Which option is not appropriate for endovascular embolization of the pseudoaneurysms?

Question:

	1. Distal embolization prior to proximal embolization
	2. Performing arteriograms to identify collateral flow prior to embolization of major vessels
	3. Use of covered stents in the absence of collaterals
	4. Direct coil embolization of the pseudoaneurysm
	5. Performing post-embolization angiograms to demonstrate adequate hemostasis

Answer:

The correct answer for the question "Which option is not appropriate for endovascular embolization of the pseudoaneurysms?" is:

4. Direct coil embolization of the pseudoaneurysm

Explanation
1. Distal embolization is completed prior to proximal embolization. If proximal embolization was completed first, one would loose their access to the distal site, and the pseudoaneurysm would be fed by the distal blood vessel. [The bleeding vessel is first embolized distal to the site of hemorrhage by placing microcoils].

2. Hepatic failure is a known complication of hepatic artery embolization. However, the chance of hepatic failure is greatly decreased with collateral flow. [Prior to embolization of the common hepatic artery, one could use arteriograms to identify collateral flow and therefore avoid the potential complication].

3. To maintain blood flow to the critical organs, covered stents can be used to occlude the site of vessel wall injury and stop the bleeding. [Furthermore, covered stents may also be used to maintain hepatic arterial patency while achieving hemostasis, although they are more technically challenging to place depending on the arterial anatomy].

4. Pseudoaneurysms should never be embolized directly, as they may rupture. [Direct coli embolization of the pseudoaneurysm sac is not recommended, given the weakened wall of the pseudoaneurysm and the risk of rupture].

5. Adequate hemostasis should be documented with a post-embolization angiogram. [An arteriogram is obtained post-embolization to demonstrate adequate hemostasis].

From the manuscript:
Post-Pancreaticoduodenectomy Hemorrhage of Unusual Origin: Treatment with Endovascular Embolization and the value of preoperative CT Angiography
Radiology Case. 2013 Apr; 7(4):29-36

This article belongs to the Interventional section.

From the manuscript

Post-Pancreaticoduodenectomy Hemorrhage of Unusual Origin: Treatment with Endovascular Embolization and the value of preoperative CT Angiography

Free full text article: Post-Pancreaticoduodenectomy Hemorrhage of Unusual Origin: Treatment with Endovascular Embolization and the value of preoperative CT Angiography

Abstract
Post-pancreaticoduodenectomy hemorrhage is a life threatening complication reported to occur in 2-7% of patients. Historically, treatment required an exploratory laparotomy. Introduction of endovascular embolization has broadened the available treatment options. The most common location for a post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage exist and are hard to localize, thus they are often treated with open surgery. Here we report two cases of CTA proven hemorrhage from the dorsal pancreatic arcade and transverse pancreatic artery, which were successfully located with conventional angiography and treated with endovascular arterial coil embolization. Both patients were status post-pancreaticoduodenectomy (Whipple procedure) and presented with a sentinel bleed and a drop in hematocrit levels.

References

1. Wente MN, Veit JA, Bassi C. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142:20-25