Hemodynamically unstable ruptured left gastric artery aneurysm due to segmental arterial mediolysis treated by endovascular embolization with resuscitative endovascular balloon occlusion of the aorta

A Japanese male patient in his 60s taking anticoagulant medication for chronic atrial fibrillation presented to a hospital with acute abdominal pain. The intra-abdominal hematoma was found on non-contrast-enhanced computed tomography (CECT). Subsequently, he was transferred to our hospital. His blood pressure and pulse rate were 120/80 mmHg and 150 bpm, respectively. Upon arrival, arterial blood gas analysis showed elevated lactic acid (60 mg/dL). He was promptly intubated and transfused with red blood cells. CECT was performed under partial occlusion of the aorta with resuscitative endovascular balloon occlusion of the aorta (p-REBOA) and showed massive extravascular leakage of contrast medium from the left gastric artery. Moreover, angiography of the celiac artery under REBOA showed beaded vascular irregularities, indicating segmental arterial mediolysis as an underlying condition, and extravasation from the left gastric artery. Coil embolization for the left gastric artery effectively halted the extravasation. During the embolization, we adjusted the intensity of the occlusion to maintain a proximal systolic blood pressure of - 90 mmHg. For hemodynamically unstable patients due to intra-abdominal hemorrhage, a p-REBOA may be useful to perform CT or angioembolization safely.