British Journal of Radiology (2006) 79, e193-e195
© 2006 British Institute of Radiology
doi: 10.1259/bjr/97367208
Embolisation of proximal anastomotic pseudoaneurysm developing after surgical repair of abdominal aortic aneurysm with a bifurcated graft with n-butyl cyanoacrylate
T Yamagami, MD, PhD
1
K Kanda, MD, PhD
2
T Kato, MD, PhD
1
T Hirota, MD
1
K Nishida, MD
1
R Yoshimatsu, MD
1
T Matsumoto, MD
1 and
T Nishimura, MD, PhD
1
1 Department of Radiology, 2 Division of Cardiovascular Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
Correspondence: Dr Takuji Yamagami, Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiichyo, KawaramachiHirokoji, Kamigyo, Kyoto, 6028566, Japan. E-mail: yamagami{at}koto.kpu-m.ac.jp
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Abstract
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We report a 60-year-old man who after undergoing surgical repair of an abdominal aortic aneurysm with a bifurcated graft subsequently developed a proximal anastomotic pseudoaneurysm, which was successfully treated by embolisation with n-butyl cyanoacrylate.
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Introduction
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Pseudoaneurysm that develops at the proximal anastomosis is a very rare complication [1] of surgical repair of abdominal aortic aneurysm (AAA). Once ruptured, it can be fatal [1]; thus, it should be treated [1, 2]. We present such a case, successfully treated by embolisation with n-butyl cyanoacrylate (NBCA).
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Case report
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A 60-year-old man underwent surgical repair of an AAA with a bifurcated graft. The proximal end of the graft was anastomosed with the infrarenal aorta and the graft limbs were anastomosed with the common iliac arteries bilaterally. Enhanced CT obtained 4 months after surgery revealed a pseudoaneurysm 3.5 cm in diameter, inside which pooling of contrast agents was seen, near the proximal anastomosis. Enhanced CT performed 2 months later (6 months after surgery) still showed pooling of contrast agents inside the pseudoaneurysm (Figure 1a
). Hence continuation of minor leakage from the anastomosis into the pseudoaneurysm was suspected. To prophylactically avoid rupture of the pseudoaneurysm, treatment was required. A serious complication was possible, that is, an ischaemic change in the small intestine or colon might occur if stent-grafting were used as therapy to cover the leaking hole because the pseudoaneurysm was near the ostium of the superior mesenteric artery in the aorta. Hence, embolisation was chosen as a treatment option.
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Figure 1. A 60-year-old man underwent surgical repair of abdominal aortic aneurysm with a bifurcated graft complicated by proximal anastomotic pseudoaneurysm. (a) Enhanced CT obtained 6 months after surgery reveals a pseudoaneurysm 3.5 cm in diameter, inside of which pooling of contrast agents is seen (arrow) close to the proximal anastomosis. Note that the origin of the superior mesenteric artery is near the pseudoaneurysm (arrowhead). (b) Aortogram shows stenosis of proximal anastomosis (arrow) and pooling of the leaked contrast agents (arrowhead) from this anastomosis. (c) Image obtained while contrast material was being infused from a microcatheter that had been coaxially advanced to the inside of the pseudoaneurysm (arrow) via a 4-French catheter advanced into the aorta near the pseudoaneurysm. The entire pseudoaneurysm is shown. (d) Just after the procedure described in Figure 1c , the microcatheter was withdrawn once and the 4-French catheter was repositioned to be wedged to the neck of the pseudoaneurysm. This allowed blood flow in the pseudoaneurysm to decrease remarkably and part of interior of the pseudoaneurysm thrombosed spontaneously. The microcatheter was coaxially advanced again and the mixture of n-butyl cyanoacrylate and Lipiodol was inserted for embolisation. (e) Enhanced CT obtained 1.5 months after embolisation shows that the pseudoaneurysm is completely thrombosed (arrowhead). Note that Lipiodol infused at the time of embolisation by being mixed with n-butyl cyanoacrylate can be seen as a high density spot in the thrombosed pseudoaneurysm (arrow).
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A 4-French catheter was advanced via the left brachial artery to the descending aorta. Aortogram showed stenosis of the proximal anastomosis and pooling of the leaked contrast agents from this anastomosis, which formed a pseudoaneurysm (Figure 1b). The tip of the catheter was positioned at the ostium of the pseudoaneurysm, then a microcatheter (Renegade-18; Boston Scientific, Watertown, MA) was coaxially advanced into the inside of the pseudoaneurysm (Figure 1c,d). Just from positioning the 4-French catheter at the ostium of the pseudoaneurysm, a marked decrease of blood flow in the pseudoaneurysm and spontaneous thrombosis of a portion of the interior of the pseudoaneurysm resulted. Therefore, embolisation of the part of the pseudoaneurysm in which blood flow remained was performed through the microcatheter. NBCA (Histoacryl-Blue; Braun, Melsungen, Germany) mixed with Lipiodol (Laboratoire Guerbet, Roissy, France) was used as the embolic agent. Total volume inserted was 0.7 ml. The NBCA:Lipiodol ratio was 1:1. In administering NBCA mixed with Lipiodol, meticulous care was taken not to have this embolic material overflow into the aorta. No complication occurred during the embolisation procedure.
Aortogram obtained from the upper level of the pseudoaneurysm showed disappearance of pooling of contrast agents in the pseudoaneurysm after embolisation. Plain CT obtained the next day showed that the pseudoaneurysm had been sufficiently filled with the embolic agent (Figure 1c). Currently, 10 months after embolisation, the patient is well and follow-up CT has shown no recurrence of leakage.
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Discussion
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According to Plate et al [1], pseudoaneurysm following surgical repair of AAA and developing at the anastomosis is rare, with a frequency of 1.3% [14] among 1087 patients after surgical repair of AAA. Once a pseudoaneurysm ruptures, the fatality rate is very high (96.2%) [1]. Thus treatment is required.
Traditionally, the treatment method for anastomotic pseudoaneurysm has been surgical repair [1, 2]. However, this method can be challenging because of severe adhesions from prior surgery [2]. With the development of interventional procedures that can be done under the guidance of imaging modalities, reports of treatment of distal anastomotic pseudoaneurysm following surgical repair of AAA with transcatheter arterial embolisation has become viewed as a feasible alternative to surgical repair [2], although such treatment of a proximal pseudoaneurysm may not have been performed at the time of this writing.
Use of coils as embolic agents for embolisation of anastomotic pseudoaneurysm following surgical repair of AAA has been previously reported [2]. However, we prefer NBCA to coil embolotherapy, which can be laborious and time-consuming and often requires placement of multiple coils, making it expensive [3]. NBCA is a liquid acrylic surgical adhesive material that is also widely used as a permanent embolic agent, especially in the field of intracerebral interventional radiology such as embolisation of arteriovenous malformation [4, 5]. In the field of cardiovascular intervention, the use of NBCA in the management of endoleak after endovascular stent-graft treatment has been reported [3, 6]. By adding Lipiodol to the NBCA, the embolised vessel can be visualized. Also, the adhesion time can be flexibly regulated according to the rate of mixed Lipiodol [6–8]. Specifically, in our case, overflow of excessive NBCA into the aorta out of the interior of the pseudoaneurysm was prevented by quickening the adhesive time, by decreasing the rate of mixed Lipiodol (NBCA:Lipiodol ratio of 1:1) and monitoring the injection of embolic material with meticulous care. Thus, at least in the present case, organ infarction, which is one complication caused by possible transarterial embolisation of peripheral arterial branches resulting from migration of NBCA [4], could be avoided.
Received for publication March 29, 2005.
Revision received July 13, 2005.
Accepted for publication November 25, 2005.
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References
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Abstract
Introduction
