Percutaneous treatment of hepatic artery and superior mesentric artery pseudoaneurysm

Transcription

1 Percutaneous treatment of hepatic artery and superior mesentric artery pseudoaneurysm Poster No.: C-0515 Congress: ECR 2012 Type: Educational Exhibit Authors: P. SHARMA, S. KUMAR ; LUCKNOW, UT/IN, LUCKNOW, UP/ IN Keywords: Gastrointestinal tract, Digital radiography, Arterial access DOI: /ecr2012/C Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Learning objectives Pseudoaneurysm are common vascular abnormalities that represent a disruption in arterial wall continuity (1). Pseudoanerysm result from inflammation, trauma, or iatrogenic causes such as surgical procedures, percutaneous biopsy, or drainage. Hepatic and superior mesentric artery pseudoaneurysm are an uncommon vascular problem. Asymptomatic pseudoaneurysm are now diagnosed more frequently due to advances in radiological techniques. Pseudoaneurysm present with varied clinical features : apoplectic to subtle symptoms. High index of suspicion is needed for timely diagnosis and treatment of pseudoaneurysm. The use of noninvasive treatments has lead to a markedly decrease in the morbidity and mortality rates for pseudoaneurysms. Images for this section: Page 2 of 24

3 Fig. 1: 47 year old male patient. (1a & 1b) Coronal and axial CT images showing right hepatic artery pseudoaneurysm as a complication of intervention : Post catheter placement. (1c & 1d) Reconstructed coronal CT images reveal relation of right hepatic artery pseudoaneurysm with tip of catheter. Page 3 of 24

4 Fig. 2: 61 year old male presented with acute necrotising pancreatitis. (2a & 2b) Axial CT images showing bilateral pleural effusion and acute necrotising pancreatitis (2c & 2d) Coronal CT images reveal pseudoaneurysm arising from left hepatic artery. Page 4 of 24

5 Fig. 3: 39 year old male presented with complication of Gastroduodenal artery pseudoaneurysm Post Percutaneous catheter drainage procedure. (3a, 3b, 3c & 3d) Axial and coronal CT images reveal gastroduodenal artery pseudoaneurysm. Page 5 of 24

6 Background The increase in the number of surgical and arteriographic procedures has lead to a real increase in the prevalence of pseudoaneurysms. Interventional radiological techniques offer attractive alternatives to traditional surgical approaches to various vascular lesions. Invasive conventional angiography remains the standard reference for diagnosis of pseudoaneurysm. Noninvasive diagnostic modalities like Ultrasound (USG), Computed Tomography (CT) and Magnetic Resonance Imaging(MRI) should be included in the initial work up of pseudoaneurysm. Pseudoaneurysm may undergo spontaneous thrombosis (2) or may progress with development of complications such as infection, development of local compression on neurovascular structures, or rupture (3). Vasoocclusion was first used to control gastrointestinal bleeding in 1970, and catheter tamponade of bleeding was described in 1974 (4). Symptomatic pseudoanerysm should be treated. Small asymptomatic pseudoanrysm should be observed and treated only if they enlarge, do not resolve, or become symptomatic. Extraorganic visceral pseudoanerysm have very high risk of spontaneous rupture and some authors have advocated definite treatment of all such cases (5). Therapeutic options for treatment of pseudoaneurysm should be tailored to the site, rupture risk and clinical setting of the pseudoaneurysm as well as to patient comorbities. Surgical management still plays an important role in following conditions : (a) failure of minimaly invasive technique (b) infected pseudoaneurysm (c) pseudoanurysm with local mass effect complications Images for this section: Page 6 of 24

7 Fig. 4: Unusual complication of traumatic gastroduodenal artery pseudoaneurysm in a 42 year old male patient : Aneurysmobiliary fistula. (4a & 4b) Axial and coronal MRI image showing gastroduodenal artery pseudoaneurysm. (4c & 4d) Surgical specimen showing gastroduodenal artery pseudoaneurysm and gangrenous gallbladder. Page 7 of 24

8 Fig. 5: T tube cholangiogram 3 weeks after surgery shows no evidence of aneurysmobiliary fistula. Page 8 of 24

9 Fig. 6: Unusual complication of superior mesentric artery pseudoaneurysm in a 47 year old female patient. (6a) Photograph showing tense abdomen due to ascites. (6b) Axial CT image showing superior mesenteric artery pseudoaneurysm with ascites. (6c) Surgical specimen showing leaking superior mesenteric artery pseudoaneurysm. Page 9 of 24

10 Fig. 7: Hemosuccus pancreaticus : 55 year old alcoholic male patient with chronic pancreatitis presented with hematemesis and malena. (7a) Axial CT image showing pseudocyst communicating with main pancreatic duct. (7b) Coronal CT image showing splenic artery pseudoaneurysm. (7c) Surgicaly resected distal pancreaticosplenectomy specimen. Page 10 of 24

11 Fig. 8: 56 year old male presenting with unusual complication of cystic artery pseudoaneurysm : bilateral lobar intrahepatic biliary radical dilatation (8a, 8b, 8c & 8d) Axial noncontrast and contrast CT images reveal cystic artery pseudoaneurysm causing obstruction at hilum with bilateral lobar intrahepatic biliary radical dilatation. Page 11 of 24

12 Fig. 9: (9a, 9b & 9c) Digital subtraction angiogram images reveal cystic artery pseudoaneurysm. Pseudoaneurysm was embolized intra-arterially using coils. (9d) Post embolization angiogram reveals patent hepatic arteries with non visualization of cystic artery pseudoaneurysm. Subsequent CT revealed no intrahepatic biliary radical dilatation. Page 12 of 24

13 Imaging findings OR Procedure details Schematic Digital Subtraction Angiography (DSA), Ultrasound (USG) and Computed Tomography (CT) images are used to illustrate various minimally invasive treatment options available for treatment of hepatic and superior mesentric artery pseudoaneurysm. USG guided percutaneous thrombin injection Percutaneous thrombin injection was first reported in This method fully embrassed only after 2000 (6). Thrombin converts inactive fibrinogen into fibrin, leading to thrombus formation. Thrombin preparation consists of adding sterile normal saline solution to the commercially available sterile thrombin powder. Concentration used can vary from 100 IU/mL to 1000 IU/mL. Under USG guidance, thrombin is injected percutaneously at constant rate until flow within pseudoaneurysm ceases, usually within seconds. Volume of injected thrombin ranges from 0.5 ml to 1.0 ml. Contraindications include history of allergic reaction to thrombin and local infection. This method is specially useful when the donor artery is endoluminally inaccessible. Complication rate as low as 4% have been reported (7). Endoluminal Management Endoluminal management serves to exclude a pseudoaneurysm from the circulation. Selecting the optimal method depends on the size of the pseudoanurysmal neck and the expandibility of the donor artery (8). Two exclusion methods used : embolization and stent placement. Pseudoaneurysm arising from expandable donor artery and not having collateral supply is treated with embolization of the afferent artery. Pseudoaneurysm arising from expandable donor artery and having collateral supply (like hepatic, gastroduodenal and splenic artery), one must embolize both proximal and distal to the pseudoaneurysm to completely exclude it from the circulation. Pseudoaneurysm arising from inexpandable donor artery is excluded from circulation while preserving the donor artery. The width of the pseudoaneurysmal neck relative to the diameter of the donor artery is the determinate factor in the method used. If the neck is narrow, the pseudoaneurysm is embolized with catheter directed delivery of coils into pseudoaneurysmal sac. Page 13 of 24

14 If the neck is wide, than remodeling is required (using devices like stent cage or temporary balloon occlusion of the donor artery) to prevent outflow of embolizing material and to ensure adequate embolization of the pseudoaneurysmal sac. Another option, if the pseudoaneurysmal neck is wide, is stent graft placement across the neck to exclude the pseudoaneurysm. Images for this section: Fig. 10: 58 year old male patient with chronic calcific pancreatitis (10a & 10b) Noncontrast axial CT images showing calcific specks in region of pancreatic parenchyma. Also note hyperdensity anterior to pancreatic neck region. (10c & 10d) Arterial and portovenous phase axial CT images showing gastroduodenal artery pseudoaneurysm within pseudocyst anterior to pancreas. Page 14 of 24

15 Fig. 11: (11a) Noncontrast axial CT images after 20 days reveal calcific specks in region of pancreatic parenchyma. However no hyperdensity was seen anterior to pancreatic neck region. (11b & 11c) Arterial and portovenous phase axial CT images reveal spontaneous resolution of gastroduodenal artery pseudoaneurysm within 20 days. Page 15 of 24

16 Fig. 12: 60 year old male patient having off and on bleeding per rectum post tauma one month back (12a, 12b, 12c & 12d) Digital subtraction angiography images showing pseudoaneurysm arising from branch of ileocolic artery. Page 16 of 24

17 Fig. 13: (13a & 13b) Post Gel Foam embolization Digital subtraction angiography images showing no residual pseudoaneurysm. Page 17 of 24

18 Fig. 14: Rare complication Post Gel foam embolization : Short Bowel syndrome. (14a) Abdominal Radiograph three days after embolization reveals dilated small bowel loops in central abdomen (14b, 14c & 14d) Coronal and axial CT images reveal diffusely thickened, featureless jejunal loops with proximal dilatation, suggestive of mesenteric ischemia. Subsequently patient had to undergo extensive ileal resection with jejunostomy and ileal mucus fistula. Page 18 of 24

19 Fig. 15: 44 year old male patient presented with history of malena for last 3 days. (15a & 15b) Axial arterial phase CT image and Coronal portovenous phase CT image reveals pseudoaneurysm arising from proximal jejunal branch of Superior mesenteric artery. (15c & 15d) Digital subtraction angiogram showing irregular pseudoaneurysm arising from branch of right colic artery with probable supply from middle colic artery. Page 19 of 24

20 Fig. 16: Percutaneous glue injection. (16a, 16b, 16c & 16d) Under ultrasound guidance, pseudoaneurysm was punctured and under fluoroscopic guidance mixture of 2.5 ml endocysl and Lipiodol was injected. Check angiogram showed no filling of the pseudoaneurysm. Page 20 of 24

21 Fig. 17: 47 year old male patient with chronic pancreatitis presented with recurrent malena with fall in haemoglobin level. (17a) Axial CT image showing pseudoaneurysm arising from proximal splenic artery. (17b) Diagnostic angiogram reveals pseudoaneurysm arising from proximal splenic artery. (17c) Image showing placement of stent graft within splenic artery at site of pseudoaneurysm. Page 21 of 24

22 Fig. 18: (18a) Post Stent graft placement angiogram showing patent splenic artery with non filling of pseudoaneurysm. (18b & 18c) Axial CT images four days after the procedure reveals patency of the stent graft and splenic artery. Also note splenic infarct at upper pole of spleen. Page 22 of 24

23 Conclusion The advent of new noninvasive diagnostic imaging techniques with increased sensitivity for asymptomatic disease has led to more frequent diagnosis of pseudoaneurysm. Complete work up to determine the location of pseudoanerysm and to evaluate surrounding structures and relevant vascular anatomy is essential in proper selection of treatment technique. Treatment options include observation, endovascular techniques like coil embolization, stent graft palcement and USG guided percutaneous thrombin injection. Treatment should be tailored to the location, rupture risk, clinical setting of the pseudoaneurysm and to any patient comorbities. Personal Information Dr Pankaj Sharma MBBS, DMRD, DNB, PDCC (Gastroradiology), Fellowship (Abdominal Radiology) pankajrad7477@yahoo.com Dr Sheo Kumar MBBS, MD kumarsheo@yahoo.com Institution : Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India Ph : , Ext 2574 Fax : , Page 23 of 24

24 References Saad NEA, Saad WEA, Davies MG, Waldman DL, et al. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005; 25: Subramanian K, Kumar EN, Gavan DR. Spontaneous resolution of a pancreatic pseudoaneurysm. Clinical Radiology Extra 2004; 59: Morgan R, Belli A. Current treatment methods for postcatheterization pseudoanrysms. J Vasc Intervent Radiol 2003; 14(6): Rosch J, Dotter CT, Brown MS. Selective arterial embolization : A new method for control of acute gastrointestinal bleeding. Radiology 1972; 102: Guillion R, Gracier JM, Abergel A, et al. Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients. Cardiovasc Intervent Radiol 2003; 26(3): Patel JV, Weston MJ, Kessel DO, Prasad GJ, et al. hepatic artery pseudoaneurysm after liver transplantation : treatment with percutaneous thrombin injection - case report. Transplantation 2003, 75 (10): Kurz DJ, Jungius K, Luscher TF. Delayed femoral vein thrombosis after ultrasound guided thrombin injection of a postcatheterization pseudoaneurysm : case report. J Vasc Intervent Radiol 2003; 14(8): Arata MA, Cope C. Principles used in the management of visceral aneurysms. Tech Vasc Intervent Radiol 2000; 3: Page 24 of 24