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• W2012657492 abstract "We report on a 55-year-old woman with recurrent chronic pancreatitis complicated by a 7-cm splenic artery pseudoaneurysm. A therapeutic endovascular treatment was chosen because of the patient’s high surgical risk. Initial embolization with fibered coils succeeded in thrombosing the aneurysm lumen, but the aneurysm neck remained patent. Further embolization was achieved with two detachable Gugliemi Detachable Coils (GDCs) deployed across the aneurysm neck, successfully thrombosing the residual aneurysm. GDCs complement the more thrombogenic traditional fibered coils and should be used advantageously in critical locations to embolize difficult splenic artery pseudoaneurysms. We report on a 55-year-old woman with recurrent chronic pancreatitis complicated by a 7-cm splenic artery pseudoaneurysm. A therapeutic endovascular treatment was chosen because of the patient’s high surgical risk. Initial embolization with fibered coils succeeded in thrombosing the aneurysm lumen, but the aneurysm neck remained patent. Further embolization was achieved with two detachable Gugliemi Detachable Coils (GDCs) deployed across the aneurysm neck, successfully thrombosing the residual aneurysm. GDCs complement the more thrombogenic traditional fibered coils and should be used advantageously in critical locations to embolize difficult splenic artery pseudoaneurysms. Splenic artery aneurysms and pseudoaneurysms account for 60% of all visceral aneurysms. Treatment options include surgery, and more recently, percutaneous methods. We describe the successful treatment of a giant splenic artery pseudoaneurysm using a combination of electrolytically detached and fibered coils To our knowledge, there is no other case report describing the use of detachable coils in combination with fibered coils to treat a wide-neck splenic artery pseudoaneurysm. Electrolytically detachable coils, which are traditionally used in neurointervention applications, can be useful in peripheral endovascular applications. The patient was a 55-year-old woman who presented with abdominal pain. Her medical history is significant for chronic pancreatitis, esophageal and gastric varices, hepatitis C, and alcohol abuse. On this admission, the patient noted that her pain was similar to her prior exacerbations of pancreatitis; however, she also noted the passage of dark stools. On admission, she was noted to be anemic with a hemoglobin count of 8.3, an elevated lipase level of 1796, and an amylase level of 212. Computed tomography (CT) examination showed a left upper quadrant pseudoaneurysm measuring approximately 4.5 × 7 × 7 cm, pancreatic calcifications, multiple pseudocysts, and cavernous transformation of the portal vein (Fig 1, A and B). While in the hospital, she underwent endoscopy and colonoscopy that confirmed the varices but showed no site of active bleeding. A mesenteric angiogram confirmed the splenic artery pseudoaneurysm in the distal portion of a tortuous splenic artery (Fig 2). Selective catheterization of the splenic artery was performed with a 5F Simmons 2 catheter (Torcon NB Advantage, Cook Inc, Bloominton, IN). Because the splenic artery was markedly tortuous, the distally located pseudoaneurysm could not be catheterized directly with the 5F catheter. Irregularities of the splenic artery were identified and thought to be secondary to scarring from the patient’s recurrent pancreatitis. Using a coaxial technique, and a 2.5F Renegade Microcatheter (Boston Scientific, Natick, MA), the pseudoaneurysm was selectively catheterized. An attempt to occlude the neck of the aneurysm was performed with a Tornado Embolization Microcoil (Cook Inc); however, because of the large neck of the pseudoaneurysm, the coil dropped into the aneurysm sac. A decision was made to pack the aneurysm sac to induce thrombosis. To improve catheter stability, a 5F Simmons 3 catheter (Torcon NB Advantage) was used to select the splenic artery. A Renegade microcatheter was used to catheterize the aneurysm sac. Twenty-one Nestor microcoils (Cook Inc) were packed into the aneurysm sac. As the coil packing progressed, the visualization of the microcatheter tip was limited because of the volume of coils. Control angiography to access aneurysm coil packing showed spasm of the aneurysm neck and residual filling of the proximal aneurysm. There was concern that further packing with the fibered MicroNestor microcoils would flip the catheter into the parent splenic artery, resulting in a coil deposited in the splenic artery. We elected at this point to stage the procedure; as neck vasospasm was encountered, it was postulated that with the introduced volume of coils there may be spontaneous thrombosis of the remaining aneurysm.Fig 2Diagnostic splenic artery injection shows the neck of the giant pseudoaneurysm (arrowhead).View Large Image Figure ViewerDownload (PPT) On angiographic reassessment 1 week later, continued filling of the proximal pseudoaneurysm was seen. Using a coaxial technique, a 2.5F Renegade microcatheter was introduced into the pseudoaneurysm. A single MicroNestor coil was introduced into the proximal aspect of the pseudoaneurysm. Control angiography through the microcatheter showed persistent filling; however, the microcatheter could not be advanced into the filling portion of the pseudoaneurysm because of the significant amount of coils. Because of significant concern for coil migration into the splenic artery and subsequent splenic infarction, Gugliemi Detachable Coils (GDCs) were selected for coiling of the aneurysm neck. A three-dimensional GDC (Boston Scientific, Natick, MA) was introduced into the proximal neck of the pseudoaneurysm. Because the coil requires electrolytic detachment, control angiography could be performed before coil detachment to evaluate for parent artery prolapse of the coil. A second two-dimensional GDC was placed more proximally in the neck, and a control angiogram showed no filling of the pseudoaneurysm (Fig 3). After removal of the microcatheter, angiography showed preservation of the native splenic artery and no further filling of the pseudoaneurysm. After the embolization procedure, the patient had an uneventful recovery from pancreatitis. The initial presenting symptoms of abdominal pain and hemosuccus pancreatitis had completely resolved at the time of discharge from the hospital. A follow-up clinic visit and CT scan were scheduled, but the patient failed to meet her appointment and was subsequently lost to further follow up. Splenic artery aneurysms and pseudoaneurysms account for 60% of all visceral aneurysms. Splenic artery pseudoaneurysms are thought to be most commonly caused by pancreatitis and blunt trauma.1Mesina L.M. Shanley C.J. Visceral artery aneurysms.Surg Clin North Am. 1997; 77: 425-442Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar The major risk of splenic artery aneurysms and pseudoaneurysms is massive hemorrhage and hemosuccus pancreatitis. Recent data suggest that the risk of hemorrhage ranges from 3% to 10% from splenic artery aneurysms, with the greatest risk in the larger aneurysms.2McDermott V.G. Shlansky-Goldberg R. Cope C. Endovascular management of splenic artery aneurysms and pseudoaneurysms.Cardiovasc Intervent Radiol. 1994; 17: 179-184Crossref PubMed Scopus (160) Google Scholar The reported rate of hemorrhage from splenic artery pseudoaneurysm is as high as 47%, of which 58% are hemodynamically unstable at presentation.3Tessier D.J. Stone W.M. Fowl R.J. Abbas M.A. Andrews J.C. Bower T.C. et al.Clinical features and management of splenic artery pseudoaneurysm case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar Surgical guidelines recommend resection of symptomatic splenic artery aneurysms, asymptomatic aneurysms larger than 2.0 cm, and all pseudoaneurysms to prevent massive hemorrhage.3Tessier D.J. Stone W.M. Fowl R.J. Abbas M.A. Andrews J.C. Bower T.C. et al.Clinical features and management of splenic artery pseudoaneurysm case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar The surgical treatment is aneurysectomy with or without splenectomy depending on the location of the aneurysm relative to the splenic hilum. The morbidity and mortality of surgical aneurysectomy are reported to be roughly 10% and 1% to 2%, respectively.4Trastek V.F. Pairolero P.C. Bernatz P.E. Splenic artery aneurysms.World J Surg. 1985; 9: 378-383Crossref PubMed Scopus (96) Google Scholar Ligation of the pseudoaneurysm and repair of the splenic artery has been reported, but is associated with a 43% failure rate.3Tessier D.J. Stone W.M. Fowl R.J. Abbas M.A. Andrews J.C. Bower T.C. et al.Clinical features and management of splenic artery pseudoaneurysm case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar More recently, percutaneous methods have been used to treat splenic artery and other visceral pseudoaneurysms. Percutaneous transarterial embolization of splenic artery pseudoaneurysms using coils, detachable balloons, covered stents, Gelfoam, and N-butyl cyanoacrylate has been described.5Appel N. Duncan J.R. Schuerer D.J.E. Percutaneous stent-graft treatment of superior mesenteric and internal iliac artery pseudoaneurysms.J Vasc Interv Radiol. 2003; 14: 917-922Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 6Guillon R. Garcier J.M. Abergel A. Mofid R. Garcia V. Chahid T. et al.Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients.Cardiovasc Intervent Radiol. 2003; 26: 256-260Crossref PubMed Scopus (156) Google Scholar, 7Kim B.S. Do H.M. Razavi M. N-butyl cyanoacrylate glue embolization of splenic artery aneurysms.J Vasc Interv Radiol. 2004; 15: 91-94Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 8Owens C.A. Yaghmai B. Aletich V. Benedetti E. Coil embolization of a wide-neck splenic artery aneurysm using a remodeling technique.Am J Roentgenol. 2002; 179: 1327-1329Crossref PubMed Scopus (21) Google Scholar Ultrasound-guided percutaneous needle placement into the pseudoaneurysm followed by injection of thrombin into the pseudoaneurysm has been reported.9Huang I.H. Zuckerman D.A. Matthews J.B. Occlusion of a giant splenic artery pseudoaneurysm with percutaneous thrombin-collagen injection.J Vasc Surg. 2004; 40: 574-577Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 10Puri S. Nicholson A.A. Breen D.J. Percutaneous thrombin injection for the treatment of a post-pancreatitis pseudoaneurysm.Eur Radiol. 2003; 13: L79-82Crossref PubMed Scopus (42) Google Scholar Percutaneous covered stents are relatively new, but provide a means of excluding the pseudoaneurysm while preserving flow to the splenic artery.5Appel N. Duncan J.R. Schuerer D.J.E. Percutaneous stent-graft treatment of superior mesenteric and internal iliac artery pseudoaneurysms.J Vasc Interv Radiol. 2003; 14: 917-922Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar In our case, the initial plans were to repair the artery with a self-expanding polytetrafluoroethylene-covered stent, but after the initial angiogram it became evident that advancing a 7F catheter through the tortuous splenic artery was not feasible. Embolization of the splenic artery distal and proximal to the aneurysm neck is a proven method for successfully treating pseudoaneurysms provided the neck is in the proximal splenic artery.6Guillon R. Garcier J.M. Abergel A. Mofid R. Garcia V. Chahid T. et al.Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients.Cardiovasc Intervent Radiol. 2003; 26: 256-260Crossref PubMed Scopus (156) Google Scholar The preservation of the splenic tissue is dependent on retrograde collateral blood flow from short gastric branches. In this patient, the aneurysm neck was in the distal splenic artery, and hence proximal and distal embolization of the splenic artery would have likely resulted in significant ischemic injury to the spleen.6Guillon R. Garcier J.M. Abergel A. Mofid R. Garcia V. Chahid T. et al.Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients.Cardiovasc Intervent Radiol. 2003; 26: 256-260Crossref PubMed Scopus (156) Google Scholar Thrombin injection and N-butyl cyanoacrylate embolization has been successful in treating splenic artery pseudoaneurysms; however, these methods result in sacrifice of some splenic tissue, and only treatment of much smaller aneurysms was discussed.7Kim B.S. Do H.M. Razavi M. N-butyl cyanoacrylate glue embolization of splenic artery aneurysms.J Vasc Interv Radiol. 2004; 15: 91-94Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 9Huang I.H. Zuckerman D.A. Matthews J.B. Occlusion of a giant splenic artery pseudoaneurysm with percutaneous thrombin-collagen injection.J Vasc Surg. 2004; 40: 574-577Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 10Puri S. Nicholson A.A. Breen D.J. Percutaneous thrombin injection for the treatment of a post-pancreatitis pseudoaneurysm.Eur Radiol. 2003; 13: L79-82Crossref PubMed Scopus (42) Google Scholar We describe the successful treatment of a giant splenic artery pseudoaneurysm using a combination of detachable GDCs and fibered coils. To our knowledge, there is no other case report describing the use of detachable GDCs in combination with fibered coils to treat a wide-neck splenic artery pseudoaneurysm. The GDC is an endovascular coil used primarily for the treatment of intracranial aneurysms. The coil was first used in people in 1990.11Guglielmi G. Viñuela F. Sepetka M.S. Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results.J Neurosurg. 1991; 75: 11-17Google Scholar The coil is made of platinum soldered to a steel pusher wire. Intra-aneurysmal thrombosis is promoted by the application of a low positive electric charge, which also detaches the coil from the steel pusher wire through a process of electrolysis. Because the coil can be detached at a specific time, in contrast to the conventional fibered push coils, if the coil is of an inappropriate size or is unstable in position when placed in an aneurysm, the coil can be withdrawn into the delivery catheter and removed from the patient. The coils are available in a variety of shapes and sizes. A two-dimensional coil consists of a single helix and is similar in configuration to the traditional fibered coil. A three-dimensional coil is a complex helix with a spherical configuration. The metal coils placed in the pseudoaneurysm obscure the aneurysm neck and splenic artery junction. Because GDCs can be retrieved and redeployed, we chose to place two detachable GDCs in the neck of the pseudoaneurysm. The GDC positions and stability were checked by angiogram and fluoroscopy before electrolytic detachment. The GDCs successfully completed the embolization without compromising the native splenic artery. Fibered coils are more thrombogenic than GDCs, and therefore should still be used initially to pack the body of the pseudoaneurysm. In addition, fibered coils are significantly less expensive than GDCs. CT examinations are used for follow up of the embolization procedure. The recurrence of the aneurysms after fibered-coil embolization has been reported to be as low as 4%.12Gabelmann A. Gorich J. Merkle E.M. Endovascular treatment of visceral artery aneurysms.J Endovasc Ther. 2002; 9: 38-47Crossref PubMed Scopus (196) Google Scholar The recurrence rate for intracranial aneurysms treated solely with detachable coils has been reported to be 14%.13Christophe C. Alain W. Laurent S. Michel P. Lina C. Alain R. et al.Long-term angiographic follow-up of 169 intracranial berry aneurysms occluded with detachable coils.Radiology. 1999; 212: 348-356PubMed Google Scholar In this report, we anticipate recurrence of the aneurysm to be similar to the reported rate of recurrence using fibered coils, based on our predominant use of fibered coils. The report shows the utility of GDC microcoils in a situation in which coil stability is of critical concern. Selective GDC coiling in combination with fibered coils resulted in a successful embolization of a difficult-to-treat wide-neck giant pseudoaneurysm. Thus, we believe that GDCs are useful in critical locations and should be considered more frequently in combination with traditional fibered coils." @default.
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• W2012657492 title "Selective use of electrolytic detachable and fibered coils to embolize a wide-neck giant splenic artery pseudoaneurysm" @default.
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