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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3726_Библиотеки_им_академика_М_И_Перельмана.pdf
182
cd
4 Abdominal Vascular Emergency
a
b
Fig. 4.75 (a) selective angiography of the left gastric
artery showing active bleeding from one branch (arrow).
(b) late phase image showing contrast extravasation
(arrows). (c, d) deployment of a micro plug (arrows) and
control image after embolization showing a good result
ab
4.4 Abdominal Arterial Bleeding
183
c
Fig. 4.76 Contrast-enhanced CT showing intraperitoneal bleeding (orange arrows). Blue arrows indicate a small aneurysm arising from the pancreaticoduodenal artery
184
4 Abdominal Vascular Emergency
a
c
b
d
Fig. 4.77 (a) selective angiography of the SMA shows a
small aneurysm arising from the pancreaticoduodenal
artery (arrow). (b) advancement of a microcatheter
beyond the origin of the aneurysm; orange arrow indicates
the tip of the microcatheter. Blue arrow indicates the
aneurysm. (c) embolization of the “back door” (arrows).
(d) control image after embolization of the “back and
front doors” (arrows)
4.4 Abdominal Arterial Bleeding
185
Fig. 4.78 Control CT scan 3months after embolization. Almost complete resorption of the haematoma and a satisfactory result were obtained. Arrows indicate micro-coils
almost complete resorption of the haematoma.
The small aneurysm is now complete occluded.
No other aneurysms were visible.
vices were administered, and the patient responded
to resuscitation and was admitted to the emergency department. The patient had a previous
ischaemic cerebral attack with complete remission and was on clopidogrel treatment.
4.4.3 Superior Mesenteric Artery-II
4.4.3.2 Pre-interventional Diagnosis
Acute contrast-enhanced CT showed rupture of a
Key Points
• There is a rich collateral network
between the visceral mesenteric vessels.
• The small branches, especially in cases
branch arising from the SMA and intraperitoneal
haematoma (Fig.4.79). On sagittal projection, it
was not possible to see the superior mesenteric
artery. Emergency embolization was planned.
of bleeding, are prone to spasm.
• A microcatheter should always be used
in such cases.
4.4.3.3 Endovascular Treatment
Under local anaesthesia, a sidewinder catheter
was inserted percutaneously into the right femoral artery for selective angiography of the supe-
4.4.3.1 Aetiology andClinical
Presentation
An 82-year-old patient complained of sharp acute
pain in the right lower abdominal quadrant.
Shortly after the pain subsided, the patient became
unresponsive and hypotensive. Emergency ser-
rior mesenteric artery (SMA). Angiography
showed the right hepatic artery arising from the
SMA, which lacked ow in the distal portion and
demonstrated a possible small thrombus within
(Fig. 4.80). After that, selective angiography of
the inferior mesenteric artery showed an open
186
bc
4 Abdominal Vascular Emergency
a
Fig. 4.79 Contrast-enhanced CT showing a bleeding branch arising from the mesenteric artery (orange arrows) in
panels (a, b). Blue arrows indicate an intraperitoneal haematoma. (c) the superior mesenteric artery is not visible
4.4 Abdominal Arterial Bleeding
187
a
c
b
d
Fig. 4.80 (a) blue arrow indicates that the right hepatic
artery arises from the SMA.Orange arrow indicates slow
ow in the SMA and possible thrombosis. (b) selective
angiography of the inferior mesenteric artery. (c) open
SMA angiography via the inferior mesenteric artery; blue
arrow indicates the SMA. (d, e) advancement of the catheter into the SMA and depiction of the bleeding site from
a small branch arising from the ileocolic artery (blue
arrow). (f) control image after the bleeding was arrested
with a micro-plug; orange arrow indicates the micro-plug
188
4 Abdominal Vascular Emergency
e
Fig. 4.80 (continued)
SMA, and again, a catheter was advanced into the
SMA.After further advancement of the catheter,
angiography conrmed an open SMA and bleeding from one branch on the right side. Then, a
microcatheter was advanced into the bleeding
branch, and a 3 mm micro-plug was used for
embolization with excellent results. There was no
signicant stenosis or thrombus of the SMA, and
the artery was open. The intervention went well,
and the patient did not experience worsening of
the haemodynamic status or develop compartment syndrome. The patient was discharged
6days after embolization.
f
4.4.4 Inferior Mesenteric Artery
Key Points
• Bleeding from the lower gastrointestinal
tract requiring endovascular treatment
can and should be diagnosed with CT.
• A microcatheter should always be used.
• Usually, small micro-coils 2 and 3 mm
in diameter are required for superselective, safe embolization.
4.4.3.4 Outcome
The patient recovered well and has not experienced new bleeding events. There were no ischaemic complications, and the patient was
symptom free. Control contrast-enhanced CT
before discharge (Fig.4.81) showed that the size
of the haematoma had not changed and that the
artery was well embolized.
4.4.4.1 Aetiology andClinical
Presentation
A 74-year-old patient was admitted to the hospital due to increased bleeding into the stool. The
patient had previously experienced discrete lower
gastrointestinal bleeding, but this time, heavy
bleeding was observed, and the patient’s blood
pressure was 90/60 mmHg. Haemoglobin was
4.4 Abdominal Arterial Bleeding
189
Fig. 4.81 Control contrast-enhanced CT before discharged showing a satisfactory result. Arrows indicate the
micro-plug
190
Fig. 4.82 Contrast-enhanced CT showing bleeding into the descending colon (arrows)
4 Abdominal Vascular Emergency
low (4.5 mmol/L). The patient was known to
have colonic diverticulosis, and bleeding from
the diverticulum was suspected.
4.4.4.2 Pre-interventional Diagnosis
Contrast-enhanced CT conrmed bleeding from
the sigmoid diverticulum and the left branch of
the colic artery (Fig.4.82).
4.4.4.3 Endovascular Treatment
Under local anaesthesia, a 5 Fr sidewinder catheter was inserted percutaneously through the
right femoral artery for selective angiography of
the inferior mesenteric artery. Angiography conrmed that the bleeding site was in the left
peripheral branch of the colic artery (Fig.4.83).
A microcatheter was then advanced very quickly,
and the target branches were occluded with small
micro-coils 2mm in diameter.
4.4.4.4 Outcome
The patient did not experience any complications,
especially ischaemic complications. Control contrast-enhanced CT 3 months after embolization
(Fig.4.84) showed a satisfactory outcome and no
new bleeding.
4.4 Abdominal Arterial Bleeding
191
a
c
b
d
Fig. 4.83 (a, b) arrows indicate active bleeding from the
mural branches of the left colic artery. (c) advancement of
a microcatheter as close as possible to the bleeding point;
arrow indicates the tip of the microcatheter. (d, e) control
angiography showing arrested bleeding and occlusion
only of the bleeding artery