A Case of Traumatic Mesenteric Bleeding Controlled by only Transcatheter Arterial Embolization

We report a case of mesenteric hematoma following blunt abdominal trauma that was successfully treated with transcatheter arterial embolization (TAE) and did not require surgical repair. A 43-year-old man with blunt abdominal trauma caused in a factory accident was admitted with a stable general condition and laboratory data. On CT examination, a large mesenteric hematoma with extravasation of contrast media was observed. TAE was first attempted to control the bleeding. A superior mesenteric angiogram showed extravasation of contrast medium from a branch of the ileocolic artery and obstruction of the cecal branch. After successful TAE using microcoils, the distal portion of the cecal branch was still preserved via collateral circulation. No abdominal symptoms have occurred during the 7 months following TAE. In mesenteric injury cases with limited intestinal damage, TAE may therefore be a reasonable alternative to emergent laparotomy.     

Transcatheter arterial embolization is effective for mesenteric arterial hemorrhage in trauma

A 58-year-old man was injured in a traffic accident and hemodynamically unstable on admission. An abdominal computed tomography (CT) with contrast enhancement was performed after fluid resuscitation. Fluid accumulated along the mesentery around the cecum. A pseudoaneurysm was found by angiography in the ileal branch. Transcatheter arterial embolization (TAE) was performed in the branch using microcoils. His hemodynamics stabilized after TAE. In a CT performed after 12 h, free air was suspected and an exploratory laparotomy was performed. No intestinal perforations were found and hemostasis was completed in the injured mesentery. No ischemic findings were obtained in the intestines. TAE is one of the treatments of choice for mesenteric hemorrhage.     

Transcatheter embolization for treatment of acute lower gastrointestinal bleeding

Treatment of lower gastrointestinal bleeding was attempted in 13 patients by selective embolization of branches of the mesenteric arteries with Gelfoam. Bleeding was adequately controlled in 11 patients with active bleeding during the examination. One patient improved after embolization but bleeding recurred within 24 hours and in another patient the catheterization was unsuccessful. Five patients with diverticular hemorrhage were embolized in the right colic artery four times, and once in the middle colic artery. Three patients had embolization of the ileocolic artery because of hemorrhage from cecal angiodysplasia, post appendectomy, and leukemia infiltration. Three patients had the superior hemorrhoidal artery embolized because of bleeding from unspecific proctitis, infiltration of the rectum from a carcinoma of the bladder, and transendoscopic polypectomy. One patient was septic and bled from jejunal ulcers. Ischemic changes with infarction of the large bowel developed in two patients and were treated by partial semi-elective colectomy, three and four days after embolization. Four other patients developed pain and fever after embolization. Transcatheter embolization of branches of mesenteric arteries is an effective way to control acute lower gastrointestinal bleeding, but still has a significant rate of complications that must be seriously weighed against the advantages of operation.     

介入治疗在腹部外科术后消化道大出血中的应用价值

目的确定介入治疗在腹部外科术后消化道大出血中的应用价值。方法回顾性分析11例腹部外科手术后急性消化道大出血并经内科保守治疗无效而介入治疗的病例,总结其DSA结果及介入治疗价值。结果11例腹部外科术后消化道出血患者中DSA发现胃左动脉出血1例,胃十二指肠动脉假性动脉瘤4例,肝动脉假性动脉瘤2例,脾动脉假性动脉瘤1例,肠系膜下动脉分支血管感染性假性动脉瘤1例,肠系膜上动脉小分支血管出血2例。结论介入治疗是治疗腹部外科术后消化道大出血的有效方法。     

CT arteriography-guided embolization in hepatic bleeding: a case report

A 33-year-old man with hepatic bleeding was transferred to our hospital. Conventional plain and enhanced spiral computed tomography (CT) with a Siemens Somatom Plus-S scanner (Siemens AG, Erlangen, Germany) revealed a large hepatic hematoma and active extrahepatic bleeding. A unified spiral CT and angiography system (IVR-CT/Angio system; Toshiba Medical Systems, Tokyo, Japan) was employed, and selective catheterization-aided CT arteriography (CTA) showed additional active extrahepatic bleeding. These findings were not detected on conventional spiral CT or angiography. The CTA findings led us to successful transarterial embolization (TAE). After TAE, CT scan revealed that the contrast material injected in the hepatic artery was diffusing into the periportal space. Twenty-four days after TAE, a central bisegmentectomy of the liver was performed. Unfortunately, the cause of the hepatic bleeding was not clear pathologically.     

Microballoon Occlusion Test to Predict Colonic Ischemia After Transcatheter Embolization of a Ruptured Aneurysm of the Middle Colic Artery

A 76-year-old woman presented with sudden massive melena, and superior mesenteric arteriography showed an aneurysm in the middle colic artery (MCA). Because she had a history of right hemicolectomy and ligation of the inferior mesenteric artery (IMA) during open abdominal aortic aneurysm repair, embolization of the MCA aneurysm was considered to pose a risk comparable to that of colonic ischemia. A microballoon occlusion test during occlusion of the MCA confirmed retrograde visualization of the IMA branches through the collateral arteries by way of the left internal iliac artery, and embolization was successfully performed using microcoils. No colonic ischemia or aneurysm rupture occurred after embolization.     

Ischemic Effects of Transcatheter Arterial Embolization with N-Butyl Cyanoacrylate-Lipiodol on the Colon in a Swine Model

This study was designed to assess the safety of transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate-lipiodol (NBCA-Lp) for the large bowel and to investigate the vital response to NBCA-Lp in a swine model. In nine swine, nine arteries nourishing the colon were embolized with NBCA-Lp (1 ml of NBCA mixed with 4 ml of lipiodol): sigmoid-rectal branch artery in six swine, right colic branch artery in two, and middle colic branch artery in one. The amount of NBCA-Lp was 0.1–0.4 ml. Sacrifice was conducted 3 days after TAE to identify histological infarction. Classification was conducted retrospectively: group A, vasa recta without NBCA-Lp embolization despite TAE; group B, three or fewer vasa recta with NBCA-Lp embolization; and group C, five or more vasa recta with NBCA-Lp embolization. In one swine in group A, no necrotic focus was observed. In group B, three of four swine experienced no ischemic damage. The remaining one swine experienced necrosis of mucosal and submucosal layers in one-fourth of the circumference. In group C, all four swine with marginal artery and five vasa recta or more embolized experienced total necrosis of mucosa, submucosa, and smooth muscle layers of the whole colonic circumference. Significant difference on the extent of ischemic damage was observed between groups B and C (P < 0.05). Microscopically, NBCA-Lp induced acute vasculitis. Embolization of three or fewer vasa recta with NBCA-Lp induced no ischemic damage or limited necrosis, whereas embolization of five or more vasa recta with NBCA-Lp induced extensive necrosis.     

Griffiths' point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon.

Griffiths' point is defined as the site of (a) communication of the ascending left colic artery with the marginal artery of Drummond, and (b) anastomotic bridging between the right and left terminal branches of the ascending left colic artery at the splenic flexure of the colon. It is upon this critical point at the splenic flexure that collateral circulation between the superior mesenteric artery and the marginal artery branch of the inferior mesenteric artery supplying the descending colon is dependent. Analysis of arteriographic studies shows that anastomosis at Griffiths' point is present in 48%, poor or tenuous in nine percent, and absent in 43%. This critical point is of significance in occlusive vascular impairment of the left colon, both in spontaneous instances and following surgical ligation of the inferior mesenteric artery, and in "nonocclusive" ischemic colitis. Its relationship to arteriosclerotic stenoses and low flow states is discussed. Individuals with absence of dependable anastomoses at Griffiths' point at the splenic flexure may be particularly vulnerable to low perfusion states and develop the syndrome of ischemic colitis. Complete arteriographic evaluation is necessary in ischemia of the colon. This includes particularly assessment of atherosclerotic changes at or near the ostia of the major visceral arteries and the vascular arrangement at Griffiths' point.     

Massive Hemorrhage from Internal Carotid Artery Pseudoaneurysm Successfully Treated by Transcatheter Arterial Embolization with Assessment of Regional Cerebral Oxygenation

A 54-year-old male presented with intermittent massive hemorrhage from recurrent oropharyngeal cancer. The angiogram showed the encasements at the main trunk of the left internal carotid artery (ICA) and external carotid artery (ECA). Transcatheter arterial embolization (TAE) of the ECA with gelatin sponge particles and microcoils was performed. However, hemorrhage recurred several hours after the initial TAE. The second angiogram showed a large pseudoaneurysm of the ICA developing at the encasement on the initial angiogram. As a simple neurologic test, regional cerebral oxygenation (rSO₂) was assessed with and without manual compression of the common carotid artery (CCA). With compression of the left CCA, the rSO₂ did not change. We therefore performed isolation of the pseudoaneurysm. We embolized proximally and distally to the ICA pseudoaneurysm with microcoils and the pseudoaneurysm disappeared. No major complications occurred and no massive hemorrhage recurred until death from the cancer. TAE was an effective treatment for massive hemorrhage caused by tumor invasion to ICA. Assessment of rSO₂ was a simple and useful neurologic test predicting the cerebral blood flow to prevent complications of TAE.     

Endovascular Stenting and Stent-graft Repair of a Hemorrhagic Superior Mesenteric Artery Pseudoaneurysm and Dissection Associated with Pancreaticoduodenectomy

This report presents a 73-year-old woman with intraperitoneal bleeding from a superior mesenteric artery (SMA) pseudoaneurysm and dissection after pancreaticoduodenectomy (PD). A self-expanding bare metal stent was placed in the distal SMA across the area of dissection, and a stent-graft was subsequently placed across the pseudoaneurysm emerging from the proximal site by overlapping the bare stent, resulting in complete exclusion of the pseudoaneurysm and control of the dissection. Bleeding was controlled after the endovascular procedure. The combination of endovascular stenting and stent-graft repair is feasible and useful in comorbid cases of SMA pseudoaneurysm and dissection.     

Local fibrinolysis for superior mesenteric artery thromboembolism

A 66-year-old man with atrial fibrillation was referred soon after developing left lower limb and abdominal pain with rectal bleeding. An immediate flush aortogram showed embolic occlusion of the left distal superficial femoral artery and superior mesenteric artery (SMA), 3 cm from its ostium. Recombinant tissue plasminogen activitor (rtPA) 40 mg was selectively in stilled in the SMA in two boluses. Abdominal symptoms resolved within 48 h, and complete recanalization of the SMA was shown on angiography. Exploratory laparotomy after 72 h showed a normal small bowel and right colon, and was completed by femoropopliteal embolectomy. Six months later, the patient remained asymptomatic.     

Stent-Graft Treatment for Bleeding Superior Mesenteric Artery Pseudoaneurysm After Pancreaticoduodenectomy

We report two cases of intraperitoneal bleeding from superior mesenteric artery (SMA) pseudoaneurysm after pancreaticoduodenectomy for pancreatic head carcinoma. In both cases, a stent-graft was deployed on the main SMA to exclude pseudoaneurysm and to preserve blood flow to the bowel. Bleeding stopped after the procedure. One patient was able to be discharged but died from carcinoma recurrence 4 months later. The other patient died of sepsis and stent-graft infection 5 months later. These patients remained free of intraperitoneal rebleeding during the follow-up period.     

Severe primary postpartum hemorrhage due to genital tract laceration after operative vaginal delivery: successful treatment with transcatheter arterial embolization

The purpose of this study was to report our experience in the management of severe primary postpartum hemorrhage due to genital tract laceration following operative vaginal delivery with forceps using pelvic transcatheter arterial embolization (TAE). Ten women (mean age, 31.9 years) with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps were treated with TAE. TAE was indicated because of intractable bleeding that could not be controlled with uterotonic drugs, blood transfusion, attempted suturing and packing in all patients. Postdelivery perineal examination showed cervical or vaginal tears in all women and associated paravaginal hematoma in four. Angiography revealed extravasation of contrast material in six patients. TAE performed with gelatin sponge allowed to control the bleeding in all patients. Cervical and vaginal suturing was made possible and successfully achieved in the six women who had failed suturing attempts before TAE. Paravaginal hematoma was successfully evacuated in four patients in whom it was present after TAE. No complications related to TAE were noted. We conclude that in women with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps, TAE is effective and safe for stopping the bleeding and helps genital tract suturing and evacuation of hematoma.     

External iliac artery pseudoaneurysm following treatment for arterio-ureteral fistula using a balloon-expandable stent-graft: A case report

Sepsis and bleeding can lead to life-threatening complications, such as stent-graft infection and pseudoaneurysm, after stent-graft implantation. An 83 year-old woman was admitted to our hospital for sepsis 14 months after treatment with a balloon-expandable stent-graft for an arterio-ureteral fistula (AUF) between the right external iliac artery and the right ureter. Blood cultures were positive for methicillin-resistant Staphylococcus aureus and Candida tropicalis. A giant infectious pseudoaneurysm (44 × 70 mm) at the distal edge of the stent-graft was suspected of having caused the sepsis. Although endovascular therapy (EVT) was planned to correct the pseudoaneurysm, the right iliac artery spontaneously became occluded from the ostium of the right common iliac artery to the common femoral artery 5 days after diagnosing the pseudoaneurysm; hence, EVT was not performed. Antibiotic administration was continued, and blood culture results were negative. Although EVT using a stent graft for AUFs is effective, data on the chronic phase outcomes are limited. Therefore, patients with AUFs treated using stent-grafts should be carefully followed up.     

Middle mesenteric artery: Angiographic and three-dimensional computed tomography findings

The middle mesenteric artery, also known as the third mesenteric artery, is a very rare anomaly. Several anatomical variations of middle mesenteric artery have been reported; in these reports, the right colic artery and/or middle colic artery often originate directly from the aorta. Here, we report a middle mesenteric artery in which the middle colic artery originated directly from the abdominal aorta. We also provide three-dimensional computed tomography and angiography findings and discuss anatomical and embryological considerations.     

Endovascular Treatment of a Giant Superior Mesenteric Artery Pseudoaneurysm Using a Nitinol Stent-Graft

A 68-year-old woman presenting with gastrointestinal bleeding (hematocrit 19.3%) and in a critical clinical condition (American Society of Anesthesiologists grade 4) from a giant superior mesenteric artery pseudoaneurysm (196.0 × 131.4 mm) underwent emergency endovascular treatment. The arterial tear supplying the pseudoaneurysm was excluded using a 5.0 mm diameter and 31 mm long monorail expanded polytetrafluoroethylene (ePTFE)-covered self-expanding nitinol stent. Within 6 days of the procedure, a gradual increase in hemoglobin levels and a prompt improvement in the clinical condition were observed. Multislice CT angiograms performed immediately, 5 days, 30 days and 3 months after the procedure confirmed the complete exclusion of the pseudoaneurysm.     

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient''s abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.     

Pseudoaneurysm and renal arteriovenous fistula after nephrectomy: two cases treated by transcatheter coil embolization

Pseudoaneurysms and arteriovenous fistulas of renal arteries are rare clinical lesions. Invasive renal procedures may lead to pseudoaneurysm or arteriovenous fistulas (AVFs). We report two pseudoaneurysms and arteriovenous fistula cases that were treated by transcatheter embolization with metallic coils. The first case is left main renal artery pseudoaneurysm after nephrectomy in a patient with a solid renal tumor. The second case is right main renal artery AVF with giant pseudoaneurysm after both gunshot injury and nephrectomy. On the basis of color Doppler sonography and computed tomography (CT) findings, cases were diagnosed as pseudoaneurysm after nefrectomy. Contrast-enhanced CT scans showed a hyperdense area within the hematoma consistent with pseudoaneurysm. Endovascular treatment with coil embolization succeeds to total occlusion in renal artery pseudoaneurysm. Delayed hemorrhage related to postnephrectomy may be life-threatening conditions because of diagnostic difficulties. AVF and pseudoaneurysm can be treated safely and successfully by transcatheter arterial embolization.     

Recurrent gastrointestinal bleeding diagnosed by delayed scintigraphy with Tc-99m-labeled red blood cells

A 56-year-old woman presented with bright-red blood from the rectum. Esophagogastroduodenoscopy revealed mild gastritis. Colonoscopy demonstrated diverticulosis without active bleeding, and in vitro tagged red blood cell scintigraphy was unremarkable. There was no further evidence of bleeding and the patient was discharged home. The patient returned with recurrent bright-red blood from the rectum. Although delayed scintigraphic images seldom demonstrate the site of bleeding, delayed images at 12 hours demonstrated active bleeding near the hepatic flexure in this patient. This was confirmed with selective mesenteric angiography, and was treated with coil embolization of the tertiary branches of the right middle colic artery.     

Transarterial embolisation for gastroduodenal bleeding following endoscopic resection

Objectives:Transcatheter arterial embolisation (TAE) is widely used to treat gastrointestinal bleeding. This paper reports the safety and efficacy of TAE for bleeding following endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection.Methods:Fifteen consecutive patients (13 males, two females; mean age 62.2 years) from two tertiary medical centres who underwent TAE for gastroduodenal bleeding after endoscopic resection from November 2001 to December 2020 were included. Patient demographics, clinical presentations, angiographic findings, and TAE details were retrospectively reviewed.Results:Immediate bleeding during endoscopic resection was noted in four patients. Delayed bleeding 1–30 days after endoscopic resection in nine patients presented with haematochezia (n = 4), haematemesis (n = 6) and melaena (n = 1). Endoscopic haemostasis was attempted in 11 patients (73.3%) but failed due to continued bleeding despite haemostasis (n = 6), failure to secure endoscopic field (n = 3) and unstable vital signs (n = 2). Eleven patients had positive angiographic findings for bleeding, and all bleeding arteries were embolised except one owing to failed superselection of the bleeder. In the other four patients with negative angiographic findings, the left gastric artery with/without the right gastric artery or the accessory left gastric artery was empirically embolised using gelatin sponge particles. Both technical and clinical success rates were 93.3% (14/15). No procedure-related complications occurred during follow-up.Conclusions:TAE is safe and effective in the treatment of immediate and delayed bleeding after endoscopic resection procedures.Advances in knowledge:This is the first and largest 20-year bicentric study published in English on this topic. Empirical TAE for angiographically negative bleeding sites was also effective without significant complications.