Long-term clinical and radiological outcome of endovascular embolization of pancreatitis-related pseudoaneurysms

Comprehensive Review of Surgical and Radiological Management of Hemorrhagic Pancreatitis: Current Strategies and Outcomes

Hemorrhagic pancreatitis, a severe complication of acute and chronic pancreatitis, involves bleeding due to vascular disruptions. This condition presents significant clinical challenges and is associated with high morbidity and mortality. The bleeding can result from arterial or venous complications, often exacerbated by inflammatory and enzymatic damage to blood vessels within the pancreas. Patients with hemorrhagic pancreatitis may experience symptoms such as abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Diagnostic imaging, including CT and MRI, is crucial in identifying the source of bleeding and guiding treatment decisions. Management strategies have evolved over the past two decades, shifting from purely surgical approaches to including interventional radiology techniques. Surgical intervention is often reserved for hemodynamically unstable patients or those with large pseudoaneurysms, offering definitive treatment but carrying higher risks of complications. Endovascular techniques, such as transcatheter embolization, provide a less invasive alternative with high success rates and shorter recovery times, though rebleeding may occur. Treatment choice depends on various factors, including the patient's stability, the size and location of the bleeding, and the availability of specialized expertise. Overall, the management of hemorrhagic pancreatitis requires a multidisciplinary approach, combining surgical and radiological techniques to optimize patient outcomes and reduce the risk of mortality. Long-term follow-up is essential to monitor for recurrent disease and manage the metabolic consequences of pancreatic insufficiency.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Major and minor complications of the pancreas after transcatheter arterial embolization using n-butyl-2-cyanoacrylate for acute bleeding from pancreatic arteries

PURPOSE

The purpose is to investigate the major and minor complications of the pancreas after transcatheter arterial embolization (TAE) using n-butyl-2-cyanoacrylate (NBCA) for bleeding from pancreatic arteries.

MATERIALS AND METHODS

Thirty-three patients who underwent TAE using NBCA for acute bleeding from pancreatic arteries and their parent arteries followed by contrast-enhanced computed tomography (CE-CT) were evaluated retrospectively. Complications and risk factors were assessed using Mann-Whitney U test or Fisher's exact test for the univariate analysis. Patients' characteristic, embolized artery, procedure details, and clinical outcomes were examined as possible risk factors.

RESULTS

TAE was performed successfully in all patients. Minor pancreatic complications occurred in 10 patients (30%), including acute mild pancreatitis (n = 4) and focal lack of pancreatic parenchymal enhancement on CE-CT without pancreatitis (n = 6). No cases of major pancreatic complications, such as moderate/severe pancreatitis, were reported. Embolized artery was the only significant risk factor. The rate of complications per embolized artery were 15% (three out of 20 patients) in the arteries of the pancreatic head and 54% (seven out of 13 patients) in the arteries of pancreatic body and tail (p = 0.025).

CONCLUSION

TAE using NBCA for acute bleeding from pancreatic arteries is efficacious and safe. Mild pancreatic complications were observed more frequently in case of embolization of the pancreatic body and tail region than the pancreatic head.

Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis

PURPOSE

To evaluate and compare the immediate and long-term outcomes of radiological interventions for hemorrhagic complications in patients with acute and chronic pancreatitis.

MATERIALS AND METHODS

This retrospective study, conducted between January 2014 and June 2020, included all patients with acute and chronic pancreatitis presenting with hemorrhagic complications who underwent angiography and/or embolization. Their clinical, angiographic, and embolization details were evaluated and correlated with procedure success, complications, recurrence, and mortality. The patients were subgrouped into groups A (acute pancreatitis) and C (chronic pancreatitis), and comparisons were made.

RESULTS

The study included 141 patients (mean age, 36.3 ± 11.2 years; 124 men), of whom 106 patients had abnormal angiography findings and underwent embolization. Of them, group A had 50 patients (56 lesions) and group C had 56 patients (61 lesions). All the patients in group A had severe acute pancreatitis, with a mean computed tomography severity index of 7.6. The technical and clinical success rates of embolization, complications, recurrence, and long-term outcomes were not significantly different between the groups. Group A had significantly higher mortality due to sepsis and organ failure. Embolic agents did not have any significant association with complications, recurrence, and mortality. After a mean follow-up of 2 years, 72.5% of the patients were asymptomatic, and none had symptoms attributable to embolization.

CONCLUSIONS

Success, complications, and recurrence after embolization for hemorrhagic complications were comparable between acute and chronic pancreatitis. Acute pancreatitis was associated with significantly higher mortality. Embolic agents did not significantly influence the outcomes. None had long-term adverse effects attributable to embolization.

Splenic artery pseudoaneurysm: Challenges of non-invasive and endovascular diagnosis and management

Splenic artery pseudoaneurysms (PAs) are uncommon and often occur as a complication of pancreatitis or trauma. Unlike true aneurysms, PAs are symptomatic in a majority of cases and patients can present with a constellation of non-specific symptoms. Diagnosis can be challenging due to variation in presenting features and mimicking pathologies. PAs are associated with a very high morbidity and mortality if left untreated. We present an unusual case of a 47-year-old gentleman diagnosed with a splenic artery pseudoaneurysm despite initial negative catheter angiography and discuss the challenges of splenic artery pseudoaneurysm diagnosis and management.

[Management of acute pancreatitis. A literature review]

The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.

Endovascular and percutaneous transabdominal embolisation of pseudoaneurysms in pancreatitis: an experience from a tertiary-care referral centre

AIM

To analyse the technical challenges, clinical success, and associated complications of endovascular and percutaneous embolisation of pancreatitis-related pseudoaneurysms.

MATERIALS AND METHODS

A retrospective study of patients referred for embolisation of pancreatitis-related pseudoaneurysms between January 2014 and March 2019 was conducted. Computed tomography angiography (CTA) was performed to assess the morphology of the aneurysms prior to any intervention. Percutaneous or endovascular embolisation was performed. Details of CTA and methods of embolisation were recorded. Technical success, clinical success, and complications were reported.

RESULTS

A total of 80 patients (mean age, 40.69 ± 13.41 years, 73 male) underwent embolisation during the study period. Pseudoaneurysms were related to chronic pancreatitis (CP) in 44 (55%) patients and acute pancreatitis (AP) in 36 (45%) patients. Pseudoaneurysms were detected in 65 (81.2%) patients on CTA. The most common site of pseudoaneurysms was gastroduodenal artery (GDA) followed by splenic artery. Seven patients were treated with percutaneous thrombin injection and five were treated with percutaneous glue injection under ultrasound/fluoroscopy guidance. The remaining patients (n=68) underwent catheter angiography with endovascular embolisation. Technical success was achieved in 4/7 (57%) percutaneous thrombin cases and in all the cases (5/5, 100%) with percutaneous glue or endovascular (68/68,100%) embolisation.

CONCLUSION

Endovascular or percutaneous embolisation of pseudoaneurysms has high technical success with an excellent safety profile.

Application of interventional embolization in the treatment of iatrogenic pseudoaneurysms

The present study aimed to investigate the clinical effectiveness and safety of endovascular embolization for the treatment of pseudoaneurysm secondary to previous abdominal and pelvic surgery or radiological percutaneous abdominal procedure. A retrospective review was performed on all patients with abdominal and pelvic pseudoaneurysm confirmed by CT angiography or digital subtraction angiography and treated with endovascular embolization. Different techniques of embolization with coils were applied and the outcomes, including clinical effectiveness and safety, were assessed. A total of 31 patients with a total of 32 pseudoaneurysms were included in the present study. Of these pseudoaneurysms, 23 were from the main trunks and branches of the gastroduodenal artery, 5 were from the splenic artery, 2 were from the common hepatic artery, 1 was from the right hepatic artery and 1 was from the right internal iliac artery. There were no serious complications observed and there was no occurrence of re-bleeding following embolization. The embolization of the pseudoaneurysms was successful in all patients. In conclusion, endovascular embolization is a safe and effective method for the treatment of secondary iatrogenic pseudoaneurysm in the abdomen and pelvis.

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.

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.

Arterial pseudoaneurysms in acute and chronic pancreatitis: Clinical profile and outcome

Objective

To evaluate the clinical profile and outcome of arterial pseudoaneurysms (PSA) associated with acute and chronic pancreatitis (CP).

Methods

Records of all patients of pancreatitis from 2010 to 2016 were analyzed retrospectively for the development PSAs; clinical profile and outcome parameters were compared between PSAs associated with acute and CP.

Results

Of the 980 patients, 46 (all males, age 39.70 ± 11.78 years) developed PSAs, including 19 of 600 of acute pancreatitis (AP) and 27 of 380 of CP. The most common clinical presentation was bleeding (37, 80.4%). The majority of patients was managed nonsurgically, with endovascular embolization in 31 (67.4%) and percutaneous thrombin injection in 9 (19.6%) patients. Pseudoaneurysms in patients with AP were associated more often with fluid collections (94.7% vs. 55.6%, P = 0.004) with more requirement of surgery compared to patients with CP (15.8% vs. 3.7%, P = 0.033). The pattern of arteries involved with PSAs and outcome was similar in AP and CP patients.

Conclusion

Arterial PSAs were more commonly associated with CP compared to AP with similar presentations. Associated fluid collections and requirement of surgical intervention were higher in PSAs in patients with AP compared to patients with CP.

[Management of traumatic and iatrogenic arterial pseudoaneurysms in a tropical environment]

A false aneurysm or pseudoaneurysm (PA) is the formation of a pulsatile and encapsulated hematoma in communication with the lumen of a perforated artery. Its origin is different but most cases are associated with a traumatic event. Currently, the referenced treatment is endovascular surgery but it is not feasible for the majority of vascular surgeons working in a tropical environment. The aim of this study was to describe the diagnostic and therapeutic aspects of arterial PA (APA) encountered in our institution and to evaluate the place of open surgical technique in their management. This was a 30-month retrospective and descriptive study carried out in our institution (CHU-JRA, Antananarivo, Madagascar). Between 2012 and 2014, ten cases of APA were operated. There were 8 men with an average age of 30 years. The etiologies were accidental trauma (n=6) or iatrogenic vascular injury (n=4). Most patients had a painful and pulsatile swelling (n=8). The presence of a wound scar located on the swelling was observed in 5 patients. The false aneurysms were localized in the radial (n=3), femoral (n=2), brachial (n=2), carotid (n=2) and ulnar (n=1) arteries. The diagnosis was confirmed by ultrasound Doppler in all patients. The treatment was an open surgical procedure and consisted of lateral suture (n=4), resection with direct end-to-end anastomosis (n=1) or using autologous saphenous vein graft (n=2) or ligation (n=3). Postoperative courses and outcomes at last follow-up were uneventful with optimal patency rate.

Pancreatitis: Preventing catastrophic haemorrhage

Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.