case_images: PMC11717752_01
case_images: Pre-procedural contrast-enhanced CTs. A Initial coronal image demonstrates a hematoma (asterisk) adjacent to the HAIP catheter insertion at the GDA. B Short interval follow-up coronal image demonstrates enlargement of the hematoma, most prominently at the inferior aspect (arrow)
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case_images: PMC11717752_01_42155_2024_515_Fig1_HTML.jpg
case_images: Fig1
case_images: Initial contrast-enhanced CT scan showed a hematoma adjacent to the HAIP catheter insertion (Fig. 1A). However, the patient's symptoms worsened, hemoglobin declined from 11.8 to 8.7 g/dL, and a short interval follow-up contrast-enhanced CT scan demonstrated enlargement of the hematoma consistent with bleeding at the GDA remnant (Fig. 1B).
case_images: PMC11717752_02
case_images: Initial angiograms. A Celiac angiogram demonstrating an occluded CHA (arrow). The DPA (arrowhead) is seen arising from the proximal aspect of the CHA. B Superior mesenteric artery angiogram demonstrating truncation of the inferior pancreaticoduodenal artery (arrow)
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case_images: PMC11717752_02_42155_2024_515_Fig2_HTML.jpg
case_images: Fig2
case_images: Celiac angiogram demonstrated an occluded CHA which could not be crossed to access the GDA remnant (Fig. 2A). Superior mesenteric artery angiogram showed truncation of the inferior pancreaticoduodenal artery without visualization of the pancreaticoduodenal arcade, findings consistent with surgical ligation of the distal GDA (Fig. 2B).
case_images: Hepatic collaterals. A Right inferior phrenic artery angiogram and (B) DPA angiogram demonstrating collateral perfusion of the hepatic arteries. The segment 5 hepatic artery (arrow) was targeted for transhepatic arterial access
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case_images: Fig3
case_images: Thorough investigation to find the source of "back-door" inflow to the GDA revealed hepatic arterial collateralization with the right inferior phrenic and dorsal pancreatic arteries (DPA) (Fig. 3), however, the collaterals were too small and tortuous to navigate with a microcatheter. Subsequent attempts were performed using fluoroscopic guidance, aiming for the segment 5 hepatic artery while it was opacified by collateral inflow during contrast injection of the DPA (Fig. 3B).
case_images: Fluoroscopic images of coil embolization. A PHA angiogram obtained after advancing the microcatheter (arrow) as far retrograde as possible. Note hepatic contrast staining from attempts at percutaneous arterial access. B Segment 5 angiogram obtained after PHA coiling and retraction of the microcatheter (arrow), demonstrating stasis at the coil pack. C Celiac angiogram demonstrating stasis at the CHA stump coil pack (arrowhead)
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case_images: PMC11717752_02_42155_2024_515_Fig4_HTML.jpg
case_images: Fig4
case_images: After discussion with hepatobiliary surgery and the patient's healthcare proxy regarding risks and benefits, the decision was made to proceed with percutaneous transhepatic arterial access (Fig. 4). Asahi Intecc, Irvine, California) was advanced into the right hepatic artery. A 2.0 Fr microcatheter (Truselect; Boston Scientific, Marlborough, Massachusetts) was advanced over the wire and positioned as far retrograde within the proper hepatic artery (PHA) as possible (Fig. 4A). Embolization of the PHA was performed with 3 and 4 mm diameter fibered detachable microcoils (Embold; Boston Scientific, Marlborough, Massachusetts), closing the "back-door" inflow to the GDA (Fig. 4B). This was done to definitively close the "front-door" and prevent potential recurrence of bleeding should the CHA recanalize (Fig. 4C).
case_images: PMC11717752_03