PMC6804465_01
Computed tomography angiography axial image through the aneurysm with calcified walls (white arrow), large mural thrombus with slightly non-homogeneous attenuation (a) and a contrast filled lumen (b). Note free pericolic and perijejunal fluid (single and double white arrowhead respectively).
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A focused assessment with sonography for trauma (FAST) scan was negative, but contrast enhanced CT revealed free fluid, attenuating at Hounsfield units indicating blood, in the abdominal cavity and a ruptured, extremely large (100 x 130 x 200 mm) aneurysm arising from a branch from the coeliac trunk and primarily localised in the right side of the abdomen (Fig. 1).
Selective angiography in the coeliac trunk showing the left gastric artery with a minor spherical aneurysm (c) also feeding left hepatic artery (white arrow). The splenic artery is normal (white arrowhead). The inflow to the aneurysm (b) comes from the hepatic artery (black arrow). Branches to the right hepatic artery just before the inlet to the aneurysm, seem to be collaterals (black arrowhead).
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A smaller aneurysm (15 mm) (Fig. 2) of the left gastric artery was also present, but otherwise all other vessels were non-aneurysmal.
Three dimensional angiogram shows the giant aneurysm located in front of aorta. Calcification in the aneurysm wall outlines the contour of the sack (white arrowheads). Note mural thrombus in the upper ventral part (a) and a minor contrast filled lumen in the lower dorsal part of the aneurysm (b).
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Calcification in the aneurysm wall and mural thrombus (Fig. 3) in the large aneurysm suggested a slow growing true aneurysm.
Pre-embolisation angiogram with selective catheterisation with a 4 F catheter (Navicross, Terumo) (black arrow) of one of the outflow branches from the aneurysm with connection to the right hepatic artery (black arrowhead).
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Initially embolisation of three distal flow contributing arteries (Fig. 4) was performed with micro coils (Nester no. 3, size range 18-7-2 to 18-14-10 and Tornado no. 8 size range 18-5/2 to 18-10/4, Cook Medical, Bloomington, IN, USA) followed by macro coils (Nester no. 3, size range 35-14-4 to 35-14-6, Cook Medical) in the proximal supplying artery.
Selective post-embolisation angiogram in the coeliac trunk. The outflow arteries (black arrow) and the inflow artery (black arrowhead) were embolised using microcoils. Flow is preserved in the left hepatic (white arrow) and splenic artery (white arrowhead), to some degree blurred by artefact from gastric peristalsis.
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Angiography immediately after embolisation showed no flow in the aneurysm (Fig. 5).