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Common hepatic artery aneurysm successfully treated with a celiac axis stent graft. Two years of follow up
European Journal of Radiology Extra 75 (2010) e125–e128
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Common hepatic artery aneurysm successfully treated with a celiac axis stent graft. Two years of follow up Michele Rossi a , Alberto Rebonato a,∗ , Michele Citone a , Marco La Torre b , Vincenzo David c a b c
Sant’Andrea Hospital-“La Sapienza” University, Interventional Radiology Unit, Rome, Italy Sant’Andrea Hospital-“La Sapienza” University, General Surgery Unit, Rome, Italy Sant’Andrea Hospital-“La Sapienza” University, Radiology Department, Rome, Italy
a r t i c l e
i n f o
Article history: Received 30 March 2010 Received in revised form 30 June 2010 Accepted 30 June 2010
Keywords: Hepatic artery aneurysm Endovascular treatment 3D rotational angiography Stent graft Embolization MDCT and reconstructions
a b s t r a c t Purpose: To present a case of partially thrombosed 5 cm wide aneurysm of the origin of common hepatic artery with occlusion of common hepatic artery distal to the aneurysm and proper hepatic artery revascularized by gastroduodenal and superior mesenteric arteries. Case report: After a preliminary 3D rotational angiography evaluation a stent graft was deployed in the celiac axis to exclude the common hepatic artery and the aneurysm taking the advantage of developed complete collateral liver blood supply. Two year CT follow up showed stent patency without clinical and radiological evidence of visceral ischemic damage. Clinical and technical considerations are discussed. Conclusions: The positive mid-term outcome confirms the efficacy of endovascular exclusion with stent graft, in the treatment of hepatic artery aneurysm in selected cases. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Hepatic artery aneurysm (HAA) is the second most common site of location among visceral arteries following those of the splenic artery [1–3]. In the past, the vast majority of the HAAs were diagnosed in emergency when associated with often fatal rupture. Recently the widespread use of ultrasound and CT abdominal imaging has led to increase detection of visceral artery aneurysms (VAAs), mainly as occasional finding in asymptomatic patients with subsequent increase of elective treatment. VAAs and then HAA have been traditionally treated surgically. In the last 20 years the continuous evolution of endovascular techniques and materials has provided alternative strategies to treat aneurysms percutaneously. More recently transcatheter embolization using a variety of embolizing materials or the deployment of stent graft are considered the treatments of choice for true and false VAAs [2–4]. Endovascular treatment offers many advantages over surgery, such as precise localization of the aneurysm, assessment of collateral vessels, easier approach, especially for the intrahepatic aneurysms, and the possibility to preserve the direct flow to the distal organs in case of stent graft deployment. We present a case of partially
∗ Corresponding author at: Interventional Radiology Unit, Sant’Andrea Hospital“La Sapienza” University, Via di Grottarossa 1035, Rome, Italy. Tel.: +39 0633775968; fax: +39 0633775968. E-mail address: [email protected] (A. Rebonato). 1571-4675/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.06.010
thrombosed common HAA treated with a celiac artery stent graft implantation.
2. Case report A 58-years-old man was admitted in our institution for a 3 weeks history of epigastric pain with an abdominal ultrasound showing a suspected cystic mass of the pancreatic head. No previous medical history of pancreatitis or trauma was reported. A CT-angiography using 16-slice multirow detector CT (Philips MDT MX 8000) was performed and showed a 5 cm partially thrombosed aneurysm at the origin of common hepatic artery (Fig. 1) with occlusion of common hepatic artery distal to the aneurysm and a proper hepatic artery revascularized by gastroduodenal artery (GDA) through the collateral pathway of superior mesenteric artery (Rio Branco Branch). The multiplanar reconstruction (MPR) provided information about the as well as the relationship with surrounding tissues and anatomy (Fig. 2). No remarkable additional pathologies of the abdomen were found. After a consultation with the general surgeon we opted for the endovascular treatment. We decided to treat the aneurysm with a stent graft in the celiac axis extented into the splenic artery to cover the origin of common hepatic artery. The patient was informed about the procedure and a written consent was obtained. A bolus of 2500 U of heparin was given at the beginning of the procedure and a second 2500 U was administered in a continuous saline flushing. First a selective angiography with
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Fig. 1. Contrast-enhanced computed tomography showing a partially thrombosed 5 cm aneurysm at the origin of common hepatic artery.
5 F SIM 1 catheter of SMA was performed to show the absence of back flow into the common hepatic artery toward the aneurysm and to demonstrate the complete blood supply to the liver trough hypertrophic GDA (Fig. 3). Subsequently celiac trunk catheterization was performed and a 3D rotational angiography (GE flat panel-Innova 4100) was obtained. The left gastric and the left phrenic arteries directly originated from the celiac trunk (Fig. 4).
Fig. 3. SMA catheterization and angiogram showing the revascularization of proper hepatic artery by a dilatated inferior duodeno-pancreatic branch (Rio Branco Branch).
The examination confirmed the aneurysm location at the origin of common hepatic artery and cul-de-sac morphology of the aneurysm without any outflow arteries. The 3D multiplanar representation of arterial anatomy was fundamental to determine the
Fig. 2. The sagittal MPR reconstruction shows the origin of left gastric artery (arrow in A) from the celiac axis and the common hepatic artery aneurysm (arrows in B).
M. Rossi et al. / European Journal of Radiology Extra 75 (2010) e125–e128
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Although the LGA was still opacified there was a clear demonstration that actually the stent was covering the origin (Fig. 6A). The patient is now under yearly US evaluation.
3. Discussion
Fig. 4. 3D rotational angiogram with MIP reconstruction demonstrates the saccular aspect of the aneurysm true lumen (arrow head) and the left gastric artery (arrow).
optimal 2D work projection to be used during the stent deployment. The catheterization of the splenic artery was performed with a standard Terumo guide wire which was subsequently exchanged with a long stiff wire (Amplatz-Boston Scientific) to provide stability to the system. Then a reshaped MP 8Fr long sheath was advanced at the origin of the celiac trunk. A self-expandable stent graft (Gore Viabahn Endoprosthesis 8 mm × 50 mm) was advanced over the wire, bridging the aneurismal neck and released with the distal end into the splenic artery. The proximal end was positioned with the intention to live uncovered the left gastric artery (LGA). The final angiogram (Fig. 5) showed total exclusion of the aneurysm with normal flow into the stent graft and regular perfusion of the spleen. SMA selective angiography showed the preservation of the pancreatic and liver supply, whereas no back refilling of the aneurysm was demonstrated. The procedure time was approximately 1 h. The fluoroscopy time was 14 min and the amount of contrast medium was approximately 120 ml. A prophylactic antibiotics therapy to prevent endograft infection and a regimen of lifelong 100 mg aspirin were administered after the procedure. Postoperative course was uneventful. The patient was discharged in the third day after procedure. MDCT angiography was performed 1 month later and demonstrated precise stent location, complete aneurysm thrombosis and normal splenic and liver perfusion (Fig. 6B). The MDCT angiography follow up at 1 and 2 year confirmed the complete exclusion of the aneurysm with the celiac and splenic artery patency and a shrinkage of the aneurysm (3 cm).
Fig. 5. After the stent graft (Viabahn 8 mm × 5 cm-Gore) deployment the final 3D rotational angiogram shows the aneurysm exclusion with a patent splenic artery.
The hepatic artery is the fourth common site of intra-abdominal aneurysm from any cause following infrarenal aorta, iliac artery and splenic artery. HAAs are extrahepatic in 80% of cases and in 20% are intrahepatic [1,5]. Historically, mycotic aneurysms were the most common cause of HAA, although currently they account for only 4% in recent reports [3]. Atherosclerosis is present in up to 30% of these lesions, although the HAAs are, most commonly associated with polyarterite nodosa, periarterial inflammation caused by either cholecystitis or pancreatitis, fibromuscular dysplasia and cystic medial necrosis [2,5]. The majority of patients are asymptomatic prior to rupture. Among the patients presenting clinical symptoms, abdominal pain is found in 55% and gastrointestinal haemorrhage or haemobilia occur in up to 46% [6–8]. In 80% of the cases rupture of the aneurysms is the first clinical manifestation [7,8]. In the last decade 65% of the described HAAs were ruptured at the presentation, with an associated mortality rate of 21% [9]. The patient of this case report complained abdominal pain, and for this reason he was undertaken to clinical and instrumental investigation in order to rule out pancreatic disease. The clinical symptoms were not surely due to the presence of the aneurysm, but they triggered the imaging process leading to an incidental finding. Because of the unpredictable course of these lesions and the high mortality rate in the event of rupture, we believe, according to other authors, that an early elective therapeutic approach is preferable [2,3]. Several authors advocated treating any visceral aneurysm that (i) is symptomatic, (ii) has grown, (iii) is found in a woman who is pregnant or expecting to be pregnant, or (iv) measures 2 cm or more [2,4]. Treatment of false aneurysms must be undertaken without delay whatever their size, even if there is no bleeding, because the risk of spontaneous rupture is very high (mortality rate close to 100% due to risk of rupture) [10]. During the last decade, endovascular techniques have provided different alternatives to treat these aneurysms: coil embolization, detachable balloons, gelfoam, thrombin, or a combination of the above. Despite the surgical solution, the endovascular alternatives offers many advantages, such as precise localization of the aneurysm, assessment of collateral flow, and easier approach, especially in case of distal location (splenic or hepatic hilum); in combination, these benefits help to reduce complications and mortality rates. Recently even the use of a stent graft to exclude completely the aneurysm has been reported as a valid alternative to the other endovascular technique [2–4,7,8]. The main advantage of using a stent graft, in comparison with coil packing, is the lower risk of embolization and the preservation of the visceral artery. A preliminary detailed study of the liver vascularization with MDCT and 3D angiography is fundamental to obtain a complete knowledge of vascular anatomy (Fig. 4). Exploiting the presence of a well-demonstrated collateral perfusion of the liver by an inferior duodeno-pancreatic branch we decided to treat the aneurysm by excluding the entire common hepatic artery. In a preliminary phase, we considered several endovascular alternatives to exclude the aneurysm, such as “coils embolization” or a bare stent assisted embolization, however the short distance between the aneurysm neck and the celiac trunk was unfavourable for coils deployment for the high risk of coils displacement and migration, and a stent assisted coils embolizations seemed a more sophisticated and expensive solution. Although we attempted to avoid coverage of the LGA the accidental occlusion did not represent a concern about gastric perfusion due to a patent GDA. Nor
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Fig. 6. (A) MDCT with VR reconstruction at 1 year follow up showing exclusion of the aneurysm with revascularization of proper hepatic artery (arrow) by hypertrophic GDA (arrowhead) and a patent LGA (asterisk). (B) MDCT at 2 years showing stent patency and shrinkage of the aneurysm (arrows). (C) MDCT with AVA reconstruction at 2 years demonstrates the complete aneurysm thrombosis.
preliminary left gastric and left phrenic arteries embolization were considered necessary in case of stent coverage because they rose from a healthy celiac trunk and therefore could not represent a risk for HAA type II endoleak. The major technical difficulties, proper of VAAs stent graft repair, are: (a) to have a stable carrier system for safely advancing the stent graft; (b) to chose an appropriate stent graft for dimensions and mechanical properties; and (c) to release the stent in the proper position [2]. Author’s suggestions for these technical aspects are: (a) the introducer sheaths today available, with a good pushability, trackability and shapeable tip allow to obtain a stable carrier system keeping the possibility for check injection flush; (b) the “ideal” stent graft for VAAs repair should be low profile to advance in small caliber carrier devices, adaptable to different vessel diameters and aneurysm lengths, and relatively flexible [2–4]; today are available many devices that respect these features; in our case we use a selfexpandable stent graft with nitinol mesh wire and high radial force to obtain a good sealing even in tortuous vessels; (c) both the preprocedural MDCT angiography evaluation with reconstructions and the 3D rotational angiography provided fundamental information for planning the treatment strategy such as precise dimension of the aneurysm (length of the neck, distance from the aorta, diameter of the afferent and efferent artery), tortuosity of the arteries, angulations of the aneurismatic tract, so that we could use the stent graft compatible with the anatomic situation. 4. Conclusion This case represents an optimal example of simple but efficient endovascular solution taking the advantage of the physiologic adaptation based on the complete occlusion of the proper hepatic artery and efficient collateral hepatic reperfusion. Stent graft
patency without filling defect and regular perfusion of the splanchnic organs at 1 and 2 year MDCT follow up, demonstrate that the endovascular treatment with stent graft could be considered the treatment of choice in selected cases and when an accurate preoperative imaging can be performed. Conflict of interest There is no financial arrangement or other relationship that could be construed as a conflict of interest. References [1] Bachar GN, Belenky A, Lubovsky L, et al. Sonographic diagnosis of a giant aneurysm of the common hepatic artery. J Clin Ultrasound 2002;30:300–2. [2] Rossi M, Rebonato A, Greco L, et al. Endovascular exclusion of visceral artery aneurysms with stent-grafts: technique and long-term follow-up. Cardiovasc Intervent Radiol 2008;31(January–February (1)):36–42 [Epub 2007 October 6]. [3] Hashim A, Allaqaband S, Bajwa T. Leaking hepatic artery aneurysm successfully treated with covered stent. Catheter Cardiovasc Interv 2009;74(September (3)):500–5. [4] Basile A, Ragazzi S, Piazza D, et al. Hepatic artery pseudoaneurysm treated using stent-graft implantation and retrograde gastroduodenal artery coil embolization. Eur Radiol 2008;18(November (11)):2579–81. [5] Nobuya A, Naofumi M, Toshio F, et al. Multiple intra-hepatic aneurysm following transcatheter embolisation. Work in progress. Radiology 1994;193:743–6. [6] Gabelmann A, Görich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9(February (1)):38–47. [7] Larson RA, Solomon J, Carpenter JP. Stent graft repair of visceral artery aneurysms. J Vasc Surg 2002;36(December (6)):1260–3. [8] Bürger T, Halloul Z, Meyer F, et al. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther 2000;7(4):324–7. [9] Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45(February (2)):276–83 [discussion 283]. [10] Vallina-Victorero Vazquez MJ, Vaquero Lorenzo F, Salgado AA, et al. Endovascular treatment of splenic and renal aneurysms. Ann Vasc Surg 2009;23(March (2)), 258e13–7 [Epub 2008 November 5].
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Common hepatic artery aneurysm successfully treated with a celiac axis stent graft. Two years of follow up Michele Rossi a , Alberto Rebonato a,∗ , Michele Citone a , Marco La Torre b , Vincenzo David c a b c
Sant’Andrea Hospital-“La Sapienza” University, Interventional Radiology Unit, Rome, Italy Sant’Andrea Hospital-“La Sapienza” University, General Surgery Unit, Rome, Italy Sant’Andrea Hospital-“La Sapienza” University, Radiology Department, Rome, Italy
a r t i c l e
i n f o
Article history: Received 30 March 2010 Received in revised form 30 June 2010 Accepted 30 June 2010
Keywords: Hepatic artery aneurysm Endovascular treatment 3D rotational angiography Stent graft Embolization MDCT and reconstructions
a b s t r a c t Purpose: To present a case of partially thrombosed 5 cm wide aneurysm of the origin of common hepatic artery with occlusion of common hepatic artery distal to the aneurysm and proper hepatic artery revascularized by gastroduodenal and superior mesenteric arteries. Case report: After a preliminary 3D rotational angiography evaluation a stent graft was deployed in the celiac axis to exclude the common hepatic artery and the aneurysm taking the advantage of developed complete collateral liver blood supply. Two year CT follow up showed stent patency without clinical and radiological evidence of visceral ischemic damage. Clinical and technical considerations are discussed. Conclusions: The positive mid-term outcome confirms the efficacy of endovascular exclusion with stent graft, in the treatment of hepatic artery aneurysm in selected cases. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Hepatic artery aneurysm (HAA) is the second most common site of location among visceral arteries following those of the splenic artery [1–3]. In the past, the vast majority of the HAAs were diagnosed in emergency when associated with often fatal rupture. Recently the widespread use of ultrasound and CT abdominal imaging has led to increase detection of visceral artery aneurysms (VAAs), mainly as occasional finding in asymptomatic patients with subsequent increase of elective treatment. VAAs and then HAA have been traditionally treated surgically. In the last 20 years the continuous evolution of endovascular techniques and materials has provided alternative strategies to treat aneurysms percutaneously. More recently transcatheter embolization using a variety of embolizing materials or the deployment of stent graft are considered the treatments of choice for true and false VAAs [2–4]. Endovascular treatment offers many advantages over surgery, such as precise localization of the aneurysm, assessment of collateral vessels, easier approach, especially for the intrahepatic aneurysms, and the possibility to preserve the direct flow to the distal organs in case of stent graft deployment. We present a case of partially
∗ Corresponding author at: Interventional Radiology Unit, Sant’Andrea Hospital“La Sapienza” University, Via di Grottarossa 1035, Rome, Italy. Tel.: +39 0633775968; fax: +39 0633775968. E-mail address: [email protected] (A. Rebonato). 1571-4675/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.06.010
thrombosed common HAA treated with a celiac artery stent graft implantation.
2. Case report A 58-years-old man was admitted in our institution for a 3 weeks history of epigastric pain with an abdominal ultrasound showing a suspected cystic mass of the pancreatic head. No previous medical history of pancreatitis or trauma was reported. A CT-angiography using 16-slice multirow detector CT (Philips MDT MX 8000) was performed and showed a 5 cm partially thrombosed aneurysm at the origin of common hepatic artery (Fig. 1) with occlusion of common hepatic artery distal to the aneurysm and a proper hepatic artery revascularized by gastroduodenal artery (GDA) through the collateral pathway of superior mesenteric artery (Rio Branco Branch). The multiplanar reconstruction (MPR) provided information about the as well as the relationship with surrounding tissues and anatomy (Fig. 2). No remarkable additional pathologies of the abdomen were found. After a consultation with the general surgeon we opted for the endovascular treatment. We decided to treat the aneurysm with a stent graft in the celiac axis extented into the splenic artery to cover the origin of common hepatic artery. The patient was informed about the procedure and a written consent was obtained. A bolus of 2500 U of heparin was given at the beginning of the procedure and a second 2500 U was administered in a continuous saline flushing. First a selective angiography with
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M. Rossi et al. / European Journal of Radiology Extra 75 (2010) e125–e128
Fig. 1. Contrast-enhanced computed tomography showing a partially thrombosed 5 cm aneurysm at the origin of common hepatic artery.
5 F SIM 1 catheter of SMA was performed to show the absence of back flow into the common hepatic artery toward the aneurysm and to demonstrate the complete blood supply to the liver trough hypertrophic GDA (Fig. 3). Subsequently celiac trunk catheterization was performed and a 3D rotational angiography (GE flat panel-Innova 4100) was obtained. The left gastric and the left phrenic arteries directly originated from the celiac trunk (Fig. 4).
Fig. 3. SMA catheterization and angiogram showing the revascularization of proper hepatic artery by a dilatated inferior duodeno-pancreatic branch (Rio Branco Branch).
The examination confirmed the aneurysm location at the origin of common hepatic artery and cul-de-sac morphology of the aneurysm without any outflow arteries. The 3D multiplanar representation of arterial anatomy was fundamental to determine the
Fig. 2. The sagittal MPR reconstruction shows the origin of left gastric artery (arrow in A) from the celiac axis and the common hepatic artery aneurysm (arrows in B).
M. Rossi et al. / European Journal of Radiology Extra 75 (2010) e125–e128
e127
Although the LGA was still opacified there was a clear demonstration that actually the stent was covering the origin (Fig. 6A). The patient is now under yearly US evaluation.
3. Discussion
Fig. 4. 3D rotational angiogram with MIP reconstruction demonstrates the saccular aspect of the aneurysm true lumen (arrow head) and the left gastric artery (arrow).
optimal 2D work projection to be used during the stent deployment. The catheterization of the splenic artery was performed with a standard Terumo guide wire which was subsequently exchanged with a long stiff wire (Amplatz-Boston Scientific) to provide stability to the system. Then a reshaped MP 8Fr long sheath was advanced at the origin of the celiac trunk. A self-expandable stent graft (Gore Viabahn Endoprosthesis 8 mm × 50 mm) was advanced over the wire, bridging the aneurismal neck and released with the distal end into the splenic artery. The proximal end was positioned with the intention to live uncovered the left gastric artery (LGA). The final angiogram (Fig. 5) showed total exclusion of the aneurysm with normal flow into the stent graft and regular perfusion of the spleen. SMA selective angiography showed the preservation of the pancreatic and liver supply, whereas no back refilling of the aneurysm was demonstrated. The procedure time was approximately 1 h. The fluoroscopy time was 14 min and the amount of contrast medium was approximately 120 ml. A prophylactic antibiotics therapy to prevent endograft infection and a regimen of lifelong 100 mg aspirin were administered after the procedure. Postoperative course was uneventful. The patient was discharged in the third day after procedure. MDCT angiography was performed 1 month later and demonstrated precise stent location, complete aneurysm thrombosis and normal splenic and liver perfusion (Fig. 6B). The MDCT angiography follow up at 1 and 2 year confirmed the complete exclusion of the aneurysm with the celiac and splenic artery patency and a shrinkage of the aneurysm (3 cm).
Fig. 5. After the stent graft (Viabahn 8 mm × 5 cm-Gore) deployment the final 3D rotational angiogram shows the aneurysm exclusion with a patent splenic artery.
The hepatic artery is the fourth common site of intra-abdominal aneurysm from any cause following infrarenal aorta, iliac artery and splenic artery. HAAs are extrahepatic in 80% of cases and in 20% are intrahepatic [1,5]. Historically, mycotic aneurysms were the most common cause of HAA, although currently they account for only 4% in recent reports [3]. Atherosclerosis is present in up to 30% of these lesions, although the HAAs are, most commonly associated with polyarterite nodosa, periarterial inflammation caused by either cholecystitis or pancreatitis, fibromuscular dysplasia and cystic medial necrosis [2,5]. The majority of patients are asymptomatic prior to rupture. Among the patients presenting clinical symptoms, abdominal pain is found in 55% and gastrointestinal haemorrhage or haemobilia occur in up to 46% [6–8]. In 80% of the cases rupture of the aneurysms is the first clinical manifestation [7,8]. In the last decade 65% of the described HAAs were ruptured at the presentation, with an associated mortality rate of 21% [9]. The patient of this case report complained abdominal pain, and for this reason he was undertaken to clinical and instrumental investigation in order to rule out pancreatic disease. The clinical symptoms were not surely due to the presence of the aneurysm, but they triggered the imaging process leading to an incidental finding. Because of the unpredictable course of these lesions and the high mortality rate in the event of rupture, we believe, according to other authors, that an early elective therapeutic approach is preferable [2,3]. Several authors advocated treating any visceral aneurysm that (i) is symptomatic, (ii) has grown, (iii) is found in a woman who is pregnant or expecting to be pregnant, or (iv) measures 2 cm or more [2,4]. Treatment of false aneurysms must be undertaken without delay whatever their size, even if there is no bleeding, because the risk of spontaneous rupture is very high (mortality rate close to 100% due to risk of rupture) [10]. During the last decade, endovascular techniques have provided different alternatives to treat these aneurysms: coil embolization, detachable balloons, gelfoam, thrombin, or a combination of the above. Despite the surgical solution, the endovascular alternatives offers many advantages, such as precise localization of the aneurysm, assessment of collateral flow, and easier approach, especially in case of distal location (splenic or hepatic hilum); in combination, these benefits help to reduce complications and mortality rates. Recently even the use of a stent graft to exclude completely the aneurysm has been reported as a valid alternative to the other endovascular technique [2–4,7,8]. The main advantage of using a stent graft, in comparison with coil packing, is the lower risk of embolization and the preservation of the visceral artery. A preliminary detailed study of the liver vascularization with MDCT and 3D angiography is fundamental to obtain a complete knowledge of vascular anatomy (Fig. 4). Exploiting the presence of a well-demonstrated collateral perfusion of the liver by an inferior duodeno-pancreatic branch we decided to treat the aneurysm by excluding the entire common hepatic artery. In a preliminary phase, we considered several endovascular alternatives to exclude the aneurysm, such as “coils embolization” or a bare stent assisted embolization, however the short distance between the aneurysm neck and the celiac trunk was unfavourable for coils deployment for the high risk of coils displacement and migration, and a stent assisted coils embolizations seemed a more sophisticated and expensive solution. Although we attempted to avoid coverage of the LGA the accidental occlusion did not represent a concern about gastric perfusion due to a patent GDA. Nor
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Fig. 6. (A) MDCT with VR reconstruction at 1 year follow up showing exclusion of the aneurysm with revascularization of proper hepatic artery (arrow) by hypertrophic GDA (arrowhead) and a patent LGA (asterisk). (B) MDCT at 2 years showing stent patency and shrinkage of the aneurysm (arrows). (C) MDCT with AVA reconstruction at 2 years demonstrates the complete aneurysm thrombosis.
preliminary left gastric and left phrenic arteries embolization were considered necessary in case of stent coverage because they rose from a healthy celiac trunk and therefore could not represent a risk for HAA type II endoleak. The major technical difficulties, proper of VAAs stent graft repair, are: (a) to have a stable carrier system for safely advancing the stent graft; (b) to chose an appropriate stent graft for dimensions and mechanical properties; and (c) to release the stent in the proper position [2]. Author’s suggestions for these technical aspects are: (a) the introducer sheaths today available, with a good pushability, trackability and shapeable tip allow to obtain a stable carrier system keeping the possibility for check injection flush; (b) the “ideal” stent graft for VAAs repair should be low profile to advance in small caliber carrier devices, adaptable to different vessel diameters and aneurysm lengths, and relatively flexible [2–4]; today are available many devices that respect these features; in our case we use a selfexpandable stent graft with nitinol mesh wire and high radial force to obtain a good sealing even in tortuous vessels; (c) both the preprocedural MDCT angiography evaluation with reconstructions and the 3D rotational angiography provided fundamental information for planning the treatment strategy such as precise dimension of the aneurysm (length of the neck, distance from the aorta, diameter of the afferent and efferent artery), tortuosity of the arteries, angulations of the aneurismatic tract, so that we could use the stent graft compatible with the anatomic situation. 4. Conclusion This case represents an optimal example of simple but efficient endovascular solution taking the advantage of the physiologic adaptation based on the complete occlusion of the proper hepatic artery and efficient collateral hepatic reperfusion. Stent graft
patency without filling defect and regular perfusion of the splanchnic organs at 1 and 2 year MDCT follow up, demonstrate that the endovascular treatment with stent graft could be considered the treatment of choice in selected cases and when an accurate preoperative imaging can be performed. Conflict of interest There is no financial arrangement or other relationship that could be construed as a conflict of interest. References [1] Bachar GN, Belenky A, Lubovsky L, et al. Sonographic diagnosis of a giant aneurysm of the common hepatic artery. J Clin Ultrasound 2002;30:300–2. [2] Rossi M, Rebonato A, Greco L, et al. Endovascular exclusion of visceral artery aneurysms with stent-grafts: technique and long-term follow-up. Cardiovasc Intervent Radiol 2008;31(January–February (1)):36–42 [Epub 2007 October 6]. [3] Hashim A, Allaqaband S, Bajwa T. Leaking hepatic artery aneurysm successfully treated with covered stent. Catheter Cardiovasc Interv 2009;74(September (3)):500–5. [4] Basile A, Ragazzi S, Piazza D, et al. Hepatic artery pseudoaneurysm treated using stent-graft implantation and retrograde gastroduodenal artery coil embolization. Eur Radiol 2008;18(November (11)):2579–81. [5] Nobuya A, Naofumi M, Toshio F, et al. Multiple intra-hepatic aneurysm following transcatheter embolisation. Work in progress. Radiology 1994;193:743–6. [6] Gabelmann A, Görich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9(February (1)):38–47. [7] Larson RA, Solomon J, Carpenter JP. Stent graft repair of visceral artery aneurysms. J Vasc Surg 2002;36(December (6)):1260–3. [8] Bürger T, Halloul Z, Meyer F, et al. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther 2000;7(4):324–7. [9] Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45(February (2)):276–83 [discussion 283]. [10] Vallina-Victorero Vazquez MJ, Vaquero Lorenzo F, Salgado AA, et al. Endovascular treatment of splenic and renal aneurysms. Ann Vasc Surg 2009;23(March (2)), 258e13–7 [Epub 2008 November 5].