Endovascular management of visceral artery aneurysms and pseudoaneurysms

Transcription

1 Endovascular management of visceral artery aneurysms and pseudoaneurysms Poster No.: C-2321 Congress: ECR 2016 Type: Authors: Keywords: DOI: Scientific Exhibit I. Paladini, C. Marcato, S. Bruni, E. Epifani, C. Rossi; Parma/IT Interventional vascular, Arteries / Aorta, Abdomen, Catheter arteriography, CT-Angiography, Angioscopy, Angioplasty, Catheters, Aneurysms /ecr2016/C-2321 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 14

2 Aims and objectives The aim of this study was to assess the feasibility and the effectiveness of the endovascular management of visceral artery aneurysms and pseudoaneurysms. Page 2 of 14

3 Images for this section: Fig. 2: Splenic artery aneurysm treated with a covered stent. (A) Pre-procedural selective arteriography showed an aneurism of the splenic artery. (B) A covered stent (Fluency Stent Graft- BARD) was placed to treat the aneurism; a post- procedural arteriography of the splenic artery was immediately performed and showed aneurysm flow exclusion (residual contrast was noted in the aneurysm sack). (C) Another follow-up angiography showed complete aneurysm flow exclusion Surgical Sciences, Radiology - Parma/IT Fig. 1: Left renal artery aneurysm treated with coils and Onyx. (A) Left renal artery aneurysm at CT image reformatted with the Volume Rendering Technique. (B) Preprocedural selective arteriography of the right renal artery showed a narrow neck hilar aneurism. (C) Microcatheterism of the right renal artery confirmed the aneurysm and Platinum coils were placed in the sack. (D) Afterwards Onyx Liquid Embolic System was used to fill the aneurysm sack. (E) Post-procedural CT showed complete aneurysm flow exclusion. Surgical Sciences, Radiology - Parma/IT Page 3 of 14

4 Methods and materials Between January 2006 and December 2015, 42 patients with a diagnosis of 45 visceral artery aneurysms and pseudoaneurysms were evaluated: 40 patients (mean age of 58,85 years) with a diagnosis of 42 aneurysms and pseudoaneurysms of splenic artery (13), renal artery (13), hepatic arteries (5), superior mesenteric artery (2), celiac axis(1), pancreaticoduodenal arteries (5), gastroduodenal artery (1), jejunal branch (1) and ileal branch (1) underwent endovascular treatment. Two out of 42 patients with 3 aneurysms were excluded from endovascular procedure and surgically treated because of a small size aneurysm (inferior to 2 cm of diameter) and a distal or intraparenchimal localization [1-2-3]. Electronic and hardcopy medical records were reviewed for demographic data and clinical variables. Corresponding computed tomography (CT) scans and fluoroscopic imaging were evaluated for treatment planning. The role of both coils and Onyx is the complete filling and exclusion of narrow neck aneurysm to prevent any further enlargement of its sack. Conversely, stents are more suitable to treat wide neck aneurysms both to secure the complete aneurysm flow exclusion and maintain the perfusion and the caliber of the main vessel. In our study, procedures were performed in the endovascular suite under local anesthesia with conscious sedation with Seldinger approach. Platinum Coils (Platinum Free Coils- BALT Extrusion, France; Fibered Platinum Coil- Boston Scientific, USA; MReye- Cook medical, USA) were utilized for aneurysm exclusion in 65% of cases and in combination with Spongostan Adsorbable Haemostatic Gelatin Sponge or Onyx Liquid Embolic System in 2.5%, respectively. Onyx Liquid Embolic System (EV3. USA) was selectively applied in 2.5% of cases. Covered stent grafts (Jostent Stent Graft Peripheral standard-abbot, USA; Hemobahn Stent Graft-Gore, USA; Fluency Stent Graft- BARD, USA) were placed in 12.5% of cases. Cardiatis Multilayer Stent (Cardiatis, Isnes, Belgium) was used in 2.5% of cases. Thanks to its specific geometry Cardiatis may slow the aneurysm blood flow inducing formation of an organized thrombus and keeping the flow in both main artery and aneurysm branching arteries. Neurovascular devices were selectively chosen in fewer cases: Solitare AB Neurvascular Remodeling Device and Xpert (self-expanding non covered stents) were both placed along with detachable coils respectively in 5% and 2.5% of cases. Flow Diverter stent (Fred Terumo) was chosen in 5% of cases to allow regular flow for the aneurysm branching arteries [ ]. Page 4 of 14

5 Images for this section: Fig. 3: Inferior pancreatico-duodenal artery aneurysm treated with coils. (A) Preprocedural selective arteriography of the superior mesenteric artery demonstrated an inferior pacreaticoduodenal aneurysm and a common origin of the common hepatic artery and the superior mesenteric artery. An hypertrofic arc of Buhler was also noted. (B) A superselective microcatheterism of the inferior pancreaticoduodenal artery confirmed the aneurysm. (C) Platinum coils were placed to fill and exclude the aneurysm sack. (D) Postprocedural CT showed complete aneurysm flow exclusion. Surgical Sciences, Radiology - Parma/IT Page 5 of 14

6 Fig. 4: Splenic artery aneurysm treated with a self-expanding stent and coils. (A) Preprocedural selective arteriography of the splenic artery demonstrated a wide neck splenic aneurysm. (B-C) A self-expanding non covered stent (Solitaire) was partially deployed next to the aneurysm neck and detachable coils were placed in the sack. (D) At the end of the procedure Solitaire stent was totally deployed; post-procedural arteriography of the splenic artery showed complete aneurysm flow exclusion and regular perfusion of the remaining artery (E) Post-procedural CT showed complete aneurysm flow exclusion. Surgical Sciences, Radiology - Parma/IT Page 6 of 14

7 Results A total of 26 subjects (65%) were asymptomatic and their vascular abnormalities were indeed CT incidental findings. The remainders (35%) were symptomatic, with 6 subjects (15%) having any ruptured aneurysm. Post-procedural follow up imaging was performed for all the interventions at a mean of 11.6 ± 1-24 months with different imaging techniques such as contrast CT and contrast enhanced ultrasound. The endovascular treatment of visceral artery aneurysms was successful in 95% of cases. Only one subject (2.5%) had major complications not strictly related to the treatment itself, while three subjects (7.5%) showed minor complications with no clinical relevance. Mortality rate was 2.5% due to unrelated causes. Page 7 of 14

8 Images for this section: Fig. 5: Right hepatic segmentary artery pseudoaneurysm treated with coils and Spongostan. (A) Pre-procedural selective arteriography of the celiac axis showed a pseudoaneurism of the segmentary branch of the fifth hepatic segment. (B) A superselective microcatheterism of the right hepatic artery confirmed the pseudoaneurysm. (C) Platinum coils and Spongostan were utilized to occlude the segmentary artery with complete exclusion of the following pseudoaneurism. (D) Postprocedural computed tomography (CT) showed complete aneurysm flow exclusion (some residual contrast was noted in the pseudoaneurysm). Surgical Sciences, Radiology - Parma/IT Page 8 of 14

9 Fig. 6: Common hepatic artery aneurism treated with coils and stents. (A) Pre-procedural selective arteriography of the superior mesenteric artery showed a common origin of the common hepatic artery (variation) and the superior mesenteric artery: a common hepatic artery aneurysm with a wide neck was noted. (B-C) A superselective microcatheterism of the common hepatic artery confirmed the aneurysm. A self-expanding non covered stent (Xpert) was partially deployed in the hepatic artery next to the aneurysm neck, while detachable coils were placed in the aneurysm sack. At the end of the procedure Xpert stent was totally deployed. (D) A covered stent was placed in the origin of the common hepatic artery. (E) Post-procedural arteriography of the superior mesenteric artery showed complete aneurysm flow exclusion and regular perfusion of the remaining arteries. Surgical Sciences, Radiology - Parma/IT Page 9 of 14

10 Conclusion Visceral artery aneurysms can be successfully treated through endovascular tools with low periprocedural morbidity and mortality regardless of their etiology, location, or clinical presentation,. These tools are therefore valid alternative procedures to conventional open surgery. Moreover, in case of disease recurrence an endovascular choice does not preclude the possibility of a second endovascular or surgical treatment [ ]. Page 10 of 14

11 Images for this section: Fig. 7: Right renal artery aneurysm treated with Flow Diverter. (A) Pre-procedural selective arteriography of the right renal artery demonstrated an hilar aneurysm (the superior polar artery originated from the sack). (B-C) A Flow Diverter was placed to both exclude the aneurysm sack and keep flow in the superior polar artery. Surgical Sciences, Radiology - Parma/IT Page 11 of 14

12 Personal information Ilaria Paladini Divison of Radiology, Department of surgical Sciences, University of Parma, Parma, Italy Rossi Cristina Divison of Radiology, Department of surgical Sciences, University of Parma, Parma, Italy Marcato Carla Divison of Radiology, Department of surgical Sciences, University of Parma, Parma, Italy Bruni Stefano Divison of Radiology, Department of surgical Sciences, University of Parma, Parma, Italy Epifani Enrico Divison of Radiology, Department of surgical Sciences, University of Parma, Parma, Italy Page 12 of 14

13 References 1. M. Jana et Al., Endovascular management in abdominal visceral arterial aneurysms: a pictorial essay. World Journal oof Radiology. 2011;3 (7): S. Spiliopoulos et Al., Endovascular treatment of visceral aneurysms and pseudoaneurysms: long-term from a multicenter European study. Cardiovascular and Interventional Radiology. 2012; 35: C. Cordova et Al.,Visceral artery aneurysms and pseudoaneurysms-should they all be managed by endovascular techniques? Annals of Vascular Disease. 2013; 6(4): A. Balderi et Al., Treatment of visceral aneurysms usung Multilayer stent: twoyears follow-up results in five consecutive patients. Cardiovascular and Interventional Radiology. 2013; 36: C. B. Kulkarni et Al., Endovascular treatment of aneurysm of splenic artery arising from splenomesenteric trunk using stent graft. Korean Journal of Radiology. 2013; 14(6): T. Vaines et Al., Endovascular treatment of a hepatic artery pseudoaneurysm associated with gastrointestinal tract bleeding. Journal of Vascular Surgery. 2012;55: R.A. Larson et Al., Stent graft repair of visceral artery aneurysms. Journal of Vascular Surgery. 2002; 36: S. A. Berceli, Hepatic and splenic artery aneurysms. Semin. Vascular surgery. 2005; 18: N.P. Schnidereit et Al., Endovascular repair of a ruptured renal artery aneurysm. Journal of Endovascular Therapy. 2003;10: R.N. Cavalcante et Al., Endovascular treatment of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review. Radiology Case. 2012; 6 (2) A. Plaza-Martinez et AL., Endograft-assisted coil embolization of a celiac trunk aneurysms. Annals of Vascular Surgery. 2014; 28:263.el-263.e A.Ikoma et Al., Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement. World Journal of Radiology.2012;4(8): A. Hussein et AL., Visceral artery aneurysms: experience in a tertiary-care center. The American Surgeon. 2001; Page 13 of 14

14 14. C. Sessa et Al., Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Annals of Vascular Surgery. 2004; 18: S. Saltzberg et Al., Is endovascular therapy the preferred treatment of all visceral artery aneurysms? Annals of Vascular Surgery. 2005; 19: Page 14 of 14