title: Percutaneous trans-hepatic gelfoam-cyanoacrylate glue embolization for ruptured post-traumatic hepatic artery pseudo-aneurysm in a limited-resource scenario.
abstract: BACKGROUND
  We present our experience with an indigenously designed percutaneous trans-hepatic ultrasound-guided Gelfoam sponge cum cyanoacrylate glue-based embolization technique for the treatment of a ruptured post-traumatic aneurysm of a branch of the right hepatic artery (RHA) as a 'life-saving emergent' procedure in a patient unfit for surgery or endovascular intervention and in a 'limited-resource' scenario (non-availability of Digital Subtraction Angiography Suite).
  
  
  METHODS
  An 8-year-old boy sustained crush-injury to the right lobe of the liver in a road-traffic accident and presented in shock. After resuscitation, a laparotomy and repair of the right lobe of liver were undertaken. Bleeding restarted 1 week after the surgery; the patient bled from drain site and went into shock. Exploration was not advisable in view of poor general condition, and sepsis, deranged coagulation and parental reluctance in view of guarded prognosis. Multi-detector Computed Tomography Angiography was performed after resuscitation which revealed active bleed from a ruptured pseudo-aneurysm of a branch of RHA.
  
  
  METHODS
  The bleeding artery was identified with duplex sonography and was embolized by the percutaneous trans-hepatic route proximal to the site of pseudo-aneurysm and rupture by a two-step process. Initially, a thin paste/'slurry' made of powdered gelfoam dissolved in sterile saline was injected into the bleeding vessel. Subsequently, the area was sealed by injecting 1.0 ml of N-butyl-2-cyanoacrylate glue. Hemostasis was confirmed by Color and Power Doppler Ultrasonography both post-procedure and after 48 h. With supportive management, the patient showed a rapid recovery and was discharged after 2 weeks. He continues to be well at 3-month follow-up.
  
  
  CONCLUSIONS
  The technique was effective in controlling hemostasis and life-saving in our set-up.
authors.affiliation: Department of Radiodiagnosis, King George's Medical University, Erstwhile King George's Medical College, Lucknow 226003, India.
authors.forename: Manoj
authors.initials: M
authors.lastname: Kumar
authors.forename: Prabudh
authors.initials: P
authors.lastname: Goel
authors.forename: J D
authors.initials: JD
authors.lastname: Rawat
authors.forename: Shweta
authors.initials: S
authors.lastname: Kumari
authors.forename: S N
authors.initials: SN
authors.lastname: Shankhwar
authors.forename: S N
authors.initials: SN
authors.lastname: Kureel
mesh_terms: D017541:Aneurysm, False / Q000628:therapy*; D017542:Aneurysm, Ruptured / Q000628:therapy*; D002648:Child; D003487:Cyanoacrylates / Q000627:therapeutic use*; D004621:Embolization, Therapeutic / Q000379:methods*; D005781:Gelatin Sponge, Absorbable / Q000627:therapeutic use*; D006490:Hemostatics / Q000627:therapeutic use*; D006499:Hepatic Artery / Q000000981:diagnostic imaging / Q000293:injuries*; D006801:Humans; D008099:Liver / Q000293:injuries*; D008297:Male; D014057:Tomography, X-Ray Computed; D018608:Ultrasonography, Doppler
chemical_list: D003487:Cyanoacrylates; D006490:Hemostatics