Successful endovascular treatment of a celiac artery pseudoaneurysm complicating pancreatitis

Glue Embolization of a Ruptured Celiac Trunk Aneurysm

The purpose of this article is to report a case of ruptured celiac trunk aneurysm treated with glue embolization. A 39-year-old man presented with abdominal pain. Abdominal computed tomography (CT) depicted the presence of hemoperitoneum, and CT angiography revealed an aneurysm in the celiac trunk. The endovascular access into the aneurysm's outflow vessel was unattainable. N-butyl cyanoacrylate (NBCA) embolization was performed. However, untargeted distal embolizations via the left gastric, splenic, and common hepatic arteries formed. Postembolization angiography showed total occlusion of the aneurysmal cavity and left gastric artery but regular retrograde filling of the stomach, liver, and spleen by branches originating from the superior mesenteric artery. After discharge on day 6, the patient was doing well, without complications at the 11-month follow-up. The operative mortality of ruptured celiac trunk aneurysm is very high. Glue embolization was successfully used as a treatment option and should be considered when there are no other options.

Systematic appraisal of the management of the major vascular complications of pancreatitis

BACKGROUND

This study is a systematic appraisal of the management of major vascular complications of pancreatitis conducted by collating individual patient-episode data from published literature.

METHODS

Searches identified 79 papers of which 62 provided detailed information on the clinical course of 214 patients. Principal outcomes were modes of presentation, results of diagnostic angiography, and embolization and overall outcome.

RESULTS

There were 160 "spontaneous" and 40 postoperative episodes of hemorrhage. Underlying pancreatic disease was chronic pancreatitis (40), pseudocyst (135), and acute pancreatitis in 39. Angiography was undertaken in 173 (81%) with embolization attempted in 115 and achieving hemostasis in 85 (75%). There were 40 (19%) deaths. Mortality was greater in patients undergoing surgery as first intervention compared with angiography first (P = .01, Fisher exact test).

CONCLUSION

This analysis of pooled data provides evidence of a central role for mesenteric angiography in the diagnosis of major vascular complications of pancreatitis and for angiographic embolization as a powerful tool for achieving hemostasis.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Emergency complications of acute and chronic pancreatitis

Acute pancreatitis is a common disease with a relatively high morbidity and mortality. In contrast, chronic pancreatitis is a recurrent disease with multiple potential complications that occasionally require urgent intervention. This article focuses on the emergency complications of acute and chronic pancreatitis that require urgent intervention. Recent developments in the diagnosis and management of such complications are discussed.

Endovascular exclusion of a ruptured pseudoaneurysm of the infrarenal abdominal aorta secondary to pancreatitis

PURPOSE

To report the successful repair of a ruptured pseudoaneurysm of the infrarenal abdominal aorta secondary to pancreatitis.

CASE REPORT

A 47-year-old man was admitted with abdominal pain due to an acute exacerbation of chronic alcoholic pancreatitis. He was found to have an infrarenal abdominal aortic aneurysm, which was confirmed by spiral computed tomography (CT), but there had been no evidence of aneurysm formation on a scan performed 1 year previously. Persistent symptoms prompted a further CT scan 48 hours later; this revealed evidence of a ruptured infrarenal abdominal aortic pseudoaneurysm. The pseudoaneurysm was excluded using a Zenith aortomonoiliac endovascular graft. Recovery was uneventful, and the patient underwent pancreatic resection 6 months later. A duplex scan 10 months after endograft placement could not identify an aneurysm sac.

CONCLUSIONS

In selected cases, endovascular repair provides a useful method of excluding ruptured aortic pseudoaneurysms due to pancreatitis. It allows hemorrhage control in a potentially infected operative field and permits elective pancreatic resection. Prolonged follow-up is mandatory to ensure there is no evidence of graft sepsis and that aneurysm exclusion is maintained.

Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent

A postoperative superior mesenteric artery pseudoaneurysm that communicates with a pancreatic pseudocyst after aortic surgery is a difficult management problem. Untreated, this condition can lead to exsanguination. Traditional surgical treatment has many potential complications. Endovascular repair has the potential for avoidance of surgical complications. We present the first superior mesenteric artery pseudoaneurysm successfully treated with A polytetrafluorethylene covered stent.

Vascular complications arising from maldeployed stents

The authors present 6 unusual vascular complications secondary to maldeployed or undeployed vascular stents. They retrospectively reviewed patients referred for complications of vascular stent placement from September 1998 to March 1999. Information on patient history was obtained from a computerized database and clinical document file. Radiographic information was obtained from arteriograms, ultrasound, and computed tomography imaging. Case 1 describes an undeployed stent in the superior mesenteric artery with subsequent thrombosis in addition to celiac occlusion secondary to attempted balloon angioplasty. Case 2 refers to a malpositioned stent placed in the aortic arch and proximal left common carotid artery. Case 3 involves an undeployed coronary stent that migrated to the right distal posterior tibial artery, causing vascular occlusion and chronic pain. In Case 4, an attempted stent placement into the left iliac artery resulted in an undeployed stent lodged across the aortic bifurcation. Case 5 illustrates a partially deployed stent occluding the left renal artery that was unamenable to further angioplasty. Case 6 demonstrates arterial dissection with a pseudoaneurysm following stent placement for right subclavian stenosis. Five patients required operative intervention. Increased use of stents may escalate the number of complications requiring operative intervention. Foreign bodies can migrate distally and potentiate thrombotic occlusion of vessels. Caution must be used not only at the time of deployment but also in the follow-up period. Continued surveillance becomes important after vascular stent placement.

Endovascular treatment of visceral artery aneurysms

PURPOSE

To review a 10-year experience with endovascular embolization of visceral artery aneurysms.

METHODS

Twenty-five patients (13 men; mean age 52.1 years, range 31-80) presented with VAAs of varying locations and etiologies: 10 splenic, 3 gastroduodenal, 2 pancreaticoduodenal, 3 hepatic, 3 superior mesenteric, 2 celiac, 1 left gastric, and 1 jejunoileal. Ten patients were asymptomatic; 7 aneurysms were ruptured. Transcatheter coil embolization was the treatment of choice in all patients.

RESULTS

Coil placement was initially (<7 days) successful in 23 (92%) patients. One superior mesenteric artery aneurysm remained perfused, and recurrent bleeding occurred 2 days after intervention in 1 case, but repeated embolization excluded the aneurysm. One patient with necrotizing pancreatitis died from sepsis 10 days after endovascular treatment and surgery (4% 30-day mortality). Long-term follow-up revealed excellent results after an average 48.7 months (range 14-75) with only 1 recurrence after 12 months.

CONCLUSIONS

Embolotherapy is the treatment of choice in visceral artery aneurysms, regardless of etiology, location, or clinical presentation.

Aortic pseudoaneurysm secondary to pancreatitis

A patient with a pseudoaneurysm of the distal abdominal aorta, which developed as the result of complicated gallstone pancreatitis, is reported. The aorta was bypassed with an axillofemoral-femorofemoral graft; the pseudoaneurysm was resected, and the infrarenal aorta was oversewn. The patient survived a complicated postoperative course and was discharged with well-perfused lower extremities. No previous description of a pseudoaneurysm of the aorta as a complication of pancreatitis was found on review of the literature.