Sent 02/23/2026 12:10:21, Page - 46

FRASER HEALTH AUTHORITY Signed
Royal Columbian Hospital

expected location of the GDA. A branch of the GDA is notably enlarged, and exactly at the site where the
endoscopic clips are. This then became our target for embolization.

Relatively easily we were able to advance a Progreat microcatheter with a Synchro wire to the point of the
endoscopic clips and beyond this into the GDA proper. Multiple angiograms were performed of this presumed
superior pancreaticoduodenal artery and the GDA proper. A combination of a Medtronic MVP plug (1-3 mm),
and 4mm x 15 cm Concerto coil were deployed with satisfactory occlusion of this vessel. During this process,
the MVP plug actually retracted further than | had expected and it was felt necessary as much as possible to
reexamine the GDA from an antegrade approach.

With the aid of a Contour catheter relatively easily we were able to cannulize the high grade stenosis in the
celiac axis.

With the Progreat microcatheter we advanced out toward GDA both proximal and distal to the area that we had
coiled. Angiograms were then performed in multiple degrees of obliquity to ensure that there was no filling of
this vessel that could result in further Gl hemorrhage. This did not appear to be apparent and | elected to
terminate the procedure.

A right groin angiogram was performed. A 6-French Angio-Seal device was deployed with good hemostasis,
and preservation of distal pulses.

The procedure was well tolerated.

FINDINGS:

Angiography was performed of the celiac artery, common hepatic artery, splenic artery, superior mesenteric
artery, inferior and superior branches of the pancreaticoduodenal arcade, and right external iliac/common
femoral arteries.

The patient has aberrant anatomy related to high grade stenosis at the origin of the celiac axis. As a result,
there is hypertrophy of the SMA with additional hypertrophy of the pancreaticoduodenal arteries and GDA.

At no point in the procedure were we able to see pseudoaneurysm or active bleeding.

The completion angiography shows that the intended vessel which was likely the vessel seen on endoscopy, is
satisfactorily occluded.

IMPRESSION:

Technically challenging embolization for upper GI hemorrhage in the context of aberrant celiac and SMA
arterial anatomy. The presumed etiology is marked hypertrophy of a superior pancreaticoduodenal artery and
this vessel has been successfully embolized.

Although there is quite a bit of collateralization evident, the patient will need to be monitored for any signs of
duodenal, hepatic or splenic ischemia.

Dictated By: Andrew K Best MD, INC.
«Electronically signed by Andrew K Best MD, INC. in OV>

RC03030788 - HOLAND,MARK THOMAS
TO: ~ Additional Copy

Fax:

Medical Imaging Report #: 0803-3762 2of3

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