Endovascular Embolisation of Visceral Artery Pseudoaneurysms

Hindawi Publishing Corporation Radiology Research and Practice Volume 2014, Article ID 258954, 6 pages http://dx.doi.org/10.1155/2014/258954 Clinical Study Endovascular Embolisation of Visceral Artery Pseudoaneurysms Yasir Jamil Khattak,1 Tariq Alam,2 Rana Hamid Shoaib,1 Raza Sayani,1 Tanveer-ul Haq,1 and Muhammad Awais1 1 2 Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan Department of Radiology, French Medical Institute for Children, Aliabad, Kabul, Afghanistan Correspondence should be addressed to Raza Sayani; Received 17 March 2014; Revised 8 June 2014; Accepted 10 June 2014; Published 15 July 2014 Academic Editor: Paul Sijens Copyright © 2014 Yasir Jamil Khattak et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To evaluate the technical success, safety, and outcome of endovascular embolization procedure in management of visceral artery pseudoaneurysms. Materials and Methods. 46 patients were treated for 53 visceral pseudoaneurysms at our institution. Preliminary diagnostic workup in all cases was performed by contrast enhanced abdominal CT scan and/or duplex ultrasound. In all patients, embolization was performed as per the standard departmental protocol. For data collection, medical records and radiology reports of all patients were retrospectively reviewed. Technical success, safety, and outcome of the procedure were analyzed. Results. Out of 46 patients, 13 were females and 33 were males. Mean patient age was 44.79 ± 13.9 years and mean pseudoaneurysm size was 35 ± 19.5 mm. Technical success rate for endovascular visceral pseudoaneurysm coiling was 93.47% (𝑛 = 43). Complication rate was 6.52% (𝑛 = 3). Followup was done for a mean duration of 21 ± 1.6 months (0.5–69 months). Complete resolution of symptoms or improvement in clinical condition was seen in 36 patients (80%) out of those 45 in whom procedure was technically successful. Conclusion. Results of embolization of visceral artery pseudoaneurysms with coils at our center showed high success rate and good short term outcome. 1. Introduction Visceral arteries include arteries of the splanchnic circulation and the renal arteries [1]. The pseudoaneurysms of visceral arteries (VPAs) are uncommon and attributed to degeneration of the vessel wall mostly due to infections and adjacent inflammation, trauma, and iatrogenic causes [2]. Hemorrhage due to rupture of these pseudoaneurysms is a rare but often life threatening complication which manifests as intraabdominal or retroperitoneal bleeding and requires emergency treatment [3, 4]. Using digital subtraction angiography the bleeding site can be evaluated followed by embolization of the bleeding vessel or pseudoaneurysm employing superselective catheterization technique [5, 6]. To the best of our knowledge there is no published data available from the developing world regarding clinical presentation, procedural results, and clinical outcome of endovascular management of visceral artery pseudoaneurysms. This study was hence carried out to present details of our initial experience with the procedure at a tertiary care hospital in a third world country. 2. Materials and Methods This cross-sectional study was carried out at radiology department of a tertiary care hospital in third world country. The study was performed in accordance with the declaration of World Medical Association Declaration of Helsinki. The study was exempted from formal ethical approval as per the institution’s policy on retrospective studies and the requirement of informed consent was waived. Data of patients was collected from July 2008 to December 2013. We included all patients who underwent endovascular coiling procedure for visceral artery pseudoaneurysms. A total of 46 patients were found to have visceral artery pseudoaneurysms during the study period. The patients were referred for treatment to our interventional radiology section from clinical departments of our hospital and from other institutions after being diagnosed to 2 Radiology Research and Practice (a) Before embolization (b) After embolization Figure 1: Digital subtraction angiogram. (a) Arrow pointing to a large pseudoaneurysm arising from segmental branch of left renal artery supplying the interpolar region. (b) Arrow pointing to a platinum coil deployed in the segmental branch of left renal artery with successful exclusion of pseudoaneurysm. (a) Before embolization (b) After embolization Figure 2: (a) Arrow pointing to pseudoaneurysm arising from branch of gastroduodenal artery. (b) Arrow pointing to platinum coil placed in gastroduodenal artery with successful exclusion of pseudoaneurysm. have pseudoaneurysm by contrast enhanced abdominal CT scan or duplex ultrasound examination. Medical records and images were scrutinized to gather data regarding age, sex, clinical presentation including the symptoms, location, number, and size of aneurysms, technical success, complications, and outcome of the embolization procedures. Informed consent for the embolization procedure was taken from all patients or their immediate attendants. Embolization was carried out by trained interventional radiologists in dedicated interventional radiology suite on a flat panel monoplane digital subtraction angiography machine (Axiom-Artis; Siemens Medical Systems, Erlangen, Germany). Majority of the cases (30 of 46) were performed under local anesthesia. Femoral artery was punctured for vascular access and a 4 or 5Fr access sheath was placed. Either 4Fr or 5Fr renal double curve catheter (Cordis; Johnson & Johnson, Miami, FL), Sidewinder Simmons, Sim 1 (Cordis; Johnson & Johnsons, Miami, FL), or a Cobra, C1 angiographic catheter (Cook; Bloomington, IN), was advanced over a 0.035 inch guide wire. In cases where there was tortuosity of the vessels or superselective catheterization was required, a microcatheter (Progreat; Terumo, Tokyo, Japan) was used. It was coaxially taken as far as possible, proximal to the aneurysm. Platinum coils were deployed proximally to the aneurysm sac to block the inflow vessel to completely exclude the aneurysm in cases of end arteries (Figures 1 and 2). Outflow vessels were also coiled wherever required as in cases of collateral Radiology Research and Practice 3 Table 1: Number, size, and anatomical distribution of the aneurysms. Artery of origin Total Renal Hepatic SMA Splenic IMA Cystic Celiac Gastroduodenal Pancreaticoduodenal Left colic Middle colic Number of aneurysms 53 23 14 2 3 1 1 2 3 1 2 1 Size range Range: 4.8–69 mm Range: 7–44 mm Range: 28–36 mm Range: 16–55 mm Range: 15 mm Range: 19 mm Range: 43–45 mm Range: 11–13 mm Range: 8 mm Range: 6–8.5 mm Range: 4.5 mm flow. Technical success was considered as total occlusion of the vascularity of lesion or aneurysmal sac and cessation of hemorrh (...truncated)