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52 Vascular Ehlers-Danlos Syndrome Complicated by Ruptured Hepatic Artery Pseudoaneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
of arterial dissection and vascular rupture with a median life
expectancy of 40–50years. Caution is required with arterial
puncture in vEDS with major morbidity reported in up to
67% of patients [2]. Surgical buttress of the common femoral
artery should be considered prior to puncture [2].
b
a
187
Fig. 52.3 MIP of arterial phase CT showing left main renal artery
pseudoaneurysm (a) and extensive renal cortical infarction (b)
Fig. 52.4 Images, Pre- (a) and post- (b) micro coil embolization of hepatic artery pseudoaneurysm. Note improved lling of intra hepatic arterial
branches post-embolization
188
M. Gonsalves and R. Morgan
ab
Fig. 52.5 Images, Pre- (a) and post- (b) embolization of left renal artery pseudoaneurysm
Bibliography
1. Malfait F, Francomano C, Byers P, Belmont J, Berglund B, Black
J, etal. The 2017 international classication of the Ehlers–Danlos
syndromes. Am J Med Genet C Semin Med Genet. 2017;175C:8–
26. https://doi.org/10.1002/ajmg.c.31552.
2. Eagleton J. Arterial complications of vascular Ehlers-Danlos syn-
drome. J Vasc Surg. 2016;64(6):1869–80. https://doi.org/10.1016/j.
jvs.2016.06.120.
Endovascular Recanalization ofHepatic
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Artery Thrombosis After Liver
Transplantation
TiagoBilhim
A 55-year-old man with alcoholic chronic hepatic disease,
Child-Pugh C (C-P score, 11), sodium model for end-stage
liver disease (MELD Na+) score of 22, presented with ascites and spontaneous bacterial peritonitis. Hepatic transplantation was performed, followed by a re-transplantation
3months later due to graft failure. CT angiography (CTA)
5days after re-transplantation showed hepatic artery thrombosis (Fig. 53.1). Immediate transfemoral endovascular
revascularization was undertaken using a 6-French 45cmlong sheath placed in the celiac trunk (Fig.53.2). After aspiration thrombectomies using the 6-French Indigo catheter
(Penumbra), persistent hepatic artery thrombosis remained
(Fig.53.3). A 6-French catheter was placed in the hepatic
artery and thrombolysis was initiated with alteplase
53
Fig. 53.2 Digital subtraction angiography (DSA) of the celiac artery
conrms hepatic artery thrombosis (arrow)
Fig. 53.1 CT angiography (CTA) 5days after re-transplantation. Axial
image shows the hepatic artery thrombosis (arrow)
T. Bilhim (*)
Department of Interventional Radiology, Curry Cabral Hospital,
Centro Hospitalar Universitário de Lisboa Central (CHULC),
Lisbon, Portugal
e-mail: tiago.bilhim@chlc.minsaude.pt
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_53
Fig. 53.3 Digital subtraction angiography shows persistent hepatic
artery thrombosis (arrows) after multiple aspiration thrombectomies
190
53 Endovascular Recanalization ofHepatic Artery Thrombosis After Liver Transplantation
191
(Actilyse, Boehringer Ingelheim) using a 10mg intra-arterial bolus, and 1.5 mg/h 18 h infusion. Follow-up DSA
showed partial revascularization. Intra-arterial alteplase
1mg/h continued for another 24 h. Fibrinogen levels were
1.67 g/L before and 1.63 g/L after thrombolysis. DSA
revealed residual stenosis of the anastomosis (Fig. 53.4);
this was addressed with a 6 mm diameter × 2.5 cm long
ePTFE stent graft (Viabahn, Gore) (Fig. 53.5). CTA at
2days (Fig.53.6) and Doppler sonography at 3months con-
rmed patency of the hepatic artery (Fig.53.7). Four months
later, he presented with pruritus, jaundice, and total bilirubin of 7.7 mg/dL. MR cholangiography showed a biliary
anastomotic stricture (Fig.53.8). Re-hepaticocoledocostomy
was performed, followed by graft dysfunction and hepatic
artery thrombosis. The patient received a third liver transplant and is currently well.
Fig. 53.4 Control digital subtraction angiography after thrombolysis
shows revascularization of the hepatic artery with a residual underlying
stenosis of the surgical anastomosis (arrow)
Fig. 53.5 Immediate CT
scan after placement of the
self-expanding covered stent
(arrow) in the hepatic artery
afrms stent patency
Fig. 53.6 CTA 2days later depicts stent and hepatic artery patency
(arrows)
192
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Fig. 53.7 Doppler ultrasound 3months afterwards conrms patency of the hepatic artery (arrow)
T. Bilhim
Fig. 53.8 MR
cholangiography
demonstrates the biliary
anastomotic stricture (arrow)
Celiac Trunk Avulsion Treated
withEndograft andEmbolization
During Open Cardiac Massage
AbdulRehmanMustafa andR.TorranceAndrews
A 45-year-old motor vehicle trauma patient with a hostile
surgical abdomen presented with celiac trunk avulsion
(Figs. 54.1 and 54.2). The bleeding was not successfully
controlled in the operating room, so the patient was transferred to the interventional suite. Whilst the patient underwent open cardiac massage, an aortic endograft extension
was placed over the origin of the avulsed celiac artery
(Fig.54.3), and coil embolization of the splenic, left gastric,
and common hepatic arteries was performed through the
pancreaticoduodenal arcade to prevent retrograde ow
(Figs. 54.4 and 54.5). The bleeding ceased and the celiac
trunk avulsion was successfully treated (Fig.54.6). However,
the patient died 24h later from multi-organ system failure
related to the severe initial trauma.
54
Fig. 54.1 Nonselective aortogram demonstrating diffuse vasospasm
and extraluminal contrast to the left of the celiac origin
A. R. Mustafa (*)
Alfaisal University College of Medicine, Riyadh, Saudi Arabia
R. T. Andrews
Department of Interventional Radiology, Swedish Medical Center,
First Hill Campus, Seattle, WA, USA
e-mail: randrews@radiax.com
Fig. 54.2 Delayed image showing the extent of the extravasation
Fig. 54.3 Following placement of an endograft across the origin of the
celiac, a microcatheter is advanced from the superior mesenteric artery
and the pancreaticoduodenal arcade to the celiac trunk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_54
194
54 Celiac Trunk Avulsion Treated withEndograft andEmbolization During Open Cardiac Massage
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195
Fig. 54.4 Microcatheter course delineated by red dots
Fig. 54.5 Coils placed across the celiac trunk, spanning from the
splenic artery to the common hepatic, to prevent backbleeding through
the avulsed celiac trunk
Fig. 54.6 Images before and after intervention demonstrate control of extravasation
Pancreas Transplant Anastomotic
Breakdown Treated withStents
andThrombin
AbdulRehmanMustafa andR.TorranceAndrews
A patient with a pancreas transplant presented with an arterial pseudoaneurysm involving the anastomosis of the right
common iliac artery and the pancreatic transplant artery
(Fig.55.1). Using a transfemoral approach, as SOS selective
catheter was advanced into the pseudoaneurysm (Fig.55.2).
A self-expanding 10 mm × 40 mm bare-metal stent was
deployed within the common iliac artery (Fig.55.3), extending across anastomosis. The SOS catheter was reintroduced
into the transplant pancreatic artery through the interstices of
the bare stent (Fig. 55.4), followed by an Ansel sheath. A
5×26mm balloon-expandable endograft was then deployed,
spanning from the iliac stent across the pseudoaneurysm and
55
Fig. 55.2 Selective arteriogram showing anastomotic disruption with
a large pseudoaneurysm
Fig. 55.1 Right common iliac arteriogram demonstrating a large volume of extraluminal contrast at the pancreatic artery anastomosis
A. R. Mustafa (*)
Alfaisal University College of Medicine, Riyadh, Saudi Arabia
R. T. Andrews
Department of Interventional Radiology, Swedish Medical Center,
First Hill Campus, Seattle, WA, USA
e-mail: randrews@radiax.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_55
into the transplant pancreatic artery (Fig. 55.5). Post-stent
arteriography showed residual opacication of the pseudoaneurysm, so a Kumpe catheter was introduced through the
interstices of the bare-metal stent and into the pseudoaneurysm. This was followed by transcatheter thrombin injection
into the pseudoaneurysm (Fig.55.6).
Subsequent iliac arteriography demonstrated excellent
ow through the transplant pancreatic artery and minimal
196
55 Pancreas Transplant Anastomotic Breakdown Treated withStents andThrombin
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Fig. 55.5 Markedly reduced opacication of the pseudoaneurysm
after endograft placement
197
Fig. 55.3 Bare stent placed across the anastomotic origin; pseudoaneurysm is still lling
Fig. 55.4 Placement of a covered endograft through the interstices of
the bare stent
Fig. 55.6 Delivery of thrombin directly into the lumen of the
pseudoaneurysm
198
ow in the pseudoaneurysm (Fig.55.7). At follow-up, the
anastomotic pseudoaneurysm was without perfusion and
stable in size (Fig.55.8). This appearance was unchanged on
serial examination over 4years of follow up, and the pancreas has remained functional.
A. R. Mustafa and R. T. Andrews
Fig. 55.8 Representative image from a contrast-enhanced CT showing
the relationship between the stents and thrombosis of the large pseudoaneurysm immediately to the right of the stents
Fig. 55.7 Final result shows no opacication of the pseudoaneurysm
with preservation of ow into the pancreatic artery
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