Subclavian arterial injury is a rare condition. However, emergency treatment is required in patients who present with bleeding or upper limb ischemic symptoms due to thrombotic ob-struction. Therefore, prompt diagnosis and treatment are important. In recent years, endo-vascular treatment has been used for the management of vascular injury because it is less in-vasive than surgery. Currently, the use of stent grafts is the only endovascular treatment option when the injured area should be managed while maintaining blood flow. Herein, we introduce the diagnosis of and treatment plan and method for this condition to safely utilize a stent graft for the subclavian and peripheral thoracic arteries.
Postpancreatectomy hemorrhage accounts for the majority of vascular injuries in the upper abdominal region. Bleeding associated with pancreatic fistula has a high case fatality rate and requires immediate hemostasis. In the past, liver failure occurred in some cases after performing coil embolization of the common hepatic artery for hemorrhage due to hepatic artery injury. Recently, self-expanding Viabahn stent grafts have been indicated for vascular injuries, making it possible to more safely perform endovascular treatment. The Viabahn is an ideal stent graft for endovascular repair of tortuous visceral arteries because of its flexibility. Bleeding after pancreatectomy most often occurs from the gastroduodenal artery stump, for which the Via-bahn is particularly useful for stent graft placement. In this paper, we describe various pre-cautions and tips regarding Viabahn placement for bleeding in the upper abdominal arteries and present some illustrative cases. With the advent of the Viabahn, treatment strategies for vascular injury have changed significantly. There are still many points to consider, such as devising optimal delivery methods and determining long-term results, but its use is expected to become more widespread in the future.
Ureteroarterial fistula (UAF) is a direct fistulous communication between the artery and ureter. It is rare but potentially life-threatening due to the risk of massive hemorrhage. UAF is clas-sified into primary and secondary causes. UAF with secondary causes, that result from prior pelvic intervention such as surgery, radiation and ureteral stent placement, is increasing with the improvement in life expectancy of patients with pelvic malignancy. The diagnosis of UAF is often challenging because extravasation into the ureter is difficult to detect directly by diag-nostic imaging. In these days, stentgraft placement is considered as the first therapeutic option for UAF because of its low invasiveness. Although stentgraft placement is an effective method to control acute hemorrhage, the hematuria recurrence rate is relatively high. Therefore, long-term follow-up is important.
Stent grafts including Viabahn and VBX are available for lower limb arteries. Viabahn is a self-expandable stent graft that is applicable for superficial femoral artery occlusive disease, injured artery, and hemodialysis fistulas. Viabahn has a high flexibility and is suitable for even tortuous vessels. On the other hand, VBX is a balloon-expandable stent graft and used for aorto-iliac occlusive disease. VBX has stronger radial force and enables more accurate place-ment compared to Viabahn. Additionally, VBX can expand the stent beyond its nominal de-ployed diameter using a larger balloon. This article introduces Viabahn and VBX for lower limb arteries, and focuses on characteristics of the devices, basic procedures, technical tips, com-plications, and literature review.
Acquired hemophilia A (AHA), caused by expression of factor VIII (FVIII) inhibitors, is a rare disease associated with severe coagulopathy and massive bleeding. A woman in her 70s pre-sented at our emergency department with lateral chest subcutaneous hemorrhage. Blood tests revealed anemia and prolonged activated partial thromboplastin time (APTT), and FVIII ac-tivity was markedly reduced, and so AHA was diagnosed. Blood transfusions did not improve the anemia. Angiography was performed to identify the bleeding source. We identified the point of extravascular leakage of contrast medium at the left intercostal arteries and performed transcatheter arterial embolization (TAE). On hospitalization day 2, the anemia did not show improvement. A second angiography revealed extravascular leakage at other intercostal arteries; subsequently, second TAE was performed. Because her anemia did not improve, third angi-ography was performed on hospitalization day 4. Extravascular leakage of contrast medium was then identified at the supreme intercostal artery and anterior intercostal branch of the internal thoracic artery; therefore, we performed third TAE, following which the bleeding was controlled; however, APTT prolongation did not improve. Considering the rebleeding risk, we administered plasma-derived FVIIa and FX (Byclot®) and prednisone for immunosuppression therapy and plasma exchange to remove the inhibitors. Thereafter, APTT was shortened and VIII activity increased. Uncontrolled bleeding is fatal in most AHA patients. In this case, TAE resulted in he-mostasis against arterial bleeding, and subsequent multidisciplinary medical treatment was lifesaving.
Rupture of a small aneurysm in the pancreatic arcade associated with segmental arterial me-diolysis (SAM) or median arcuate ligament compression syndrome has been increasingly treated with transcatheter arterial embolization in recent years. Although the retroperitoneal hematoma is gradually resorbed, severe duodenal obstruction may occur during this process. In our 4 cases, the obstruction resolved spontaneously after 4 to 5 weeks, and no necrosis or ulceration of the mucosa was observed at any time. Furthermore, in one of the four cases, no embolization was performed, suggesting that embolization may not be the direct cause of duodenal obstruction. In this study, we analyze our cases and discuss the mechanism of delayed duodenal stenosis after retroperitoneal hemorrhage in the pancreaticoduodenal arcade region and its relation to vascular embolization.
We report a case of large pancreatic duodenal artery aneurysm with fistula formation to superior mesenteric vein (SMV), which was successfully treated by coil embolization. This patient had a history of surgery for pancreatic pseudocyst approximately 30 years earlier, that might have been related to the arteriovenous fistula formation. Coil embolization was successfully per-formed for the aneurysm with the arteriovenous fistula to SMV. After the embolization, SMV thrombosis was temporarily observed but disappeared one month later on enhanced CT.