Failure Of Embolization Research Articles

Treatment strategies for bleeding from gastroduodenal artery pseudoaneurysms complicating the course of chronic pancreatitis-A case series of 10 patients.

We analyzed our experience with management of gastroduodenal artery (GDA) pseudoaneurysms associated with chronic pancreatitis using a multidisciplinary approach. We treated 10 patients with GDA pseudoaneurysms (all men, aged 24-62year) who underwent treatment during April 1998 to December 2016. All had presented with recent hematemesis and/or melena. Hemodynamically, stable patients were initially subjected to transcatheter embolization or radiologically guided thrombin injection. Recurrence of bleeding within 48h was taken as failure. Emergency surgery was done for hemodynamic instability and recurrent bleeding, and elective surgery was carried out as per specific indications. Ten interventional procedures were performed in nine patients, while one was directly subjected to surgery. Angioembolization was done in five patients (with success in four) and thrombin injection in five patients (including one with embolization failure; with success in three). Six patients underwent surgery, two on emergency basis, for hemodynamic instability and recurrent bleeding in one each, and four for definitive treatment of pancreatitis/associated complication. One patient died while the other nine survived and well with no recurrence of bleeding during follow up (6months to 10years). Management of GDA pseudoaneurysms requires a multidisciplinary approach. Pseudoaneurysms with narrow neck are suitable for thrombin injection while those with wide neck should be subjected to angioembolization. Emergency surgical treatment is reserved for non-surgical failures, and choice between trans-ductal or trans-cystic approach is based on the location of the aneurysm.

Transcatheter arterial embolization of acute bleeding as 24/7 service: predictors of outcome and mortality.

To analyze times of occurrence and identify risk factors (RFs) for technical and clinical failure and mortality of transcatheter arterial embolization (TAE) of acute bleeding in a major hospital. All TAEs performed at our hospital from 2006 to 2013 (n = 327) were retrospectively analyzed. TAEs were performed during regular weekday hours in 165 (50%) and during off-hours in 162 (50%) cases. With 40 regular and 128 off-hours/week, 3.25 times more TAEs were performed during regular hours. There was an even distribution across weekdays (Mon-Fri:16.9 ± 1.5%), while fewer TAEs were performed on weekends (Sat: 8.3%, Sun: 7.3%). Technical success of TAEs was 93.9% with a clinical success of 79.2% and a 30-day mortality of 18.4%. Shock was an RF for technical failure (p = 0.022). RFs for clinical failure were low hemoglobin (Hb) (p = 0.021) and transfusion of ≥6 units packed cells (p = 0.009). Independent RFs for mortality were clinical failure (p < 0.001), coagulopathy (p = 0.005), and shock (p < 0.001). Our results provide no evidence for a subjectively perceived increase in TAEs during off-hours but rather appear to show that most TAEs are performed during regular hours. Prompt TAE to control acute bleeding is crucial to prevent a drop in Hb with shock and the need for transfusion, which may promote coagulopathy and rebleeding, all of which are risk factors for a negative outcome. The presented analysis provides insights of occurrences and risk factors for success of transcatheter arterial embolization in acute bleeding in a large study population.

Splenic artery embolisation in trauma: A five-year single-centre experience at a UK major trauma centre

Introduction Since the introduction of major trauma centres and regional trauma networks in 2012, management of splenic injury has shifted, with non-operative management now favoured. For those requiring intervention, splenic artery embolisation is well established as a first-line treatment in all but the most severely injured. Follow-up is variable, with few guidelines, highlighting the paucity of data addressing the need for further imaging and antimicrobial prophylaxis. This review was undertaken to assess practice and outcomes at our centre in the context of the contemporary literature. Methods This retrospective study captured splenic embolisations over five years (January 2012–December 2016). CRIS interventional radiology codes were used to retrieve embolisation cases and Trauma Audit and Research Network and hospital event statistics data were used to identify all cases of traumatic splenic injury and to identify splenectomy and non-operative management patients. Outcomes were compared with available standards from different sources. Results Over the study period 176 splenic injuries were identified, of which 122 underwent non-operative management, 28 were laparotomy first, and 26 undergoing embolisation with an increased trend to an ‘embolisation-first’ approach over this time. In the embolisation group, the age range was 16–79 yr (mean 41), 18 were male and the median time to intervention was 2 h 9 min (range 1.1–171 h), with eight following failed non-operative management. The proportion of proximal versus selective embolisation versus both was 10:14:1 and the predominant mechanism was coiling. One patient was not embolised due to absence of contrast extravasation on initial angiogram and two proceeded to splenectomy due to failure of splenic artery embolisation. There were complications in six patients: five ongoing left upper quadrant pain, one infected haematoma requiring drainage, two chest infections with pleural effusions, one of which required drainage. There were two deaths from other injuries. Fifteen of the 25 patients who underwent splenic artery embolisation had follow-up imaging, seven did not and three were excluded due to splenectomy and/or death; five patients were vaccinated according to the hospital splenectomy protocol, and six received prophylactic antibiotics. Conclusion Our data show that non-operative management is the mainstay of treatment for the majority of splenic injury patients. Serious complications are not common but variation does exist in follow-up. The changing management trends are in line with national data. These findings will help to further implement and develop local protocols but more work is required to address splenic function after embolisation and the requirement for antimicrobial prophylaxis.

The Failure of Uterine Artery Embolization with Methotrexate Infusion Combined Curettage as Treatment for Cesarean Scar Pregnancy – A Case Report

The rates of caesarean scar pregnancy have increased. An increasing incidence has been considered most likely related to much higher rates of cesarean section. It is a rare and potentially life-threatening complication of pregnancy because of misdiagnosis. Therefore, it is important to train gynecologists and sonographers in timely diagnosis of CSP and management. Here we present one cases of CSP that were treated in our department by uterine artery embolization with methotrexate infusion combined curettage. She was treated successfully by laparotomy because of profuse bleeding 21 days after UAE.

Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective.

There is no standard protocol for the management of non-operative liver or spleen injuries (LSI). In 2011, our institution changed the non-operative management (NOM) protocol of LSI from prolonged bed rest (PBR) to early mobilization (EM). We aim to show that EM safely decreases length of stay (LOS), ICU LOS, and cost. We conducted a retrospective review in which non-operative LSI patients observed PBR from January 2008 through July 2011 and were mobilized early from August 2011 through December 2014. Endpoints assessed were length of bed rest, hospital LOS, ICU LOS, failure of NOM, cost, angiography/embolization, and mortality. There were a total of 184 patients with LSI who met study criteria and were not excluded. 77 patients utilized PBR between 2008 and 2011 and 107 followed EM protocol between 2011 and 2014. There was no significant difference in the male to female ratio, age, ISS, anticoagulant use, or MOI. Both groups had similar injury profiles. PBR included 34 liver injuries, 45 splenic injuries and two patients with both. EM included 63 liver injuries, 55 splenic injuries and 11 patients with both (for liver injury p = 0.053, for splenic injury p = 0.37, and for combined p = 0.08). LOS and cost were significantly decreased in the EM cohort. LOS was shortened by 1.07days (p = 0.005) and cost of hospitalization was reduced by $7077 (p = 0.046). There was no difference in NOM failure, angiography/embolization, or mortality. EM in non-operative LSI is safe and cost-effective. It results in decreased LOS and cost without increasing failure of NOM, angiography, embolization, or mortality.

Primary Management of Large Pancreatic Pseudoaneurysm by Ultrasound-Guided Percutaneous Thrombin Injection after Failure of Transarterial Pseudoaneurysm Embolization

AbstractPancreatic pseudoaneurysm is a rare but life-threatening complication secondary to pancreatitis, surgery, trauma, or infection. Early treatment is advocated due to high risk of rupture and bleeding. Surgical treatment has traditionally been the first line but is associated with high morbidity. Transarterial embolization or exclusion is the treatment of choice; however, in cases with failure of endovascular treatment, percutaneous thrombin injection can be used successfully. We present a case of a large pancreatic pseudoaneurysm managed successfully with percutaneous ultrasound-guided thrombin injection after failure of transarterial management.

Predictors of the success and failure of emergency pelvic artery embolisation for primary postpartum haemorrhage: a 12-year review.

This study aimed to identify predictors of the outcome and clinical efficacy of emergency pelvic artery embolisation (PAE) for primary postpartum haemorrhage (PPH) and to assess the post-embolisation fertility of PAE patients in a regional hospital setting. A 12-year retrospective study of patients undergoing emergency PAE was conducted at a regional acute general hospital. Clinical and procedural parameters, clinical outcomes and post-embolisation pregnancy success rates were analysed. There were 47,221 deliveries at the hospital during the study period, of which 33 patients required urgent PAE for primary PPH. The technical success rate of embolisation was 97.0% (n = 32). Clinically adequate haemostasis was achieved by a single embolisation procedure in 24 (72.7%) patients; the remaining eight eventually required surgery to achieve cessation of bleeding. Among the parameters studied, multivariate logistic regression analysis showed that pre-embolisation platelet count (p = 0.036) and maternal age (p = 0.019) were the only significant independent predictors of embolisation failure. Only two patients successfully conceived after PAE, although one of them had an ectopic pregnancy. Emergency PAE is an effective measure to arrest life-threatening bleeding in patients with primary PPH. As low pre-embolisation platelet count and advanced maternal age are associated with higher odds of embolisation failure, careful post-embolisation monitoring may be required for such patients. Embolisation also allows subsequent pregnancy. However, further studies are required to assess the outcomes of post-embolisation pregnancies.

Early microsurgery in a paradigm of “intervention first” for skull base Cognard grade IV dural arteriovenous fistulas

Abstract Background The optimal management of skull base DAVFs remains controversial. Some groups advocate endovascular therapy, which is an efficient therapeutic option, but can be limited by inadequate access to the fistula point, non-target embolization, and recanalization risk. We report our experience in microsurgical obliteration after embolization failure, emphasizing the importance of a prompt effective treatment for the long-term clinical status improvement. Patients and methods This is a retrospective review, on 6 patients undergoing surgery for skull base Cognard grade IV DAVF after one or several failed embolization procedures in our institution between January 2006 and July 2016. Patients and treatments characteristics/outcomes are reported. Results In all patients endovascular therapy had failed prior to surgery. The mean modified Rankin scale from diagnosis to preoperative surgical cure increased from 1.8 range to 2.7. After surgical treatment, symptoms improved in 5 (83.3%), stayed the same in 1 (16.7%). In all cases total elimination of arteriovenous shunting was achieved, without hemorrhage and recurrence during the mean follow-up period of 5.4 years. Conclusion Surgical occlusion of skull base Cognard IV DAVFs yields excellent exclusion rate. However, complete occlusion of the shunt may not lead to clinical improvement if symptoms had been progressing for an excessively long period of time before curative treatment was initiated. Hence the patient remains at risk of rebleeding as long as the shunt is open. We do believe that a single stage endovascular attempt can be decided, but a failed procedure should lead to immediate surgery.

Preliminary experience in uterine artery embolization for second trimester pregnancy induced labor with complete placenta previa, placenta implantation, and pernicious placenta previa

To explore the application of uterine artery embolization (UAE) in complete placenta previa, placenta implantation, and pernicious placenta previa during second trimester pregnancy induced labor. From April 2013 to April 2014, the present hospital admitted 12 cases of second-trimester complete placenta previa, placenta implantation, and pernicious placenta previa. Six of 12 cases at first were given UAE before cesarean section or labor induction. The other six cases, which were introduced into the present hospital after a failed embolization, underwent UAE, followed by hysteroscopy or curettage or laparotomy. None of the 12 patients underwent hysterectomy. The average blood loss of six patients with UAE was 383 ml and the average hospitalization was 8.66 days. While the remaining six patients without embolization in advance experienced 1,533 ml mean blood loss and 18 days in average stay. Among 12 patients, seven reported abdominal pain following embolization, four had a fever, and two had nausea and vomiting. Nine patients were followed-up and the menstrual cycles of seven returned to normal in one+ month, one in two+ months, and one suffered amenorrhea. Among the same nine patients, six menstruated regularly, two had menstrual disorders, and one had amenorrhea. No serious short- and long-term complications were observed. UAE is the safe method to avoid serious bleeding due to complete placenta previa, placenta implantation, and pernicious placenta previa with second-trimester pregnancy termination.

Percutaneous Direct Embolization for Pseudoaneurysm at the Gallbladder Fossa after Cholecystectomy.

Postoperative pseudoaneurysm at the gallbladder fossa is a rare complication of cholecystectomy. The typical clinical presentations of this condition are intraparenchymal or intraperitoneal hemorrhage or rupture into the gastrointestinal tract, and this may be life-threatening. For the treatment of pseudoaneurysms, percutaneous transarterial embolization is considered first-line. We present a case of pseudoaneurysm at the gallbladder following cholecystectomy, which was successfully treated with echo-guided percutaneous transhepatic direct embolization using N-butyl cyanoacrylate, after the failure of transarterial embolization.

Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review.

AIMTo report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODSBetween January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTSFrom January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSIONRescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.

Preliminary application of monopolar coagulation in suturelesslaparoscopic partial nephrectomy

Objective: To study the safety and feasibility of using monopolar coagulation in sutureless laparoscopic partial nephrectomy (LPN). Methods: From February 2015 to March 2016, sutureless LPN using monopolar coagulation was performed on 25 patients with renal tumors. Mean patient age was 50 years (range 31 to 68). Mean tumor size was 4.1 cm (range 1.2 to 10.1). Mean RENAL nephrometry score was 6.1 (range 4 to 12). The renal hilar vessels were clamped in 14 surgeries, whereas 11 surgeries were carried out without clamping. The tumors were resected by cold scissors and monopolar hook. The tumor beds were coagulated by monopolar hookrepeatedly in spray and fulgurate modes.N-butyl-2-cyanoarcrylat (NBCA) was used in 13 patients when bleeding was observed after coagulation. Results: Mean operative time was 129.6 mins (range 70 to 300). Mean warm ischemic timein clamped cases was 22.6 min (range 15 to 32). Mean estimated blood loss was 166 ml (range 10 to 800). Mean hospital stay was 16.2 days (range 7 to 36). Two patients received blood transfusions. One patient received open surgery and suturing repair after failure of selective arterial embolization for postoperative hemorrhage. Two patients had urine leakage without any intervention. Conclusions: The technique using monopolar coagulation in sutureless LPN was safe and feasible. For exophytic and small tumors, the off-clamped technique could berecommended.

Obstructive sleep apnea is the triggering factor for massive hemoptysis : Obstructive sleep apnea and hemoptysis.

The purpose of this study was to investigate the prevalence of obstructive sleep apnea (OSA) in patients with hemoptysis. Files of patients who had undergone bronchial arterial embolization due to hemoptysis between 1 December 2009 and 2015 were evaluated and interviews of patients were conducted until 1 June 2016. Pittsburgh Sleep Quality Index (PSQI), STOP and STOP-BANG surveys were administered. OSA risk was determined with Berlin Questionnaire. Study group consisted of 53 patients and 58 control subjects. Mean age was 46.94±14.36 and 41.97±12.92 in patient and control group, respectively. Of these patients, seven had re-embolization procedure because of recurrence of hemoptysis. High OSA risk was more common among patients with hemoptysis (24.5%, n=13) than the control group (8.6%, n=5) (p=0.023). Percentage of high risk OSA patients with massive hemoptysis, nonmassive hemoptysis, and control subjects was 29.7% (n=11), 12.5% (n=2), and 8.6% (n=5), respectively (p=0.022). There were more high OSA risk subjects among patients with idiopathic hemoptysis 44.4% (four out of nine), while 20.5% (nine out of 53) patients with a known etiology had high risk (p=0.127). The number of patients with high OSA risk was also higher in patients who required a second embolization procedure (four out of seven, 57.1%), while 19.6% of patients without need for re-embolization had high risk (p=0.031). OSA is found to be a risk factor for hemoptysis and also may provoke massive hemoptysis. It seems reasonable to consider OSA as an underlying condition in idiopathic hemoptysis. OSA may contribute to embolization failure.

Validation of an ‘endovascular-first’ approach to spinal dural arteriovenous fistulas: an intention-to-treat analysis

Background/objectiveSpinal dural arteriovenous fistulas (SDAVFs) require pretreatment angiography; embolization can be performed in the same session. To validate this approach, obliteration and morbidity rates of ‘endovascular-first’ (embolization and microsurgery in...

0354: Paravalvular aortic regurgitations with SAPIEN 3 prosthesis lowest seen with balloon-expandable TAVR

Paravalvular aortic regurgitation (PAR) after TAVR has been associated with increased mortality. The Sapien 3 device (Edwards Life-sciences) is different than the prior devices released by the same manufacturer in that it has a skirt designed to prevent paravalvular leak, improved coaxial alignment, and more accurate positioning. To evaluate paravalvular aortic regurgitations after 30-day after TAVI using the Edwards SAPIEN 3 prosthesis. Prospective monocentric study including 66 high-risk or non-operable patients with severe aortic stenosis undergoing TAVI using Edwards SAPIEN 3 prosthesis via transfemoral access, between September 2014 and March 2015. Mean age of patient was 84±7,1 years (70% female). The MDCT estimated an aortic annular diameter 25,07±2mm. Mean logistic EuroSCORE was 15,8±10,8. In our study, the device success rate was 98.5%. The pros-thesis has been deployed correctly in all cases and no failure of valve or embolization had occurred. Post TAVR, mean transaortic gradient decreased from 46,0±12,33mmHg to 8,2±3,37mmHg (p<0.001). No patient had moderate or severe PAR. At 30 days follow up, transthoracic echocardiography (TTE) showed that the PAR was absent or trivial in 66% of patients and mild in the remainder. Possible reasons for this low PAR rate include: 1) the outer polyethylene terephthalate sealing cuff, which enhances paravalvular sealing; 2) more accurate positioning; and 3) improved sizing with adjunctive MDCT. In our study, TAVI with Edwards SAPIEN 3 demonstrated lower paravalvular aortic leak rates than earlier generation devices in patients at high risk for surgery.

Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistulas are a rare and underdiagnosed pathology. Rapid diagnosis and treatment are, however, major determining factors for the outcome of the disease. The spontaneous course of this pathology can result in a substantial degree of morbidity that may be irreversible. Proper interpretation of the MRI imaging, and particularly the medullar angiography, allow for an appropriate level of therapeutic intervention. In our center, surgery is recommended in case of embolization contraindication or failure or in patients with recurrence of the fistula following embolization.

Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation

Persistent type II endoleaks (T2Ls) with sac enlargement after endovascular abdominal aortic aneurysm repair are still of concern in view of the potential for rupture. Current treatments (embolization and stent graft [SG] explantation) are associated with lack of efficacy or high perioperative morbidity and mortality. This study evaluated an alternative technique that combines sacotomy, ligation of patent back-bleeding vessels, and SG preservation for T2L or unspecified endoleak repair. This multicenter study in France included 28 patients (27 men; median age, 78years). Twenty-one patients (75%) had a bifurcated SG (including 3 fenestrated SGs) and seven (25%) had an aortouni-iliac SG (2 for ruptured aneurysm). Unsuccessful embolization had been performed in 10 patients (36%). Four patients (14%) presented sac enlargement with no endoleak visible on computed tomography. The origin of the endoleak remained unspecified in three patients 3 (11%). The median diameter of the aneurysmal sac was 78mm (vs 55mm at the time of endovascular abdominal aortic aneurysm repair) after a median follow-up of 24months. A transperitoneal approach was used in 21 patients (75%) and a retroperitoneal approach was used in seven (25%). A guidewire was placed in the supraceliac aorta in 14 patients, and an occlusion balloon was temporarily inflated in six. Aortic cross-clamping was performed in five patients. T2Ls were identified in 26 patients, and associated with a distal type I endoleak in 1 patient, a type III endoleak in 3, and a type IV endoleak in 1. Two patients presented with endotension. All the endoleaks were treated successfully, with a mean operating time of 120minutes and a mean blood loss of 450mL. One SG was explanted 12days after the procedure because of early infection. One patient died during SG explantation for an aortoduodenal fistula 26months after the endoaneurysmorrhaphy. During a median follow-up of 24months, the control computed tomography scan showed shrinkage of the aneurysmal sac with stable diameters in all patients. No missed T2Ls, no recurrence of T2L, and no SG migration or disjunction was observed. Obliterating endoaneurysmorrhaphy with SG preservation can be considered as an alternative to SG removal in cases of persistent T2L responsible for aneurysmal sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, and reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery.

Lower GI bleeding: a review of current management, controversies and advances.

Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.

Obliterative Endoaneurysmorrhaphy with Stent Graft Preservation for Treatment of Type II Progressive Endoleak

Persistent type II endoleak (EL II) with sac enlargement after endovascular repair of abdominal aortic aneurysm requires treatment to prevent rupture. Embolization is not always effective. Conversion to open repair with stent graft (SG) explantation is a high risk option. The aim of this study was to evaluate the feasibility and immediate results of an alternative technique combining obliterative endoaneurysmorrhaphy (OEA) with SG preservation. The open surgical technique combined sacotomy, ligation of all patent back-bleeding vessels and SG preservation. The aneurysmal shell was tightly closed over the SG to protect it from the intestines. An intra-aortic occlusion balloon was used when clamping was required. Twelve patients were treated with the OEA technique at Amiens University Hospital. All 12 procedures were successful. Four patients had previously undergone unsuccessful transarterial or translumbar embolization. Aortic clamping was performed in four cases. No SG migration or graft dislocation was observed. Follow up computed tomography scan at a median of 12 months showed shrinkage of the aneurysm sac with stable diameters and no recurrence of EL II in all cases. The OEA technique is an alternative option for the treatment of progressive EL II, which can be particularly useful after failure of embolization.

Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients.

The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm. Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms. False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P<0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible. Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.