Massive Hemorrhage From Multiple Hepatic Artery Aneurysms.

A 66-year-old man, with an abnormal porta hepatis, consistent with tumor or inflammation, developed massive bleeding from one of numerous hepatic artery aneurysms, and coil embolization achieved control of bleeding. He died of subsequent multisystem organ failure, and the most likely diagnosis was either polyarteritis nodosa or segmental arterial mediolysis. Although the dual hepatic blood supply allows a degree of arterial embolization, this case demonstrates the risks associated with large territory hepatic arterial embolization in the presence of hemodynamic instability. We discuss the management issues related to massive hepatic bleeding when no surgical approach is possible.

Extravascular Revascularization of a Chronic Total Occlusion Using the Dual Bull's-Eye Technique.

PURPOSE: To describe the dual bull's-eye technique to achieve successful extravascular revascularization of an occlusion after vessel perforation when the antegrade and retrograde catheters are too far apart for salvage with a reentry catheter. TECHNIQUE: The dual bull's-eye technique, which is an adaptation of the "gun-sight" method for transjugular portosystemic shunt procedures, is demonstrated in a popliteal artery occlusion in which multiple recanalization attempts have produced vessel perforation. Via antegrade femoral and retrograde anterior tibial artery accesses, 10-mm Amplatz GooseNeck snares were advanced in plane from each access to rendezvous in the popliteal fossa to obtain through-and-through wire access. A 15-cm Chiba needle was advanced percutaneously in plane through both snares, and a hydrophilic guidewire was maneuvered across an extravascular tract parallel to the popliteal artery. The tract was carefully predilated, and a 5×100-mm Viabahn stent-graft was deployed across the extravascular tract. CONCLUSION: Owing to potential complications (limited patency, injury to adjacent structures) and only single-case use, this new technique should be considered a bailout strategy exclusively employed for limb salvage when traditional methods have failed and there are no viable surgical options.