In the renal circulation the vessels are end arteries and so it is usually sufficient to block the branch feeding the see more bleeding site. In the liver a rich collateral circulation

means that this approach may not be ideal and embolising the vessels on both sides of the bleeding, so called ‘closing the front and back door!’ might be better. This can Fedratinib sometimes be achieved by passing beyond the bleeding point with the microcatheter and deploying a coil, then withdrawing proximal to the haemorrhage and deploying a second coil. Table 1 Embolic materials TEMPORARY PERMANENT GELFOAM SLURRY COILS OR MICROCOILS (OFTEN FIBRED TO SPEED THE THROMBOTIC EFFECT) AUTOLOGOUS CLOT PARTICLES   OCCLUSION DEVICES   GLUE   ONYX If it proves impossible to obtain a superselective position close to the bleeding site then the choice is between proximal vessel embolisation with an occlusion device or larger coil to decrease haemostatic pressure at the bleeding site (good for splenic bleeding but prevents a second embolisation attempt if bleeding recurs) EPZ015938 in vivo or the use of particles or

gel foam to pass into the distal circulation, blocking smaller vessels. Use of particles runs a higher risk of ischaemic damage than superselective coil embolisation and therefore a temporary agent is often preferable. If using particles then larger sizes (500 μm diameter) are preferred as this leaves the capillary bed the potential to revascularise later from collaterals. Onyx (ev3, Irvine, California,

USA) is a polymer dissolved in dimethyl sulphoxide (DMS0) which is ZD1839 purchase delivered as a liquid but becomes solid when in contact with blood. It takes time to prepare and deliver and is therefore less useful in the acute situation, but in the context of prevention of delayed haemorrhage it can be extremely useful as it can be deployed from a microcatheter proximal to a target. From the point of injection it will follow even tiny vessels distally to fill a pseudo aneurysm and continue on beyond, shutting both front and back doors without necessitating manipulation through the lesion with a microcatheter and wire. Figure 2 demonstrates embolisation of multiple hepatic artery aneurysms with onyx. Figure 2 a) A patient with vasculitic hepatic artery aneurysms presented following minor trauma. Axial contrast enhanced CT demonstrates haematoma around a pseudoaneurysm (arrow) indicating that this is the likely cause of recent haemodynamic instability. b) 3D volume rendered reconstruction demonstrates 3 aneurysms arising from a branch of the left hepatic artery (arrows). The right hepatic artery arose from the SMA. c) Selective arteriogram of the coeliac axis with standard catheter after 2 aneurysms had been embolised with onyx (ev3, Irvine, CA, USA). The cast of the onyx is demonstrated, and some distal embolisation (arrow) of onyx. d) A microcatheter is demonstrated within the final bleeding aneurysm (arrow).