Hemosuccus pancreaticus successful treatment by double balloon-assisted coil embolization for active bleeding from the main trunk of the superior mesenteric artery

Anterior superior pancreaticoduodenal artery pseudoaneurysm after distal pancreatectomy with en bloc celiac axis resection successfully treated with balloon-assisted coil embolization

Bleeding is a fatal complication after pancreatectomy. Although coil embolization is a widely accepted treatment option, ischemia of the remaining organs should be prevented. This study reports the successful treatment of intra-abdominal hemorrhage following distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using balloon-assisted coil embolization (BACE). A 59-year-old man was diagnosed with locally advanced pancreatic cancer. The tumor involves the common hepatic artery, splenic artery, and celiac artery. After four cycles of treatment with gemcitabine/nab-paclitaxel, the soft-density masses, surrounding the artery, shrunk. DP-CAR and R0 resections were performed. A minor postoperative pancreatic fistula occurred. Six months postoperatively, the computed tomography showed delayed asymptomatic bleeding from an anterior superior pancreaticoduodenal artery (ASPDA) pseudoaneurysm located near the gastroduodenal artery confluence. BACE was performed by placing a microballoon catheter in the region of confluence of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA) to prevent coil migration. After inserting the microballoon catheter, coil embolization was performed in the ASPDA. Hepatic blood flow was maintained from the PSPDA. BACE is a useful technique to preserve blood flow to the remnant organs when performing coil embolization for bleeding following a distal pancreatectomy, especially following a DP-CAR.

Pseudoaneurysm associated haemosuccus pancreaticus - a rare and dangerous disease

Background

In patients with upper gastrointestinal bleeding and hemorrhage originating from the major duodenal papilla pseudoaneurysm associated haemosuccus pancreaticus (HP) is a rare differential diagnosis which should be considered. Diagnosis may be challenging, as clinical presentation is often unspecific with only intermittent hemorrhage. Treatment of the causal pseudoaneurysm is mandatory and endovascular coil embolization is the suitable first-line management strategy.

Until now there are only a very few studies about this clinical picture and its therapeutic options, especially data regarding whether additional fluid embolization is beneficial/necessary in HP is currently lacking.

Case presentation

We report a case of a 59-year-old male patient with chronic pancreatitis and haemosuccus pancreaticus caused by a pancreatico-arterial fistula with an associated inflammatory pseudoaneurysm of the splenic artery. Initially we sought to embolize the pseudoaneurysm with microcoils. As only one coil could be safely deployed in the pseudoaneurysm we additionally employed tissue adhesive embolization in order to achieve complete occlusion of the pseudoaneurysm as well as the pancretico-arterial fistula. In the presented case inflammatory levels decreased following embolization, possibly linked to a decline in pathologic excretion of elastase and autodigestion. As not only the pseudoaneurysm but also the underlying fistula were occluded, the risk of recurrence may conceivably be reduced.

Conclusions

Diagnosis of HP is difficult and treatment of the causal pseudoaneurysm is mandatory. Endovascular embolization is the suitable first-line management strategy, complete occlusion of the fistula should be considered when possible.

Embolisation of branches of the superior mesenteric artery in the treatment of haemosuccus pancreaticus

Haemosuccus pancreaticus (HP) is an uncommon cause of upper gastrointestinal (GI) bleeding, most often intermittent, making it difficult to diagnose, becoming fatal. It usually occurs in patients with chronic pancreatitis and is caused by the rupture of a visceral aneurysm within the main pancreatic duct. The association between pseudoaneurysm formation and pancreatitis is well established. Pseudoaneurysm occurs in 3.5%–10% of pancreatitis cases and its rupture is a rare but life-threatening complication of chronic pancreatitis occurring in 6%–8% of patients with pseudocysts and corresponds to less than 1% of cases of GI bleeding.

Its diagnosis is challenging, given the intermittent nature of bleeding. Angiographic therapy is considered the first-choice treatment, especially in patients who are stable haemodynamically. We present a case of embolisation of inferior pancreaticoduodenal branches with polyvinyl alcohol microparticles in the treatment of HP.