A young man presented with pulsatile swelling of the left pinna, with reddish brown skin discoloration.
He was diagnosed to have arteriovenous malformation and was taken up for  DSA and embolisation under local anesthesia.
DSA showed a high flow AVM with a large fistula. This was then catheterized with a Progreat 2.7 Fr microcatheter, considering the large size of the feeder and the macro-fistula. Embolisation was done with 20% nBCA-lipiodol mixture. Complete exclusion of the AVM was achieved.
There was subsequently blackening of the skin of the earlobe, which necrosed and fell off, it was conservatively managed, with normal smooth skin formation over the ulcerated area and near comparable appearance with the opposite pinna. However there was some redness present in the mid-pinna, which was not explained, and was left behind. This patient is now in follow up since three years.

A middle aged male with Lymphoma had undergone CT guided retroperitoneal lymph node biopsy.
Subsequently, after 4 hours he started complaining of severe radiating pain.
A CT was done which showed a pseudoaneurysm from the lumbar artery wiht a large psoas hematoma.
Immediately the patient was taken up for DSA which showed the pseudoaneurysm from the right first lumbar artery branch.
This was embolised using nBCA-lipiodol mixture and microcoil.
Subsequently, the hematoma resolved.

Flow diverters are used for many purposes:
1. Giant aneurysms
2. Dissecting aneurysms
3. Blister aneuryms
4. Fusiform aneuryms
5. Wide neck aneurysms

While many cases have contrast stasis immediately after flow diverter placement, actual aneurysm 'closure' and arterial wall remodeling  and endothelialisation takes place after a variable time-frame.
We came across a case of subarachnoid hemorrhage, wherein DSA showed a irregular mild fusiform dilatation of the supraclinoid ICA with multiple blister like outpouchings.

Single PED Flex was placed, with no immediate change in appearance.
Patient developed vasospasm features, and was taken up for intra-arterial spasmolysis, during which the DSA showed smoothing of the arterial contour and non-visualisation of the blisters.

It can be said with guarantee that endothelialisation has not taken place, and the smoothening is due to the flow diversion effect. Probably the vasospasm also has added to the appearance.

DIAGNOSTIC DSA





FLOW DIVERTER



NEXT MORNING CHECK ANGIOGRAM

24 years male patient with post traumatic hemorrhage-was comatose for 24 days, then recovered.
DSA was done as there was a left parasellar mass, and showed a dissecting aneurysm.
Pipeline Flex was inserted on elective basis.
No contrast stasis was seen in control angiogram, however CT done after few hours showed complete thrombosis
Patient is doing well and is on follow up.
Check DSA is planed after 6 months.







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