication, hemorrhagic complication, new neurological deficit, aneurysm occlusion, and in‐stent thrombosis were also recorded. Results One‐hundred and eighty patients were included in analysis, 18 of which were acutely ruptured. One hundred and sixty‐two patients had a single device placed, while the remaining had two devices placed. Three patients were maintained on SAPT post‐procedurally (aspirin or clopidogrel), with two additional patients treated with SAPT plus an anticoagulant for other purposes. One hundred and seventy‐two patients were maintained on DAPT, most commonly aspirin/clopidogrel (115), followed by aspirin/ticagrelor (40), and aspirin/prasugrel (16). Seven patients had strokes of any kind, three of which were unrelated to the treatment territory, and two of the remaining 4 were non‐compliant with antiplatelet therapy. One patient had a new intraparenchymal hemorrhage, but no appreciable deficit. Of the 135 patients with 6‐month follow‐up, 77 had complete aneurysm occlusion, and 116 demonstrated no in‐stent thrombosis. Conclusion We demonstrate herein the similar safety profile and efficacy of PED Shield with varying antiplatelet regimens, including SAPT in isolated cases.

Abstract 018: External carotid artery Pseudo aneurysm induced Internal Carotid Artery compression causing acute ischemic stroke

Introduction Here, we describe a patient in whom ischemic stroke was caused by compression of the Internal Carotid Artery (ICA) by a Pseudoaneurysm (PSA) of the External Carotid Artery (ECA) after Gun Shot injury. Eventually, the PSA of the Internal maxillary artery (IMAX) was embolized, resulting in resolution of the patient's symptoms. Methods Case Report Results A 75‐year‐old male with a history of atrial fibrillation on Eliquis presented to the emergency department after sustaining a gunshot wound to the left face. He had extensive injuries through the left masticator and submandibular space with an inferior orbital wall fracture. A Computed Tomography Angiography (CTA) neck showed injuries to the left proximal IMAX with a small PSA. As the PSA was asymptomatic it was managed with observation. On HOD day 13, CTA was done for a brief period of unresponsiveness, which showed high‐grade narrowing of left cervical ICA due to extrinsic compression from PSA which was supplied by a branch of the left ECA with distal re‐constitution (image A). The next day, patient developed right sided plegia and aphasia with NIHSS of 17. A CT head showed no acute intracranial abnormality. The patient underwent emergent Digital Subtraction Angiography (DSA), which demonstrated occlusion of the left cervical ICA from compression from a left IMAX PSA which was treated with n‐butyl‐cyanoacrylate TRUFILL embolization with resolution of flow limitation in the left cervical ICA (Image B1,B2). After embolization, the patient was oriented and able to lift right arm and leg anti‐gravity. Magnetic Resonance Imaging (MRI) was contraindicated due to retained bullet fragments. Repeat CT head did not show stroke. Conclusion A Pseudo aneurysm is characterized by a rupture of the arterial wall and the formation of an aneurysmal sac by the adjacent structures while the sustaining artery remains intact. The most prevalent causes are penetrating or acute blunt neck trauma, hyperextension injury, and injury to the base of the skull (1). Predisposing factors for PSA include carotid endarterectomy or a late complication of carotid artery dissection, infection, radiotherapy, and malignancy (1‐2). Cox et al. reported 124 patients with significant neck and head penetrating injuries. Eleven patients were found to have thirteen head and neck PSA: two in the ICA, one in the vertebral artery, and ten involving branches of the ECA. Two of seven symptomatic PSAs manifested with episodes of massive hemorrhage (3). There have been case reports describing the consequences of an elongated styloid process causing an ischemic stroke due to subsequent dissection and PSA formation (4). According to our knowledge, this case report is one of the first to describe acute ischemic symptoms resulting from ECA PSA‐induced ICA compression, with resolution of symptoms following PSA embolization. The educational value of our case lies not only in the rarity of the condition but also in the uniqueness of its presentation. This case is a fundamental addition to the existing literature on rare neuro‐vascular anomalies leading to potential catastrophic outcomes.

Embolization of pseudoaneurysms in the ureteral branch of the renal artery

BackgroundAlthough transcatheter arterial embolization for pseudoaneurysms is already well-established, ureteral artery pseudoaneurysm embolization is extremely rare. The present case shows a successful transcatheter arterial embolization for pseudoaneurysms in the ureteral branch of the renal artery due to ureteral invasion from gastric cancer.Case presentationA 57-year-old female presented with gross hematuria after treatments for poorly differentiated gastric adenocarcinoma. A contrast-enhanced computed tomography revealed pseudoaneurysms around the right ureter with a massive hematoma in the right ureter and bladder. The diagnosis was ureteral branch pseudoaneurysms resulting from possible retroperitoneal invasion due to pelvic lymph node metastasis of gastric cancer. Transcatheter arterial embolization was performed using gelatin particles, successfully controlling her hematuria without complications.ConclusionsUreteral branch artery embolization, although extremely rare, may be an effective and safe treatment option.

Embolization of Pseudoaneurysms is Associated With Improved Outcomes in Blunt Splenic Trauma

IntroductionThe necessity of angioembolization for all splenic pseudoaneurysms (PSAs) is unknown after blunt trauma. We compared the outcomes of patients with PSAs managed with splenic artery embolization (EMBO) versus no embolization (NO-EMBO). MethodsWe retrospectively reviewed all patients with blunt splenic trauma and PSA on initial computed tomography scan admitted to an academic, urban, Level I trauma center from 2016 to 2021. Patients who had emergent splenectomy or died before discharge were excluded. Demographics, injury and computed tomography characteristics, and details regarding angiography, if pursued, were collected. The primary outcome was failure of nonoperative management (FNOM), as defined by need for delayed splenectomy for the EMBO group versus delayed splenectomy or embolization for the NO-EMBO group. ResultsOne hundred and fifty-six patients were in the final study population, of which 96 (61.5%) were in the EMBO group and 60 (38.5%) were in the NO-EMBO group. Patient demographics and mechanism of injury were similar between the two cohorts. The two cohorts had similar imaging findings, however, EMBO patients had more compartments with hemoperitoneum (2 versus 1, P < 0.01). Patients who underwent embolization had a lower FNOM rate (3.1% versus 13.3%, P = 0.02). ConclusionsSplenic artery embolization in the setting of PSA is associated with lower rates of FNOM versus nonembolization. It is unclear if addressing the PSA itself with embolization drives the decreased FNOM rate.

Selective Arterial Embolization of Pseudoaneurysms and Arteriovenous Fistulas after Partial Nephrectomy: Safety, Efficacy, and Mid-Term Outcomes.

The primary objective was to evaluate the clinical success rate after endovascular embolization of iatrogenic vascular lesions caused during partial nephrectomy. The secondary objective was to evaluate the technical success and to assess potential effects on renal function. We retrospectively included consecutive patients from our center who underwent selective embolization to treat iatrogenic renal arterial lesions induced during partial nephrectomy between June 2010 and June 2020. The technical and clinical success rates and renal outcomes were collected. We identified 25 patients with 47 pseudoaneurysms and nine arteriovenous fistulas. Among them, eight were treated by coils only, eight by liquid embolization agents only, and nine by both. The technical success rate was 96% after the first attempt and 100% after the second attempt. The median follow-up was 27.1 ± 24.3 months. Clinical success, defined as no need for further hemostatic surgery during follow-up, was also obtained in 96% and 100% of patients with one and two attempts, respectively. Renal function estimated by the modification of diet in renal disease equation did not change significantly despite a mean 13.8% ± 15.1% decrease in kidney functional volume estimated by angiography. No complications were attributable to the endovascular treatment. No significant difference was found across embolization agents; however, the subgroup sizes were small. Endovascular embolization is safe and effective for treating iatrogenic arterial lesions after partial nephrectomy: success rates are high, complications are infrequent, and renal function is maintained. Recommendations by interventional radiology societies are needed to standardize this treatment.

Percutaneous Imaging Guided Puncture and Embolization of Visceral Pseudoaneurysms

Background: Visceral pseudoaneurysms (PSAs) are usually treated endovascularly. No official guidelines exist regarding the correct management when this management option fails. The aim of this study is to assess the efficacy and safety of percutaneous imaging guided puncture of visceral PSAs in patients where intra-arterial embolization was unsuccessful or unfeasible.Methods: Five patients with visceral artery pseudoaneurysms (VAPAs) were enrolled in the study. The diagnosis was made using a 64-slice multi-detector computed tomography (MDCT) scanner and all patients were previously considered unsuitable for the procedure or underwent the procedure unsuccessfully; all patients had anemia with hemoglobin loss greater than 2 g/dL in the last 24 hours. A 22-gauge Chiba needle was used to get percutaneous access to the lesion, where N-butyl cyanoacrylate (NBCA) and lipiodol or coils and onyx were subsequently injected.Results: Four patients received a mixture of NBCA and lipiodol in a 1:2 ratio (80%, n = 4), and only one participant received coils and onyx. Primary clinical success was 100% and embolization was not repeated in any cases. No life-threatening secondary conditions or major complications were observed throughout the follow-up period; in one patient an asymptomatic embolic agent migration was reported. Secondary clinical success was also obtained in the current study. None of the remaining four participants experienced re-bleeding episodes or any procedure-related problems.Conclusions: Percutaneous embolization of visceral PSAs is a safe and effective treatment alternative that should be considered when the trans-arterial method cannot be used.

Embolization of Renal Pseudoaneurysm Following Partial Nephrectomy of Localized Tumour and Preserving Renal Function: Clinical Case and Review of Literature

Surgical procedures in highly vascularized renal parenchyma sometimes can cause iatrogenic vascular complications. Although incidence renal pseudoaneurysms after partial nephrectomy is low, around 1%, clinical presentation of these patients can be quite severe – hematuria, lumbar pain, dizziness, weakness. Prompt and precise diagnostics and treatment are essential. Ultrasound and Computed Tomography are two most common diagnostic approaches for the assessment of pseudoaneurysms or arteriovenous fistulas following partial nephrectomy. Endovascular selective microcoil embolization is a safe and effective kidney-preserving procedure for treating iatrogenic vascular complications. Although when embolizing renal arteries some of renal parenchyma loses perfusion and becomes fibrotic, no significant decrease in renal function in early post-embolization period was noted. Comparing open surgery to endovascular treatment of pseudoaneurysms, latter one allows shorter average hospital stay and less frequent cardiac and peripheral vascular complications. The article discusses a case of a patient that had developed renal pseudoaneurysm after partial nephrectomy. During a routine check-up of a middle-aged woman a presumable renal cyst was found. On more throughout examination the cyst was ruled as a tumour and partial nephrectomy was performed. After 12 days from surgery patient was admitted to hospital complaining macrohematuria, lower abdomen pain, episodic right-side ache. Urgent contrast enhanced computed tomography was performed, which confirmed that patient was bleeding from the operated kidney. Patient was admitted to interventional radiology departament and perform embolization of bleeding vessel. After embolization of pseudoaneurysm, bleeding was controlled and patient was completely treated.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients.

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Percutaneous embolization of renal pseudoaneurysms: A retrospective study.

We evaluated the efficacy of the mixture of autologous blood and a hemostatic agent, oxidized regenerative cellulose (ORC), as an alternative material for ultrasound (US)-guided percutaneous embolization of renal pseudoaneurysm (PA). In this retrospective study, consecutive patients diagnosed with renal PA were included. The exclusion criteria were: PA of the main renal artery, tiny PA not visualized on the colour doppler ultrasonography, PA more than 3 cm in max diameter or extracapsular PA with the possibility of massive bleeding, and patients with a history of coagulation disorders. After localizing the PA, a mixture of autologous blood and ORC was injected under US guidance with a 15G coaxial needle. Patients were followed up for at least 6 months. Twenty-nine patients with PA were included, of which 26 had a history of percutaneous nephrolithotomy, and three patients had a history of renal biopsy (24 men and five women with an average age of 44.3 years). Gross hematuria was the most common mode of presentation. The mean size of the PA was 16.6 mm and the mean duration of follow-up was 9 months. The clinical and the technical success rate was 100%. The PA could be thrombosed in all the patients with a single-session of injection. No acute (hematoma, infection, and bleeding) or chronic (thromboembolic events, renal cortical atrophy, and recurrence) complications were seen. Percutaneous embolization of renal PA under US guidance with a mixture of autologous blood and ORC is an efficient and easily available first-line method to treat this potentially life-threatening condition when endovascular embolization or other expensive thrombotic agents are not available.

PARTIAL NEPHRECTOMY IN RENAL TRAUMA WITH GRADE IV INJURY: DESCRIPTION OF A CASE AND REVIEW OF THE LITERATURE.

Renal trauma is present in 5% of polytrauma cases, which is more frequent in young males. The management of severe renal trauma is a diagnostic and therapeutic challenge that requires the participation of multidisciplinary Urology and Radiology teams. We present the case of a 19-year-old male, with polytrauma secondary to an electric skateboard accident at a speed of 30 km/hour, with direct trauma against a bollard in the right lumbar region. In the chest-abdominal-pelvic CT, right renal lacerations are identied, the largest in the upper pole, without signs of vascular avulsion or active bleeding and retroperitoneal collection suggestive of perirenal hematoma with high-attenuation content surrounding it, compatible with urinary extravasation. Given the hemodynamic stability of the patient and the fact that there was signicant urine extravasation, a double J catheter was inserted. The CT performed at 48 hours shows hypoperfusion of the upper pole and peripheral vascular injury, compatible with several pseudoaneurysms, the largest of which was approximately 14 mm, and small peripheral anomalous vessels with arteriovenous stulas. Given the radiological ndings, selective catheterization of arteriovenous stula afferents and embolization of pseudoaneurysms with microcoils and with cyanoacrylate-lipiodol were performed. Due to the absence of vascularization of the upper renal pole and the persistence of the perirenal collection of blood and urine, it was decided to perform an open lumbar heminephrectomy of the upper pole of the right kidney. The evolution of the patient was satisfactory without hemodynamic or infection problems. One month after surgery, the double J catheter was removed. Six months after the heminephrectomy, the patient is asymptomatic with the disappearance of the perirenal collection and good morphology of the lower right hemi-kidney. Preservation of nephrons after major renal trauma in young patients is a therapeutic approach to be taken into account, despite the technical difculties that may exist.

SC194 - Renal scintigram assessment of the residual renal function following partial nephrectomy and embolization of postoperative pseudoaneurysm or arteriovenous fistula: a single center series

SC194 - Renal scintigram assessment of the residual renal function following partial nephrectomy and embolization of postoperative pseudoaneurysm or arteriovenous fistula: a single center series

Imaging in Uterine Artery Pseudoaneurysm: A Rare, Potentially Fatal Cause of Secondary Post-partum Hemorrhage

Secondary postpartum hemorrhage is one of the important cause of postpartum morbidity and mortality. Uterine artery pseudoaneurysm is a rare, potentially fatal but treatable cause of secondary post-partum hemorrhage. If not diagnosed timely, it can lead to life-threatening hemorrhage. We report the case of a 41-year-old woman who presented with profuse vaginal bleeding on 32nd day of cesarean section. On imaging a left uterine artery pseudoaneurysm was found in the uterine wall with blood clots in the uterine cavity. Patient was managed with aggressive fluid resuscitation and immediate interventional radiology procedure of selective embolization of pseudoaneurysm. High index of suspicion is needed to search for rare vascular causes like pseudoaneurysm.

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.

Late endovascular coil migration following traumatic pulmonary artery pseudoaneurysm embolization: case report

BackgroundPercutaneous vascular interventions are performed for the treatment of haemoptysis and involve embolization of bronchial arteries, pulmonary arteries and pulmonary arteriovenous malformations. There are isolated reports of embolization of pseudoaneurysms forming in the pulmonary vasculature. The migration of components of the coils used in the embolization of vascular pulmonary pathologies is rare.Case presentationA 46-year-old man presented to the emergency department with cough, haemoptysis, and expectoration of lengths of metal wire. He had an episode of coughing out a wire about a year prior to his admission to our hospital, which he attributed to be present in the can of coke he had consumed at that time and did not report it to the doctors. His past medical history was significant for stab injury to the right chest 17 years ago, for which he underwent right thoracotomy and exploration for bleeding. Injury to the lung parenchyma was noted and repair was performed by suturing the defect. Post operatively the CT scan demonstrated development of pulmonary artery pseudoaneurysm. We report a case of a patient expectorating coils 17 years after embolization of this traumatic pulmonary artery pseudoaneurysm. Radiological imaging demonstrated coils in the perihilar area of the lung parenchyma and in the tracheobronchial lumen. Operative intervention was used to remove the coils.ConclusionsAlthough percutaneous catheter based vascular interventions have emerged as safe and effective procedures, the long-term complications such as coil migration, recanalization and need for further embolization ought to be considered and patients need to be counselled and followed-up accordingly. To the best of our knowledge, this is the first case of migrated coil post embolization of post-traumatic pulmonary artery pseudoaneurysm. Ultimately, the management of endobronchial coil migration post embolization, be it surgical or bronchoscopic, should be decided on a case-by-case basis, considering the patient’s symptoms and the risk fatal complications.

A Complication Hanging by a Thread

Question: A 75-year-old man presented with a 1-month history of mild abdominal pain and cramping, associated with weight loss (3 kg). He denied any nausea, vomiting, chills, diarrhea, or hematochezia. The patient reported no trauma. He had a history of ampullary adenocarcinoma treated with pancreaticoduodenectomy 2 years earlier. The postoperative course was marked by hemorrhagic shock owing to a splenic artery pseudoaneurysm that was successfully treated by trans-arterial embolization. On physical examination, the patient was afebrile and had normal vital signs. He had a slight tender abdomen on palpation. Blood tests revealed a C-reactive protein level of 20.2 mg/L (reference value, <3.5 mg/L) and a white blood cell count of 3670/mm3 with 87% neutrophils. Other laboratory tests were unremarkable. A contrast-enhanced computed tomography (CT) scan showed a status post embolization of the splenic artery with hyperattenuating embolic material (Figure A) and long thin hyperattenuating foreign bodies in the small bowel lumen (Figure B–D; the entire CT scan is provided as supplemental material) that were better assessed on a coronal maximum intensity projection view (Figure E). The small bowel wall was normal. There was no sign of bowel perforation, no fluid collection, and no sign of active or recent bleeding. The colon was normal. The pancreaticojejunal anastomosis was unremarkable. There was no evidence of tumor recurrence. What is the diagnosis? Look on page 55 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The pancreaticoduodenectomy was complicated with a pseudoaneurysm arising from the splenic artery (Figure F) that was successfully treated with transarterial embolization with steel wire coils. A postembolization CT scan showed complete occlusion of the lesion and the splenic artery (coronal view; Figure G). There was no bleeding recurrence, and the patient was discharged. The patient was regularly followed-up with a CT scan that showed no evidence of tumor recurrence and no modification of the embolization site. A multidisciplinary team recommended conservative management with no invasive procedure to remove the migrated coils. The patient spontaneously and painlessly evacuated the coils in stools 5 weeks after the diagnosis (Figure H). A contrast-enhanced CT scan performed 3 weeks later showed the evacuation of migrated coils, and the persistence of coils in the splenic artery (Figure I). The patient is currently asymptomatic and free from tumor recurrence. Complications of splenic artery embolization include splenic infarction (1%–2%), splenic abscesses, left pleural effusion (10%), or basal atelectasis (30%), and rarely portal thrombosis. Migration of coils is exceptional and has been described after embolization of splenic pseudoaneurysms owing to vascular coil erosion into the gastrointestinal tract.1Shah N.A. Akingboye A. Haldipur N. et al.Embolization coils migrating and being passed per rectum after embolization of a splenic artery pseudoaneurysm, "the migrating coil": a case report.Cardiovasc Intervent Radiol. 2007; 30: 1259-1262Crossref PubMed Scopus (36) Google Scholar, 2Tekola B.D. Arner D.M. Behm B.W. Coil migration after transarterial coil embolization of a splenic artery pseudoaneurysm.Case Rep Gastroenterol. 2013; 7: 487-491Crossref PubMed Scopus (21) Google Scholar, 3Takahashi T. Shimada K. Kobayashi N. et al.Migration of steel-wire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case.Surg Today. 2001; 31: 458-462Crossref PubMed Scopus (46) Google Scholar As previously reported, migration was a delayed complication (3 months to 10 years in the literature). Of note, several cases reported evidence of infection at the erosion site, which was not present here. Management depends on the extent of material migration and symptoms and ranges from conservative treatment to more invasive procedures (endoscopic or surgical retrieval). No evidence suggests that specific coils are more prone to secondary migration. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwMDVhZjJiODcwMzAzNjk2ZmI2YWIzMjUzYjdlYWQxOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgwMjM3NDk5fQ.LS386lU7wuNg_A2l4X5T61IP2FppVGq2DNjFd7aTwKDD2CnGpQETIi90YGkob6isNUAcHjGC4yhMDhQNo1DG5HKu1dFwUcd02ku-3-ijbtwufokHYbR9GkgBLJJrKiVWexXPcCmjZ80L7FxHY7cNGxrNvpL2raueVLp6qDpzbURZecPBVy2dgcAXpt6jsm1aasdWat3eZkIIzv_GjPqtCeiF2xd_C5fCUMsrsLpgVJRc4TUlfE7LeeevSOcSauQrdo1mVy7_4gMzUgxnWKEuzCzZQJNc2cgIvMo0DQPGSs8o2SDa7TKbqSjnpikBuxPR43PNpPDaTpv5tnSCsdVXbQ Download .mp4 (6.04 MB) Help with .mp4 files Video

Successful transcatheter embolization of splenic artery pseudoaneurysm in acute necrotising pancreatitis.

Splenic artery pseudoaneurysm is a rare condition commonly arises as a sequelae of pancreatitis. Pseudoaneurysm is clinically silent until it ruptures. Thus, untreated pseudoaneurysm carries a high mortality rate up to 90%. We present a case of necrotising pancreatitis complicated with unruptured splenic artery pseudoaneurysm, which was found incidentally from computed tomography (CT) of abdomen. Patient was presented with symptomatic anemia and bleeding from the abdominal drain. We proceeded with embolization of pseudoaneurysm by using Histoacryl glue, resulting in successful complete resolution of pseudoaneurysm with good patient outcome. Transcatheter embolization is considered the current treatment of choice for pseudoaneurysm as it provides an alternative to conventional surgery due to its high successful rate. In this case report, we want to shed light on an alternative treatment approach of the splenic artery pseudoaneurysm.