Superior mesenteric artery branch pseudoaneurysm with coiling

Case contributed by RMH Core Conditions

Presentation

Past history of metastatic rectal cancer (AP resection; Pelvic exenteration; colostomy and ileal conduit). Laparotomy 2014 for excision of right adrenal metastasis and partial hepatectomy. Day 25 post-operative; high inotropic support required ?source of bleeding.

Patient Data

Age: 58
Gender: Male

Large pre-aorto-caval haematoma, increased in size since previous study is high density on precontrast scan, shows no significant change in density on delayed images indicating no active high volume bleeding. There is a false aneurysm in the upper retroperitoneum to the right of midline. 

This haematoma is contiguous with the macerated right lobe of liver and markedly compresses the IVC, measuring approximately 10.5 x 5.5 x 10.9 cm ((S 11 i44, S 9 i27). Moderate size liver subcapsular haematoma of low density.Small volume free fluid seen within the pelvis and para colic gutters. Portal vein thrombosis. Atrophic left kidney and left hydronephrosis and hydroureter to level of uretero-ilial anastamosis. Poorly functioning right kidney.

Postoperative changes including pelvic exenteration, left and right sided stoma and right subdiaphragmatic drain. No free gas seen. 

Modality: Annotated image

Arrow indicates position of new hyperdensity on arterial-phase imaging, which persists on portal venous phase (not shown), in keeping with a false aneurysm. 

Modality: DSA (angiography)

Mesenteric angiography via the coeliac axis and SMA confirms the presence of a false aneurysm arising from a small proximal branch of the SMA. No filling from the coeliac axis was demonstrated. The false aneurysm corresponds in position to the false aneurysm identified on the CT scan.

Using a Simmons 2 catheter as a guide in the SMA, a Progreat microcatheter was manipulated as far as the false aneurysm. From there it was possible to fill the false aneurysm and occlude the feeding vessel using 5 mm fibred straight 0.018 inch micro coils. Final runs demonstrate no filling of the false aneurysm and no compromise to adjacent SMA branches.

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Case Information

rID: 28606
Case created: 2nd Apr 2014
Last edited: 20th Oct 2015
Inclusion in quiz mode: Included

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