Type IA endoleaks associated with endovascular aortic aneurysm repair are typically treated with endovascular adjuncts. Technical failure results when such maneuvers are unsuccessful, and endograft removal may, unfortunately, become necessary. The novel management of a recalcitrant type IA endoleak using the artificial embolization device, Onyx (Micro Therapeutics Inc, Irvine, Calif) is presented for the case of a nonagenarian with prohibitive surgical risk after conventional techniques had failed.

Hemorrhagic cholecystitis is a potentially deadly and difficult to recognize entity. It is associated with cystic artery pseudoaneurysm and is usually seen in the setting of acute calculous cholecystitis. We report two cases of hemorrhagic cholecystitis with arteriographic findings of cystic artery pseudoaneurysms that were successfully embolized using microcoils, facilitating subsequent cholecystectomy. Both cases had unusual presentations of gallbladder rupture with hemoperitoneum, the latter of which was atypical occurring in the absence of gallstones. We believe when hemorrhagic cholecystitis is suspected, a two-step therapeutic approach should be employed with embolization of the bleeding cystic artery followed by cholecystectomy. A comprehensive literature review and discussion of hemorrhagic cholecystitis will be provided. CASE REPORT Case Report 1: Calculous hemorrhagic cholecystitis (typical)A 74-year-old white male with a history of atrial fibrillation on coumadin was referred from an outside hospital with a 5-day history of abdominal pain, nausea, and vomiting, followed by 2 days of severe right upper quadrant pain. He experienced no hematemesis or melena. His physical examination was significant for abdominal tenderness, particularly in the right upper quadrant and epigastric region. A hepatic panel revealed markedly elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin. The patient's coagulation studies were only mildly elevated. Of greater clinical concern, however, laboratory values showed a significant drop in hemoglobin at 6.4 g/dL (normal: 14-17.4 g/dL) compared to 12.3 g/dL at the outside hospital.A CT of the abdomen and pelvis performed at the outside hospital revealed right upper quadrant hematoma and hemoperitoneum around the liver and spleen. In addition, a 1cm gallstone was impacted at the gallbladder neck with suggestion of erosion of the gallbladder wall. An ultrasound CASE REPORT