A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).
A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.