Traumatic Pseudoaneurysm of the Inferior Mesenteric Artery Branch: A Rare Cause of Lower GI Bleeding and Treatment with Selective Coil Embolization

Abstract

To the Editor, A forty-five-year-old man presented to emergency services with history of assault on the abdomen by a blunt object. He presented with diffuse abdominal pain and inability to pass stools and flatus. On examination, diffuse abdominal tenderness was present with guarding and rigidity. Emergency plain CT revealed perforation with free air in abdomen. Free air surrounding ileum and sigmoid loops was noted, suggesting the possibility of perforation. Patient was taken for immediate laparotomy in which about 2–2.5 L of hemoperitoneum was present. Sigmoid mesocolon perforation was noted with dusky appearing sigmoid colon. Resection of injured bowelwith anastomosiswas performed. Two perforations in the ileum were noted approximately 120 cm from the ileocecal junction and about 5 cm of ileum at that region appeared dusky. Resection of around 30 cm of ileum was done and brought out as ileostomy. Two mesenteric tears were noted involving mesentery of ileum, which were closed. He was on elective ventilation for 2 days and extubated. On tenth post-operative day, he developed hematemesis, and it was thought to be due to his alcoholic liver disease and was conservatively managed. Patient was transfused with 4 units of fresh frozen plasma during procedure. Twenty days after the resection and anastomosis, he developed bleeding per rectum of about 500ml (of both fresh blood with clots). Emergency CECT revealed pseudoaneurysm probably arising from the inferior mesenteric artery branch that probably communicated with the sigmoid colon (Fig. 1A, B). The pseudoaneurysm was located in the region of the sigmoid mesocolon tear. The pseudoaneurysm measured about 2.2 9 2.0 cm. No active extravasation was noted. In this case, recent laparotomy along with poor general condition of the patientmeant endovascular intervention was the only option available. Patient was taken up for emergency coil embolization, as another episode of hematochezia might be fatal. Informed written consent for the procedure was taken from the patient and his wife. As it was done as emergency life-saving step, approval from Institutional Review Board was not required. Through left brachial arterial access, the inferior mesenteric artery (IMA) was catheterized using a 4F diagnostic catheter, and diagnostic angiogram was done. The left brachial approach was chosen as femoral approach was unsuccessful in reaching the sigmoid branch as normally inferior mesenteric artery has acute angle take-off from the aorta. Digital Subtraction Angiography (DSA) confirmed a pseudoaneurysm arising from the sigmoid branch of IMA between the left colic and superior rectal branches (Fig. 2A). The pseudoaneurysm measured about 2.2 9 2.0 cmwith distal branch continuing toward the sigmoid. There were no branches distal to the pseudoaneurysm. Due to nature of pseudoaneurysm in the setting of acute massive rectal bleeding of more than 500 ml, coil embolization was considered in the proximal artery rather than within the pseudoaneurysmal sac itself. The left colic and marginal artery appeared normal, and hence, it was thought collateralization may develop even if the sigmoid branch is occluded without colic ischemia. The catheter was advanced into the sigmoid branch close to ostium of the pseudoaneurysm and 0180 pushable coil (03 9 20 mm) & Krishnan Nagarajan lknagarajan1@gmail.com

DOI: 10.1007/s00270-016-1338-x

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@article{Nagarajan2016TraumaticPO, title={Traumatic Pseudoaneurysm of the Inferior Mesenteric Artery Branch: A Rare Cause of Lower GI Bleeding and Treatment with Selective Coil Embolization}, author={Krishnan Nagarajan and Swamiappan Elango and Laroiya Ishita and Dasarathan Shanmugam}, journal={CardioVascular and Interventional Radiology}, year={2016}, volume={39}, pages={1358-1360} }