Successful embolization of a primary bronchial artery racemose hemangioma by the ingenious use of a microballoon catheter.

Primary racemose hemangioma of the bronchial artery (RHBA) is a rare congenital condition characterized by enlarged and convoluted bronchial arteries, often forming fistulas between the pulmonary artery or vein. Herein, we report a case of balloon-assisted embolization using N-butyl-2-cyanoacrylate (NBCA) performed for a primary RHBA in an asymptomatic 57-year-old woman. There were 2 tortuous and dilated branches of the right bronchial artery (RBA) (arising from the left subclavian artery and the descending thoracic aorta) which merged in the right pulmonary hilar region, forming multiple aneurysms that short-circuited the right pulmonary artery. Embolization was performed via the RBA arising from the subclavian artery using a triaxial system (a 5-Fr guiding catheter, a 2.7-Fr microballoon catheter, and a 1.9-Fr microcatheter). The guiding catheter was inserted into the peripheral side of the RBA using the microballoon catheter as an anchor; the balloon was slightly inflated and advanced further into the peripheral side using blood flow. The microcatheter was inserted as close to the aneurysms as possible and embolization was done using an NBCA-iodized oil mixture under blood flow control by the microballoon catheter. Bronchial artery embolization is the treatment of choice for primary RHBA because of the risk of rupture, and balloon-assisted techniques can help guide the catheter distally while also controlling blood flow.

Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction.

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that bleeding.