Visceral artery pseudoaneurysms: two case reports and a review of the literature

Spontaneous hepatic artery pseudoaneurysm rupture as a first presentation of polyarteritis nodosa

A man in his 70s presented with a sudden onset stabbing back pain radiating to the chest and pre-syncopal symptoms. He underwent urgent investigations, including a CT angiogram aorta which did not reveal any abnormalities within the thorax, abdomen or pelvis and no cause of symptoms was identified. After being discharged, he re-presented 2 days later with syncopal episodes, abdominal pain and a significant drop in haemoglobin levels. This time, a CT mesenteric angiogram showed two hepatic artery pseudoaneurysms and a large haemoperitoneum. Following a hepatic artery embolisation, a workup showed that the likely cause of the pseudoaneurysms was a rare first presentation of polyarteritis nodosa. This case highlights the importance of considering the possibility of an aneurysmal rupture, especially when common causes of an acute abdomen have been excluded, and not relying on previous negative investigations to exclude pathology, as the outcomes can be detrimental.

Pseudoaneurysm of the Gastroduodenal Artery: A Rare Complication of Bile Duct Surgery

Pseudoaneurysm of the gastroduodenal artery (GDA) is an exceptional complication of common bile duct (CBD) resection. We present the case of a 60-year-old woman with a history of cholecystectomy. The patient was admitted to our hospital for surgical management of the cystic dilatation of the CBD. The patient presented on postoperative day 21 with hemodynamic instability related to a pseudoaneurysm of the GDA. An urgent open surgery was performed with dissection and ligation of the GDA.

Endovascular management of colic artery pseudoaneurysm: A case report of successful intervention in a 59-year-old male with abdominal hematoma

Visceral artery pseudoaneurysms, including inferior mesenteric artery pseudoaneurysms, are rare, occurring at an estimated incidence of 0.01%-0.2%. The literature reports only around 60 cases of inferior mesenteric pseudoaneurysm to date. The management of this condition lacks a consensus; nevertheless, coil embolization remains the preferred approach for stable patients. Here, we present a unique clinical scenario involving a 59-year-old male who underwent exploratory laparotomy for a retroperitoneal hematoma. Subsequently, he was diagnosed with an inferior mesenteric pseudoaneurysm, specifically affecting the left colic artery, and successfully managed using coil embolization.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Hemosuccus pancreaticus as a rare cause of gastrointestinal bleeding

Hemosuccus pancreaticus is a life-threatening condition that should be considered in patients with abdominal pain, gastrointestinal hemorrhage and high serum amylase. The varied presentation of hemosuccus pancreaticus and the limited literature evidence due to its rarity make it challenging to diagnose. Diagnostic modalities include contrast-enhanced computed tomography scans, endoscopic procedures (esophagoduodenoscopy and endoscopic retrograde cholangiopancreatography) and angiography. Therapeutic management through an interventional radiology using coil embolization is safe and effective in hemodynamically stable patients with hemosuccus pancreaticus. Endosonography can be an innovative approach for the diagnosis and treatment of patients in whom contrast cannot be administered; however, its safety and efficacy need to be confirmed by future studies. This review presents current views on the diagnosis and treatment of patients with hemosuccus pancreaticus.

Ruptured ileocolic artery pseudoaneurysm after laparoscopic appendectomy for acute appendicitis

Background

A pseudoaneurysm of the splanchnic vessels is considered to be rare, and in particular, very few cases of pseudoaneurysm in the ileocolic artery are reported. Here, we report a case of rupture of a pseudoaneurysm of the appendicular branch of the ileocolic artery after laparoscopic appendectomy.

Case presentation

A 52-year-old man was diagnosed as having phlegmonous appendicitis, and an emergency laparoscopic appendectomy was performed. Bleeding from the inter-appendicular ligament during detachment of adhesions was stopped by white coagulation and Z-suture, and the inter-appendicular ligament was treated. The postoperative course was uneventful, and there were no adverse events or findings suggestive of abscess formation. On postoperative day 30, he presented with a ruptured pseudoaneurysm of the appendicular branch of the ileocolic artery. A definitive diagnosis was made by computed tomography, and emergency interventional radiology was performed with hemostasis achieved by coiling. The patient’s postprocedure course was favorable, and he was discharged with no adverse events, such as intestinal ischemia.

Conclusions

We experienced a case of delayed pseudoaneurysm rupture after laparoscopic appendectomy. Care must be taken when handling the appendicular artery during the procedure, and the potential for pseudoaneurysm formation should be considered at postoperative follow-up.

Rupture of pseudoaneurysm of a digiunal artery in the pancreatic duct

Visceral arterial pseudoaneurysms are uncommon vascular abnormalities affecting renal or splanchnic arteries. They can be complications of chronic pancreatitis, blunt or penetrating abdominal trauma, or surgical, endoscopic and interventional radiological procedures. Visceral arterial pseudoaneurysms can be life-threatening because of hemorrhagic shock secondary to rupture and massive bleeding. We report an unusual case of rupture of a pseudoaneurysm of a digiunal artery in the pancreatic duct.

Gastrointestinal bleeding due to pseudoaneurysms in children

Radiological embolization is the treatment of choice in adults with visceral artery pseudoaneurysm (PSA) and gastrointestinal bleeding, but pediatric data is scanty. We analyzed the etiology, clinical presentation, and outcome of radiological intervention in children with PSA of celiac (CA) or superior mesenteric artery (SMA) branches. Electronic records of children with PSA of CA or SMA branches were reviewed and data on clinical and laboratory profile, radiological intervention, and outcome was recorded. Eleven children with PSA (5 boys, 11 [7-17] years) were studied. Etiology was liver abscess (n 4), abdominal trauma (n 3), pancreatitis (n 3), and indeterminate in 1 case. Ten (91%) patients were symptomatic: abdominal pain (10, 91%), hematemesis/melena (9, 81%), and Quincke's triad (1, 9%). One child with pancreatic pseudocyst was diagnosed incidentally on imaging. Doppler ultrasound identified PSA only in 3 cases, while computed tomography angiography (CTA) picked all cases. Children with liver abscess, trauma, and unknown etiology had PSA from CA (right hepatic artery 7, left hepatic artery 1). Of the 3 pancreatitis cases, 2 had PSA from SMA (inferior pancreatico-duodenal artery and ileal branch) and 1 from CA (left gastric artery). Radiological embolization was done in 9 (81%) cases (coil 6, glue 2, both 1), without any complications or failure. One case resolved spontaneously and 1 died pre-intervention. Nine intervened cases were asymptomatic in follow-up [6 (1-24) months].Conclusion: Liver abscess, trauma, and pancreatitis are causes of PSA of CA and SMA branches in children. A majority present with gastrointestinal bleeding and are identified on CTA. Radiological embolization was safe with 100% success. What is Known: • Pseudoaneurysm of visceral artery is an uncommon cause of gastrointestinal bleeding. • Endoluminal intervention is an established and efficacious treatment modality in adults and preferred over surgery. What is New: • Liver abscess, abdominal trauma and pancreatitis are common causes of celiac artery and superior mesenteric artery branch pseudoaneurysm in children and computed tomography angiography has high sensitivity in identifying these pseudoaneurysms. • Minimally invasive radiological angio-embolization, in the hands of trained radiologists, is a safe and successful modality of treatment in children.

Left Gastric Artery Pseudoaneurysm Due to Pancreatitis

Acute or chronic pancreatitis can cause pseudoaneurysms of visceral arteries. The left gastric artery (LGA) is the least common visceral artery being affected. Here, we report a case of chronic pancreatitis with a pseudoaneurysm of the LGA. A 42-year-old male, a chronic alcoholic, and smoker, presented with abdominal pain, haematemesis, and melena. Diagnosis of pseudoaneurysm of LGA aneurysm was confirmed by computed tomography abdomen. The endovascular coil embolization was done successfully, following which the patient had an uneventful recovery.

Post-embolization outcomes of splenic artery pseudoaneurysms: A single-center experience

PURPOSE

Splenic artery pseudoaneurysms (PSA) are relatively rare but associated with high mortality/morbidity when presenting acutely. Embolization has emerged as the treatment of choice. We aim to evaluate the outcomes of embolization for the treatment of splenic artery PSAs.

METHODS

From 2007 to 2019, all patients that underwent embolization for splenic artery PSAs were included in this IRB-approved review. Evaluated outcomes included complications, morbidity/mortality rates, and 30-day white blood cell count. Student t-tests were performed to compare laboratory values before and after embolization. 5-year survival rates were estimated using Kaplan Meier methodology.

RESULTS

A retrospective analysis of 24 patients (14 males, mean age 51 ± 19 years) who underwent splenic artery PSA embolization was performed. Fifteen PSA embolizations were performed in an emergent setting. There was technical success in 23/24 patients. Etiologies included trauma (10), pancreatitis (9), post-surgical (3), and malignancy (2). Post-embolization patients had a mean length of stay of 19 days and within 30 days, 9 patients developed leukocytosis (median of 14,800/μl). The 5-year survival rate of these patients was 89% [95% CI 75% - 100%]. Post-procedure, 4 patients developed grade 2 complications. Grade 3 complications were observed in 5 patients. One (4.2%) splenic abscess was identified. Of the 19 patients with follow-up imaging, 14 patients had splenic infarcts (5 infarcts were >50% of splenic volume).

CONCLUSIONS

Splenic artery PSAs are encountered in the emergent setting and are most frequently secondary to trauma or pancreatitis. Embolization can be life-saving in these critically ill patients.

Endovascular management of ruptured left gastric artery pseudoaneurysm giving rise to replaced left hepatic artery following radical cystectomy: A case report

Visceral artery pseudoaneurysms are rare and potentially fatal unless recognized and treated immediately. Here we present to our mind the first documented case of a ruptured pseudoaneurysm involving the left gastric artery giving rise to Michels' Type II replaced left hepatic artery. An 84-year-old female presented with an acute rupture of such an aneurysm post radical cystectomy. CT Angiogram prior to intervention was key for appropriate catheter selection. Endovascular embolization proved effective, and the patient recovered unremarkably. The case report includes a brief discussion regarding the investigation and management of such ruptures, as well as the rarity of the variant anatomy described.

An Undiagnosed Case of Chronic Pancreatitis With Multiple Visceral Arteries Pseudoaneurysm

Visceral artery aneurysms, which could be either true or pseudo, are abnormal focal dilations of vessels supplying the abdominal organs. True aneurysms, by definition, suggest dilation of the vessel in response to increased blood flow, ultimately causing a blood-filled sac to form. Pseudoaneurysm, however, is the pooling of blood in surrounding tissues secondary to trauma or rupture. A 43-year-old woman G9 P9, known hypertensive was admitted electively for investigation of melena, hematemesis, hematochezia for one week along with weight loss and epigastric pain. Laboratory studies showed mild anemia with a hemoglobin level of 9.6 g/dL, hematocrit 29.5%, mean corpuscular hemoglobin (MCH) 26.7, upon which she was transfused two pints of blood and commenced at Injectable Vitamin K, injectable transamine, and infusion omeprazole. Two days later her levels improved to HB 12.4 g/dL, hematocrit 37.5%, MCH 26.7 pg, RBC 4.64 × 10*12/L. while being on treatment, a computed tomography (CT) mesenteric angiography was also conducted that showed multiple splanchnic pseudoaneurysms involving celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing significant mass effect on the second part of duodenum. On the basis of such findings, it was advised to perform coiling and embolization of the corresponding arteries. Multiple other small aneurysms with secondary arteriovenous malformations (AVM) were also seen. The whole circuit of flow retrograde and antegrade along with the aneurysm sac was blocked with multiple coils of variable sizes. An angiogram was repeated that revealed a good outcome. Pseudoaneurysms of the visceral arteries are very rare and affect mainly the splenic artery. The rarest of which is gastroduodenal artery (1.5%), pancreaticoduodenal artery (2%), and coeliac truck (4%). Therefore, this can be an incidental finding. The diagnosis is usually made with an angiography combined with clinical presentation. Variable treatment options are available depending on the patient’s fitness and hemodynamic stability. The endovascular approach, however, is mostly used in such cases.

Giant Celiac Artery Pseudoaneurysm in a Case of Chronic Pancreatitis: A Rare Case Report With Literature Review

Pancreatic pseudoaneurysms though uncommon can result in life-threatening spontaneous acute gastrointestinal or intraperitoneal hemorrhage. Celiac artery pseudoaneurysm in a background of chronic pancreatitis is a very rare event. Digital Subtraction Angiography is an important adjunct in the diagnosis and follow-up with the advantage of providing therapeutic options along with giving other details regarding the site, size, and flow characteristics. It has replaced emergency surgical procedures with the added advantage of fewer postoperative complications and lower morbidity and mortality. An urgent surgical intervention remains the only option when such endovascular management fails, not feasible, or is unavailable. Surgical options include proximal arterial ligation or a pancreatic resection, depending on the location of the pseudoaneurysm. We report a case of a 35-year-old gentleman, a known patient of chronic pancreatitis, who presented to our emergency with clinical features of hypovolemic shock and was diagnosed to have celiac artery pseudoaneurysm. Following a failed endovascular coiling, he was successfully managed with operative celiac artery ligation.

Interdisciplinary Management of Visceral Artery Aneurysms and Visceral Artery Pseudoaneurysms

The paper presents the results of treating 14 patients, namely eight patients with visceral artery aneurysms and six patients with visceral artery pseudoaneurysms. In 64.3% of the patients, the initial diagnosis was made based on the ultrasound examination. All the patients (100%) underwent CT angiography, while angiography was performed in 71.4% of the cases. Five (35.7%) patients with visceral artery pseudoaneurysms were emergently hospitalized; among them, the signs of bleeding were observed in 2 patients. In 9 patients, pathology was detected during tests for other conditions. Five (35.7%) patients underwent endovascular treatment, while 9 (64.3%) patients received surgical treatment. Endovascular interventions and open surgery demonstrated a nil mortality rate. After endovascular treatment, stent thrombosis was found in 1 patient. In the case of surgical treatment, visceral artery aneurysm was observed in 1 patient who underwent the resection of superior mesenteric artery pseudoaneurysm. Conclusions. The choice of the method of treating visceral artery aneurysms and visceral artery pseudoaneurysms depends on the location, size, anatomic features of the visceral arteries and the clinical course of the disease. Both endovascular and surgical treatment demonstrate good postoperative outcomes. Visceral ischemia is one of the most serious complications in the postoperative period, which can complicate both the diagnosis and the choice of treatment tactics.

Hemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis: A case report and review of literature

BACKGROUND

Hemosuccus pancreaticus is a very rare but severe form of upper gastrointestinal hemorrhage. The most common etiology is peripancreatic pseudoaneurysm secondary to chronic pancreatitis. Due to the rarity of gastroduodenal artery pseudoaneurysms, most of the current literature consists of case reports. Limited knowledge about the disease causes diagnostic difficulty.

CASE SUMMARY

A 39-year-old man with a previous history of chronic pancreatitis was hospitalized due to hematemesis and melena for 2 wk, with a new episode lasting 1 d. Two weeks prior, the patient had visited a local hospital for repeated hematemesis and melena. Esophagogastroduodenoscopy indicated hemorrhage in the descending duodenum. The patient was discharged after the bleeding stopped, but hematemesis and hematochezia recurred. Bedside esophago-gastroduodenoscopy showed no obvious bleeding lesion. On admission to our hospital, he had hematemesis, hematochezia, left middle and upper abdominal pain, severe anemia, and elevated blood amylase. After admission, intermittent hematochezia was observed. Abdominal contrast-enhanced computed tomography revealed a pseudoaneurysm in the pancreas head. Angiography confirmed the diagnosis of gastroduodenal artery pseudoaneurysm. The pseudoaneurysm was successfully embolized with a coil and cyanoacrylate. No bleeding was observed after the operation. After discharge from the hospital, a telephone follow-up showed no further bleeding signs.

CONCLUSION

Hemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis is very rare. This diagnosis should be considered when upper gastrointestinal bleeding and abdominal pain are intermittent. Abdominal enhanced computed tomography and angiography are important for diagnosis and treatment.

[Endovascular treatment of aneurysms and pseudoaneurysms of visceral arteries]

AIM

The purpose of the study was to demonstrate the possibilities and efficacy of endovascular interventions in patients with visceral artery aneurysms.

PATIENTS AND METHODS

From 2013 to June 2020, we performed 15 embolizations of visceral artery aneurysms in 15 patients (8 men and 7 women). The technical success rate was 100%. The patients' age varied from 32 to 71 years. In 8 cases, the aneurysm was located in the basin of the splenic artery, in 3 cases in the gastroduodenal artery, in 2 cases in the superior mesenteric artery and in 2 cases in the renal artery. Three aneurysms were classified as false, and 12 as true. All aneurysms were saccular, with their diameter ranging from 6 to 32 mm. In 2 patients aneurysms were detected after endured infective endocarditis, in 8 during examination in abdominal pain syndrome, and in 5 cases as an incidental finding while performing computed tomography of abdominal organs. One patient was subjected to embolization of the afferent vessel, two underwent implantation of stent grafts into the aneurysmal neck area, and eleven underwent aneurysmal sac embolization with microcoils. In 9 cases, embolization was performed using microcoils only in 1 case using microcoils with balloon assistance, and in 2 cases using microcoils with stent assistance. We used from 1 to 12 microcoils, with a diameter of from 2 to 30 mm.

RESULTS

During endovascular embolization of visceral artery aneurysms there were no target-organ infarctions, haemorrhagic complications, nor lethal outcomes. In the early postoperative period, 7 patients developed pain syndrome. In 1 case pain syndrome was relieved by narcotic analgesics, in 4 cases by spasmolytics, and in 2 cases by a combination of spasmolytics and non-narcotic analgesics.

CONCLUSION

Endovascular treatment of visceral arterial aneurysms is an efficient and safe method.

A Unique Case of Severe Hematochezia: Ruptured Pseudoaneurysm of the Superior Rectal Artery

Visceral artery aneurysms are rare, with an incidence of 0.01%–2% based on autopsy results. Among the visceral arteries, inferior mesenteric artery aneurysms are the rarest. To our knowledge, we report the first case of acute lower gastrointestinal bleeding in a 45-year-old man, arising from a nontraumatic pseudoaneurysm of the superior rectal artery, a branch of the inferior mesenteric artery. Urgent angiography provided the diagnosis and allowed successful hemostatic intervention via endovascular coil embolization. A subsequent routine colonoscopy revealed an ulcer with central yellow-bluish bulge in the distal rectum correlating with the site of the treated pseudoaneurysm.

Hemosuccus pancreatitis due to a ruptured splenic artery pseudoaneurysm - diagnosis and endovascular management

Hemosuccus pancreatitis is a rare and potentially fatal cause of upper gastrointestinal bleeding characterized by hemorrhage from the ampulla of Vater via the pancreatic duct. In this case, a patient with chronic pancreatitis on a background of chronic alcoholism is found to have a splenic artery pseudoaneurysm that was bleeding into the pancreatic duct. This was identified on contrast-enhanced computed tomography imaging and successfully managed via microcoil embolization.

A Rare Case of Ruptured Bronchial Artery Pseudoaneurysm and Its Nonsurgical Management With Interventional Techniques

Ruptured bronchial artery pseudoaneurysms with mediastinal hematoma are rare entities with a very limited number of published cases to date. The diagnosis of such cases can be difficult as the patient may present with symptoms mimicking other diseases, mainly mediastinal malignancy. A high degree of clinical suspicion and imaging techniques like contrast-enhanced computed tomography (CECT) chest and computed tomography angiography (CTA) aids in the diagnosis. Under the lights of an interventional radiologist, an urgent endovascular approach is most commonly preferred for its nonsurgical management. We present a rare case of a 47-year-old male with no previous lung disease or trauma with dyspnea and sudden onset chest pain. A massive effusion was suspected on the right side. CECT chest and digital subtraction angiography (DSA) revealed a pseudoaneurysm of a bronchial vessel with associated mediastinal hematoma, collapse of basal right lower lobe, and collection in right pleural space. This patient was later successfully treated by endovascular embolization techniques. Bronchial artery pseudoaneurysm may be considered a remote possibility in the absence of trauma or other lung diseases that may present with a massive hemothorax or mediastinal hematoma. Although CECT can be useful, digital angiography is considered the gold standard. Early intervention with the endovascular approach is a commonly recommended technique.

Large spontaneous median sacral artery pseudoaneurysm masquerading as hip pain

We report the case of an 81-year-old man who presented with severe right hip pain and reduced physical function secondary to a large spontaneous median sacral artery pseudoaneurysm measuring 83.5 × 55.4 mm. The patient had no history of recent trauma, infective or inflammatory disease, or any recent procedures. The patient was taking apixaban for atrial fibrillation. Percutaneous coil embolization was used to occlude the pseudoaneurysm. This case describes a novel disease, spontaneous median sacral artery pseudoaneurysm, presenting with hip pain.

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.

False in Name Only-Gastroduodenal Artery Pseudoaneurysm in a Recurrently Bleeding Patient: Case Report and Literature Review

Although the diagnosis of visceral pseudoaneurysm is unusual, it requires emergent attention due to the risk of rupture. We describe a 70-year-old man with a gastroduodenal artery pseudoaneurysm that manifested as recurrent hemorrhage. We highlight the possible etiologies, clinical presentations, diagnostic tools, and treatment options for this condition. In this instance, the patient was successfully treated by selective angioembolization. A visceral pseudoaneurysm should be considered in patients with abdominal pain and GI hemorrhage. At present, angioembolization is a first-line therapy.

'Enemy within': an interesting cause for anemia during warfarin therapy for atrial fibrillation

The oral anticoagulant warfarin is a vitamin K antagonist and is considered the first line anticoagulant in valvular atrial fibrillation. However prothrombin time should be closely monitored, drug interactions checked and compliance regarding diet ensured when the patient is on warfarin therapy. Anaemia should be looked for, evaluated for the cause and corrected since it is an independent predictor of bleeding and thrombotic episodes during warfarin therapy for atrial fibrillation We present an interesting case of anaemia which developed during warfarin therapy for atrial fibrillation. The patient was on amiodarone and was consuming leafy vegetables resulting in frequent raise in prothrombin time during which time she developed bleeding into the right femoral pseudoaneurysm which had developed following catheterisation for thrombectomy. Surgical correction of pseudoaneurysm was done, comedication was changed and diet compliance ensured which resulted in the subsequent maintenance of prothrombin time in the therapeutic range and steady haemoglobin levels.