Peripancreatic pseudoaneurysms: a management-based classification system

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

Perihepatic caudate lobe haematoma originating from a pancreatic pseudoaneurysm: a diagnostic dilemma

Despite advances in diagnostic imaging and interventional techniques, pancreatic pseudoaneurysms remain a life-threatening complication of pancreatitis. Presentation varies among patients and may include intra-abdominal, retroperitoneal, or gastrointestinal bleeding and bleeding into the pancreatic or common bile duct. We present a unique case of a 74-year-old man with a history of heavy alcohol consumption who presented with a haematoma surrounding the caudate lobe of the liver. Initially, alcoholic cirrhosis and a ruptured hepatocellular carcinoma were suspected. Therefore, transarterial embolization (TAE) of the caudate branch of the hepatic artery was performed. However, 3 months later, the patient experienced abdominal pain with a lesser sac haematoma and a seemingly interconnected pancreatic cyst. One month later, a pseudoaneurysm appeared in the pancreatic cyst. TAE was successfully performed for the pseudoaneurysm, and the patient showed no signs of recurrence during the 1-year follow-up.

Post-traumatic jejunal branch of superior mesenteric artery pseudoaneurysm in paediatrics: a compelling case report highlighting early diagnosis and successful endovascular embolization

Introduction and importance

This manuscript underscores the critical significance of prompt diagnosis and intervention in cases of post-traumatic gastroduodenal artery pseudoaneurysms. Such occurrences, particularly in the paediatric population, are rare but potentially life-threatening complications following abdominal trauma, necessitating heightened clinical awareness. Despite their rarity, the devastating consequences of delayed recognition and management emphasize the necessity for advanced imaging modalities and individualized treatment strategies.

Case presentation

A 17-year-old male presented with severe epigastric pain following a football fall. Despite initial stability, persistent symptoms prompted further investigation. Conventional screening methods proved inconclusive, leading to a contrast-enhanced computed tomography (CT) scan that revealed a jejunal branch of superior mesenteric artery (SMA) pseudoaneurysm. The subsequent fluoroscopy-guided angiography and successful embolization using glue exemplify the importance of timely intervention in such cases.

Conclusion

This case highlights the importance of early recognition and appropriate intervention in post-traumatic jejunal branch of SMA pseudoaneurysms. The successful outcome achieved through endovascular embolization underscores the necessity for vigilant monitoring and tailored management strategies in similar clinical scenarios.

Embolization using both n-butyl cyanoacrylate and gelatin sponges in a patient with a posterior superior pancreaticoduodenal artery pseudoaneurysm that ruptured and bled into the drain tube

Transcatheter arterial embolization is a useful treatment for postpancreatectomy hemorrhage, a severe complication of pancreatic surgery. N-butyl cyanoacrylate is a liquid and permanent embolic material that is widely used in transcatheter arterial embolization. However, its use can lead to the adherence of the catheter to the vessel wall and occlusion of the catheter lumen. This case report presents the case of a 63-year-old man with a postpancreatectomy posterior superior pancreaticoduodenal artery pseudoaneurysm, which ruptured and bled into a drain tube. The patient underwent transcatheter arterial embolization using N-butyl cyanoacrylate and a gelatin sponge without the incidence of adherence or occlusion of the drain tube. Gelatin sponge, which was used as a temporary embolic material, was effective in preventing the drain tube from adhering and occluding.

Current Endovascular Management of Arterial Complications After Pediatric Liver Transplantation in a Tertiary Center

PURPOSE

Pediatric liver transplant surgery is burdened by arterial complications whose endovascular treatment is not standardized. We report the outcomes of a cohort of pediatric recipients with hepatic artery complications treated by endoluminal procedures.

MATERIALS AND METHODS

From December 2019 to December 2022, consecutive transplanted pediatric patients who underwent endovascular treatment of hepatic artery complications were reviewed. The analysis included: type of complication (occlusion, stenosis, pseudoaneurysm); onset (acute =  < 15 days, subacute = 15-90 days, late =  > 90 days); endovascular technique (angioplasty, stenting); complications and outcomes. Technical success was defined as the opacification of the hepatic artery at the final angiogram with < 50% residual stenosis and no pseudoaneurysms. Clinical success was defined by graft's and patient's survival.

RESULTS

Seventeen patients (8 males; median age 33 months, IQR 9-103) underwent 21 hepatic arteriography procedures for predominantly acute or subacute occlusions (n = 7) or stenosis (n = 11) with concurrent pseudoaneurysms (n = 4). Primary and secondary technical success was achieved in 13/18 and 3/3 procedures, respectively, with overall technical success of 76%. Angioplasty alone was successful in 5/21 procedures; stent-retriever thrombectomy was performed in one occlusion with thrombosis; stenting was required in 9/17 (53%) patients. Clinical success was obtained in 14/17 (82%) patients with hepatic artery patency after a median of 367 days (IQR 114.5-500). Clinical failure occurred in 3 permanent occlusions, with 2 deaths and 1 re-transplantation. Procedure-related complications included minor events in 3/17 (18%) patients and 1/17 (6%) death.

CONCLUSION

In liver transplanted children with hepatic artery complications, endovascular treatment may provide clinical success, with stenting often required in acute and subacute conditions.

LEVEL OF EVIDENCE

Level 4.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.

Lumbar Artery Pseudoaneurysms Presenting as a Novel Complication of Severe, Necrotizing Pancreatitis

Splanchnic artery pseudoaneurysms are a known complication of necrotizing pancreatitis. Lumbar artery pseudoaneurysms are rare and usually associated with trauma, renal biopsy, or spinal procedures. We present a rare case of lumbar artery pseudoaneurysms as a complication of necrotizing pancreatitis. A 55-year-old man initially presented with necrotizing biliary pancreatitis complicated by peripancreatic necrotic fluid collections and walled-off necrosis requiring multiple endoscopic ultrasound-guided necrosectomies. Inferoposterior extension of collections to the retroperitoneum caused lumbar artery pseudoaneurysms, leading to hemorrhagic shock from retroperitoneal and intraperitoneal hemorrhages.

Gastrointestinal Bleeding Due to the Rupture of Splenic Artery Caused by Pancreatic Carcinoma: A Case Requiring Repeated Transcatheter Arterial Embolization in a Short Period of Time

In this report, we present a case of gastrointestinal bleeding due to splenic artery rupture, which required repeated transcatheter arterial embolization (TAE) within a short period of time. A 75-year-old man with pancreatic carcinoma was transported to our hospital with active hematemesis and vital signs consistent with shock. Contrast-enhanced computed tomography images showed a pancreatic tumor that had caused a pseudoaneurysm of the splenic artery to rupture. The pseudoaneurysm was embolized using only an N-butyl-2-cyanoacrylate (NBCA) and lipiodol mixture. However, hematemesis with signs of shock recurred 13 h later, and angiography showed rebleeding from the origin of the splenic artery. The splenic artery was subsequently embolized using an NBCA and lipiodol mixture. Repeated TAE finally controlled the hemorrhage; however, asymptomatic splenic infarction and hepatic infarction occurred due to nontarget embolization.

Acute pancreatitis complicated with peripancreatic pseudoaneurysm and subsequent intra-abdominal hematoma

Acute pancreatitis is a common disease, but peripancreatic pseudoaneurysm is rare. Bleeding from peripancreatic pseudoaneurysm without connection to GI tract may delay treatment and cause mortality. Being aware of this rare complication after acute pancreatitis is important.

N-butyl-2-cyanoacrylate Packing of a Gastroduodenal Artery Pseudoaneurysm due to Distal Pancreatectomy After Subtotal Esophagectomy

We describe the successful n-butyl cyanoacrylate (NBCA) packing of a large gastroduodenal artery pseudoaneurysm after distal pancreatectomy in a patient with a history of subtotal esophagectomy and gastric tube reconstruction. The pseudoaneurysm was considered to be caused by direct injury to the gastroduodenal artery (GDA). However, embolization of the GDA was not possible in this case because due to prior esophageal surgery, the main blood vessel supplying the gastric tube was the right epigastric artery from the GDA. Packing a pseudoaneurysm with NBCA is a treatment option when preservation of the parent artery is required.

The role of repeated imaging in detecting complications in the post-operative period following pancreaticoduodenectomy: Serial CT imaging post-pancreaticoduodenectomy

BACKGROUND

Post-pancreaticoduodenectomy haemorrhage is a potentially life-threatening complication. Delay in the detection and subsequent management of complications contribute significantly to post-operative mortality and morbidity associated with pancreaticoduodenectomy.

METHODS

All patients undergoing pancreaticoduodenectomy at an Australian-based tertiary referral center between 2017 and 2022 were reviewed retrospectively. We identified those patients who suffered a post-pancreaticoduodenectomy haemorrhage and further analysed those patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeated CT imaging performed within 24 h of their previous CT scan.

RESULTS

A total of 232 pancreaticoduodenectomies were identified for analysis during the study period, of which 23 patients (9.9%) suffered a post-pancreaticoduodenectomy haemorrhage. We present four patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeat CT scan in the setting of a recent (within 24 h) CT scan which showed no evidence of active haemorrhage or pseudoaneurysm formation. All patients received prompt and definitive endovascular management through stent insertion or coil embolization resulting in successful cessation of bleeding. Three patients made an uncomplicated recovery thereafter. Unfortunately, one patient died as a complication of the bleed despite early and definitive endovascular intervention.

CONCLUSION

Our study highlights the importance of having a low threshold for repeated CT imaging in the post-pancreaticoduodenectomy setting, particularly when there remains a high index of suspicion clinically for a post-operative complication, even in the context of previous benign imaging. Given the complexity of pancreaticoduodenectomy, we believe early detection with liberal imaging allows the best chance at successfully managing the morbidity and mortality associated in the post-pancreaticoduodenectomy setting.

Ruptured Gastroduodenal Artery Pseudoaneurysms as a Complication of Pancreatitis

Visceral artery pseudoaneurysms is a known vascular complication of pancreatitis that can lead to life-threatening hemorrhages with a high mortality rate if left untreated. We present a case of ruptured gastroduodenal artery pseudoaneurysm in a 68-year-old male with acute pancreatitis presenting with fatal gastrointestinal and retroperitoneal bleeding that was successfully managed with endovascular coil embolization of the involved vasculature. Patients with hemorrhagic pancreatitis or those presenting with unexplained retroperitoneal or gastrointestinal bleeding in the setting of pancreatitis with an unexplained drop in hematocrit or sudden expansion of pancreatic fluid collection should be screened in a timely manner for pseudoaneurysm using CT angiogram of the abdomen, which is the gold standard imaging modality to identify pseudoaneurysms. Once pseudoaneurysm is diagnosed, it should be treated immediately. Endovascular treatment options are now favored over surgical options in most cases.

Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery

Superior mesenteric arteries pseudoaneurysms are rare entity, usually asymptomatic but they can appear as an abdominal pain, throbbing mass or shock, being jaundice an exceptional type of presentation. Diagnosis is made by imaging tests (CT) and currently the endovascular approach is the most widespread, reserving open surgery in selected cases. We describe the case of a patient with an 86mm SMA pseudoaneurysm with compression of the extrahepatic bile duct.

Intratumoral Air Bubbles and Hematemesis as Predictors of Pseudoaneurysm Rupture in Unresected Pancreatic Cancer

Objective Pseudoaneurysm rupture associated with unresected pancreatic cancer can cause rare but fatal hemobilia and gastrointestinal bleeding. This study aimed to identify factors predicting pseudoaneurysm rupture. Methods We conducted a single-center case-control study of unresected pancreatic cancer patients treated at Shizuoka General Hospital between January 2011 and July 2020 using a retrospective cancer registry database. Included in the study were 611 consecutive patients with unresected pancreatic cancer, of whom 55 developed overt upper gastrointestinal bleeding or hemobilia. Twenty patients were excluded, as they had not undergone contrast-enhanced computed tomography (CT) or angiography. Patients were classified into pseudoaneurysm and non-pseudoaneurysm groups. One patient with arterial bleeding but without obvious pseudoaneurysm was included in the pseudoaneurysm group. Factors predicting pseudoaneurysm rupture at the onset of overt gastrointestinal bleeding were investigated using a logistic regression analysis. CT findings revealing air bubbles inside the tumor were described as intratumoral air bubbles. Results Thirty-five patients were included (15 in the pseudoaneurysm group, 20 in the non-pseudoaneurysm group). In the multivariate analysis, intratumoral air bubbles [odds ratio (OR), 12.9; 95% confidence interval (CI), 2.14-77.9; p=0.005] and hematemesis (OR, 6.30; 95% CI, 1.03-38.6; p=0.047) were independent predictors of pseudoaneurysm rupture. In addition, patients who experienced successful hemostasis and were re-administered chemotherapy survived more than six months. Conclusions This study reveals that intratumoral air bubbles and hematemesis may predict pseudoaneurysm rupture at the onset of overt gastrointestinal bleeding. For patients presenting these findings, an examination with conventional or CT angiography may lead to an early diagnosis and improve the patient prognosis.

Vascular complications of pancreatitis

More than 200000 hospital admissions happen per year for acute pancreatitis and more than 50000 for chronic pancreatitis in the United States of America. Necrotizing pancreatitis accounts for 20%-30% of the cases. One-quarter of the patients with pancreatitis develop vascular complications, which carries a high mortality. This mini-review will address these complications that can help primary care physicians and hospitalists in managing their patients effectively.

Placement of a flow diverter-like stent together with coil embolisation for treatment of pancreatic pseudoaneurysm involving the origin of the gastroduodenal artery

A pancreatic pseudoaneurysm can occur following an attack of pancreatitis. This occurs due to erosion of the pancreatic or peripancreatic artery by the pancreatic enzyme-rich pancreatic secretion pseudocyst. If left untreated, it may cause massive and even fatal haemorrhage. Interventional radiology with coil embolisation of the pseudoaneurysm is the standard of care in such cases. We describe a patient who developed a pseudoaneurysm involving the origin of the gastroduodenal artery (GDA). This was successfully managed by coil embolisation of the pseudoaneurysm along with placement of a flow diverter-like stent in the common hepatic artery across the origin of the GDA leading to exclusion of the diseased segment.

Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents

BACKGROUND AND AIMS

Visceral artery pseudoaneurysm (PSA) in necrotizing pancreatitis (NP) is associated with significant morbidity and mortality. This study aimed to evaluate the incidence, clinical presentation, management, and outcomes of PSA in NP.

METHODS

All NP patients managed at our institution between 2010 and 2020 were retrospectively reviewed from a prospectively maintained database for PSA. Demographics, clinical presentation, method of diagnosis, management, and outcomes were collected.

RESULTS

Thirty-nine of 607 patients (6.4%) with NP had a confirmed diagnosis of PSA. Demographics, presence of infected necrosis, development of organ failure(s), and severity of disease were similar between PSA and no PSA. Endoscopic and percutaneous drainages for walled-off necrosis (WON) were more common in the PSA group. Seven patients developed PSA without requiring any intervention for WON, and 17 patients (43.6%) had lumen-apposing metal stents (LAMSs) placed before PSA diagnosis. The time from NP diagnosis to PSA diagnosis was shorter in these patients (n = 17) compared with the remaining patients (n=22; 47 days [interquartile range {IQR}: 17-85] vs 109 days [IQR: 61-180.5, P=0.009]). In addition, 7 of 11 patients (63.6%) with early PSA (defined by <3 weeks from index cystgastrostomy/cystduodenostomy) had an indwelling LAMS at the time of the PSA diagnosis. Seventy-seven percent of patients presented with anemia, 74.3% with GI bleeding, and 30% with hemorrhagic shock. CT was diagnostic for PSA in 83.9% with a false-negative rate of 16.1%. Splenic (50%) and gastroduodenal (28%) arteries were the most common arteries involved by PSA. Angiography and embolization for PSA were successful in 33 of 35 patients. In-hospital mortality was observed in 9 patients (23.1%).

CONCLUSIONS

Although visceral artery PSA affects a small percentage of NP patients, it is associated with significant morbidity and mortality. In addition, bleeding from PSA induced by erosion of LAMSs may occur in the first 2 weeks, prompting individualization of removal intervals.

Emergency Pancreatoduodenectomy: A Non-Trauma Center Case Series

(1) Background: Emergency pancreatoduodenectomy (EPD) is a rare procedure, especially in non-trauma centers. Pancreatoduodenectomy is a challenging intervention, that has even higher risks in emergency settings. However, EPD can be a life-saving procedure in selected cases. (2) Methods: Our study is a single-center prospective consecutive case series, on patients that underwent emergency pancreatoduodenectomies in our surgical department between January 2014 to May 2021. (3) Results: In the 7-year period, 4 cases were operated in emergency settings, out of the 615 patients who underwent PD (0.65%). All patients were male, with ages between 44 and 65. Uncontrollable bleeding was the indication for surgery in 3 cases, while a complex postoperative complication was the reason for surgery in one other case. In three cases, a classical Whipple procedure was performed, and only one case had a pylorus-preserving pancreatoduodenectomy. The in-hospital mortality rate was 25% and the morbidity rate was 50%; the two patients that registered complications also needed reinterventions. The patients who were discharged had a good long-term survival. (4) Conclusion: EPD is a challenging procedure, rare encountered in non-traumatic cases, that can be a life-saving intervention in well-selected cases, offering good long-term survival.

Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning

Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.

Endovascular treatment of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery as a complication of chronic pancreatitis: a case report

A pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. Prompt diagnosis and appropriate treatment are of great clinical importance. We herein present an unusual case of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery that developed as a complication of chronic pancreatitis. It was detected in a timely manner and successfully treated with minimally invasive endovascular therapy.

Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up

Purpose

To investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm.

Materials and Methods

A retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients’ surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined.

Results

In total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up.

Conclusion

Stent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.

Hepatic Artery Pseudoaneurysm Presenting as Gastrointestinal Hemorrhage

A hepatic artery pseudoaneurysm (HAP) is a rare complication of laparoscopic cholecystectomy. It can vary in its clinical presentation; however, given its severe nature, prompt assessment and management are crucial. We report a case of a 73-year-old male who underwent a laparoscopic cholecystectomy complicated by a right hepatic artery injury. This subsequently presented as a life-threatening case of upper gastrointestinal bleeding from HAP, with presumable hemobilia and septic shock from multiple liver abscesses. The diagnosis was made with computed tomography angiography (CTA) of the abdomen and pelvis followed by visceral angiography. The patient ultimately underwent a right hepatectomy for definitive treatment. The primary objective of this case is to highlight a less novel, though rare, case presentation and define a spectrum of treatment options available based on severity.

Treatment of mycotic superior mesenteric vein pseudoaneurysm via placement of covered endovascular stent

Vascular pseudoaneurysms are a rare yet life-threatening complication of untreated pancreatic pseudocysts related to their high risk of rupture and bleeding. Several studies and reports have established endovascular approaches as a successful first-line therapy in the management of arterial pancreatic pseudoaneurysms. However, no reports have been published describing endovascular repair of a venous pseudoaneurysm that developed after infection of a chronically stable pancreatic pseudocyst, most likely due to its rare occurrence. We report in this technical note the treatment of a superior mesenteric vein pseudoaneurysm that developed as a result of an infected small pancreatic pseudocyst, by radiologic placement of a covered endovascular stent.

Abdominal rebleeding after transcatheter arterial embolization for ruptured pseudoaneurysms associated with severe acute pancreatitis: a retrospective study

Introduction

Patients are at risk of abdominal rebleeding after transcatheter arterial embolization (TAE) for pancreatitis-related pseudoaneurysm, which increases the mortality rate.

Aim

This study was performed to evaluate the effects of an intestinal fistula (IF) and the anatomical location of the pseudoaneurysm on abdominal rebleeding after TAE of a ruptured pseudoaneurysm associated with severe acute pancreatitis (SAP).

Material and methods

From February 2013 to November 2019, 24 patients with SAP-related pseudoaneurysm rupture and hemorrhage in our hospital underwent TAE. All patients’ epidemiological data and related medical histories were collected and statistically analyzed. We classified the pseudoaneurysms as type I, II, and III according to their anatomical locations and as type A (without an IF) and type B (with an IF).

Results

The interventions for abdominal infection in patients with type I pseudoaneurysms were percutaneous drainage in 6 patients, endoscopic necrotic tissue removal in 5, and surgical necrotic tissue removal or enterostomy in none, with a rebleeding rate of 33.3% (3/9 patients). The interventions for abdominal infection in patients with type II pseudoaneurysms were percutaneous drainage in 7 patients, endoscopy in three, and surgery in one, with a rebleeding rate of 20.0% (2/10 patients). The interventions for abdominal infection in patients with type III pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 1, and surgery in 2, with a rebleeding rate of 80.0% (4/5 patients). There was no statistically significant difference in the types of interventions for abdominal infection among patients with type I, II, and III pseudoaneurysms (p = 0.355) or in the rate of abdominal rebleeding after TAE for type III pseudoaneurysms (p = 0.111). The interventions for abdominal infection in patients with type A pseudoaneurysms were percutaneous drainage in 13 patients, endoscopy in 6, and surgery in 1, with a rebleeding rate of 22.2% (4/18 patients) and mortality rate of 11.1% (2/18 patients). The interventions for abdominal infection in patients with type B pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 3, and surgery in 2, with a rebleeding rate of 83.3% (5/6 patients) and mortality rate of 66.7% (4/6 patients). There was no significant difference in the types of interventions for abdominal infection in patients with and without IF (p = 0.215); however, the rebleeding rate and mortality rate were significantly higher in patients with IF (p = 0.015 and 0.018, respectively).

Conclusions

IF may increase the rate of abdominal rebleeding after TAE for ruptured SAP-related pseudoaneurysms, while the anatomical location of the pseudoaneurysm may not affect the rate of rebleeding after TAE.

Visceral artery pseudoaneurysm in necrotizing pancreatitis: incidence and outcomes

Background

Visceral artery pseudoaneurysms (VA-PSA) occur in necrotizing pancreatitis; however, little is known about their natural history. This study sought to evaluate the incidence and outcomes of VA-PSA in a large cohort of patients with necrotizing pancreatitis.

Methods

Data for patients with necrotizing pancreatitis who were treated between 2005 and 2017 at Indiana University Health University Hospital and who developed a VA-PSA were reviewed to assess incidence, presentation, treatment and outcomes.

Results

Twenty-eight of 647 patients with necrotizing pancreatitis (4.3%) developed a VA-PSA between 2005 and 2017. The artery most commonly involved was the splenic artery (36%), followed by the gastroduodenal artery (24%). The most common presenting symptom was bloody drain output (32%), followed by incidental computed tomographic findings (21%). The median time from onset of necrotizing pancreatitis to diagnosis of a VA-PSA was 63.5 days (range 1-957 d). Twenty-five of the 28 patients who developed VA-PSA (89%) were successfully treated with percutaneous angioembolization. Three patients (11%) required surgery: 1 patient rebled following embolization and required operative management, and 2 underwent upfront operative management. The mortality rate attributable to hemorrhage from a VA-PSA in the setting of necrotizing pancreatitis was 14% (4 of 28 patients).

Conclusion

In this study, VA-PSA occurred in 4.3% of patients with necrotizing pancreatitis. Percutaneous angioembolization effectively treated most cases; however, mortality from VA-PSA was high (14%). A high degree of clinical suspicion remains critical for early diagnosis of this potentially fatal problem.

Duodenal Necrosis Associated with a Threatened Ruptured Gastroduodenal Artery Pseudoaneurysm Complicated by Chronic Pancreatitis: Case Report

Visceral artery pseudoaneurysm (PSA) complicated by pancreatitis is a relatively rare and potentially life-threatening condition. The formation of pancreatic PSA is mainly attributed to continuous inflammation response, which induces the enzymatic autodigestion of the adjacent artery wall. The spleen artery is the most affected vessel, and other vessels such as gastroduodenal artery (GDA) and pancreaticoduodenal artery are usually involved. The treatment options for pancreatic PSA include conservative therapy, open surgery (OS), and endovascular procedure. Currently, no broad consensus on the indications for pancreatic PSA treatment is available because of the rarity of the disease. We report an urgent case of a threatened ruptured GDA PSA with duodenal necrosis complicated by chronic pancreatitis that has been treated successfully with OS. The treatment choice, puzzles, and reflections of this case were all discussed in this paper.

Giant Splenic Artery Pseudoaneurysms: Two Case Reports and Cumulative Review of the Literature

BACKGROUND

Giant splenic artery pseudoaneurysms (GSAPs) > 5 cm are a rare clinical entity. The aim of this study was to present our experience with 2 such patients successfully treated by coil embolization and surgery and review the pertinent literature.

METHODS

A 58-year-old woman and 57-year-old man with a history of chronic pancreatitis were diagnosed with GSAP based on computed tomography (CT) angiography. The first patient had a 6-cm pseudoaneurysm, which was successfully treated with transcatheter coil embolization using a sandwich exclusion method. The second patient had two 7-cm lesions, which were successfully treated with distal pancreatectomy and splenectomy.

RESULTS

Postembolization CT angiography at 12 months showed remaining calcified pseudocyst without evidence of pseudoaneurysm in the first patient. Both patients remained well and symptom-free at 12 months.

CONCLUSIONS

Combined with the experience of the previous literature, we believe that management of GSAP should be tailored for each individual case depending on the location and number of pseudoaneurysms, the underlying etiology, and the patient's hemodynamic status. Embolization should be considered as the first-line treatment for clinically stable patients with GSAP, whereas GSAPs with a pseudocyst are best treated with surgery.

Successful treatment of visceral pseudoaneurysm after pancreatectomy using flow-diverting stent device

Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipeline™ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.

Spontaneous Resolution of Hemorrhagic Pseudocyst-Associated Pseudoaneurysm in Groove Pancreatitis

Hemorrhagic pseudocyst (HP) and pseudocyst-associated pseudoaneurysms (PPs) are complications of pseudocyst. Angiography with embolization has been advocated as the first-line intervention for HP. A 47-year-old man with groove pancreatitis combined with HP near the pancreatic head was treated conservatively. He had relapsed pancreatitis with a newly identified pseudoaneurysm; however, the pseudocyst size was reduced. Although pseudoaneurysm was identified, angiography was not performed because there was no evidence of ongoing bleeding, and he was in a stable condition. Sphincterotomy and stent insertion in the pancreatic duct was applied to prevent relapsed pancreatitis with facilitation of the flow of pancreatic juice. He has done well during the 10-month follow-up, without recurrent pancreatitis. Angiography as an initial approach in HP and PPs may need to be more selective depending on the clinical presentation of the patient. A lysed clot within the strictured pancreatic duct during the healing process has been thought to be the cause of relapsed pancreatitis, and pancreatic sphincterotomy and stent insertion should be the preferred treatment methods.

Embedment of the gastroduodenal artery stump into the jejunal serosa: A new technique aiming to prevent post-pancreatectomy hemorrhage

Post-pancreaticoduodenectomy hemorrhage has an estimated incidence of 5% and a mortality rate of 11-38%. Vascular erosion resulting from pancreatic leak and skeletonization of the arterial wall during pancreatic mobilization may be the two possible mechanisms responsible for this complication, which most commonly affects the gastroduodenal artery stump. A novel technique of wrapping up the gastroduodenal artery stump into the jejunal serosa to decrease postoperative hemorrhage is presented.

Pancreatic Pseudoaneurysm from a Gastroduodenal Artery

Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst. However, it may happen after pancreatic or gastric bypass surgery or trauma. It may lead to fatal complications if left untreated. Herein, we report a unique case of pseudoaneurysm from a gastroduodenal artery in a patient with recurrent episodes of acute pancreatitis, which was managed successfully with coil embolization.

Management of post-pancreatectomy haemorrhage using resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Delayed massive post-pancreatectomy haemorrhage (PPH) is a highly lethal complication after pancreatectomy. Angiographic procedures have led to improved outcomes in the management of these patients. In the setting of an acute haemorrhage, laparotomy and packing are often required to help stablise the patient. However, re-operative surgery in the post-pancreatectomy setting is technically challenging.

METHODS

A novel strategy of incorporating the resuscitative endovascular balloon occlusion of the aorta (REBOA) is described.

RESULTS

Two patients where the specific application of this technique uses the REBOA were described.

CONCLUSION

The REBOA serves as a useful adjunct in haemorrhage control and haemodynamic stablisation to allow successful management of delayed massive PPH.

Arterial Pseudoaneurysm within a Pancreatic Pseudocyst

The formation of pancreatic pseudocysts and (pseudo-)aneurysms of intestinal vessels are rare but life-threatening complications in acute and chronic pancreatitis. Here we report the rare case of a patient suffering from chronic pancreatitis with an arterial pseudoaneurysm within a pancreatic pseudocyst and present its successful therapeutic management by angioembolization to prevent critical bleeding. A 67-year-old male with a history of chronic pancreatitis presented with severe acute abdominal pain and vomiting to the emergency department. Seven weeks prior to the present admission, a CT scan had displayed a pancreatic pseudocyst with a maximum diameter of 53 mm. A laboratory examination revealed an elevated white blood cell count (15.40 × 103/μL), as well as elevated serum lipase (191 U/L), bilirubin (1.48 mg/dL), and blood glucose (353 mg/dL) levels. Sonographically, the previously described pancreatic pseudocyst revealed a slightly increased maximum diameter of 65 mm and an inhomogeneous echo of the cystic content. A contrast-enhanced CT scan showed a further increase in maximum diameter to 70 mm of the known pseudocyst. Inside the pseudocyst, a pseudoaneurysm originating from the splenic artery with a maximum diameter of 41 mm was visualized. After interdisciplinary consultation, prophylactic coil embolization of the splenic artery was immediately performed. The pseudoaneurysm was shut off from blood supply by back-door/front-door occlusion employing 27 coils, resulting in complete exclusion of the pseudoaneurysm from the circulation. Pseudoaneurysms are a rare complication of acute and chronic pancreatitis which has been shown to be efficiently treated by coil embolization.

A Case of Pancreatic Pseudocyst Complicated by Pseudoaneurysm

Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Overtime, this encapsulated enzyme-rich fluid collection may erode into surrounding vasculature and result in the formation of a pseudoaneurysm. Pseudoaneurysms can rupture into the gastrointestinal tract and present as upper, lower, and biliary bleeding. Evaluation of pancreatic pseudocysts involves computed tomography imaging or magnetic resonance imaging for both identification and monitoring. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) can be done to further visualize the lesion. In the presence of gastrointestinal bleed, management involves the combination of interventional radiology and surgery.

Pseudoaneurysm associated with complicated pancreatic pseudocysts

A pseudoaneurysm associated with a pseudocyst is a serious and unusual complication of chronic pancreatitis. Its treatment is complex due to its elevated mortality and the need for multidisciplinary management. Initial measures consist in locating the hemorrhage through computerized dynamic tomography and arteriography. The treatment of choice is controversial due to the lack of controlled studies. For managing hemorrhages in stable patients, the most accepted initial measure currently is arterial embolization. In the event of failure of the same, hemodynamic instability or the impossibility of drainage of the pseudocyst, surgery is the subsequent therapeutic option.

Pancreaticoduodenal Artery Aneurysm Associated with Celiac Trunk Stenosis: Case Illustration and Literature Review

Pancreaticoduodenal artery aneurysms (PDA) are rare visceral aneurysms. Celiac trunk stenosis represents a common attributable aetiology for those aneurysms. Therefore, an alternative treatment approach, which differs from those isolated aneurysms, is recommended. We hereby present a 77-year-old male patient who was admitted with sudden onset of severe abdominal pain and significant drop in haemoglobin, occurring within a 24-hour interval. Contrast-enhanced computed tomography revealed a ruptured visceral aneurysm arising from the anterior branch of the inferior pancreaticoduodenal artery. A severe stenosis was also noted at the take-off of the celiac trunk. Selective catheterization of the supplying branch of the superior mesenteric artery, followed by coil embolization of the aneurysm, was performed, resulting in cessation of flow within the aneurysm, with preservation of the posterior branch, supplying the celiac territory. PDAs are usually asymptomatic and discovered incidentally at rupture. The risk of rupture is independent of the aneurysmal size and is associated with a 50% mortality rate. The consensus on coping with aneurysms is to treat them whenever they are discovered. Selective angiography followed by coil embolization represents a less invasive, and frequently definitive, approach than surgery. The risk for ischemia mandates that the celiac territory must not be compromised after embolization.

Drug-Induced Acute Pancreatitis and Pseudoaneurysms: An Ominous Combination

Rupture of pseudoaneurysms is rare but can be life-threatening complications of acute or chronic pancreatitis, usually due to enzymatic digestion of vessel walls crossing peripancreatic fluid collections. We report the case of a 40 year-old female, with multisystemic lupus and anticoagulated for prior thrombotic events, admitted for probable cyclosporine-induced acute pancreatitis. Hemodynamic instability occurred due to abdominal hemorrhage from two pseudoaneurysms inside an acute peri-pancreatic collection. Selective angiography successfully embolized the gastroduodenal and pancreatoduodenal arteries. The hemorrhage recurred two weeks later and another successful embolization was performed and the patient remains well to date. The decision to restart anticoagulants and to suspend cyclosporine was challenging and required a multidisciplinary approach. Despite rare, bleeding from a pseudoaneurysm should be considered when facing a patient with pancreatitis and sudden signs of hemodynamic instability.

Blunt pancreatic trauma: A persistent diagnostic conundrum?

Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma.