Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis

The Importance of Early Detection and Minimally Invasive Treatment of Pseudoaneurysms Due to Chronic Pancreatitis: Case Report

The occurrence of the pseudoaneurysm of visceral arteries in the field of chronic pancreatitis is a very rare complication that represents a life-threatening condition. The higher frequency of this complication is in the necrotic form of pancreatic inflammation, especially in patients with formed peripancreatic necrotic collections. The degradation of the arterial wall leads to bleeding and transforms these necrotic collections into a pseudoaneurysm. Urgent endovascular angioembolization is the first choice in the therapeutic approach as a valid minimally invasive solution with very satisfactory immediate and long-term outcomes. This successfully avoids open surgery, which is associated with a high mortality rate in these patients, especially in acute-on-chronic pancreatitis.

Technical tips for EUS-guided embolization of varices and pseudoaneurysms

Backgrounds and Aims

EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms.

Methods

This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed.

Results

Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented.

Conclusions

Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.

Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report

Introduction and importance

In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before.

Case presentation

The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery.

Clinical discussion

An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively.

Conclusion

In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Marginal Artery of Drummond Masquerading as a Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding (LGIB) can be caused by a variety of causes. Pseudoaneurysms have been described as a rare etiology of LGIB and are associated with pancreatic pseudocysts that involve adjacent vasculature. Our study describes a 38-year-old man with recent severe coronavirus disease 2019 and necrotizing pancreatitis presenting with hematochezia and blood clots by gastrostomy-jejunostomy. Initial flexible sigmoidoscopy did not elicit an etiology for the LGIB. Recurrent hematochezia prompted colonoscopy and angiography, which demonstrated a pseudoaneurysm in the marginal artery of Drummond as the source. Our case highlights the importance of repeat evaluation of gastrointestinal bleeding of unknown etiology.

Case report: Splenic artery pseudoaneurysm mimicking a bleeding marginal ulcer in a patient with gastric bypass

INTRODUCTION

Upper gastrointestinal (GI) bleeding in patients with roux-en-Y gastric bypass can be difficult to localize. Marginal ulcers are the most common cause, but a broad differential should be maintained in cases of severe bleeding, especially since the stomach and duodenum are not easily accessible by regular upper endoscopy.

PRESENTATION OF CASE

A 38-year-old female with Roux-en-Y gastric bypass presented with abdominal pain and hematochezia. Due to history of smoking and heavy use of ibuprofen, she was initially thought to have a bleeding marginal ulceration. Further investigation with computed tomographic (CT) angiography revealed a splenic artery pseudoaneurysm that had ruptured into a pancreatic pseudocyst, the gastric remnant and the peritoneum. The patient underwent successful treatment with trans-arterial embolization.

DISCUSSION

Splenic artery pseudoanerysms are rare but potentially lethal if unrecognized, particularly in patients with altered foregut anatomy. Their most likely origin is a nearby pancreatic pseudocyst, which erodes into the splenic artery by direct pressure and enzymatic digestion. Bleeding inside the pseudocyst is the most feared complication, resulting in massive intraperitoneal, extraperitoneal or endoluminal hemorrhage. Surgery is particularly challenging due to intense peripancreatic inflammation. Trans-Anterial embolization is the preferred treatment modality.

CONCLUSION

Marginal ulcers continue to be the most common cause of GI bleeding in patients with Roux-en-Y anatomy, although high index of suspicion for alternative diagnosis should be maintained in cases of massive hemorrhage.

Arterial Pseudoaneurysm Mimicking a Mural Nodule Within a Pancreatic Cyst

Pancreatic cysts with high-risk characteristics are at increased risk of harboring high-grade dysplasia or pancreatic cancer. Endoscopic ultrasound may clarify the nature of the cystic lesion and its malignant potential. A mural nodule found through endoscopic ultrasound within a cyst may represent malignancy and require fine-needle aspiration. Pancreatic pseudocysts are benign walled-off fluid collections that form in the setting of pancreatitis and may be difficult to differentiate from neoplastic cysts. Pseudoaneurysms form when pancreatitis inflammation damages vessel walls and can cause fatal hemorrhage. We present a pancreatic pseudocyst with pseudoaneurysm mimicking a neoplastic cyst with a mural nodule.

Endovascular embolization of visceral artery aneurysm: a retrospective study

To assess the safety and efficacy of endovascular embolization techniques, we compared the short- to medium-term prognosis of coil embolization for symptomatic visceral aneurysms (SVAA) and asymptomatic visceral aneurysms (ASVAA) to identify risk factors associated with 30-day mortality. Explore the symptom profile and intrinsic associations of SVAA. A retrospective study of 66 consecutive patients at two tertiary care hospitals from 2010 to 2020 compared the short- to mid-term outcomes of 22 symptomatic VAAs and 44 asymptomatic VAAs treated with coil embolization. Univariate and log-rank tests were used to analyze the prognostic impact of SVAA and ASVAA. SVAA group had significantly higher 30-day mortality than ASVAA group (2(9.1%) vs 0, P = 0.042), both patients who died had symptomatic pseudoaneurysms. Perioperative complications such as end-organ ischemia (P = 0.293) and reintervention (P = 1) were similar in both groups. No difference in event-free survival was identified between the two groups (P = 0.900), but we found that the majority of pseudoaneurysms were SVAA (4/5) and that they had a much higher event rate than true aneurysms. In addition, dyslipidemia may be an influential factor in the development of VAA (P = 0.010). Coil embolization is a safe and effective method of treatment for VAA. Most pseudoaneurysms have symptoms such as abdominal pain and bleeding, and in view of their risk, more attention should be paid to symptomatic patients and the nature of the aneurysm should be determined as soon as possible to determine the next stage of treatment.

Hemosuccus Pancreaticus: Diagnostic Pitfalls of a Rare Condition

The combination of cirrhosis and chronic pancreatitis is rare and poses increased risk of hemorrhage requiring close clinical monitoring. We present a patient with history of alcohol-associated cirrhosis and chronic pancreatitis who was admitted to the intensive care unit with clinical hemorrhage believed secondary to epistaxis. After initial delay, esophagogastroduodenoscopy ultimately found blood and clots evacuating through the ampulla consistent with hemosuccus pancreaticus confirmed with computed tomography angiography. The patient ultimately improved with coil and gel foam vascular embolization. This case highlights the dangers of early diagnostic closure and presents a rare finding of hemosuccus without pseudoaneurysm formation.

Left Gastric Artery Pseudoaneurysm Complicating Chronic Calcifying Pancreatitis in a Child

A left gastric artery pseudoaneurysm is a rare complication of pancreatitis and is associated with significant morbidity and mortality. We report a 14-year-old male with severe abdominal pain and a palpable upper abdominal mass, earlier diagnosed as chronic idiopathic calcifying pancreatitis, and awaiting surgical intervention. Computed tomography showed a pseudocyst and a pseudoaneurysm in the lesser sac near the left gastric artery. The patient underwent successful angiographic coiling of the left gastric artery and definitive pancreatic surgery weeks thereafter. The early detection and interventional radiologic management of the vascular complication averted a life-threatening hemorrhage without emergency surgery in a pediatric patient.

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.

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.

Hemosuccus Pancreaticus: A Comprehensive Review of Presentation Patterns, Diagnostic Approaches, Therapeutic Strategies, and Clinical Outcomes

Hemosuccus pancreaticus is a rare but potentially torrential and life-threatening cause of acute upper gastrointestinal bleeding. It is described as an intermittent hemorrhage from the major duodenal papilla via the main pancreatic duct. Peripancreatic pseudoaneurysm following chronic pancreatitis is a common underlying etiology. However, gastroduodenal artery pseudoaneurysm-related hemosuccus pancreaticus remains exceedingly rare in the etiological spectrum of upper gastrointestinal bleeding. We hereby delineate a rare case of hemosuccus pancreaticus associated with gastroduodenal artery pseudoaneurysm in a patient who initially presented with abdominal pain and hematochezia. He was successfully managed with coil embolization without recurrence or sequelae. Furthermore, we conducted a search of the MEDLINE (PubMed and Ovid) database for relevant studies on hemosuccus pancreaticus published between inception and September 15, 2021. The available clinical evidence on causes, presentation patterns, diagnosis, and management was analyzed and summarized. This article highlights the rarity, the intermittent nature of hemorrhage, and the lack of a standardized diagnostic approach for this elusive disease. Clinicians should remain cognizant of hemosuccus pancreaticus, especially in patients presenting with symptoms and signs of intermittent gastrointestinal bleeding and abdominal pain. Prompt diagnosis carries paramount importance in saving patients from repeat hospital admissions and disease-associated morbidity and mortality. Conventional angiography with coil embolization may constitute an effective treatment strategy.

An Unusual Case of Gastric Outlet Obstruction After Embolization of Gastroduodenal Artery Pseudoaneurysm

Gastric outlet obstruction can occur secondary to intrinsic or extrinsic pathology. Historically peptic ulcer disease was the most common cause of gastric outlet obstruction but now malignancy-associated disease process is more common. Gastric outlet obstruction from mucosal ischemia caused by embolization of gastroduodenal artery is unheard of. This is due to the extensive blood supply of the stomach. We present an unusual presentation of gastric outlet obstruction in a patient with recent embolization of pancreatitis-induced pseudoaneurysm of the gastroduodenal artery. The diagnosis was confirmed with esophagogastroduodenoscopy, computed tomography, and upper gastrointestinal series. The case was managed conservatively with a clear liquid diet and proton pump inhibitors. Repeat upper endoscopies at 1 and 6 months after presentation confirmed disease resolution. No guidelines exist on the management of such cases due to the rarity of the disease.

Hemorrhagic Shock Revealing Rupture of Splenic Artery Pseudoaneurysm Three Years After Post-Traumatic Pancreatitis

Splenic artery pseudoaneurysm (SAP) is an uncommon entity but extremely serious, given the high mortality rate if untreated. Only a limited literature reports association with post-traumatic pancreatitis. We report the case of a 30-year-old man, who was brought to the emergency department (ED) for acute confusion. His past medical history includes trauma of right hypochondriac and epigastric regions, three years ago. Three days before his admission to the hospital, he experienced abdominal pain with nausea and vomiting, without transit disorders or fever. When examined, the patient was disoriented, pale with profuse sweating, cold extremities, and a temperature of 36.3°C. Blood pressure was 75/51 mmHg, heart rate was 126 beats per minute, and oxygen saturation was 96% on room air. The abdominal exam detected generalized abdominal sensitivity. A CT angiography of the abdomen revealed hemoperitoneum of medium abundance, with extravasation of the contrast product from the splenic artery. The size of the spleen was normal with a lower polar hypodense area. In addition, a pancreas of normal size, steady outlinings, seat of bilobed cystic formation suggested a pancreatic pseudocyst. This led us to suspect a rupture of a pseudoaneurysm of the splenic artery. A laparotomy was performed and showed an estimated 2 L hemoperitoneum. Active bleeding was noted from an SAP in the mid-portion of the splenic artery, next to the pancreatic pseudocyst. Ligation of the splenic artery and splenectomy was carried out. The patient was discharged home on the 10th post-operative day. Our case highlights an uncommon cause of hemorrhagic shock, but critical to recognize. Indeed, ruptured SAP needs to be promptly detected and managed, to avoid fatal complications if left untreated.

Ruptured Pancreaticoduodenal Artery Pseudoaneurysm in an Unusual Location in a Patient with Chronic Pancreatitis: A Case Report

Bleeding pseudoaneurysm is a rare but yet potentially lethal complication in a patient with chronic pancreatitis. It also poses a diagnostic challenge among the radiologists and the attending physicians. The mortality rate can be as high as 50% depending on the clinical status, patient hemodynamics, site, and characteristics of the bleeding pseudoaneurysm. Multidisciplinary team approach is essential to deliver the optimum treatment strategy to each individual patient. In this article, we present a case of chronic pancreatitis that presents with acute epigastric pain caused by ruptured pancreaticoduodenal artery pseudoaneurysm in an unusual location. This patient was successfully treated with transcatheter coil embolization.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients

Objective

To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis.

Summary Background Data

Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods.

Methods

A meta-analysis of 5500 patients.

Results

Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods.

Conclusions

In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

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.

Transcatheter Arterial Embolization Treatment for Bleeding Visceral Artery Pseudoaneurysms in Patients with Pancreatitis or Following Pancreatic Surgery

Simple Summary

Transcatheter arterial embolization (TAE) with coils is widely used to treat pseudoaneurysms; recently, the use of N-butyl cyanoacrylate (NBCA) in TAE has been reported as a feasible and effective approach. The purpose of our retrospective study was to evaluate the efficacy and safety of TAE with coils and NBCA for pseudoaneurysms associated with pancreatitis or pancreatic surgery. This retrospective study included 42 consecutive patients. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. All cases obtained hemostasis after TAE (the technical success rate was 100%). Complications were seen in only two patients. Clinical success rate that was evaluated in terms of 30-day mortality was 76.2%. TAE is then an effective treatment modality for pseudoaneurysms associated with pancreatitis or pancreatic surgery. Accurate diagnosis using angiography contributes to the proper choice of embolic agents and management of such hemorrhages.

Abstract

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for pseudoaneurysms occurring secondary to pancreatitis or because of leakage of pancreatic juice after pancreatectomy. Materials and Methods: This retrospective study included 42 consecutive patients (38 males and 4 females; mean age, 60 years; range, 33–80 years) who underwent TAE for bleeding visceral artery pseudoaneurysms between March 2004 and December 2018. The technical and clinical success rates, incidence of recurrent bleeding, complications, including pancreatitis, and overall survival after TAE were evaluated. Results: Of the 42 enrolled patients, 23 had bleeding due to a complication of pancreatectomy and 19 had bleeding as a complication of pancreatitis. TAE with N-butyl cyanoacrylate (NBCA) or NBCA plus microcoils recurrent bleeding or inability to control bleeding was 15.8% (3 of 19) following TAE with NBCA and 17.4% (4 of 23) following TAE with coils. No clinically significant ischemic events of the pancreas or duodenum were observed in the embolized areas. Serum amylase did not increase compared with the initial levels after any of the procedures. At 30 days after TAE, 32 patients were alive. Conclusion: TAE has a high success rate for the management of hemorrhage, with few complications. The procedure appears to be safe and effective for pseudoaneurysms associated with either pancreatitis or pancreatectomy.

Endovascular Management of Pancreatitis-Related Hemorrhage: Single-Center Experience

Purpose The main purpose of this article is to assess the outcomes of endovascular management of pancreatitis-related hemorrhage.

Materials and Methods Retrospective analysis of patients referred for endovascular management of pancreatitis-related bleeding from January 2010 to December 2017 was performed. Patients’ demographics, clinical presentation, etiology, laboratory findings, angiography findings, details of the endovascular procedure, technical outcome, clinical outcome, and complications were assessed.

Results One hundred and five patients with a mean age of 37 years were included in this study. Splenic artery (41.7%) was the most commonly involved vessel. Middle colic, left colic, superior mesenteric, jejunal, left inferior phrenic, and left renal subcapsular arteries were the less commonly involved vessels. Embolization was performed using coils in 72 (68.5%) patients, n-butyl cyanoacrylate (n-BCA) in 21 (20%) patients, both coil and n-BCA in 8 (7.6%) patients, and 4 (3.8%) patients underwent stent graft placement. Technical success was achieved in 98% (n = 103) and clinical success in 93.2% (n = 96) of patients. Rebleeding was seen in 6.8% (n = 7) of patients. Six patients with rebleeding were managed by reintervention. Four patients had rebleeding from the same vessel, and two patients had rebleeding from a different vessel. One patient died due to massive rebleeding. Minor complications were seen in 14.2% (n = 15), major complications were seen in 3.8% (n = 4), and mortality rate was 0.9% (n = 1).

Conclusion Endovascular treatment is effective in the management of pancreatitis-related bleeding and is associated with low rebleeding rate and low mortality rate.

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.

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.

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.

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.

Strategy and management of severe hemorrhage complicating pancreatitis and post-pancreatectomy

PURPOSE

Transcatheter arterial embolization (TAE) is increasingly used as the first-line treatment for hemorrhage complicating pancreatitis and post-pancreatectomy. However, the optimal therapeutic strategy remains unclear.

METHODS

Among 1924 consecutive patients, 40 patients with severe pancreatic hemorrhage in Xuanwu Hospital were enrolled between 2005 and 2017. Patients underwent angiography and direct TAE for primary diagnosis and treatment of bleeding. Repeat TAE, watch and wait, and laparotomy were used as the other therapeutic options. Patient data, technical success, and 90-day survival were identified.

RESULTS

Pancreatic diseases underlying hemorrhage included acute pancreatitis (n=19, 47.5%), chronic pancreatitis (n=12, 30%), and pancreatic cancer (n=9, 22.5%). A history of percutaneous catheter drainage or pancreatic surgery was seen in 29 patients (72.5%). There were 48 angiographies, 31 embolizations, and 5 laparotomies performed. Rebleeding occurred in 8 patients (20%); 4 of whom underwent re-embolization, 3 had laparotomy, and 1 had conservative treatment. Successful clinical hemostasis was achieved in 37 patients. Complications were observed in only 2 patients with renal failure and 1 patient with hepatic insufficiency. In total, 25 patients (62.5%) were alive at the 90-day follow-up.

CONCLUSION

Endovascular management is effective for achieving hemostasis in severe pancreatic hemorrhage with a high success rate and low recurrence, and laparotomy is not suitable for rebleeding cases.

A case of pancreatic pseudocysts accompanied by infection, pseudoaneurysm ruptures, and pseudocystocolonic fistulae

Pancreatic pseudocysts (PPs) can be accompanied by infection, pseudoaneurysm ruptures, and fistulae to other organs, which can be fatal without appropriate treatment. Herein, we present the case of an 82-year-old man with PPs accompanied by infection, pseudoaneurysm rupture, and pseudocystocolonic fistula that were managed via multidisciplinary treatment. Computed tomography (CT) revealed two inflamed PPs, one each in the pancreatic head and tail. He was, therefore, diagnosed with infectious PPs. The pancreatic head PP shrunk on endoscopic nasopancreatic drainage (ENPD), but the pancreatic tail PP did not. Endoscopic ultrasound (EUS)-guided transluminal drainage was performed to treat the pancreatic tail PP; his symptoms improved. However, he vomited blood at 14 day post-drainage. Angiography revealed pseudoaneurysm rupture in a left gastric artery branch. After successful angioembolization, he developed hematochezia 2 days later. We suspected re-bleeding of the pseudoaneurysm. The bleeding stopped spontaneously, but CT and radiography revealed the presence of a pseudocystocolonic fistula. Careful follow-up was performed, and he has not had any symptoms at 9 month post-discharge. We managed PP-related complications via ENPD, EUS-guided transluminal drainage, angioembolization, and careful follow-up. Infection, pseudoaneurysm rupture, and pseudocystocolonic fistula are rare, but can occur simultaneously. Therefore, clinicians should consider these complications when treating patients with PPs.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking

Excess alcohol consumption is a leading cause of preventable morbidity and mortality globally. The pattern of consumption of alcoholic beverages has changed in our society in the recent past, with binge drinking becoming more and more common, especially among young adults. Abdominal pain following alcohol consumption can be secondary to a wide range of pathologies, the treatment algorithm of which can range from medical supportive treatment to more invasive life-saving procedures such as transarterial embolization and emergency laparotomy. Correct diagnosis, differentiation among these conditions, and implementing the correct management algorithm is heavily reliant on accurate and appropriate imaging. We review the pathophysiology, clinical presentation, imaging features and management options of acute abdominal emergencies secondary to binge drinking, based on a selection of illustrative cases.

Acute-phase endovascular management of an uncommon bleeding peripancreatic pseudoaneurysm

Pancreatic pseudoaneurysms represent relatively rare but potentially lethal complications of acute or chronic pancreatitis, involving several visceral arteries. Due to their intrinsic instability and subsequent high risk of massive bleeding, these lesions require prompt treatment, regardless of the size of the pseudoaneurysm. First option of treatment is today represented by transcatheter embolization; this treatment, in fact, shows higher rates of clinical and technical success and lower recurrence rates than conventional surgery. We present a clinical case of endovascular management of a large pseudoaneurysm, measuring 54 × 53 mm (AP × LL), involving right gastric artery in a 35-year-old woman with history of chronic alcoholic abuse presenting with severe anemia.

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.

Surgical Management of Pancreatic Pseudocysts

Open surgical intervention for treatment of simple pancreatic pseuodocyst (PP) has a high success rate and has been the historical gold standard. Open surgical intervention, however, confers significant morbidity and mortality, which has spurred the development of less invasive techniques. Laparoscopic approaches are feasible with the potential for lower complication rates and length of stay. The endoscopic approach has the appeal of potentially shorter hospitalization length of stays and does not require general anesthesia. Complicated PPs or those that arise in the setting of chronic pancreatitis warrant additional workup and special consideration.

Hemosuccus pancreaticus: A mini-review

Determining the cause of obscure bleeding in the gastrointestinal tract is the key in treating the disease. Hemosuccus pancreaticus (HP) could be an extremely rare disease. Ordinarily, bleeding in the pancreatic duct is defined as HP. At present, HP is the least frequent cause of upper gastrointestinal bleeding (1/1500), but can lead to massive gastrointestinal bleeding, which is potentially life threatening. Owing to its rarity, HP is difficult to diagnose, and the mortality rate of HP remains high in various studies. The purpose of this study is to expound on the basic symptoms and mechanisms of HP and to describe a potential significant examination method and treatment for usage in clinical practice.

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.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm

BACKGROUND AND AIMS

Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

AIM

To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms.

METHODS

Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's.

RESULTS

The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient.

CONCLUSIONS

Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.

Visceral Artery Aneurysms: A Symptomatic Aneurysm of the Ileocolic Artery

Visceral artery aneurysm is a rare but clinically important form of vascular pathology, showing a high mortality rate in emergency surgery. Most often these aneurysms cause no symptoms and are therefore incidental findings. Reports on ileocolic artery aneurysms are rare and often anecdotal. Therapeutic procedures can be performed either surgically or by interventional therapeutic techniques. This article presents a case of ruptured ileocolic artery aneurysm and reviews the literature on this topic.

Successful resolution of a hemorrhagic pancreatic pseudocyst ruptured into the stomach complicating obstructive pancreatitis due to pancreatic cancer: a case report

BACKGROUND

Hematemesis is uncommon as an initial presenting symptom in pancreatic cancer. We present herein a case of a pseudoaneurysm that ruptured and fistulized into the stomach. The pseudoaneurysm was secondary to a pancreatic pseudocyst complicating obstructive pancreatitis due to pancreatic cancer. The patient was successfully treated using trans-arterial embolization followed by curative surgery.

CASE PRESENTATION

A 61-year-old man presented to the emergency room with hematemesis. Laboratory examinations revealed a low level of hemoglobin (5.0 g/dl). The patient had presented to another hospital due to hematemesis 1 month before presenting to our hospital. A low-density mass in the pancreatic body with dilatation of the distal main pancreatic duct and a pseudocyst in the pancreatic tail had been observed by radiology at the previous hospital. Further investigation had been planned. Abdominal computed tomography on admission to our hospital demonstrated a pseudoaneurysm in close contact with the wall of the pseudocyst of the pancreatic tail, compressing the stomach. The pseudoaneurysm had not been detected by abdominal computed tomography at the previous hospital. Emergency selective angiography revealed that the pseudoaneurysm arose from the left gastroepiploic artery branching from the splenic artery. Trans-arterial embolization of the left gastroepiploic artery through the splenic artery was successfully performed. Elective distal pancreatectomy and splenectomy with regional lymph node dissection combined with partial resection of the stomach was performed 3 weeks after coil embolization. Pathological examination revealed a moderately differentiated tubular adenocarcinoma in the pancreatic body with regional lymph node metastasis and revealed the pseudoaneurysm rupturing into the pancreatic pseudocyst. The patient has experienced no tumor recurrence or metastasis during 1 year of follow-up.

CONCLUSIONS

Spontaneous rupture of a pseudoaneurysm is a rare and potentially lethal complication of a pancreatic pseudocyst. Most affected patients have a history of alcoholism and suffer from acute or chronic pancreatitis. To our knowledge, this is the first reported case of a hemorrhagic pancreatic pseudocyst complicating obstructive pancreatitis due to pancreatic cancer.

Hemorrhagic Pseudocyst of Pancreas Treated with Coil Embolization of Gastroduodenal Artery: A Case Report and Review of Literature

Hemorrhage into pseudocyst of pancreas can rarely present as life threatening massive UGI bleeding. We present a case of 21-year-old male, admitted to our department, who was a known case of posttraumatic acute pancreatitis and who developed massive upper GI bleeding. CT angiography of abdomen showed aneurysm of gastroduodenal artery. Patient was successfully treated with coil embolization of gastroduodenal artery.

Endoscopic ultrasound guided thrombin injection of angiographically occult pancreatitis associated visceral artery pseudoaneurysms: Case series

Pseudoaneurysm is a known complication of pancreatitis associated with significant mortality and morbidity. Imaging plays an important role in the diagnosis and management. Computed tomography (CT) helps localize the lesion and the severity of the background pancreatitis but digital subtraction angiography with coil embolization is recommended to avoid bleeding and inadvertent surgery. However, in cases where angiographic coil embolization is not feasible due to technical reasons, thrombin injection via CT or ultrasound guidance remains a viable option and often described in literature. In this series, effort has been made to highlight the role of endoscopic ultrasound guided thrombin instillation especially in patients with poorly visualized pseudoaneurysm on ultrasound thereby avoiding surgery and the associated mortality and morbidity.

Management of Giant Splenic Artery Aneurysm: Comprehensive Literature Review

To provide an overview of the medical literature on giant splenic artery aneurysm (SAA).The PubMed, Medline, Google Scholar, and Google databases were searched using keywords to identify articles related to SAA. Keywords used were splenic artery aneurysm, giant splenic artery aneuryms, huge splenic artery aneurysm, splenic artery aneurysm rupture, and visceral artery aneurysm. SAAs with a diameter ≥5 cm are considered as giant and included in this study. The language of the publication was not a limitation criterion, and publications dated before January 15, 2015 were considered.The literature review included 69 papers (62 fulltext, 6 abstract, 1 nonavailable) on giant SAA. A sum of 78 patients (50 males, 28 females) involved in the study with an age range of 27-87 years (mean ± SD: 55.8 ± 14.0 years). Age range for male was 30-87 (mean ± SD: 57.5 ± 12.0 years) and for female was 27-84 (mean ± SD: 52.7 ± 16.6 years). Most frequent predisposing factors were acute or chronic pancreatitis, atherosclerosis, hypertension, and cirrhosis. Aneurysm dimensions were obtained for 77 patients with a range of 50-300 mm (mean ± SD: 97.1 ± 46.0 mm). Aneurysm dimension range for females was 50-210 mm (mean ± SD: 97.5 ± 40.2 mm) and for males was 50-300 mm (mean ± SD: 96.9 ± 48.9 mm). Intraperitoneal/retroperitoneal rupture was present in 15, among which with a lesion dimension range of 50-180 mm (mean ± SD; 100 ± 49.3 mm) which was range of 50-300 mm (mean ± SD: 96.3 ± 45.2 mm) in cases without rupture. Mortality for rupture patients was 33.3%. Other frequent complications were gastrosplenic fistula (n = 3), colosplenic fistula (n = 1), pancreatic fistula (n = 1), splenic arteriovenous fistula (n = 3), and portosplenic fistula (n = 1). Eight of the patients died in early postoperative period while 67 survived. Survival status of the remaining 3 patients is unclear. Range of follow-up period for the surviving patients varies from 3 weeks to 42 months.Either rupture or fistulization into hollow organs risk increase in compliance with aneurysm diameter. Mortality is significantly high in rupture cases. Patients with an evident risk should undergo either surgical or interventional radiological treatment without delay.

Hemosuccus pancreaticus: a rare complication of chronic pancreatitis

Hemosuccus pancreaticus is a very rare cause of gastrointestinal bleeding and it should be considered in every patient with history of chronic pancreatitis who presents with acute or intermittent gastrointestinal haemorrhage. A 54-year-old man with a history of chronic alcoholic pancreatitis was admitted to hospital for an acute exacerbation. During hospital stay, he presented with haematemesis and haemodynamic instability. Upper gastrointestinal endoscopy revealed a blood clot on Vater papilla. CT investigation showed a 4 cm cephalopancreatic pseudocyst and angiography identified a large pseudoaneurysm of the right gastroepiploic artery, bleeding into the pseudocyst-hemosuccus pancreaticus. Microcoil transcatheter embolisation was performed with success.

Arterial pseudoaneurysms complicating pancreatitis: literature review

Arterial pseudoaneurysm formation of visceral arteries as a vascular complication of pancreatitis, either acute or chronic, is an uncommon phenomenon. This review article discusses the incidence, pathophysiology, imaging, treatment strategies, and prognosis of mesenteric pseudoaneurysms complicating pancreatitis.

Hepatic artery pseudoaneurysm after surgical treatment for pancreatic cancer: minimally invasive angiographic techniques as the preferred treatment

BACKGROUND

Delayed intra-abdominal bleeding related to hepatic artery pseudoaneurysm is a potentially lethal complication after pancreaticoduodenectomy for pancreatic cancer. Locally advanced tumors, which result in vessel erosion or extensive operative skeletonization, may contribute to weakness of the arterial wall. Reoperation is often technically difficult with high rate of mortality; therefore, alternative less invasive options are ideal.

AIMS

The study was to present an alternative endovascular treatment of a large hepatic artery pseudoaneurysm after pancreatic resection for locally advanced multicystic adenocarcinoma.

MATERIALS AND METHODS

Transcatheteric mesenteric angiography with deployment of detachable coils in the pseudoaneurysm sac was utilized to manage the hepatic artery pseudoaneurysm.

RESULTS

Completion angiography confirmed cessation of contrast enhancement in the pseudoaneurysm sac with preservation of normal antegrade hepatic artery flow.

CONCLUSION

Minimally invasive angiographic technique is the preferred treatment for hepatic artery pseudoaneurysm after pancreatic resections.

Peripancreatic pseudoaneurysms: a management-based classification system

BACKGROUND

Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.

METHODS

A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.

RESULTS

The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.

CONCLUSION

The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Necrotizing pancreatitis complicated by oesophageal haemorrhage

Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management.

Spontaneous bleeding in pancreatitis treated by transcatheter arterial coil embolization: a retrospective study

Background/Objectives

A rare, but life-threatening complication in pancreatitis is a spontaneous bleeding from intestinal vessels with or without previous formation of (pseudo-) aneurysms. And yet, the optimal diagnostic and therapeutic strategies remain unclear.

Methods

We performed a retrospective analysis of all patients with pancreatitis and intraabdominal bleeding at a German tertiary referral center between January 2002 and December 2012.

Results

Bleeding occurred in <1% (14/3,421) of patients with pancreatitis. Most involved vessels were arteria lienalis, arteria gastroduodenalis, and arteria pancreaticoduodenalis. All bleedings could be stopped by transcatheter arterial coil embolization. Recurrent bleeding after coil embolization occurred in 2/14 (14%) patients.

Conclusions

In cases of intraabdominal hemorrhage in patients with pancreatitis, transcatheter arterial coil embolization should be considered as the first interventional procedure.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.