Two-stage treatment of an unusual haemobilia caused by intrahepatic pseudoaneurysm

A 84-year-old man with a surgical history of subtotal gastrectomy for gastric cancer was transferred to our department because of a disorder of consciousness. Septic shock due to obstructive suppurative cholangitis secondary to choledocholithiasis was diagnosed. Anemia was also present,and upper gastrointestinal tract endoscopy revealed blood emerging from the Papilla of Vater.The cause of the anemia was identified as haemobilia.Angiography showed a small aneurysm over the artery on segment 3(A3) .The cause of the haemobilia was suspected to be the bleeding into the biliary tree from this aneurysm.Because the patient's general condition was poor,minimally invasive therapy was needed.Transcatheter arterial embolization(TAE) was selected initally.Later,lateral sectionectomy was performed in order to remove the aneurysm on A3. No surgical complication occurred and,after surgery,no haemobilia was identified.In conclusion,a twostage treatment,namely,surgery following TAE,is recommended for patients in a physically poor condition who have haemobilia due to intrahepatic aneurysm.

Percutaneous thrombin embolization of a pancreaticoduodenal artery pseudoaneurysm after failing of the endovascular treatment

Pancreatico-duodenal artery(PDA) pseudoaneurysms are rare vascular conditions with high mortality rates after rupture and they are frequently secondary to pan-creatitis, surgery, trauma or infection. Due to the high risk of rupture and bleeding, it is mandatory to treat all pseudoaneurysms, regardless of their size or symp-tomatology. First option of treatment is open surgical repair, but it has high mortality rate, especially in he-modynamically unstable patients. In the recent years, percutaneous ultrasonography(US)- or computed to-mography-guided thrombin injection was proposed as an alternative method for treating visceral aneurysms and pseudoaneurysms, but few reports described this therapy in case of peri-pancreatic pseudoaneurysms. We present a rare case of pseudoaneurysm of the PDA in a patient with no previous history of pancreatitis nor major surgery but with an occlusive lesion of the celiac axis. To the best of our knowledge this is the first reported case of PDA pseudoaneurysm successfully treated in emergency by single transabdominal US-guided injection of thrombin after failed attempts of percutaneous catheterization of the feeding vessel of the pseudoaneurysm.

多学科诊疗模式应用于动静内瘘假性动脉瘤患者的效果

目的 探讨多学科诊疗模式(MDT)应用于动静脉内瘘(AVF)假性动脉瘤患者的效果。方法选取2021年11月—2023年1月医院收治的137例AVF假性动脉瘤患者作为研究对象,按照组间基本特征具有可比性的原则分为对照组68例和观察组69例。对照组给予常规护理,即在患者入院后予以健康指导,提高患者的疾病认知度,并依据其透析情况及时进行干预,护士在做好穿刺评估后可采用跳跃式或绳梯式穿刺方法,成功后进行透析,结束后利用纱布加压止血。观察组在多学科诊疗模式基础上组建内瘘专项小组,建立患者健康档案进行分类及分层管理,小组成员通过语言及示范等多种方式在透析前后进行健康宣教,透析时选用适合的血管进行穿刺并依据患者血检报告调整止血时间,依据患者具体情况制订外科治疗方案。观察两组自我护能力,穿刺次数及瘤体情况,生活质量,并发症发生率。结果干预3个月后,观察组自我护理技巧、自我概念、健康知识水平及自我护理责任感评分均高于对照组,差异有统计学意义(P<0.05);观察组平均穿刺次数及瘤体个数均少于对照组,观察组瘤体较对照组小,差异有统计学意义(P<0.05);干预3个月后,观察组KDQOL-SFTM量表中SF-36总分及肾病和透析相关生存质量量表总分均高于对照组,差异有统计学意义(P<0.05);观察组并发症发生率低于对照组,差异有统计学意义(P<0.05)。结论 与单一接受常规护理比较,对AVF假性动脉瘤患者予以MDT模式可减少穿刺次数,提高自我护能力,降低并发症发生率。

Post-traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection

Post-traumatic hepatic artery pseudoaneurysm is unc-ommon,appearing in approximately 1%of hepatic trauma cases.Most are extrahepatic(80%)and have a late onset.Although they are usually asymptomatic, they should always be treated becasue of the high risk of complications,especially breakage.Currently the treatment of choice is endovascular embolization with coils or the exclusion of the pseudoaneurysm using other intravascular devices.Recently there have been accounts of a treatment that combines embolization with coils and image-guided percutaneous human thrombin injection.We present a case of post-traumatichepatic artery pseudoaneurysm that was successfully treated using this combined technique.

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy.Here,we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery(CHA)stump that developed after distal pancreatectomy with en block celiac axis resection(DP-CAR),and was successfully treated through covered stent placement.The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer.She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery,and computed tomography(CT)showed an occluded portal vein due to the spreading inflammation around the abscess.Her general condition improved after CT-guided drainage of the abscess.However,19 d later,she presented with melena,and CT showed a pseudoaneurysm arising from the CHA stump.Because the CHA had been resected during the DP-CAR,this artery could not be used as the access route for endovascular treatment,and instead,we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery.After stent placement,cessation of bleeding and anterograde hepatic artery flow were confirmed,and the patient recovered well without any further complications.CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow.To our knowledge,this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

Percutaneous Embolization of a Hepatic Artery Pseudoaneurysm under Combined Angiographic and Fluoroscopic Guidance

Hepatic artery pseudoaneurysm is a rare complication of liver directed procedures. Several strategies for treatment of pseudoaneurysms have been described. We describe a challenging case in which a small bleeding hepatic artery pseudoaneurysm is complicated by a proximal hepatic arterial occlusion, preventing transcatheter access. The aneurysm was too small to be seen on ultrasound. Using combined angiographic and fluoroscopic guidance, however, the aneurysm was triangulated and successfully treated with percutaneous direct thrombin injection. Combined angiography and fluoroscopy guided percutaneous thrombin injection of intrahepatic pseudoaneurysms can be a valuable treatment approach, particularly when other methods are not feasible or have failed.

Echo-guided pin-point compression can effectively repair pseudoaneurysms associated with catheter procedure

Background: Catheter intervention is occasionally complicated by a pseudoaneurysm at the puncture site. Although the feasibility of echo-guided repair of a pseudoaneurysm has been reported, this method does not always repair the pseudoaneurysm. We hypothesized that if the communication to the artery could be effectively closed by pin-point compression, the clot that forms in the residual lumen would effectively cover the communication. We studied the safety and efficacy of the echo-guided pinpoint compression procedure for repairing a pseudoaneurysm. Methods: Ten consecutive patients with a pseudoaneurysm were enrolled. We determined the site of communication by echography with a high-frequency linear probe. We performed pin-point compression on the communication point with the right index finger, and we confirmed closure of the communication by color Doppler. During compression, we monitored echo images to confirm clot formation. Results: A pseudoaneurysm was located on the femoral artery in 6 patients and on the brachial artery in 4 patients. The sizes of the pseudoaneurysms ranged from 13 to 40 mm in diameter. We successfully closed the communication with one-finger compression in all patients. During the compression, we observed clot formation in the residual lumen of the pseudoaneurysm in all patients by echography. The duration of compression ranged from 5 to 40 minutes (mean, 18 minutes). We succeeded in repairing the pseudoaneurysm in all patients using this method. The success of the procedure was also confirmed 24 hours later in all patients. Conclusions: Echo-guided pin-point compression of the communication might be an effective technique for repairing a pseudoaneurysm at the puncture site, and echography is useful for confirming the success of the procedure.

Left Ventricle Postinfarction Pseudoaneurysm: Anatomical Forms and Surgical Management

Introduction: Left Ventricle Postinfarction Pseudoaneurysm (LVPS)—false aneurysm occurs after a free-wall rupture contained by the adjacent pericardium. LVPS lacks the normal structure of the ventricular wall and disrupts the normal chamber anatomy. However, the natural history, clinical presentation and surgical outcome are still unclear. For that reason, it is necessary to describe the most relevant anatomical characteristics of LVPS and the appropriate surgical strategies currently applied. Methods: We reviewed the anatomical characteristics of several patients diagnosed of LVPS and the surgical technique performed. In this work two different anatomical types of LVPS are described in detail, with the surgical and structural implications for left ventricle reconstruction. Results: There are two different anatomical forms of LVPS: 1) Typical pseudoaneurysm, with a small gateway neck between the Left Ventricle and the false aneurysm chamber (Figure 1(A));2) Atypical pseudoaneurysm, in which the anatomical defect is bigger, without well-defined edges, extends over a large segment of infarcted and thinned myocardial tissue. In both cases, the therapeutics targets and the surgical techniques used were directed to restore the normal geometry of Left Ventricle, keeping the optimal mitral valve function. Conclusions: The surgical key-step is to preserve or to remodel the ventricular chamber anatomy. This fact restores the ventricular geometry, not only removing the wall discontinuity that generated the pseudoaneurysm. Nevertheless, final prognosis depends on the underlying ischemic cardiomyopathy and mechanical complications, such us mitral regurgitation or ventricular septal defect.

Plain and Contrast Enhanced CT Imaging Findings of a Rare Case of IVC Pseudoaneurysm

Inferior vena cava pseudo aneurysms are rare clinical entities with an uncertain natural history due to its rarity and limited follow up information. IVC injuries are managed according to the patient’s presentation and hemodynamic status. This case report describes clinical presentation of a 30 years old man with history of fall from height, infra renal IVC pseudoaneurysm found with FAST and CT scan abdomen, our treatment plan and his clinical outcome.

Traumatic Middle Meningeal Artery Pseudoaneurysms Presenting with Intractable Epistaxis: A Rare Case Report and Review of Literature

Middle meningeal artery (MMA) pseudoaneurysms are very rare and are most often traumatic. They may present as an epidural or intraparenchymal hematoma. This study reports a rare case in which a patient suffered from intractable epistaxis because of a pseudoaneurysm in middle meningeal artery and skull base fracture after craniocerebra trauma. Pseudoaneurysm and the feeding artery were embolized by using Onyx-18 liquid embolic system. Complete cessation of bleeding was achieved in this case immediately after the endovascular therapies. In this study, clinical manifestation, diagnostic imaging and endovascular treatment are described. Formation mechanisms and the treatment of traumatic pseudoaneurysm of middle meningeal artery are discussed.

创伤性硬膜下假性动脉瘤的临床特点及治疗选择(附6例报道)

目的 探讨创伤性硬膜下假性动脉瘤(TS-PSAN)的治疗方法选择及疗效。方法 回顾性分析中国人民解放军联勤保障部队第九〇〇医院神经外科2016年1月—2021年12月收治的6例TS-PSAN患者的临床治疗。所有患者均通过头颅DSA明确诊断,4例行血管内治疗,其中2例闭塞载瘤动脉,2例双支架联合弹簧圈栓塞;1例患者行颅内外血管搭桥手术;1例保守治疗。术后随访8个月~6年。结果 6例TS-PSAN外伤后均有蛛网膜下腔出血,5例首次CTA或DSA检查明确动脉瘤诊断,1例伤后第1次CTA阴性,因眼球充血肿胀,42 d后行CTA检查明确颅内巨大动脉瘤伴颈内动脉海绵窦瘘。6例患者动脉瘤均治愈,4例获得CTA随访,2例获得DSA随访,术后6个月随访时改良Rankin量表评分0分2例,1分1例,2分3例。随访(33.95±13.86)个月内均无复发。结论 应根据动脉瘤位置及形态,结合患者颅脑损伤的治疗策略选择最佳治疗方案,血管内治疗首选血管重建;代偿良好者或较末梢且不影响功能者,闭塞载瘤动脉是安全的;开颅手术同样是一项重要治疗方法。

假腔内注射凝血酶治疗股动脉假性动脉瘤(附6例临床分析)

目的 探讨超声引导下假腔内注射凝血酶对股动脉假性动脉瘤的治疗效果。方法 对本科 1999年 9月～ 2 0 0 2年 8月行心脏介入诊疗后并发的 6例右侧股动脉假性动脉瘤进行假腔内凝血酶注射治疗 ,并对其结果进行了分析。结果 6例患者均即刻治疗成功 ,未见明显并发症 ,随访 30d无复发。结论 假腔内注射凝血酶是一种安全、简便、快速、耐受性佳、经济和有效的治疗股动脉假性动脉瘤的方法。

瘤腔内栓塞结合血管壁内支架重建治疗颅内假性动脉瘤

目的探讨血管内治疗颅内假性动脉瘤的效果。方法对17例颅内假性动脉瘤患者选用弹簧圈、NBCA胶栓塞及血管内支架置入等方法进行血管内治疗。术后即刻复查血管造影并进行造影随访评价血管内治疗效果。结果除1例栓塞过程中发生动脉瘤破裂引起死亡外,其余16例患者手术均获成功。动脉瘤腔弹簧圈致密填塞率:单纯瘤腔内弹簧圈栓塞组致密填塞率50%;支架辅助弹簧圈栓塞组的致密填塞率42.9%。15例3个月到2年随访,单纯瘤腔内弹簧圈栓塞组2例复发,给予支架辅助弹簧圈补充栓塞,疗效满意;支架辅助弹簧圈栓塞组动脉瘤消失。结论根据病变不同特点选择个体化的血管内治疗技术治疗假性动脉瘤,而瘤腔内栓塞结合血管壁内支架重建治疗颅内假性动脉瘤可最大限度的减少复发,提高治愈率,是一种安全、有效的治疗手段。

超声下凝血酶注射治疗假性动脉瘤

目的 经皮超声引导下注射凝血酶（UGTI）治疗股动脉假性动脉瘤（PS）的方法学探讨及可行性评价。方法 15例经股动脉径路选择性冠脉造影和冠脉介入术后医源性股动脉PS患者接受了UGTI治疗。男5例，女10例，平均（68．5±12）岁，选择性冠脉造影1例，经皮冠脉介入14例。单腔的单纯型PS9例，2腔或3腔的复杂型PS6例。局麻后在超声引导下准确定位注射器针头，单纯PS尽可能在瘤腔底部，远离瘤颈部，复杂PS首选在远端瘤腔的底部，注射凝血酶速度宜慢，剂量为100-800IU凝血酶，超声下观察瘤腔内血栓形成，UGTI后24h、5～7d接受二维超声随访。结果 PS平均容积为（13±4．89）cm^3。共注射凝血酶21次，单腔注射凝血酶剂量为（250±120）IU，双腔或多腔为（650±150）IU。9例单腔患者全部一次成功；6例双腔或多腔的复杂PS患者4例首次成功，1例24hr出现“再通”，1例15d出现“再通”，经重复3次注射凝血酶后，封闭成功。无1例出现血栓形成、感染、过敏等并发症。结论 掌握正确的UGTI操作方法是治疗股动脉PS成功的前提条件，也是减少操作并发症的重要因素。采用正确的UGTI方法可作为医源性股动脉PS的首选治疗。

创伤性假性动脉瘤介入治疗的疗效分析

目的探讨利用介入栓塞方法治疗创伤性假性动脉瘤的临床疗效。方法对24例经DSA检查确诊为创伤性假性动脉瘤的患者行介入栓塞治疗。结果经DSA造影检查,均能清楚显示创伤性假性动脉瘤的位置、形态、开口及大小。其中17例行弹簧钢圈栓塞供血动脉,5例用无水乙醇栓塞供血动脉,2例行假性动脉瘤孤立术。24例患者全部得以有效止血。结论介入治疗是创伤性假性动脉瘤治疗的有效方法,可以达到立即止血的目的。

血管内栓塞治疗外周假性动脉瘤

目的：探讨血管内栓塞治疗外周假性动脉瘤的方法及疗效。方法本组21例患者，肝动脉瘤2例，肾动脉瘤12例，直肠上动脉瘤1例，胃十二指肠动脉瘤1例，下肢动脉瘤3例及子宫动脉瘤2例。均行相关动脉造影，明确假性动脉瘤部位、范围、程度及血供情况，然后超选择插管至病变处，进行栓塞治疗，栓塞方法及栓塞剂的种类、剂量根据病变性质、造影表现及插管具体位置进行选择。结果21例患者均通过动脉造影明确诊断，DSA 造影假性动脉瘤呈现类圆形囊状突起。栓塞后再次造影见动脉瘤及其供血动脉消失，21例介入治疗均获成功。随防1～18个月，均未复发。结论血管内栓塞治疗外周假性动脉瘤，安全有效、创伤小、并发症少，是行之有效的治疗方法。

创伤性假性动脉瘤的诊治

目的探讨各种创伤性假性动脉瘤的诊断与治疗方法。方法回顾性分析1998年6月～2010年7月收治的32例创伤性假性动脉瘤患者的诊治情况。根据假性动脉瘤的大小、位置与受损血管口径不同,采用相应的方法进行治疗:(1)假性动脉瘤切除+动脉重建;(2)瘤体切开或切除+破口修补;(3)瘤体切除+受损动脉结扎;(4)血管腔内治疗,带膜支架置入;(5)B超引导下破口压迫。结果患者近期治愈率100%,29例随访1～13年,假性动脉瘤未再复发,无死亡;1例截肢。结论根据假性动脉瘤的大小、位置与受损血管口径大小不同,采用相应的治疗方法可获良好疗效。

介入诊疗相关医源性股动脉假性动脉瘤危险因素及治疗分析

目的探讨经股动脉入路介入诊疗过程中发生医源性股动脉假性动脉瘤(IFPA)的危险因素。方法回顾性分析2015年1月至2019年12月在福建医科大学附属协和医院就诊并接受经股动脉穿刺入路手术患者临床和影像学资料,统计分析术后IFPA发生及治疗情况。结果纳入经股动脉穿刺介入诊疗患者1605例,其中42例(2.61%)术后发生IFPA。多元logistic回归分析结果显示,年龄>65岁(OR=5.17,95%CI=1.92~13.93)、女性(OR=14.72,95%CI=6.06~35.78)、吸烟史(OR=20.90,95%CI=5.89~74.12)和置管溶栓(OR=6.25,95%CI=2.51~15.55)是IPFA发生的独立预测因子,使用血管闭合装置(OR=0.03,95%CI=0.004~0.22)是IFPA发生的保护因素。42例IFPA患者中40例经超声定位手动按压破口治愈,2例通过覆膜支架腔内隔绝治疗。结论高龄、女性、有吸烟史及置管溶栓治疗患者经股动入路介入诊疗术后发生IFPA风险较高,应密切关注,早诊断早处理。采用血管闭合装置联合手动压迫可有效减少IFPA发生。

彩色多普勒超声介入诊治医源性假性动脉瘤的应用价值

目的 探讨彩色多普勒(CDFI)对医源性假性动脉瘤的诊断和治疗价值。方法 11 例(20 个囊)经皮穿刺腔内冠状动脉成形术(PTCA)后穿刺部位发现搏动性肿块和(或)听诊有血管杂音的患者,采用彩色多普勒检查股动脉及其周围组织;在超声引导下经皮穿刺假性动脉瘤,向囊腔内注射凝血酶封闭治疗。结果 11 例假性动脉瘤全部明确诊断,并在彩色多普勒引导下注射凝血酶后瘤腔内彩色血流信号消失,被类实性中等回声充填。结论 CDFI对医源性假性动脉瘤的诊断很有价值,且该微创方法可重复性强,值得推广。

超声引导下凝血酶注射法治疗股动脉假性动脉瘤的临床研究

目的评价超声引导下瘤腔内注射凝血酶治疗医源性假性动脉瘤的临床应用价值。方法冠状动脉介入诊治术后股动脉假性动脉瘤(PSA)患者16例,在超声引导下穿刺PSA瘤腔并注射200u凝血酶行封闭治疗,所有病例均在治疗后24h和3～5d复查超声。结果11例患者在瘤囊内注入200u凝血酶后瘤腔即刻闭合,5例患者动脉与瘤腔通道血流明显减弱,在超声指引下压迫5～10min闭合,治愈率100%,无并发症发生。所有病例24h及3～5d后复查无复发。结论该法治疗PSA简便、安全、有效,可作为临床治疗PSA的首选方法。