visceral arterial aneurysms embolotherapy zhang shiyi,md vascular surgeon and endovascular surgeon...
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Visceral Arterial AneurysmsEmbolotherapy
Zhang Shiyi ,MD
Vascular Surgeon and
Endovascular Surgeon
Shandong Provincial
Hospital, P.R. China
Visceral Arterial AneurysmsDefinition
Visceral arteries Celiac trunk
Hepatic artery
Gastroduodenal artery
Splenic artery
Left gastric artery
SMA
Renal arteries
VAAs
Visceral Arterial AneurysmsDefinition
VAAs include both true aneurysms and pseudoaneurysmsTrue aneurysms
Limited by all three layers of the arterial wall, which undergo progressive dilation and wall thinning.
Pseudoaneurysms (VAPAs)There is a tear of the vessel wall and a periarterial
hematoma.
Visceral Arterial AneurysmsIncidence
Visceral artery aneurysms (VAAs) are rare with a reported incidence of 0.01 to 0.2% on routine autopsies.
However, VAAs are clinically important and potentially lethal.22% of all visceral artery aneurysms present as
clinical emergencies8.5% result in death.
Celiac trunk
9×30mm Prescise , Cordis
Splenic Aneurysm
Incidence60% of all VAAsF > M, 4:1- typically in multiparous womenEtiology
Portal hypertension, PancreatitisEndocarditis, Cystic medial necrosis Iatrogenic, Collagen disease (Ehlers-Danlos)
Splenic Aneurysm
ManagementAnatomic/physiologic consideration
Splenic artery arises from celiac axis and tortuousOne of the most amenable arteries for stent graft
placementSupplying branches to the body and tail of pancreasEmbolization of SA proximal and distal to the neck
Splenic Aneurysm
Technique5F Sos or Cobra catheter combined with
microcatheterCoils embolization
>15% bigger than the vessel lumen “Sandwich” or “nest” technique necessary to ensure
a compact and occlusive embolus
Stent graft placementGood landing zone of 1-2 cm required
Splenic Aneurysm
Results of embolization100% of success rate can be achieved
It may be difficult when celiac artery is occludedRetrograde cannulation of GDA from SMAGDA may be hypertrophied if celiac artery occluded
chronicallyCoils may not be delivered easilyParticles (Gelfoam) can be used for temporary stop acute
bleed before open surgery
Splenic Aneurysm
Splenic AneurysmComplications
Nontarget emboliztion
-Pancreatic body and tail
-Splenic infarction
Increased risk of
infection
-Encaptuated bacteria
Pneumococus -Abscess/sepsis/Coils
migration
Reports in literature v.s. our results Mycotic aneurysm – most common cause in the past Traumatic and iatrogenic – most common in our study (80%) Atherosclerosis Inflammatory and vacuities
Polyarteritis nodosa Systemic lumpus erythematosus Takayasu’s arteritis Wegener’s granulomatosis Congenital arteriopathy
Marfan syndrome Ehlers-Danlos syndrome Hereditary hemorrhagic telangiectasia (HHT)
Hepatic Arterial Aneurysm Causes
Hepatic Arterial Aneurysm
The second common visceral aneurysmMore common now due to increased use of IR
procedure in the liver and improvement of imaging study.
HAP - the most common type of saccular hepatic arterial aneurysm (HAA)Comprising of 20% of all visceral aneurysm
Extrahepatic = 80%Intrahepatic = 20%
Hepatic Arterial Aneurysm
Reported mortality rate ranges from 10 – 50%HAP location
contributes to the varying
Infrequent with few reports in the current literatureRetrospective
review/Small cohorts
Hepatic Arterial Aneurysm
HAA renders a medical emergencyEarlier intervene/better clinical outcomeCorrection of coagulopathy, hydration, and fluid
resuscitation/ transfusion should be no delay in IR procedure
ICU monitoring necessary Periprocedure antibiotics
Abscess formation Hepatic ischemia Hematoma Biliary obstruction
Hepatic Arterial Aneurysm
A 41-year-old woman with hepatitis-C
S/p percutaneous liver biopsy
Presenting with severe RUQ painc positive stools, and decreased hemoglobin and hematocrit
Contrast enhanced CT scan
Mesenteric AneurysmsIncidence
Third most common VAA, but only 6%May associate with thrombosis and dissection
Presented with mesenteric ischemia or intestinal angina
Occurring frequency of other mesentericCeliac > GDA > gastric artery
No significant gender difference, typically in 60-70 years
Mesenteric Aneurysms Causes
General causes SMA aneurysms – mycotic Celiac aneurysms – cystic medial degeneration GDA – pseudoaneurysms – duodenal ulceration Gastroepiploic, pancreaticoduodenal aneurysms – pancreatitis
Other causes PAN, amphetamine abuse, and connective tissue disorders
Mesenteric Aneurysms
Risks posed by the aneurysms Ischemia
Proximal thrombosis Distal embolization
Rupture Hematoma infection –
sepsis Bowel resection
Severe ischemia
Mesenteric Aneurysms Management
Anatomic/physiologic considerationOcclusion of splenic, peripheral hepatic, and
GDA are well toleratedEmbolization of peripheral SMA and IMA may
result in ischemiastricture, and infarction of bowel.
It is unwise to place a stent graft in SMA due to potential risk of infection
Mesenteric Aneurysms
TechniqueTypically celiac and proximal SMA aneurysm
are best treated surgicallyLeft brachial artery approach may be necessary
for catheterizing celiac and SMA with acute angel from aorta
GDA can be prophylactically embolized if the origins of SMA and celiac arteries are not compromised
Mesenteric AneurysmsResults and Complications
ResultsEmbolization of SMA aneurysms appeared
to be favorableTechnical success can be reached in 70-
100%Complications
Major complicating factorBowel ischemia and infarction
Renal Artery AneurysmIncidence
Rates range (0.015 to 9.7%)Classification
Saccular/fusiformDissectionPseudoaneurym
Low rupture rate (0-14%)
典型病例张某,男, 25岁,因间断腹痛半年,加重1天入院。患者 6年前曾有下腹部钝性撞击外伤史,无明显皮肤破损,保守治疗。 CT:肠系膜上动脉瘤、肠系膜上动脉瘤分支与门静脉相通。诊断: 1.GDA假性动脉瘤 2.肠系膜上动脉 -静脉瘘
Renal Artery AneurysmCauses
Renal artery PAIatrogenic or traumatic
Other causesFMD, PAN,
amphetamine abuse, AML, and neurofibromatosis
Renal Artery AneurysmRisks posed by the aneurysms
Rupture is rarePregnant woman more prone to ruptureNon-calcified aneurysm was at risk of ruptureHighest reported rate of rupture was 14%
Many other autopsy series showed no rupture
In case of FMDDistal embolization and dissection can be seen
Malignant hypertension
Renal Artery AneurysmAnatomic/physiologic consideration
Kidney – end organInfarction is common
For patients with chronic renal failure or underline diseaseNephron-sparing
procedure is vital Super-selective
embolization
Renal Artery PA
S/p percutaneous core biopsy
presented with left flank pain
and hematuria
Renal Artery AneurysmResults and Complications
Technical successVery high when RA securely accessedVery little chance of ischemia/renal failure
ComplicationsDissection/perforation/rupture of RA
Balloon tamponade for ruptureEmergent surgery may be necessaryBalloon angioplasty for tacking down the flaps
Experience
Branchial approach-- Easier manipulations through difficult lesions
Some neurointerventional embolization techniques (stent ,catheter,wire, IDC etc) helpful to the visceral arterial aneurysms—Devices are designed to
Flexibility , pushability, Very low profile to cross the
tortuous or kink site
Visceral Arterial AneurysmsConclusion
Interventional radiologist play a major role in management of VAAsLife-threatening hemorrhage
Aggressive and emergent interventionSurgical morbidity/mortality is high
Asymptomatic lesionsTiming of tx depending on VAA size and location
Visceral Arterial AneurysmsConclusion (2)
Small lesions can be observedException, not a ruleAll splenic aneurysms in childbearing women should
be treatedHigh rupture rate
All mesenteric aneurysms should be treatedHigh complications from rupture, thrombosis, or distal
embolization
Minimally invasive embolization procedures proved to be effective and safe
Visceral Arterial AneurysmsConclusion4
Surgery is always our powerful weapon.
Individualized treatment plan is important.
谢谢