SET 2022 Abstracts
Jameson Petrochko
jamesonmpetrochko1@gmail.com
6102093956
St. Luke’s University Health Network
1471 Harmor Lane
Bethlehem, PA 18017
Abstract Body:
The purpose of this study is to present a case of ruptured renal artery aneurysm (RAA) that was successfully treated via an endovascular approach. Our patient gave informed consent for the publication of a case report, and data were gathered via chart review and literature review. We discuss the role of endovascular therapy in the management of RAA.
Renal artery aneurysms are a rare entity with an incidence of roughly 0.1%. Symptomatic aneurysms require urgent intervention and ruptured aneurysms require emergent life-saving intervention, though commonly resulting in nephrectomy, loss of renal function, or death.
We present a 65-year-old male with COPD and hypertension who was found to have a ruptured 6cm left renal artery aneurysm after presenting with flank pain and hypotension (systolic blood pressure 80 mmHg). Given the morbidity of an open operation in a patient with COPD and concern for adhesions in the setting of prior abdominal wall mesh placement, the decision was made to attempt endovascular intervention. Right femoral artery access was obtained and selective left renal angiogram revealed adequate landing zones. A 6mm x 25mm Gore Viabahn covered stent was placed across the aneurysm, excluding it while maintaining perfusion to the kidney. The patient only required one unit of blood and was discharged after resolution of a mild AKI. Three-month surveillance CTA revealed a patent left renal artery stent, sustained aneurysm exclusion, and a small renal infarct.
Although frank rupture of RAA is traditionally associated with nephrectomy, there are no consensus guidelines for the management of this condition. The limited amount of literature on the subject suggests that an endovascular approach to treatment of RAA may be a viable first approach that is associated with good outcomes and minimal morbidity. Theoretical advantages include avoidance of morbidity associated with laparotomy, and the ability to rapidly and safely obtain proximal control compared to attempting an open operation in a bloody retroperitoneal plane.
Relevant History, Physical Exam & Test Results
65 year-old male presenting with two hours of left flank pain, found to be hypotensive with a ruptured 6cm renal artery aneurysm notable for active extravasation.
Teaching points:
Ruptured renal artery aneurysm is an uncommon but life-threatening situation that traditionally has been managed via an open approach. Endovascular-first therapy may be appropriate and beneficial in the appropriate patient.
Nathan Leaphart, Antony Gayed
LEAPHARN@MUSC.EDU, gayed@musc.edu
8033912320, 8436701532
Medical University of South Carolina, Medical University of South Carolina
171 Ashley Ave
Charleston, SC 29425
Abstract Body:
Learning objectives: 1) Understand the pathogenesis of non-iatrogenic cystic artery pseudoaneurysms (CAP). 2) Discuss the typical presentation and complications of CAP. 3) Outline the treatment of CAP.
Background: Non-iatrogenic cystic artery pseudoaneurysm (CAP) is a rare diagnosis with only 50-60 reported cases in the literature; most are described in concurrence with the presence of gallstones. This has led to the theory that CAP is due to the inflammatory response to the cholelithiasis eroding into the arterial wall. Most patients with CAP are found have an elevated white blood cell count, alkaline phosphatase, and gamma-glutamyl transferase. On physical exam, most patients have right upper quadrant pain and jaundice {1-3}.
While CAP in the setting of cholecystitis can be treated with an open surgical procedure, many view endovascular embolization as an important pre-surgical adjunctive procedure. This is to control the risk of bleeding and decrease further surgical complications during the cholecystectomy {1, 3-4}. Therapies such as transcatheter embolization and direct stick percutaneous thrombin injection may be the sole interventional treatments in patients with prohibitive surgical risk {1, 5}.
Due to the rarity of this pathology, there is no prevailing embolization agent for endovascular interventions; coils and glue embolization have been described as options {3-4}. In instances in which the source artery cannot be cannulated, percutaneous thrombin injection can be utilized {5}.
Clinical Findings: We review a case of 2.2 cm x 3.5 cm CAP in a 30-year-old male with acute on chronic cholecystitis. A focal hypervascularity with a “ying-yang” sign was seen on US with Color Doppler; arterial hyperenhancement was demonstrated on CT and MRI. In the angiography suite, the patient’s cystic artery was cannulated, and n-BCA glue was used to embolize the CAP. Soon after, the patient underwent an uncomplicated subtotal cholecystectomy. The patient’s subsequent clinical follow-up was uneventful.
Conclusions: CAP is a rare but dangerous complication of chronic cholecystitis. Interventional radiologists should be familiar with the utility of embolizing a CAP, especially as a pre-surgical adjunctive procedure.
Relevant History, Physical Exam & Test Results
– 30-year-old previously healthy man presenting with right upper quadrant and epigastric abdominal pain, weakness, and anorexia for four weeks.
– His pain was initially intermittent, but for the past four days the pain has been constant, sharp, and 7/10.
– He reported food aversion and nausea with 20-pound weight loss over the past month. He reported dark urine and stool.
– He denied recent travel, history of liver disease, fever, chills, vomiting, shortness of breath, alcohol use, toxic exposure, supplements, over-the-counter medications use, or relevant family history.
– Physical Exam notable for jaundice, scleral icterus, soft abdomen with tenderness in RUQ
– Pertinent labs: WBC 14.9, Hgb 11.9, PT/INR 13.6/1.16, Lipase 28, Total Bilirubin 5.6, AST 446, ALT 1015, Alkaline Phosphatase 244
Teaching points:
– Cystic artery pseudoaneurysm (CAP) is a rare diagnosis with only 50-60 cases reported in the literature. [1-2]
– Most are reported with concurrent cholelithiasis leading some to hypothesize that the inflammatory changes erode into the arterial wall causing CAP. [1-2]
– Median age of presentation is 70 yo with a male predominance; this patient was uniquely young. [1-2]
– Embolization of CAP is viewed as an important presurgical adjunctive procedure to control risk of iatrogenic hemorrhage during cholecystectomy. [1, 3-4]
– Given the rarity of this pathology, there is no prevailing embolization agent – case reports show success with both glue and coils. [1, 3-4]
– Case report of also treating CAP with percutaneous thrombin injection. [5]
Brett Fowler, Michael McNally, Scott Stevens, Michael Freeman
bfowler1@utmck.edu, mmcnally@utmck.edu, sstevens@utmck.edu, mfreeman@utmck.edu
8435988466, 2524140893, 8654068509, 8652105924
University of Tennessee Medical Center, University of Tennessee Medical Center, University of Tennessee Medical Center, University of Tennessee Medical Center
1924 Alcoa Highway
Knoxville, TN 37920
Abstract Body:
Complex Endovascular Repair of a 10cm Innominate Artery Pseudoaneurysm via Bilateral Upper Extremity Access
Fowler BB, McNally MM, Cardentey D, Stevens SL, Freeman MB
PURPOSE: Case report demonstrating successful endovascular management of a complex 10cm innominate artery pseudoaneurysm via bilateral upper extremity access.
METHODS: A 75-year-old man with history of laryngeal cancer and remote history of right radical neck dissection and radiation presented with an enlarging, pulsatile right chest wall mass. CT angiography and diagnostic arteriography revealed a 10 cm pseudoaneurysm at the distal innominate bifurcation of the subclavian and carotid arteries with erosion through the right clavicle including the additional anatomic challenge of a bovine aortic arch. The aneurysm had rapidly expanded and was causing compression of the recurrent laryngeal nerve with worsening symptoms of pain and hoarseness. With prior extensive radiation and radical neck dissection surgery, endovascular management was selected. Due to target cerebral vessel size and limited iliac limb device length, bilateral upper extremity access was required. In the endovascular suite, open exposure of the left axillary artery and right brachial artery was obtained followed by sheath and wire access. A 12 Fr sheath was inserted into the innominate artery using a through and through flossing wire. A 16mm x 10mm x 7 cm GORE limb graft was deployed from the innominate artery extending into the right common carotid artery and covering the right subclavian origin. The proximal right subclavian origin was then coil embolized extending to the right vertebral artery origin using Penumbra Ruby coils. Completion arteriogram revealed exclusion of the pseudoaneurysm with widely patent stent graft. An axillary-axillary bypass was deferred as the patient had adequate right upper extremity perfusion. The patient had an uneventful post-operative course and was discharged home.
RESULTS: Follow-up CTA revealed a widely patent innominate-carotid artery stent graft with successful aneurysmal exclusion and distal perfusion confirmed in the right upper extremity.
CONCLUSION: Isolated innominate artery aneurysmal disease is a challenging vascular pathology. This case demonstrates the feasibility of complex endovascular repair of a large innominate artery pseudoaneurysm in a hostile neck utilizing bilateral upper extremity vascular access.
Relevant History, Physical Exam & Test Results
A palpable 10 cm innominate artery pseudoaneurysm after remote radical neck dissection and extensive radiation.
Teaching points:
1) Endovascular management of an innominate artery pseudoaneurysm.
2) Surgical management of the hostile neck.
3) Endovascular management challenges in the setting of a bovine arch.
4) Bilateral upper extremity arterial access.
5) Off label use of iliac branch device limb graft.
Christine Shokrzadeh, Junji Tsukagoshi, Mitchell Cox
cqli@utmb.edu, Jutsuka@utmb.edu, mwcox@utmb.edu
2816300543, 4094659196, 9198122222
University of Texas Medical Branch, University of Texas Medical Branch, University of Texas Medical Branch
301 University Blvd
Galveston, TX 77555-0140
Abstract Body:
Inferior vena cava filters are used to mechanically prevent thrombi from propagating or migrating to pulmonary circulation. Studies have shown that IVC filters are most clinically beneficial if retrieved within 90 days after implantation. Reportedly, 1-year retrieval rate remains at 14.3% in the US. We present a case that required complex intraoperative techniques. A 28-year-old woman with history of retrievable IVC filter placement (Cook Celect® Platinum Vena Cava Filter) 5 months prior for acute PE presented for filter removal. Günther Tulip® Vena Cava Filter Retrieval Set was initially used and an 11-French sheath was introduced into the right internal jugular vein. This was advanced cranially to the IVC filter. Engagement of the hook of the filter was attempted using a snare. However, the hook straightened while the entire filter traveled cranially and tilted to the left, extending the leg struts into the right renal vein. Multiple attempts to retrieve the filter using the same snare by capturing the struts resulted in entanglement of the snare and the filter struts, disabling snare disengagement. A second 11-French sheath was introduced from the RIJV. A glidewire was passed through the IVC filter caudally and then snared back into the same 11-French sheath using a reversed-curved catheter and another snare. This resulted in the reverse-curved catheter engaging the proximal portion of the struts. The two 11-French systems, one with entangled snare and another with reverse-curved catheter were simultaneously pulled cranially which resulted in successful migration of the filter to the level of hepatic veins. A third access with 8-French sheath was obtained in the right femoral vein and a 12mm balloon was inflated caudally to the filter. Simultaneous pulling-back of the two 11-French systems and pushing-forward of the 12mm balloon successfully moved the IVC filter into the RIJV. Keeping the balloon inflated in proximal RIJV to prevent filter migration, two 11-French sheaths were removed and the filter as well as the entangled snare were pulled out from the second 11 French access site. Completion venogram showed patent venous system without extravasation. Patient was kept overnight and discharged home the next day.
Relevant History, Physical Exam & Test Results
A 28-year-old woman with medical history of retrievable IVC filter placement (Cook Celect® Platinum Vena Cava Filter) 5 months prior for acute PE in the setting of contraindication to anticoagulation due to significant postpartum hemorrhage requiring multiple transfusions and uterine artery embolization presented for elective IVC filter removal. Since discharge, patient was continued on apixaban and resolution of lower extremity deep venous thrombosis (DVT) was confirmed on venous ultrasound. Upon presentation, patient’s vital signs were all within normal limits and patient denied any respiratory or swelling symptoms.
Teaching points:
This case serves as an example of complex IVC filter removal that was successfully overcome by utilizing multiple reported advanced techniques. Importance of preprocedural imaging cannot be overlooked to assess the complexity of retrieval, with dwell time being an important risk factor.
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