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DOI: 10.1148/rg.266055732
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Visceral and Renal Artery Aneurysms: A Pictorial Essay on Endovascular Therapy1

John L. Nosher, MD, Jerry Chung, MD, Lucy S. Brevetti, MD, Alan M. Graham, MD and Randall L. Siegel, MD

1 From the Department of Radiology, UMDNJ-Robert Wood Johnson Medical School, Medical Education Building, Rm 404, PO Box 19, New Brunswick, NJ 08903-0019. Received December 15, 2005; revision requested April 13, 2006 and received May 25; accepted June 13. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Drawing illustrates how coils are placed distal and then proximal to the aneurysm, thereby trapping the aneurysm and isolating it from the circulation, with resultant thrombosis of the aneurysm.

 

Figure 2
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  		Figure 2a.  Pseudoaneurysm in a 59-year-old alcoholic man who presented with acute upper gastrointestinal hemorrhage. The patient had a history of recurrent acute pancreatitis. (a) Arteriogram of the superior mesenteric artery (S) demonstrates retrograde filling of the proper hepatic artery (P) through the inferior pancreaticoduodenal artery, pancreatic arcade, and gastroduodenal artery. The anterior (double arrows) and posterior (single arrow) superior pancreaticoduodenal arteries are seen, with a pseudoaneurysm (arrowhead) originating from the latter. (b) Angiogram obtained after selective injection of contrast material into the inferior pancreaticoduodenal artery better demonstrates the origin of the pseudoaneurysm (arrow). (c) Angiogram shows a catheter that was advanced into the posterior arcade artery and coils that were placed distal and then proximal to the pseudoaneurysm (arrowhead). (d) Postembolization arteriogram demonstrates coils (arrow and arrowhead) isolating the pseudoaneurysm from the circulation, resulting in thrombosis of the pseudoaneurysm.

 

Figure 2
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  		Figure 2b.  Pseudoaneurysm in a 59-year-old alcoholic man who presented with acute upper gastrointestinal hemorrhage. The patient had a history of recurrent acute pancreatitis. (a) Arteriogram of the superior mesenteric artery (S) demonstrates retrograde filling of the proper hepatic artery (P) through the inferior pancreaticoduodenal artery, pancreatic arcade, and gastroduodenal artery. The anterior (double arrows) and posterior (single arrow) superior pancreaticoduodenal arteries are seen, with a pseudoaneurysm (arrowhead) originating from the latter. (b) Angiogram obtained after selective injection of contrast material into the inferior pancreaticoduodenal artery better demonstrates the origin of the pseudoaneurysm (arrow). (c) Angiogram shows a catheter that was advanced into the posterior arcade artery and coils that were placed distal and then proximal to the pseudoaneurysm (arrowhead). (d) Postembolization arteriogram demonstrates coils (arrow and arrowhead) isolating the pseudoaneurysm from the circulation, resulting in thrombosis of the pseudoaneurysm.

 

Figure 2
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  		Figure 2c.  Pseudoaneurysm in a 59-year-old alcoholic man who presented with acute upper gastrointestinal hemorrhage. The patient had a history of recurrent acute pancreatitis. (a) Arteriogram of the superior mesenteric artery (S) demonstrates retrograde filling of the proper hepatic artery (P) through the inferior pancreaticoduodenal artery, pancreatic arcade, and gastroduodenal artery. The anterior (double arrows) and posterior (single arrow) superior pancreaticoduodenal arteries are seen, with a pseudoaneurysm (arrowhead) originating from the latter. (b) Angiogram obtained after selective injection of contrast material into the inferior pancreaticoduodenal artery better demonstrates the origin of the pseudoaneurysm (arrow). (c) Angiogram shows a catheter that was advanced into the posterior arcade artery and coils that were placed distal and then proximal to the pseudoaneurysm (arrowhead). (d) Postembolization arteriogram demonstrates coils (arrow and arrowhead) isolating the pseudoaneurysm from the circulation, resulting in thrombosis of the pseudoaneurysm.

 

Figure 2
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  		Figure 2d.  Pseudoaneurysm in a 59-year-old alcoholic man who presented with acute upper gastrointestinal hemorrhage. The patient had a history of recurrent acute pancreatitis. (a) Arteriogram of the superior mesenteric artery (S) demonstrates retrograde filling of the proper hepatic artery (P) through the inferior pancreaticoduodenal artery, pancreatic arcade, and gastroduodenal artery. The anterior (double arrows) and posterior (single arrow) superior pancreaticoduodenal arteries are seen, with a pseudoaneurysm (arrowhead) originating from the latter. (b) Angiogram obtained after selective injection of contrast material into the inferior pancreaticoduodenal artery better demonstrates the origin of the pseudoaneurysm (arrow). (c) Angiogram shows a catheter that was advanced into the posterior arcade artery and coils that were placed distal and then proximal to the pseudoaneurysm (arrowhead). (d) Postembolization arteriogram demonstrates coils (arrow and arrowhead) isolating the pseudoaneurysm from the circulation, resulting in thrombosis of the pseudoaneurysm.

 

Figure 3
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  		Figure 3.  Drawing illustrates how large particles or small coils are used to occlude outflow from the aneurysm, followed by placement of coils proximal to the aneurysm, again trapping the aneurysm, with resultant thrombosis.

 

Figure 4
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  		Figure 4.  Drawing illustrates a PHA aneurysm with inflow from the CHA and out-flow from the gastroduodenal artery and distal PHA. To preserve flow to the liver, a covered stent is placed across the aneurysm. Before stent placement, however, the gastroduodenal artery distal to the aneurysm is occluded with coils to exclude the aneurysm from the circulation and prevent retrograde filling of the liver.

 

Figure 5
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  		Figure 5a.  SAA. (a) Arteriogram shows an aneurysm (arrows) that originates from a parenchymal branch of the splenic artery. (b) Arteriogram shows that the branch has been selectively catheterized, with the catheter (arrow) advanced distal to the aneurysm. (c) Arteriogram shows coils (arrows) that were placed distal and then proximal to the neck of the aneurysm. (d) Arteriogram obtained upon completion of the procedure demonstrates occlusion of the aneurysm with preservation of flow to the spleen.

 

Figure 5
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  		Figure 5b.  SAA. (a) Arteriogram shows an aneurysm (arrows) that originates from a parenchymal branch of the splenic artery. (b) Arteriogram shows that the branch has been selectively catheterized, with the catheter (arrow) advanced distal to the aneurysm. (c) Arteriogram shows coils (arrows) that were placed distal and then proximal to the neck of the aneurysm. (d) Arteriogram obtained upon completion of the procedure demonstrates occlusion of the aneurysm with preservation of flow to the spleen.

 

Figure 5
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  		Figure 5c.  SAA. (a) Arteriogram shows an aneurysm (arrows) that originates from a parenchymal branch of the splenic artery. (b) Arteriogram shows that the branch has been selectively catheterized, with the catheter (arrow) advanced distal to the aneurysm. (c) Arteriogram shows coils (arrows) that were placed distal and then proximal to the neck of the aneurysm. (d) Arteriogram obtained upon completion of the procedure demonstrates occlusion of the aneurysm with preservation of flow to the spleen.

 

Figure 5
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  		Figure 5d.  SAA. (a) Arteriogram shows an aneurysm (arrows) that originates from a parenchymal branch of the splenic artery. (b) Arteriogram shows that the branch has been selectively catheterized, with the catheter (arrow) advanced distal to the aneurysm. (c) Arteriogram shows coils (arrows) that were placed distal and then proximal to the neck of the aneurysm. (d) Arteriogram obtained upon completion of the procedure demonstrates occlusion of the aneurysm with preservation of flow to the spleen.

 

Figure 6
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  		Figure 6a.  SAA. (a, b) Arteriograms show stainless steel coils (arrows) that were placed to occlude the middle third of the splenic artery. Perfusion of the distal portion of the splenic artery is preserved by means of collateral flow from the caudal pancreatic arteries (arrowheads in b). (c) Arteriogram shows pancreatic collateral vessels (arrowheads) and short gastric branches (arrow), all of which contribute to distal perfusion. Sacrifice of a portion of the main splenic artery is generally safe because collateral blood supply in the celiac and SMA distribution is extensive.

 

Figure 6
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  		Figure 6b.  SAA. (a, b) Arteriograms show stainless steel coils (arrows) that were placed to occlude the middle third of the splenic artery. Perfusion of the distal portion of the splenic artery is preserved by means of collateral flow from the caudal pancreatic arteries (arrowheads in b). (c) Arteriogram shows pancreatic collateral vessels (arrowheads) and short gastric branches (arrow), all of which contribute to distal perfusion. Sacrifice of a portion of the main splenic artery is generally safe because collateral blood supply in the celiac and SMA distribution is extensive.

 

Figure 6
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  		Figure 6c.  SAA. (a, b) Arteriograms show stainless steel coils (arrows) that were placed to occlude the middle third of the splenic artery. Perfusion of the distal portion of the splenic artery is preserved by means of collateral flow from the caudal pancreatic arteries (arrowheads in b). (c) Arteriogram shows pancreatic collateral vessels (arrowheads) and short gastric branches (arrow), all of which contribute to distal perfusion. Sacrifice of a portion of the main splenic artery is generally safe because collateral blood supply in the celiac and SMA distribution is extensive.

 

Figure 7
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  		Figure 7a.  PHA in a 25-year-old man who presented with spontaneous perforation of the sigmoid colon. US performed as part of the diagnostic work-up demonstrated a mass in the porta hepatis with arterial flow. (a) Selective arteriogram of the celiac artery demonstrates an aneurysm (arrow) of the PHA, a finding that, in conjunction with the mass seen at US, led to the diagnosis of Ehlers-Danlos syndrome. (b) Arteriogram shows coils (arrowhead) that were placed distal and then proximal to the aneurysm to occlude the PHA. Although occlusion of the PHA generally carries an unacceptable risk of liver ischemia, the presence of a replaced left hepatic artery off the left gastric artery was believed to diminish the risk in this case.

 

Figure 7
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  		Figure 7b.  PHA in a 25-year-old man who presented with spontaneous perforation of the sigmoid colon. US performed as part of the diagnostic work-up demonstrated a mass in the porta hepatis with arterial flow. (a) Selective arteriogram of the celiac artery demonstrates an aneurysm (arrow) of the PHA, a finding that, in conjunction with the mass seen at US, led to the diagnosis of Ehlers-Danlos syndrome. (b) Arteriogram shows coils (arrowhead) that were placed distal and then proximal to the aneurysm to occlude the PHA. Although occlusion of the PHA generally carries an unacceptable risk of liver ischemia, the presence of a replaced left hepatic artery off the left gastric artery was believed to diminish the risk in this case.

 

Figure 8
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  		Figure 8a.  PHA pseudoaneurysm in a patient who developed brisk hemorrhage from a Jackson-Pratt drain placed during a Whipple procedure. The procedure had been performed for duodenal carcinoma 2 months earlier. The drain had been left in place because of a persistent anastomotic leak. (a) Arteriogram demonstrates a pseudoaneurysm (arrow) at the gastroduodenal artery stump. The drain (arrowheads) can be seen in the background. Trapping of the pseudoaneurysm would have involved occlusion of the proximal PHA with significant risk of liver ischemia. (b) Arteriogram shows a covered stent (arrows) that was placed to connect the CHA to the PHA, thereby occluding the pseudoaneurysm and providing continued hepatic perfusion.

 

Figure 8
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  		Figure 8b.  PHA pseudoaneurysm in a patient who developed brisk hemorrhage from a Jackson-Pratt drain placed during a Whipple procedure. The procedure had been performed for duodenal carcinoma 2 months earlier. The drain had been left in place because of a persistent anastomotic leak. (a) Arteriogram demonstrates a pseudoaneurysm (arrow) at the gastroduodenal artery stump. The drain (arrowheads) can be seen in the background. Trapping of the pseudoaneurysm would have involved occlusion of the proximal PHA with significant risk of liver ischemia. (b) Arteriogram shows a covered stent (arrows) that was placed to connect the CHA to the PHA, thereby occluding the pseudoaneurysm and providing continued hepatic perfusion.

 

Figure 9
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  		Figure 9a.  Gastroduodenal artery pseudoaneurysm in a 57-year-old woman who presented with chronic pancreatitis and upper gastrointestinal tract hemorrhage. (a) Unenhanced CT scan shows pancreatic calcifications (arrow) and a retroperitoneal soft-tissue mass (arrowheads). (b) Contrast material–enhanced CT arteriogram demonstrates immediate enhancement of the mass (arrows). (c) Arteriogram of the CHA demonstrates a pseudoaneurysm originating from the junction of the gastroduodenal and proper hepatic arteries. (d) Arteriogram shows coils (arrows) that were placed to occlude the gastroduodenal artery and its proximal branches, thereby preventing retrograde flow to the pseudoaneurysm. (e) Arteriogram shows a covered stent (arrows) that was placed to complete pseudoaneurysm exclusion while maintaining perfusion of the PHA.

 

Figure 9
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  		Figure 9b.  Gastroduodenal artery pseudoaneurysm in a 57-year-old woman who presented with chronic pancreatitis and upper gastrointestinal tract hemorrhage. (a) Unenhanced CT scan shows pancreatic calcifications (arrow) and a retroperitoneal soft-tissue mass (arrowheads). (b) Contrast material–enhanced CT arteriogram demonstrates immediate enhancement of the mass (arrows). (c) Arteriogram of the CHA demonstrates a pseudoaneurysm originating from the junction of the gastroduodenal and proper hepatic arteries. (d) Arteriogram shows coils (arrows) that were placed to occlude the gastroduodenal artery and its proximal branches, thereby preventing retrograde flow to the pseudoaneurysm. (e) Arteriogram shows a covered stent (arrows) that was placed to complete pseudoaneurysm exclusion while maintaining perfusion of the PHA.

 

Figure 9
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  		Figure 9c.  Gastroduodenal artery pseudoaneurysm in a 57-year-old woman who presented with chronic pancreatitis and upper gastrointestinal tract hemorrhage. (a) Unenhanced CT scan shows pancreatic calcifications (arrow) and a retroperitoneal soft-tissue mass (arrowheads). (b) Contrast material–enhanced CT arteriogram demonstrates immediate enhancement of the mass (arrows). (c) Arteriogram of the CHA demonstrates a pseudoaneurysm originating from the junction of the gastroduodenal and proper hepatic arteries. (d) Arteriogram shows coils (arrows) that were placed to occlude the gastroduodenal artery and its proximal branches, thereby preventing retrograde flow to the pseudoaneurysm. (e) Arteriogram shows a covered stent (arrows) that was placed to complete pseudoaneurysm exclusion while maintaining perfusion of the PHA.

 

Figure 9
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  		Figure 9d.  Gastroduodenal artery pseudoaneurysm in a 57-year-old woman who presented with chronic pancreatitis and upper gastrointestinal tract hemorrhage. (a) Unenhanced CT scan shows pancreatic calcifications (arrow) and a retroperitoneal soft-tissue mass (arrowheads). (b) Contrast material–enhanced CT arteriogram demonstrates immediate enhancement of the mass (arrows). (c) Arteriogram of the CHA demonstrates a pseudoaneurysm originating from the junction of the gastroduodenal and proper hepatic arteries. (d) Arteriogram shows coils (arrows) that were placed to occlude the gastroduodenal artery and its proximal branches, thereby preventing retrograde flow to the pseudoaneurysm. (e) Arteriogram shows a covered stent (arrows) that was placed to complete pseudoaneurysm exclusion while maintaining perfusion of the PHA.

 

Figure 9
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  		Figure 9e.  Gastroduodenal artery pseudoaneurysm in a 57-year-old woman who presented with chronic pancreatitis and upper gastrointestinal tract hemorrhage. (a) Unenhanced CT scan shows pancreatic calcifications (arrow) and a retroperitoneal soft-tissue mass (arrowheads). (b) Contrast material–enhanced CT arteriogram demonstrates immediate enhancement of the mass (arrows). (c) Arteriogram of the CHA demonstrates a pseudoaneurysm originating from the junction of the gastroduodenal and proper hepatic arteries. (d) Arteriogram shows coils (arrows) that were placed to occlude the gastroduodenal artery and its proximal branches, thereby preventing retrograde flow to the pseudoaneurysm. (e) Arteriogram shows a covered stent (arrows) that was placed to complete pseudoaneurysm exclusion while maintaining perfusion of the PHA.

 

Figure 10
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  		Figure 10a.  Pancreaticoduodenal artery aneurysms in a previously healthy 41-year-old woman who presented with acute onset of abdominal pain. (a) Emergent CT scan reveals retroperitoneal hemorrhage (arrowheads). (b) Arteriogram of the gastroduodenal artery demonstrates aneurysms (arrowheads) of the anterior and posterior superior pancreaticoduodenal arteries. (c) Arteriogram shows coils (arrowheads) that were placed to occlude the inferior pancreaticoduodenal artery, followed by particulate occlusion of the anterior and posterior superior pancreaticoduodenal arteries (arrow). It was thought that exclusion and thrombosis of the aneurysm had been achieved. (d) Arteriogram obtained following the injection of contrast material into the dorsal pancreatic artery demonstrates residual perfusion of the posterior superior pancreaticoduodenal branch aneurysm (arrowhead) via the pancreaticoduodenal artery. Following occlusion of this branch with 1000 µm of polyvinyl alcohol particles, there was no further filling of the aneurysm. Perfusion of the pancreas is maintained via the transverse pancreatic artery (arrow). This case demonstrates the importance of totally excluding visceral aneurysms from the circulation by seeking out and eliminating all collateral flow to the aneurysm.

 

Figure 10
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  		Figure 10b.  Pancreaticoduodenal artery aneurysms in a previously healthy 41-year-old woman who presented with acute onset of abdominal pain. (a) Emergent CT scan reveals retroperitoneal hemorrhage (arrowheads). (b) Arteriogram of the gastroduodenal artery demonstrates aneurysms (arrowheads) of the anterior and posterior superior pancreaticoduodenal arteries. (c) Arteriogram shows coils (arrowheads) that were placed to occlude the inferior pancreaticoduodenal artery, followed by particulate occlusion of the anterior and posterior superior pancreaticoduodenal arteries (arrow). It was thought that exclusion and thrombosis of the aneurysm had been achieved. (d) Arteriogram obtained following the injection of contrast material into the dorsal pancreatic artery demonstrates residual perfusion of the posterior superior pancreaticoduodenal branch aneurysm (arrowhead) via the pancreaticoduodenal artery. Following occlusion of this branch with 1000 µm of polyvinyl alcohol particles, there was no further filling of the aneurysm. Perfusion of the pancreas is maintained via the transverse pancreatic artery (arrow). This case demonstrates the importance of totally excluding visceral aneurysms from the circulation by seeking out and eliminating all collateral flow to the aneurysm.

 

Figure 10
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  		Figure 10c.  Pancreaticoduodenal artery aneurysms in a previously healthy 41-year-old woman who presented with acute onset of abdominal pain. (a) Emergent CT scan reveals retroperitoneal hemorrhage (arrowheads). (b) Arteriogram of the gastroduodenal artery demonstrates aneurysms (arrowheads) of the anterior and posterior superior pancreaticoduodenal arteries. (c) Arteriogram shows coils (arrowheads) that were placed to occlude the inferior pancreaticoduodenal artery, followed by particulate occlusion of the anterior and posterior superior pancreaticoduodenal arteries (arrow). It was thought that exclusion and thrombosis of the aneurysm had been achieved. (d) Arteriogram obtained following the injection of contrast material into the dorsal pancreatic artery demonstrates residual perfusion of the posterior superior pancreaticoduodenal branch aneurysm (arrowhead) via the pancreaticoduodenal artery. Following occlusion of this branch with 1000 µm of polyvinyl alcohol particles, there was no further filling of the aneurysm. Perfusion of the pancreas is maintained via the transverse pancreatic artery (arrow). This case demonstrates the importance of totally excluding visceral aneurysms from the circulation by seeking out and eliminating all collateral flow to the aneurysm.

 

Figure 10
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  		Figure 10d.  Pancreaticoduodenal artery aneurysms in a previously healthy 41-year-old woman who presented with acute onset of abdominal pain. (a) Emergent CT scan reveals retroperitoneal hemorrhage (arrowheads). (b) Arteriogram of the gastroduodenal artery demonstrates aneurysms (arrowheads) of the anterior and posterior superior pancreaticoduodenal arteries. (c) Arteriogram shows coils (arrowheads) that were placed to occlude the inferior pancreaticoduodenal artery, followed by particulate occlusion of the anterior and posterior superior pancreaticoduodenal arteries (arrow). It was thought that exclusion and thrombosis of the aneurysm had been achieved. (d) Arteriogram obtained following the injection of contrast material into the dorsal pancreatic artery demonstrates residual perfusion of the posterior superior pancreaticoduodenal branch aneurysm (arrowhead) via the pancreaticoduodenal artery. Following occlusion of this branch with 1000 µm of polyvinyl alcohol particles, there was no further filling of the aneurysm. Perfusion of the pancreas is maintained via the transverse pancreatic artery (arrow). This case demonstrates the importance of totally excluding visceral aneurysms from the circulation by seeking out and eliminating all collateral flow to the aneurysm.

 

Figure 11
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  		Figure 11a.  RAA in an 18-year-old man with a diagnosis of Behçet disease who had developed increasing left flank pain. (a) Abdominal CT scan demonstrates a contrast material–filled mass (arrowheads) in the left kidney. (b) Selective arteriogram of the left renal artery demonstrates a pseudoaneurysm (arrowheads) originating from the anterior superior segmental artery (double arrows). The posterior segmental artery (single arrow) is partially obstructed by the pseudoaneurysm. (c) Arteriogram shows a catheter that was advanced into the partially obstructed posterior segmental artery. (d) Arteriogram shows distal particulate occlusion and proximal coil occlusion (arrows), with preservation of flow to the remainder of the kidney.

 

Figure 11
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  		Figure 11b.  RAA in an 18-year-old man with a diagnosis of Behçet disease who had developed increasing left flank pain. (a) Abdominal CT scan demonstrates a contrast material–filled mass (arrowheads) in the left kidney. (b) Selective arteriogram of the left renal artery demonstrates a pseudoaneurysm (arrowheads) originating from the anterior superior segmental artery (double arrows). The posterior segmental artery (single arrow) is partially obstructed by the pseudoaneurysm. (c) Arteriogram shows a catheter that was advanced into the partially obstructed posterior segmental artery. (d) Arteriogram shows distal particulate occlusion and proximal coil occlusion (arrows), with preservation of flow to the remainder of the kidney.

 

Figure 11
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  		Figure 11c.  RAA in an 18-year-old man with a diagnosis of Behçet disease who had developed increasing left flank pain. (a) Abdominal CT scan demonstrates a contrast material–filled mass (arrowheads) in the left kidney. (b) Selective arteriogram of the left renal artery demonstrates a pseudoaneurysm (arrowheads) originating from the anterior superior segmental artery (double arrows). The posterior segmental artery (single arrow) is partially obstructed by the pseudoaneurysm. (c) Arteriogram shows a catheter that was advanced into the partially obstructed posterior segmental artery. (d) Arteriogram shows distal particulate occlusion and proximal coil occlusion (arrows), with preservation of flow to the remainder of the kidney.

 

Figure 11
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  		Figure 11d.  RAA in an 18-year-old man with a diagnosis of Behçet disease who had developed increasing left flank pain. (a) Abdominal CT scan demonstrates a contrast material–filled mass (arrowheads) in the left kidney. (b) Selective arteriogram of the left renal artery demonstrates a pseudoaneurysm (arrowheads) originating from the anterior superior segmental artery (double arrows). The posterior segmental artery (single arrow) is partially obstructed by the pseudoaneurysm. (c) Arteriogram shows a catheter that was advanced into the partially obstructed posterior segmental artery. (d) Arteriogram shows distal particulate occlusion and proximal coil occlusion (arrows), with preservation of flow to the remainder of the kidney.

 

Figure 12
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  		Figure 12a.  RAA in a patient who developed persistent hematuria following nephrostomy. (a) Arteriogram of the left renal artery demonstrates the penetration of a pseudoaneurysm (arrowheads) of the posterior segmental renal artery by the nephrostomy tube (arrow). (b) Arteriogram reveals that the pseudoaneurysm (arrowheads) is associated with an arteriovenous fistula with an early draining vein (arrows). (c) Arteriogram obtained following coil occlusion of the pseudoaneurysm and feeding artery (arrow) shows no filling of the pseudoaneurysm or fistula.

 

Figure 12
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  		Figure 12b.  RAA in a patient who developed persistent hematuria following nephrostomy. (a) Arteriogram of the left renal artery demonstrates the penetration of a pseudoaneurysm (arrowheads) of the posterior segmental renal artery by the nephrostomy tube (arrow). (b) Arteriogram reveals that the pseudoaneurysm (arrowheads) is associated with an arteriovenous fistula with an early draining vein (arrows). (c) Arteriogram obtained following coil occlusion of the pseudoaneurysm and feeding artery (arrow) shows no filling of the pseudoaneurysm or fistula.

 

Figure 12
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  		Figure 12c.  RAA in a patient who developed persistent hematuria following nephrostomy. (a) Arteriogram of the left renal artery demonstrates the penetration of a pseudoaneurysm (arrowheads) of the posterior segmental renal artery by the nephrostomy tube (arrow). (b) Arteriogram reveals that the pseudoaneurysm (arrowheads) is associated with an arteriovenous fistula with an early draining vein (arrows). (c) Arteriogram obtained following coil occlusion of the pseudoaneurysm and feeding artery (arrow) shows no filling of the pseudoaneurysm or fistula.

 

Figure 13
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  		Figure 13a.  Branch RAA in a 26-year-old professional baseball player who presented with accelerated hypertension. The patient was being treated for subacute bacterial endocarditis. (a) Unenhanced CT scan demonstrates a mass (arrowhead) in the renal hilum. (b) Abdominal aortogram demonstrates a pseudoaneurysm (arrow) originating from a branch of an accessory superior polar renal artery. (c) Arteriogram obtained after selective injection of contrast material into the accessory artery better demonstrates the pseudoaneurysm (arrow) originating from the anterior superior segmental artery. The pseudoaneurysm was treated with a combination of alcohol occlusion of the outflow parent artery and distal vascular bed and large particle occlusion of inflow to the pseudoaneurysm. (d) Arteriogram shows exclusion of the pseudoaneurysm.

 

Figure 13
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  		Figure 13b.  Branch RAA in a 26-year-old professional baseball player who presented with accelerated hypertension. The patient was being treated for subacute bacterial endocarditis. (a) Unenhanced CT scan demonstrates a mass (arrowhead) in the renal hilum. (b) Abdominal aortogram demonstrates a pseudoaneurysm (arrow) originating from a branch of an accessory superior polar renal artery. (c) Arteriogram obtained after selective injection of contrast material into the accessory artery better demonstrates the pseudoaneurysm (arrow) originating from the anterior superior segmental artery. The pseudoaneurysm was treated with a combination of alcohol occlusion of the outflow parent artery and distal vascular bed and large particle occlusion of inflow to the pseudoaneurysm. (d) Arteriogram shows exclusion of the pseudoaneurysm.

 

Figure 13
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  		Figure 13c.  Branch RAA in a 26-year-old professional baseball player who presented with accelerated hypertension. The patient was being treated for subacute bacterial endocarditis. (a) Unenhanced CT scan demonstrates a mass (arrowhead) in the renal hilum. (b) Abdominal aortogram demonstrates a pseudoaneurysm (arrow) originating from a branch of an accessory superior polar renal artery. (c) Arteriogram obtained after selective injection of contrast material into the accessory artery better demonstrates the pseudoaneurysm (arrow) originating from the anterior superior segmental artery. The pseudoaneurysm was treated with a combination of alcohol occlusion of the outflow parent artery and distal vascular bed and large particle occlusion of inflow to the pseudoaneurysm. (d) Arteriogram shows exclusion of the pseudoaneurysm.

 

Figure 13
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  		Figure 13d.  Branch RAA in a 26-year-old professional baseball player who presented with accelerated hypertension. The patient was being treated for subacute bacterial endocarditis. (a) Unenhanced CT scan demonstrates a mass (arrowhead) in the renal hilum. (b) Abdominal aortogram demonstrates a pseudoaneurysm (arrow) originating from a branch of an accessory superior polar renal artery. (c) Arteriogram obtained after selective injection of contrast material into the accessory artery better demonstrates the pseudoaneurysm (arrow) originating from the anterior superior segmental artery. The pseudoaneurysm was treated with a combination of alcohol occlusion of the outflow parent artery and distal vascular bed and large particle occlusion of inflow to the pseudoaneurysm. (d) Arteriogram shows exclusion of the pseudoaneurysm.

 

Figure 14
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  		Figure 14a.  Aneurysm of the MRA in a 67-year-old hypertensive man. The aneurysm was found incidentally at abdominal CT. (a) Arteriogram demonstrates an aneurysm (arrow) originating at the bifurcation of the MRA. Surgical exploration was performed to determine the resectability of the aneurysm, which proved to be unresectable owing to its size and hilar location. (b) Arteriogram shows a bypass graft (arrowheads) that was placed to connect the proximal MRA to a common segmental branch in the lower pole in anticipation of coil occlusion of the aneurysm. (c) Arteriogram shows that the aneurysm has been excluded from the circulation by occluding the renal artery distal to the aneurysm with coils (arrows), packing the aneurysm with coils, and occluding the distal MRA, with flow preserved by means of the bypass graft (arrowhead).

 

Figure 14
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  		Figure 14b.  Aneurysm of the MRA in a 67-year-old hypertensive man. The aneurysm was found incidentally at abdominal CT. (a) Arteriogram demonstrates an aneurysm (arrow) originating at the bifurcation of the MRA. Surgical exploration was performed to determine the resectability of the aneurysm, which proved to be unresectable owing to its size and hilar location. (b) Arteriogram shows a bypass graft (arrowheads) that was placed to connect the proximal MRA to a common segmental branch in the lower pole in anticipation of coil occlusion of the aneurysm. (c) Arteriogram shows that the aneurysm has been excluded from the circulation by occluding the renal artery distal to the aneurysm with coils (arrows), packing the aneurysm with coils, and occluding the distal MRA, with flow preserved by means of the bypass graft (arrowhead).

 

Figure 14
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  		Figure 14c.  Aneurysm of the MRA in a 67-year-old hypertensive man. The aneurysm was found incidentally at abdominal CT. (a) Arteriogram demonstrates an aneurysm (arrow) originating at the bifurcation of the MRA. Surgical exploration was performed to determine the resectability of the aneurysm, which proved to be unresectable owing to its size and hilar location. (b) Arteriogram shows a bypass graft (arrowheads) that was placed to connect the proximal MRA to a common segmental branch in the lower pole in anticipation of coil occlusion of the aneurysm. (c) Arteriogram shows that the aneurysm has been excluded from the circulation by occluding the renal artery distal to the aneurysm with coils (arrows), packing the aneurysm with coils, and occluding the distal MRA, with flow preserved by means of the bypass graft (arrowhead).

 

Figure 15
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  		Figure 15a.  CAAs in a 71-year-old patient who had previously undergone esophagectomy and gastric pull-through. (a) CT scan obtained for nonspecific abdominal pain shows aneurysm formation in the distal celiac trunk and proximal splenic (arrow) and hepatic (arrowhead) arteries. Coil occlusion of the splenic artery, CHA, proximal PHA, and distal celiac trunk was planned to trap the aneurysms and exclude them from the arterial circulation. Because of the risk of ischemic injury to the liver prior to embolization, an ilio–right hepatic artery bypass procedure was performed. (b) Arteriogram demonstrates the lumina of the splenic (arrow) and hepatic (arrowhead) artery aneurysms. (c) Arteriogram demonstrates coil occlusion of the splenic (arrow) and hepatic (arrowhead) artery aneurysms, with initial coil placement distal to the aneurysm followed by packing of the aneurysm and occlusion of the proximal inflow to the aneurysm. (d) Follow-up arteriogram demonstrates a patent iliohepatic bypass graft and no retrograde filling of the aneurysm.

 

Figure 15
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  		Figure 15b.  CAAs in a 71-year-old patient who had previously undergone esophagectomy and gastric pull-through. (a) CT scan obtained for nonspecific abdominal pain shows aneurysm formation in the distal celiac trunk and proximal splenic (arrow) and hepatic (arrowhead) arteries. Coil occlusion of the splenic artery, CHA, proximal PHA, and distal celiac trunk was planned to trap the aneurysms and exclude them from the arterial circulation. Because of the risk of ischemic injury to the liver prior to embolization, an ilio–right hepatic artery bypass procedure was performed. (b) Arteriogram demonstrates the lumina of the splenic (arrow) and hepatic (arrowhead) artery aneurysms. (c) Arteriogram demonstrates coil occlusion of the splenic (arrow) and hepatic (arrowhead) artery aneurysms, with initial coil placement distal to the aneurysm followed by packing of the aneurysm and occlusion of the proximal inflow to the aneurysm. (d) Follow-up arteriogram demonstrates a patent iliohepatic bypass graft and no retrograde filling of the aneurysm.

 

Figure 15
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  		Figure 15c.  CAAs in a 71-year-old patient who had previously undergone esophagectomy and gastric pull-through. (a) CT scan obtained for nonspecific abdominal pain shows aneurysm formation in the distal celiac trunk and proximal splenic (arrow) and hepatic (arrowhead) arteries. Coil occlusion of the splenic artery, CHA, proximal PHA, and distal celiac trunk was planned to trap the aneurysms and exclude them from the arterial circulation. Because of the risk of ischemic injury to the liver prior to embolization, an ilio–right hepatic artery bypass procedure was performed. (b) Arteriogram demonstrates the lumina of the splenic (arrow) and hepatic (arrowhead) artery aneurysms. (c) Arteriogram demonstrates coil occlusion of the splenic (arrow) and hepatic (arrowhead) artery aneurysms, with initial coil placement distal to the aneurysm followed by packing of the aneurysm and occlusion of the proximal inflow to the aneurysm. (d) Follow-up arteriogram demonstrates a patent iliohepatic bypass graft and no retrograde filling of the aneurysm.

 

Figure 15
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  		Figure 15d.  CAAs in a 71-year-old patient who had previously undergone esophagectomy and gastric pull-through. (a) CT scan obtained for nonspecific abdominal pain shows aneurysm formation in the distal celiac trunk and proximal splenic (arrow) and hepatic (arrowhead) arteries. Coil occlusion of the splenic artery, CHA, proximal PHA, and distal celiac trunk was planned to trap the aneurysms and exclude them from the arterial circulation. Because of the risk of ischemic injury to the liver prior to embolization, an ilio–right hepatic artery bypass procedure was performed. (b) Arteriogram demonstrates the lumina of the splenic (arrow) and hepatic (arrowhead) artery aneurysms. (c) Arteriogram demonstrates coil occlusion of the splenic (arrow) and hepatic (arrowhead) artery aneurysms, with initial coil placement distal to the aneurysm followed by packing of the aneurysm and occlusion of the proximal inflow to the aneurysm. (d) Follow-up arteriogram demonstrates a patent iliohepatic bypass graft and no retrograde filling of the aneurysm.

 

Figure 16
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  		Figure 16a.  Left gastric artery aneurysm in an 81-year-old man. The aneurysm had been incidentally discovered at follow-up CT performed after nephrectomy for hypernephroma and had increased in size by 1 cm over the past 12 months. (a, b) Axial (a) and sagittal (b) CT angiograms show the hepatic artery (H), the celiac artery (C), and the aneurysm (arrows), which originates from the left gastric artery (arrowheads). (c) Axial color Doppler flow image clearly depicts the aneurysm (arrows) anterior to the aorta (A). Interestingly, the left gastric artery distal to the aneurysm supplied a replaced left hepatic artery. (d) Arteriogram shows coil occlusion of the outflow from the aneurysm to the left gastric artery (arrowheads) and to a replaced left hepatic artery (arrows). (e) Arteriogram depicts a covered stent (arrows) that was placed across the origin of the left gastric artery following coil occlusion to completely exclude the aneurysm and preserve flow in the celiac artery.

 

Figure 16
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  		Figure 16b.  Left gastric artery aneurysm in an 81-year-old man. The aneurysm had been incidentally discovered at follow-up CT performed after nephrectomy for hypernephroma and had increased in size by 1 cm over the past 12 months. (a, b) Axial (a) and sagittal (b) CT angiograms show the hepatic artery (H), the celiac artery (C), and the aneurysm (arrows), which originates from the left gastric artery (arrowheads). (c) Axial color Doppler flow image clearly depicts the aneurysm (arrows) anterior to the aorta (A). Interestingly, the left gastric artery distal to the aneurysm supplied a replaced left hepatic artery. (d) Arteriogram shows coil occlusion of the outflow from the aneurysm to the left gastric artery (arrowheads) and to a replaced left hepatic artery (arrows). (e) Arteriogram depicts a covered stent (arrows) that was placed across the origin of the left gastric artery following coil occlusion to completely exclude the aneurysm and preserve flow in the celiac artery.

 

Figure 16
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  		Figure 16c.  Left gastric artery aneurysm in an 81-year-old man. The aneurysm had been incidentally discovered at follow-up CT performed after nephrectomy for hypernephroma and had increased in size by 1 cm over the past 12 months. (a, b) Axial (a) and sagittal (b) CT angiograms show the hepatic artery (H), the celiac artery (C), and the aneurysm (arrows), which originates from the left gastric artery (arrowheads). (c) Axial color Doppler flow image clearly depicts the aneurysm (arrows) anterior to the aorta (A). Interestingly, the left gastric artery distal to the aneurysm supplied a replaced left hepatic artery. (d) Arteriogram shows coil occlusion of the outflow from the aneurysm to the left gastric artery (arrowheads) and to a replaced left hepatic artery (arrows). (e) Arteriogram depicts a covered stent (arrows) that was placed across the origin of the left gastric artery following coil occlusion to completely exclude the aneurysm and preserve flow in the celiac artery.

 

Figure 16
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  		Figure 16d.  Left gastric artery aneurysm in an 81-year-old man. The aneurysm had been incidentally discovered at follow-up CT performed after nephrectomy for hypernephroma and had increased in size by 1 cm over the past 12 months. (a, b) Axial (a) and sagittal (b) CT angiograms show the hepatic artery (H), the celiac artery (C), and the aneurysm (arrows), which originates from the left gastric artery (arrowheads). (c) Axial color Doppler flow image clearly depicts the aneurysm (arrows) anterior to the aorta (A). Interestingly, the left gastric artery distal to the aneurysm supplied a replaced left hepatic artery. (d) Arteriogram shows coil occlusion of the outflow from the aneurysm to the left gastric artery (arrowheads) and to a replaced left hepatic artery (arrows). (e) Arteriogram depicts a covered stent (arrows) that was placed across the origin of the left gastric artery following coil occlusion to completely exclude the aneurysm and preserve flow in the celiac artery.

 

Figure 16
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  		Figure 16e.  Left gastric artery aneurysm in an 81-year-old man. The aneurysm had been incidentally discovered at follow-up CT performed after nephrectomy for hypernephroma and had increased in size by 1 cm over the past 12 months. (a, b) Axial (a) and sagittal (b) CT angiograms show the hepatic artery (H), the celiac artery (C), and the aneurysm (arrows), which originates from the left gastric artery (arrowheads). (c) Axial color Doppler flow image clearly depicts the aneurysm (arrows) anterior to the aorta (A). Interestingly, the left gastric artery distal to the aneurysm supplied a replaced left hepatic artery. (d) Arteriogram shows coil occlusion of the outflow from the aneurysm to the left gastric artery (arrowheads) and to a replaced left hepatic artery (arrows). (e) Arteriogram depicts a covered stent (arrows) that was placed across the origin of the left gastric artery following coil occlusion to completely exclude the aneurysm and preserve flow in the celiac artery.

 




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