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Principles used in the management
Principles Used in the Management of Visceral Aneurysms Michael A. Arata, MD and Constantine Cope, MD
Aneurysms of the visceral arteries were rarely encountered before the development of modern imaging; most presented with rupture. Now, however, visceral artery aneurysms are detected with increasing frequency, particularly in asymptomatic individuals, because of the widespread availability of high-quality cross-sectional imaging. Rupture of these aneurysms is associated with significant morbidity and mortality. Percutaneous techniques are effective and safe methods for aneurysm exclusion. Copyright © 2000 by W.B. Saunders Company
efore the advent of modern imaging, visceral aneurysms
B were infrequently encountered. They occurred symptom-
atically, with almost 25% presenting emergently, which is associated with approximately 9% mortality. 1 Asymptomatic lesions were incidentally noted on arteriography or radiography when calcified. The widespread availability of modern cross-sectional imaging resulted in increased detection of these lesions. Whereas aneurysms of the visceral arteries account for a small percentage of all aneurysms, they are a serious vascular disorder because of the risks of rupture. The majority, approximately 60%, arise from the splenic artery. Hepatic artery aneurysms constitute 20% of visceral aneurysms hut are being detected with increasing frequency. Less-common visceral aneurysms occur, in decreasing order of frequency, in the superior mesenteric, celiac, gastric-gastroepiploic, pancreaticoduodenal-pancreatic, and gastroduodenal arteries. 2 Most visceral aneurysms are acquired lesions and represent true aneurysms (Fig 1). Pseudoaneurysms, those with a defect in a component of the normal arterial wall, occur less frequently. Causes include atherosclerosis, medial degeneration, fibrodysplasia, infection, inflammation, trauma, and pregnancy. Pseudoanenrysms are typically related to trauma and surgery. Before the advent of interventional techniques, therapy was expectant or surgical. Surgical treatment is necessary for treating symptomatic and ruptured aneurysms. Asymptomatic aneurysms are generally excised when they are greater than 1.5 to 2.5 cm in diameter; splenic artery aneurysms in women of childbearing age are especially prone to rupture and should be treated when they are as small as twice the diameter of the
From the Hospital of the University of Pennsylvania, Department of Radiology, Interventional Section, Philadelphia, PA; and Newport Harbor Radiology Associates, Newport Beach, CA. Address reprint requests to Michael A. Arata, MD, Hoag Hospital, Department of Radiology, 1 Hoag Drive, Box 6100, Newport Beach, CA 92658. Copyright © 2000 by W.B. Saunders Company 1089-2516/00/0303-0003510.00/0 doi:10.1053/tvir.2000.9147
124
main feeding artery. Surgical options include aneurysmectomy with direct arteriorrhaphy or patch angioplasty or resection of the affected arterial segment with end-to-end anastomosis, interpositional graft, or graft bypass. Intraparenchymal aneurysms are often managed with end-organ resection. Surgical resection of ruptured visceral aneurysms is associated with an 8.5% mortality rate. Many interventional techniques are available (Fig 2) for occluding visceral anenrysms once they are accessed by either percutaneous vascular catheterization or by direct transabdominal puncture.
Therapeutic Principles Abdominal aortography should be performed in almost all patients with aneurysms to check for multiple unsuspected aneurysms; it also serves to identify aneurysmal feeding vessels, which can be multiple, and to eliminate confusion caused by guidewire- or catheter-induced spasm. Selective and superselective catheterization are required; some aneurysms may not otherwise be detected because of slow blood flow. In some cases, percutaneous drainage catheters, eg0 after biliary drainage, may have to be removed to see a pseudoaneurysm angiographically.3 High-quality diagnostic arteriography is essential for the development of a therapeutic strategy. The use of multiple angiographic projections is necessary to assess properly the diameter of the aneurysm neck (Figs 3 and 4), the number of feeding vessels, the presence of efferent vessels in the sac, and the type of collateral flow. This information is vital to determine the most appropriate therapeutic approach. The end organ supplied by the parent vessel and the presence of collateral flow must also be considered, eg, hepatopetal portal flow in relation to hepatic artery aneurysms. Regardless of the aneurysm exclusion technique being used, it is important to ensure that the aneurysmal sac is completely obliterated. For example, an aneurysm can still be subject to rupture after being completely filled with coils so long as the contained blood is still seen circulating within the sac (Figs 5 and 6).4
Catheter-Directed Techniques A Cobra catheter (Cook Inc, Bloomington, IN) is good for most first- and second-order catheterization of the splanchnic vessels. Sidewinder and hockey-stick catheters (Cook Inc) may also be helpful. Third-order catheterization and beyond can now be accomplished with hydrophilic catheter and guidewire combinations. Superselection and complex approaches through collateral vessels such as the Arch of Riolan will necessitate the use of a microcatheter. Catheterization of especially tortuous vessels such as the splenic artery may he facilitated with the use of a nondetachable, partially inflated balloon catheter, which will be carried passively down the vessel by the blood flow
Techniques in Vascular and Interventional Radiology, Vol 3, No 3 (September), 2000: pp 124-129
by obliterating the lumen of the aneurysm while preserving the lumen of the parent vessel by catheterization from an endovascular approach or percutaneously. The availability of appropriately sized covered stents may provide the most efficacious method for aneurysm exclusion. At present, these are not commercially available in the United States.
Materials
Fig 1. This aneurysm arose from the proximal splenic artery and was treated by filling the sac with thrombin-soaked Gianturco coils (Cook Inc), followed by coil occlusion of the afferent artery. Alternatively, the efferent and afferent segments of the splenic artery at the neck of the aneurysm could have been occluded, as in Fig 2A.
(Figs 7 and 8). The most easily accomplished catheter-directed technique for occlusion of visceral aneurysms is afferent artery occlusion• This is the method of choice for use in vessels supplying end organs (eg, the kidney) that lack significant collateral supply. It is also useful in the setting of rapid exsanguination or when advancement of the catheter beyond the aneurysm proves difficult or unsafe. To ensure complete vascular exclusion of an aneurysm, afferent and efferent artery occlusion should be performed• This is particularly important when a rich collateral network is present as, for example, in aneurysms arising from the gastroduodenal artery. At times, occlusion of the parent vessel is not desired because it provides important collaterals to nontarget tissues• In this type of case, aneurysm exclusion may be accomplished
A Fig 2. Techniques for aneurysmal occlusion include the following: (A) Occlusion of aneurysmal afferent and efferent limbs; (B) occlusion of flow to aneurysmal neck with coils or covered stent; (C) thrombosis of aneurysm without occlusion of the feeding vessel; and (D) preliminary occlusion of aneurysmal branch before sac occlusion is considered.
c
MANAGEMENT OF VISCERAL ANEURYSMS
Coils are the primary embolic agents in the treatment of visceral aneurysms. They are commercially available in a wide variety of sizes and configurations for use through standard catheters and microcatheter systems. Coil shapes include straight, curved, and complex curved. The coils are constructed of platinum or stainless steel alloys and are usually furnished with intercoil Dacron (duPont, Wilmington, DE) thread to promote thrombosis. The type and size of coil chosen should, in its expanded form, be slightly larger than the lumen of the structure being embolized. A similar result can be obtained by the nesting of a combination of large and small coils. Straight microcoils may be all that is needed when superselective embolization with a microcatheter is performed. GDC coils (Target Therapeutics, Fremont, CA) that are electronically released from their pusher wire can be helpful, particularly when one is directly embolizing an aneurysm that has a wide neck. Adhesives such as N-butyl-2-cyanoacrylate or thrombin may be used as a primary embolic agent, but they are most useful as adjuncts to coil embolization. Thrombin is particularly useful as an adjunct, either for soaking the coils before their deployment or for directed injection into the aneurysm to hasten pericoil thrombosis. Thrombin is most efficacious when injected in small boluses of 250 U in areas of blood stasis with no heparin present; it is recommended that the maximum dose be less than 1,000 U. Nondetachable occlusion balloons are typically used with tissue glue embolization to block inflow and washout• They can also be deployed distally in the parent vessel to prevent outflow into the end organ. Detachable balloons are useful for aneurysm exclusion by parent vessel occlusion. Appropriate size can be determined angiographically with balloon inflation before deployment.
:[
D
•
125
Fig 3. Assessment of renal artery aneurysm for possible embolization. (A) Demonstration of a left single renal artery hilar aneurysm. (B) Subselective catheterization and opacification showed the aneurysm to have too wide a neck for safe coil embolization, as well as a segmental branch arising directly from the sac.
Balloons can be used precisely within the afferent vessel or the afferent and efferent vessels as primary treatment. A detachable balloon deployed in the efferent vessel can protect against end-organ embolization. Particles such as polyvinyl alcohol or Gelfoam (Pharmacia & Upjohn, Kalamazoo, MI) may also be used as adjuncts to coils but are otherwise not well suited for aneurysm embolization. Similarly sclerosing agents, such as alcohol or hot contrast, are not usually helpful.
126
Fig 4. Coil thrombosis of renal branch artery aneurysm in a young hypertensive woman. (A) Small-neck aneurysm arose from a major renal artery branch effected by severe fibromuscular hyperplasia. (B) After percutaneous transluminal angioplasty (PTA) of the artery, the aneurysm was filled with 3 platinum coils with prompt thrombosis of the sac but not of the neck. On follow-up study 2 weeks later, the aneurysm was completely thrombosed, and the patient was normotensive.
Percutaneous
Techniques
Aneurysms that are not accessible by catheter can be embolized by direct percutaneous needle access of the aneurysm with imaging guidance (Fig 7). This is particularly helpful when catheterization of the aneurysm is not feasible and occlusion of the parent vessel is not a viable option. Direct access with a 20-gauge needle allows embolization with coils, thrombin, or a combination of the 2 (Fig 8A and B).5
ARATAAND COPE
A
Fig 5. Balloon flotation technique for accessing a distal splenic aneurysm. (A) After the selective Cobra catheter was replaced by an occlusion balloon catheter, the inflated balloon was noted to float promptly through the very tortuous splenic artery to reach the aneurysm. (B) The balloon catheter was exchanged for hockey-stick catheter, but it proved impossible to catheterize the distal splenic artery branches for possible occlusion of the aneurysmal neck.
Complications Interventional techniques for management of visceral aneurysms are safe; potential complications can be minimized by careful preprocedural planning of access routes, sizing of aneurysmal neck, careful visualization of afferent and efferent arteries, and accurate matching of coils to the vessels. Potential complications are usually minor but can be severe, including mortality. Most complications are those are that occur with any angiographic procedure and typically are access-site-related. Complications that are unique to embolization therapy include nontarget embolization and problems related to ischemia, leading to infarction of vital organs and nerve damage. If
MANAGEMENT OF VISCERAL ANEURYSMS
Fig 6. Occlusion of posthysterectomy iliac branch pseudoaneurysm. (A) A 2-cm aneurysm arose from a small anterior branch of the left hypogastric artery adjacent to a large pelvic abscess. (B) The aneurysm and distal small vessels were successfully occluded with coils and Gelfoam slurry with loss of cross-filling inflow.
dislodged, embolic material can migrate in a retrograde fashion and be delivered elsewhere in the body by the circulation or, more commonly, distal embolization can occur and result in end-organ ischemia. Postembolization syndrome is a selflimited syndrome that manifests as pain, fever, nausea, and vomiting; it can occur with all embolizations but is more common with embolization of visceral organs that lack collateral supply, such as the liver.
127
Fig 7, Percutaneous thrombosis of large hypogastric aneurysm, (A) After unsuccessful attempts to selectively catheterize the feeding vessel, the sac was punctured transabdominally with a 20-gauge Teflon-sheathed (duPont, Wilmington, DE) needle. (B) There was immediate thrombosis of the aneurysm after 500 U thrombin was injected intraluminally (arrows). (Reprinted with permission from Cope C, Zeit R, Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgeno11986;147:383-387).
128
Fig 8. Percutaneous coil embolization of pancreatic pseudoaneurysm. (A) Pseudoaneurysm (arrows) is opacified through tiny collaterals from the superior mesenteric artery, (B) The aneurysm was punctured transabdominally with a 21-gauge needle during opacification of the superior mesenteric artery and thrombosed platinum microcoils (arrows) and thrombin.
ARATA AND COPE
References 1. Carr SC, Pearce WH, Vogelzang RL, et al: Current management of visceral artery aneurysms. Surgery 120:627-633, 1996 2. Stanley JC, Messina LM, Zellenock GB: Splanchnic and renal artery aneurysms, in Moore WS (ed): Vascular Surgery. Philadelphia, PA, Saunders, 1998, pp 468-482 3. Cope C: Embolization--General principles and techniques, in Haskal
MANAGEMENT OF VISCERAL ANEURYSMS
ZJ, Kerlan RK, Terotola SO (eds): SCVIR Syllabus--Thoracic and Visceral Vascular Interventions. Fairfax, VA, Society of Vascular & Interventional Radiology, 1996, pp 214-234 4. McDermott VG, Shlansky-Goldberg R, Cope C: Endovascular management of splenic artery aneurysms and pseudoaneurysms. Cardiovasc Intervent Radiol 17:179-184, 1994 5. Cope C, Zeit R: Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgeno1147:383-387, 1986
12g
Aneurysms of the visceral arteries were rarely encountered before the development of modern imaging; most presented with rupture. Now, however, visceral artery aneurysms are detected with increasing frequency, particularly in asymptomatic individuals, because of the widespread availability of high-quality cross-sectional imaging. Rupture of these aneurysms is associated with significant morbidity and mortality. Percutaneous techniques are effective and safe methods for aneurysm exclusion. Copyright © 2000 by W.B. Saunders Company
efore the advent of modern imaging, visceral aneurysms
B were infrequently encountered. They occurred symptom-
atically, with almost 25% presenting emergently, which is associated with approximately 9% mortality. 1 Asymptomatic lesions were incidentally noted on arteriography or radiography when calcified. The widespread availability of modern cross-sectional imaging resulted in increased detection of these lesions. Whereas aneurysms of the visceral arteries account for a small percentage of all aneurysms, they are a serious vascular disorder because of the risks of rupture. The majority, approximately 60%, arise from the splenic artery. Hepatic artery aneurysms constitute 20% of visceral aneurysms hut are being detected with increasing frequency. Less-common visceral aneurysms occur, in decreasing order of frequency, in the superior mesenteric, celiac, gastric-gastroepiploic, pancreaticoduodenal-pancreatic, and gastroduodenal arteries. 2 Most visceral aneurysms are acquired lesions and represent true aneurysms (Fig 1). Pseudoaneurysms, those with a defect in a component of the normal arterial wall, occur less frequently. Causes include atherosclerosis, medial degeneration, fibrodysplasia, infection, inflammation, trauma, and pregnancy. Pseudoanenrysms are typically related to trauma and surgery. Before the advent of interventional techniques, therapy was expectant or surgical. Surgical treatment is necessary for treating symptomatic and ruptured aneurysms. Asymptomatic aneurysms are generally excised when they are greater than 1.5 to 2.5 cm in diameter; splenic artery aneurysms in women of childbearing age are especially prone to rupture and should be treated when they are as small as twice the diameter of the
From the Hospital of the University of Pennsylvania, Department of Radiology, Interventional Section, Philadelphia, PA; and Newport Harbor Radiology Associates, Newport Beach, CA. Address reprint requests to Michael A. Arata, MD, Hoag Hospital, Department of Radiology, 1 Hoag Drive, Box 6100, Newport Beach, CA 92658. Copyright © 2000 by W.B. Saunders Company 1089-2516/00/0303-0003510.00/0 doi:10.1053/tvir.2000.9147
124
main feeding artery. Surgical options include aneurysmectomy with direct arteriorrhaphy or patch angioplasty or resection of the affected arterial segment with end-to-end anastomosis, interpositional graft, or graft bypass. Intraparenchymal aneurysms are often managed with end-organ resection. Surgical resection of ruptured visceral aneurysms is associated with an 8.5% mortality rate. Many interventional techniques are available (Fig 2) for occluding visceral anenrysms once they are accessed by either percutaneous vascular catheterization or by direct transabdominal puncture.
Therapeutic Principles Abdominal aortography should be performed in almost all patients with aneurysms to check for multiple unsuspected aneurysms; it also serves to identify aneurysmal feeding vessels, which can be multiple, and to eliminate confusion caused by guidewire- or catheter-induced spasm. Selective and superselective catheterization are required; some aneurysms may not otherwise be detected because of slow blood flow. In some cases, percutaneous drainage catheters, eg0 after biliary drainage, may have to be removed to see a pseudoaneurysm angiographically.3 High-quality diagnostic arteriography is essential for the development of a therapeutic strategy. The use of multiple angiographic projections is necessary to assess properly the diameter of the aneurysm neck (Figs 3 and 4), the number of feeding vessels, the presence of efferent vessels in the sac, and the type of collateral flow. This information is vital to determine the most appropriate therapeutic approach. The end organ supplied by the parent vessel and the presence of collateral flow must also be considered, eg, hepatopetal portal flow in relation to hepatic artery aneurysms. Regardless of the aneurysm exclusion technique being used, it is important to ensure that the aneurysmal sac is completely obliterated. For example, an aneurysm can still be subject to rupture after being completely filled with coils so long as the contained blood is still seen circulating within the sac (Figs 5 and 6).4
Catheter-Directed Techniques A Cobra catheter (Cook Inc, Bloomington, IN) is good for most first- and second-order catheterization of the splanchnic vessels. Sidewinder and hockey-stick catheters (Cook Inc) may also be helpful. Third-order catheterization and beyond can now be accomplished with hydrophilic catheter and guidewire combinations. Superselection and complex approaches through collateral vessels such as the Arch of Riolan will necessitate the use of a microcatheter. Catheterization of especially tortuous vessels such as the splenic artery may he facilitated with the use of a nondetachable, partially inflated balloon catheter, which will be carried passively down the vessel by the blood flow
Techniques in Vascular and Interventional Radiology, Vol 3, No 3 (September), 2000: pp 124-129
by obliterating the lumen of the aneurysm while preserving the lumen of the parent vessel by catheterization from an endovascular approach or percutaneously. The availability of appropriately sized covered stents may provide the most efficacious method for aneurysm exclusion. At present, these are not commercially available in the United States.
Materials
Fig 1. This aneurysm arose from the proximal splenic artery and was treated by filling the sac with thrombin-soaked Gianturco coils (Cook Inc), followed by coil occlusion of the afferent artery. Alternatively, the efferent and afferent segments of the splenic artery at the neck of the aneurysm could have been occluded, as in Fig 2A.
(Figs 7 and 8). The most easily accomplished catheter-directed technique for occlusion of visceral aneurysms is afferent artery occlusion• This is the method of choice for use in vessels supplying end organs (eg, the kidney) that lack significant collateral supply. It is also useful in the setting of rapid exsanguination or when advancement of the catheter beyond the aneurysm proves difficult or unsafe. To ensure complete vascular exclusion of an aneurysm, afferent and efferent artery occlusion should be performed• This is particularly important when a rich collateral network is present as, for example, in aneurysms arising from the gastroduodenal artery. At times, occlusion of the parent vessel is not desired because it provides important collaterals to nontarget tissues• In this type of case, aneurysm exclusion may be accomplished
A Fig 2. Techniques for aneurysmal occlusion include the following: (A) Occlusion of aneurysmal afferent and efferent limbs; (B) occlusion of flow to aneurysmal neck with coils or covered stent; (C) thrombosis of aneurysm without occlusion of the feeding vessel; and (D) preliminary occlusion of aneurysmal branch before sac occlusion is considered.
c
MANAGEMENT OF VISCERAL ANEURYSMS
Coils are the primary embolic agents in the treatment of visceral aneurysms. They are commercially available in a wide variety of sizes and configurations for use through standard catheters and microcatheter systems. Coil shapes include straight, curved, and complex curved. The coils are constructed of platinum or stainless steel alloys and are usually furnished with intercoil Dacron (duPont, Wilmington, DE) thread to promote thrombosis. The type and size of coil chosen should, in its expanded form, be slightly larger than the lumen of the structure being embolized. A similar result can be obtained by the nesting of a combination of large and small coils. Straight microcoils may be all that is needed when superselective embolization with a microcatheter is performed. GDC coils (Target Therapeutics, Fremont, CA) that are electronically released from their pusher wire can be helpful, particularly when one is directly embolizing an aneurysm that has a wide neck. Adhesives such as N-butyl-2-cyanoacrylate or thrombin may be used as a primary embolic agent, but they are most useful as adjuncts to coil embolization. Thrombin is particularly useful as an adjunct, either for soaking the coils before their deployment or for directed injection into the aneurysm to hasten pericoil thrombosis. Thrombin is most efficacious when injected in small boluses of 250 U in areas of blood stasis with no heparin present; it is recommended that the maximum dose be less than 1,000 U. Nondetachable occlusion balloons are typically used with tissue glue embolization to block inflow and washout• They can also be deployed distally in the parent vessel to prevent outflow into the end organ. Detachable balloons are useful for aneurysm exclusion by parent vessel occlusion. Appropriate size can be determined angiographically with balloon inflation before deployment.
:[
D
•
125
Fig 3. Assessment of renal artery aneurysm for possible embolization. (A) Demonstration of a left single renal artery hilar aneurysm. (B) Subselective catheterization and opacification showed the aneurysm to have too wide a neck for safe coil embolization, as well as a segmental branch arising directly from the sac.
Balloons can be used precisely within the afferent vessel or the afferent and efferent vessels as primary treatment. A detachable balloon deployed in the efferent vessel can protect against end-organ embolization. Particles such as polyvinyl alcohol or Gelfoam (Pharmacia & Upjohn, Kalamazoo, MI) may also be used as adjuncts to coils but are otherwise not well suited for aneurysm embolization. Similarly sclerosing agents, such as alcohol or hot contrast, are not usually helpful.
126
Fig 4. Coil thrombosis of renal branch artery aneurysm in a young hypertensive woman. (A) Small-neck aneurysm arose from a major renal artery branch effected by severe fibromuscular hyperplasia. (B) After percutaneous transluminal angioplasty (PTA) of the artery, the aneurysm was filled with 3 platinum coils with prompt thrombosis of the sac but not of the neck. On follow-up study 2 weeks later, the aneurysm was completely thrombosed, and the patient was normotensive.
Percutaneous
Techniques
Aneurysms that are not accessible by catheter can be embolized by direct percutaneous needle access of the aneurysm with imaging guidance (Fig 7). This is particularly helpful when catheterization of the aneurysm is not feasible and occlusion of the parent vessel is not a viable option. Direct access with a 20-gauge needle allows embolization with coils, thrombin, or a combination of the 2 (Fig 8A and B).5
ARATAAND COPE
A
Fig 5. Balloon flotation technique for accessing a distal splenic aneurysm. (A) After the selective Cobra catheter was replaced by an occlusion balloon catheter, the inflated balloon was noted to float promptly through the very tortuous splenic artery to reach the aneurysm. (B) The balloon catheter was exchanged for hockey-stick catheter, but it proved impossible to catheterize the distal splenic artery branches for possible occlusion of the aneurysmal neck.
Complications Interventional techniques for management of visceral aneurysms are safe; potential complications can be minimized by careful preprocedural planning of access routes, sizing of aneurysmal neck, careful visualization of afferent and efferent arteries, and accurate matching of coils to the vessels. Potential complications are usually minor but can be severe, including mortality. Most complications are those are that occur with any angiographic procedure and typically are access-site-related. Complications that are unique to embolization therapy include nontarget embolization and problems related to ischemia, leading to infarction of vital organs and nerve damage. If
MANAGEMENT OF VISCERAL ANEURYSMS
Fig 6. Occlusion of posthysterectomy iliac branch pseudoaneurysm. (A) A 2-cm aneurysm arose from a small anterior branch of the left hypogastric artery adjacent to a large pelvic abscess. (B) The aneurysm and distal small vessels were successfully occluded with coils and Gelfoam slurry with loss of cross-filling inflow.
dislodged, embolic material can migrate in a retrograde fashion and be delivered elsewhere in the body by the circulation or, more commonly, distal embolization can occur and result in end-organ ischemia. Postembolization syndrome is a selflimited syndrome that manifests as pain, fever, nausea, and vomiting; it can occur with all embolizations but is more common with embolization of visceral organs that lack collateral supply, such as the liver.
127
Fig 7, Percutaneous thrombosis of large hypogastric aneurysm, (A) After unsuccessful attempts to selectively catheterize the feeding vessel, the sac was punctured transabdominally with a 20-gauge Teflon-sheathed (duPont, Wilmington, DE) needle. (B) There was immediate thrombosis of the aneurysm after 500 U thrombin was injected intraluminally (arrows). (Reprinted with permission from Cope C, Zeit R, Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgeno11986;147:383-387).
128
Fig 8. Percutaneous coil embolization of pancreatic pseudoaneurysm. (A) Pseudoaneurysm (arrows) is opacified through tiny collaterals from the superior mesenteric artery, (B) The aneurysm was punctured transabdominally with a 21-gauge needle during opacification of the superior mesenteric artery and thrombosed platinum microcoils (arrows) and thrombin.
ARATA AND COPE
References 1. Carr SC, Pearce WH, Vogelzang RL, et al: Current management of visceral artery aneurysms. Surgery 120:627-633, 1996 2. Stanley JC, Messina LM, Zellenock GB: Splanchnic and renal artery aneurysms, in Moore WS (ed): Vascular Surgery. Philadelphia, PA, Saunders, 1998, pp 468-482 3. Cope C: Embolization--General principles and techniques, in Haskal
MANAGEMENT OF VISCERAL ANEURYSMS
ZJ, Kerlan RK, Terotola SO (eds): SCVIR Syllabus--Thoracic and Visceral Vascular Interventions. Fairfax, VA, Society of Vascular & Interventional Radiology, 1996, pp 214-234 4. McDermott VG, Shlansky-Goldberg R, Cope C: Endovascular management of splenic artery aneurysms and pseudoaneurysms. Cardiovasc Intervent Radiol 17:179-184, 1994 5. Cope C, Zeit R: Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgeno1147:383-387, 1986
12g