PMC5467359_01
(a) Urgent CT reveals rupture of the aneurysm sac (a) in the arterial phase and (b) in the delayed phase without obvious endoleak.
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AAA sac without obvious endoleak (Figures 1(a) and 1(b)). After the initial fluids granting, the patient remained hemodynamically stable without need for blood transfusion or any intervention.
DSA angiography showing (a) antegrade flow through the aortounilateral stent graft and femorofemoral right to left bypass without Type I or III endoleaks, (b) the SMA and Riolano's collateral arch (c) infusion from the microcatheter which revealed blush from an "unusual" collateral, and (d) exclusion of endoleak (black arrow) using OnyxR with protection of vital collaterals (white arrow).
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Then, an aortounilateral graft (Talent, Medtronic) was installed in the right side and a femorofemoral bypass was executed from the right common femoral artery (CFA) to the left CFA using a 6 mm e-PTFE standard wall graft. The left common iliac artery (CIA) was blocked with a plug (see Figure 2(a)). After exclusion of a Type I or III endoleak (Figure 2(a)), we followed the superior mesenteric artery (SMA) and Riolano's arch (Figure 2(b)) to visualize the inferior mesenteric artery (IMA). The angiography that followed revealed an uncommon inverted collateral branch of the IMA which was feeding the sack and caused the rupture (Figure 2(c)). We embolized it using Onyx with good result and rescue of the other vital branches (Figure 2(d)).
Drainage of hematoma under CT guidance: (a) guide trocar inserted from lumbar (b) pigtail in place drains the hematoma; (c) immediate shrinkage of hematoma cavity; (d) left iliopsoas muscle with almost normal shape (upward arrow) and reduction of remaining aneurysm sac (downward arrow) in a follow-up CT imaging four months later.
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We inserted an 8 Fr locking pigtail catheter which evacuated the cavity immediately and remained for a month until the inflammation markers had fallen and the patient became stable without fever for two days (Figures 3(a)-3(c)). CT follow-up after four months showed shrinkage of both the sac and the hematoma (Figure 3(d)).