Clinical Features and Endovascular Treatment of Visceral Artery Pseudoaneurysms

Clinical Profile, Management, and Outcome of Visceral Artery Pseudoaneurysms: 5-Year Experience in a Tertiary Care Hospital

Visceral artery pseudoaneurysms are potentially lethal lesions and tend to rupture in a high proportion of cases, thereby warranting an immediate and active intervention. We present our experience of splanchnic visceral artery pseudoaneurysms in a university hospital over a 5-year time interval with emphasis on etiology, clinical presentation, management (endovascular/surgical), and final outcome. This was a retrospective study in which we searched our image database for pseudoaneurysms of visceral arteries over a period of 5 years. The clinical and operative details were retrieved from the medical record section of our hospital. The lesions were analyzed for the vessel of origin, size, etiology, clinical features, mode of treatment, and outcome. Twenty-seven patients with pseudoaneurysms were encountered. Pancreatitis (8) was the most common cause, followed by previous surgery (7) and trauma (6). Fifteen were managed by the interventional radiology (IR) team, 6 by surgery, and in 6 no intervention was done. Technical and clinical success was achieved in all patients in the IR group with few minor complications. Surgery and no intervention carry a high mortality in such a setting (66 and 50%, respectively). Visceral pseudoaneurysms are potentially fatal lesions, commonly encountered after trauma, pancreatitis, surgeries, and interventional procedures. These lesions are easily salvageable by minimally invasive interventional techniques (endovascular embolotherapy), and surgeries carry a lot of morbidity and mortality in such cases and a prolonged hospital stay.

Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm

Visceral artery pseudoaneurysms are rare but potentially life-threatening. Among visceral artery pseudoaneurysm (VAPA), the superior mesenteric artery (SMA) pseudoaneurysm is the rarest type. VAPAs are usually related with infection, inflammatory disease, trauma, or arises as a postoperative complication. Early diagnosis and endovascular or surgical intervention are key in lowering the risk of intestinal infarction and death due to potentially fatal hemorrhage. A 49-year-old man presented with cough, shortness of breath, weight loss, and an incidental finding of spontaneous SMA pseudoaneurysm with localized bleed on CT angiography. An urgent endovascular embolization was performed of the pseudoaneurysm, with an adequate outcome and recovery. SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and related morbidity and mortality. Direct oral anticoagulants like apixaban (Eliquis) have also been reported to cause pseudoaneurysm formation by slow and constant bleeding, which may have contributed here as a cause of pseudoaneurysm along with infective endocarditis, which was diagnosed later after endovascular embolization. The treatment can be either an endovascular, endoscopic, or open surgical approach. 

Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis

BACKGROUND

There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms.

METHODS

Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I² 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I² 42%), 86% (95% CI-75-92%, I² 44%), and 88% (95% CI-83-91%, I² 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I² 0%)). Splenic infarction was the most common complication (n = 47).

CONCLUSION

Endovascular embolization is associated with a high technical and clinical success.

Giant visceral artery pseudoaneurysm treated with endovascular transradial coil embolization

Visceral artery pseudoaneurysms (PSAs) are relatively rare, and cases associated with distal vasculature of the superior mesenteric artery are largely unreported. Visceral artery PSAs, without intervention, can lead to morbidity or mortality from rupture or mesenteric ischemia. Historically, open aneurysmectomy is the gold standard; however, endovascular modalities have emerged as the first-line treatment in patients who are poor surgical candidates and/or have unfavorable anatomy. Herein, we describe a case of a symptomatic PSA of the distal superior mesenteric artery treated via the transradial approach with endovascular coil embolization, showing successful aneurysmal exclusion and preservation of enteric collateral flow.

Splenic Artery Pseudoaneurysm in Chronic Pancreatitis Causing Obstructive Jaundice: Endovascular Management

BACKGROUND

Splenic artery pseudoaneurysm (SAP) around the pancreatic head causing obstructive jaundice is an extremely rare complication but can be life threatening once occurs. This case report is to raise awareness of this catastrophic complication and share our experience of successful endovascular management.

METHODS

A 47-year-old male with a history of chronic pancreatitis clinically presented with epigastric pain and jaundice. Proximal SAP complicated with obstructive jaundice was confirmed by laboratory and imaging investigations. The SAP was successfully treated by transarterial coil embolization, and the jaundice subsequently improved.

RESULTS

Abdominal contrast-enhanced computed tomography 11 months after embolization showed complete occlusion and reduction in the volume of the SAP as well as normal biliary tract.

CONCLUSIONS

SAP complicated with obstructive jaundice should be managed timeously and aggressively once diagnosed, given its potential adverse consequences. Transarterial embolization using the isolation technique may be a safe and effective strategy for treating this disease.

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.

Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report

Background

Visceral arterial pseudoaneurysms (VAPAs) are rare vascular entities with serious consequences. Traditionally, they are associated with trauma, infection, and inflammatory disease, or they can arise as a post-operative complication.

Report

An 87 year old man presented with abdominal pain and was found to have a spontaneous VAPA on a computed tomography angiogram. Serial imaging 4 months previously had demonstrated no aneurysm. Between scans, warfarin was changed to apixaban for aortic valve replacement, but he had no other changes to any other medications. He required urgent endovascular coiling of the pseudoaneurysm, with satisfactory recovery and outcome.

Discussion

VAPAs are extremely rare, with splenic artery VAPAs the most commonly reported. Regardless, fewer than 250 cases of splenic artery pseudoaneurysm have been reported. Superior mesenteric artery (SMA) pseudoaneurysms are the rarest type of VAPAs. Early identification and urgent treatment are warranted because of the associated high mortality risk, with a 50% risk of rupture in any given VAPA. Treatment options range from open operation to endoscopic and endovascular procedures. Apixaban has been proposed to contribute to pseudoaneurysm formation by slow and continuous bleeding that results in the formation of the pseudoaneurysm.

Conclusions

Spontaneous VAPAs are extremely rare and this is the first time a VAPA has been associated with the novel oral anticoagulant "apixaban". Urgent management of any VAPAs is important because of the high risk of rupture and potential life threatening haemorrhage.

Hemosuccus pancreaticus secondary to pseudoaneurysm of the splenic artery

A 41-years-old male who presents abdominal pain and rectal bleeding with acute anemization. Both the gastroscopy and the colonoscopy dont identify any potential cause of bleeding. The computed tomography (CT) shows a pseudoaneurysm of the splenic artery. Gastrointestinal bleeding was attributed to a hemosuccus pancreaticus secondary to the pseudoaneurysm of the splenic artery. An arteriography was performed to embolize it. Pseudoaneurysm of the splenic artery is a rare cause of gastrointestinal bleeding. Given the risk of a rupture, the treatment is mandatory irrespective of the size or symptoms.