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Fig. 1. Pelvic arteriogram shows filling of a pelvic pseudoaneurysm from the right internal pudendal artery. |
Fig. 2. Injection of the anterior division of the right internal iliac artery following Gelfoam embolization shows persistent filling of the pseudoaneurysm. |
Case Reference No. CC-997-06 A 69-year-old woman underwent surgical staging and debulking of an ovarian giant cell lymphoma. At surgery, a large tumor mass was found to involve both ovaries, the uterus, and the pelvic sidewall. The patient underwent extensive debulking including bilateral oophorectomy and hysterectomy. She received 4 units of packed cells during surgery and, at closure, appeared hemodynamically stable. Over the next 14 hours the patient became hypotensive, requiring an additional 6 units of packed cells. An emergent pelvic arteriogram was requested with a view to transcatheter embolization. When the patient arrived in the angiography suite, she had developed massive abdominal distention and a systolic blood pressure of 80 mm Hg. An AP flush aortogram showed extravasation from a right internal pudendal artery pseudoaneurysm (Fig. 1). A 5-F ben-Menachem catheter was used to selectively catheterize the left internal iliac artery, which showed no cross-filling of the pseudoaneurysm. The same catheter was then used to catheterize the anterior division of the right internal iliac artery. Gentle hand injections of contrast material showed reflux into the posterior division of the internal iliac artery, so coil embolization of the posterior division was performed to protect the gluteal musculature from further embolization. |
Fig. 3. Selective injection of the right internal pudendal artery following selective catheterization shows filling of the pseudoaneurysm. A single microcoil has been deployed at the end of the vessel.
Fig. 4. Selective arteriogram of the right pudendal artery at the conclusion of microcoil/Gelfoam embolization shows stasis of contrast material but no filling of the pseudoaneurysm. | |||
Gelfoam slurry was administered in multiple aliquots to the anterior division, producing stasis within distal branch vessels but persistent filling of the pseudoaneurysm (Fig. 2). As a result, the internal pudendal artery was selectively catheterized with a Tracker-18 catheter and guide wire (Fig. 3). Multiple 2-mm straight fiber and helical microcoils were deposited along the vessel through the Tracker system by slowly withdrawing the catheter and interposing the coils with aliquots of Gelfoam slurry. No filling was seen on the final right arteriogram (Fig. 4). Another left-sided internal iliac arteriogram was performed to confirm absence of collateral cross-filling. The patient underwent surgical evacuation of her tension hematoperitoneum through her laparotomy incision several hours later. Her surgical bed was found to be dry. She remained hemodynamically stable for the remainder of her hospitalization, although she developed acute respiratory distress syndrome 2 weeks later. |
Questions 1) How do you catheterize the internal iliac artery quickly to embolize a pelvic fracture or postoperative bleed? 2) Which embolic agents do you use? Do you "sandwich" Gelfoam slurry with coils? 3) Do you embolize the posterior division with coils to protect it when embolizing the anterior division ? Related Cases: |
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