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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3726_Библиотеки_им_академика_М_И_Перельмана.pdf
152
4 Abdominal Vascular Emergency
a
b
Fig. 4.43 (a, b) CT showing a vast gastroduodenal aneu-
rysm (blue arrows). (c) angiography obtained through
femoral access; arrow indicates the aneurysm. It was not
c
possible to advance the stent graft, and thus left brachial
access was prepared
4.2 Visceral Artery Aneurysms
153
a
b
c
Fig. 4.44 Angiography via left brachial access. It was
not possible to advance the stent graft; therefore, the aneurysm was embolized at the origin of the gastroduodenal
artery. Blue arrows indicate the aneurysm (a, b). (c)
orange arrow indicates the tip of the 6mm Amplatz Plug
used to occlude the origin of the gastroduodenal artery.
Yellow arrow indicates the spastic hepatic artery after
manipulation with different materials
154
4 Abdominal Vascular Emergency
Fig. 4.45 Three months later, control CT showing a completely thrombosed gastroduodenal artery- Blue arrows indicate the tip of the Amplatz plug. Orange arrow indicates the micro-coils inside the aneurysm
4.2 Visceral Artery Aneurysms
155
a
Fig. 4.46 Index contrast-enhanced CT showing intraperitoneal haematoma (a and b) (blue arrows). (b) orange arrow
indicates a small focus with active bleeding
4.2.9 Inferior Mesenteric Artery
b
at the distal part and an arteriovenous stula
(Fig. 4.49). The inferior mesenteric vein was
dilated as well. Embolization of the arteriove-
Key Points
• CT imaging should be carefully assessed
before treatment decisions are made.
• Microcatheters should always be used,
and super-selective embolization should
always be performed.
• Liquid embolic agents should never be
used for arteriovenous stulas.
nous stula and aneurysm was planned.
4.2.9.3 Endovascular Treatment
Under local anaesthesia, a 5 Fr pigtail catheter
was percutaneously inserted through the
right femoral artery for abdominal aortography, and a sidewinder catheter was used for
selective angiography of the inferior mesenteric artery (Fig.4.50). The microcatheter was
coaxially advanced close to the aneurysm,
and micro-coils with diameters of 10mm were
4.2.9.1 Aetiology andClinical
Presentation
A 67-year-old patient underwent aortic surgery due
to a 6cm abdominal aortic aneurysm 7years prior.
The patient was not controlled after the surgery. In
the last few months, the patient complained of con-
used for embolization with a satisfactory
outcome. The diameter of the artery proximal
to the aneurysm and fistula was 6–6.5 mm,
and 10 mm micro-coils were used to avoid
potential migration due to high flow through
the fistula.
stant pain in the lower abdomen. There were no
other symptoms or abnormalities. Abdominal
ultrasound showed an enlarged inferior mesenteric
artery, and a CT scan was scheduled.
4.2.9.4 Outcome
The patient did not experience any complica-
tions during the follow-up, and the pain
disappeared. Contrast-enhanced CT 3 months
4.2.9.2 Pre-interventional Diagnosis
Contrast-enhanced CT showed an enlarged,
dilated inferior mesenteric artery, an aneurysm
after embolization showed a thrombosed
aneurysm and an occluded arteriovenous stula
(Fig.4.51).
156
4 Abdominal Vascular Emergency
a
b
Fig. 4.47 Control contrast-enhanced CT after explorative laparotomy and packing. The patient was haemodynamically unstable with clinical signs of ongoing
bleeding. Active bleeding was observed from the superior
c
mesenteric artery branch (blue arrows). Orange arrow
indicates gauze (a). (b, c) orange arrows indicate
haemoperitoneum
4.2 Visceral Artery Aneurysms
157
a
c
b
d
Fig. 4.48 Selective superior mesenteric artery angiography showing active bleeding from the jejunal branches
(arrows) (a, b). (c, d) images; super-selective angiography
advanced through a microcatheter of the jejunal artery with
active bleeding (arrows). (e) the diameter of the bleeding
artery was 1.93mm. (f, g) control imaging after successful
embolization with 2mm micro-coils –(arrows)
158
4 Abdominal Vascular Emergency
e
f
g
Fig. 4.48 (continued)
4.2 Visceral Artery Aneurysms
159
Fig. 4.49 Contrast-enhanced CT showed an enlarged inferior mesenteric artery and an aneurysm at the distal part (blue
arrows)
160
4 Abdominal Vascular Emergency
a
c
b
d
Fig. 4.50 (a, b) Abdominal aortography showed enlarged
an inferior mesenteric artery and an aneurysm-(blue
arrows). (c, d) Selective angiography of the inferior mes-
enteric artery showed arteriovenous stula-(orange
arrows). (e, f) Embolization of the aneurysm and stula;
blue arrows indicate micro-coils and arrested ow
4.2 Visceral Artery Aneurysms
161
e
Fig. 4.50 (continued)
f
4.2.10 Renal Artery-I
Key Points
• Familiarization with balloon- or stentassisted coil aneurysm embolization
should be undertaken.
• Detachable micro-coils should be used.
• Stent grafts with diameters of 5 or 6mm
should be kept in stock.
4.2.10.1 Aetiology andClinical
Presentation
A 73-year-old patient with arterial hypertension
and an incidentally discovered left renal artery
aneurysm presented to our department. No other
signicant disease was reported. Baseline contrastenhanced CT showed a left renal artery aneurysm
26 mm in diameter. The patient was asymptomatic. Control contrast-enhanced CT 6months later
showed enlargement of the aneurysm up to 29mm
(Fig.4.53).
4.2.10.2 Pre-interventional Diagnosis
Control contrast-enhanced CT 6 months later
showed enlargement of the aneurysm up to 29mm
(Fig. 4.52). Functional diagnostics conrmed that
the left kidney contributed to 49% of the renal function; therefore, every effort was made to preserve
renal function as much as possible (Fig.4.53).
4.2.10.3 Endovascular Treatment
A 5 Fr renal-shaped catheter was inserted percutaneously through the right femoral artery for
selective catheterization of the left renal artery.
Angiography conrmed the diagnosis, and a
microcatheter was coaxially advanced into the
aneurysm. The microcatheter was placed deep