Treatment strategies for bleeding from gastroduodenal artery pseudoaneurysms complicating the course of chronic pancreatitis-A case series of 10 patients

Gastroduodenal artery aneurysm/ pseudoaneurysm: a systematic review of reported cases

Background

This systematic review and meta-analysis investigated the clinical characteristics of patients with gastroduodenal artery aneurysm (GDA), identified risk factors associated with poor clinical outcomes, and elucidated potential differences between various GDA etiologies.

Methods

A systematic literature search was conducted from January 2000 to October 2023 in the PubMed, EMBASE, and Google Scholar databases. The analysis focused on extracting data regarding clinical presentations, diagnostic modalities, and patient outcomes.

Results

This meta-analysis included data from 224 patients derived from 207 case reports spanning 47 countries over a 23-year period. The majority of patients presented with comorbidity (85.3%) and had a predisposing factor for GDA (71.9%). The diagnostic accuracy of the three most common diagnostic investigations-namely angiography, abdominal computed tomography, and ultrasound-was 100.0%, 86.2%, and 59.6%, respectively. Transarterial embolization (75.0%) and surgery (24.1%) were the two most common therapeutic approaches. Emergent treatment for GDA was necessary in 31.7% of patients. Notably, hemostasis was achieved after the initial treatment attempt in 82.6% of patients. The in-hospital mortality rate was 6.7%, with complications occurring in 16.1% of cases. A higher percentage of patients with a complicated hospital course were subjected to observation management and presented with shock during hospitalization.

Conclusions

Patients with GDA often have comorbidities and predisposing factors. Clinical presentations of GDA were found to include abdominal pain, hemorrhage, and obstruction of peripheral structures in the vicinity of the gastroduodenal artery. Splanchnic artery angiography and abdominal computed tomography are recognized as the most accurate tools for diagnosing GDA. Endovascular management is the mainstay treatment approach for most patients and have a high rate of hemostasis success during the initial intervention. Surgical intervention is also a practical treatment. Conservative management with observation management may lead to a complicated hospital course, highlighting the potential benefit of aggressive treatment strategies for GDA. Patients with pancreatitis exhibited more comorbidities, predisposing factors, and a broader spectrum of clinical manifestations compared to those without pancreatitis. However, the in-hospital mortality rate was lower in the pancreatitis group, likely due to the younger age of the patients and the more prominent clinical presentations, which prompted earlier and more extensive diagnostic imaging studies.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

A Ruptured Pseudoaneurysm of an Anomalous Gastroduodenal Artery: A Rare Presentation

Gastroduodenal artery (GDA) anomalies are a rare entity. Rupture of such anomalies can present with a diagnostic challenge. In this report, we describe a case of ruptured pseudoaneurysm of an anomalous GDA arising directly from the aorta presenting with recurrent abdominal pain and anemia. The diagnosis was made on computed tomography scan which showed acute retroperitoneal fluid collection. Further angiographic intervention highlighted the anomalous GDA arising directly from the aorta.

Hemosuccus Pancreaticus and Obstructive Jaundice: Two Rare Complications of Chronic Pancreatitis Treated by Arterial Embolization

The formation of a peripancreatic pseudoaneurysm is a rare and serious complication of chronic pancreatitis. In this report, we present the case of a 56-year-old male with a history of alcohol-related chronic pancreatitis resulting in both hemosuccus pancreaticus and obstructive jaundice due to a pseudoaneurysm of the gastroduodenal artery that was treated successfully by angiographic coiling.

Successful Embolization of Posterior Inferior Pancreaticoduodenal Artery Pseudoaneurysm on the Grounds of Chronic Pancreatitis-Case Report and Literature Review

Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color–Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., “sandwich technique”.

Hemorrhage complicating the course of severe acute pancreatitis

Backgrounds/Aims

The course of severe acute pancreatitis (SAP) complicated by hemorrhage is associated with poor outcome.

Methods

Twenty-four (13%) out of 183 cases of SAP had hemorrhagic complications- 12 intraabdominal & 12 intraluminal, 13 had major & 11 had minor and 16 had de-novo & 8 post-surgical bleeding. The mean duration of pancreatitis prior to bleeding was 27±27.2 days.

Results

Predictors of haemorrhage on univariate analysis were delayed admission (0.037), more than one organ failure (p=0.008), presence of venous thrombosis (p=0.033), infective necrosis (0.001) and systemic sepsis – bacterial (0.037) & fungal (p=0.032). On multivariate analysis infected necrosis (OR=11.82) and presence of fungal sepsis (OR=3.73) were the significant factors. Patients presenting with more than one organ failure and bacterial sepsis had borderline significance on multivariate analysis. Need for surgery (50% vs. 12.6%), intensive care stay (7.4±7.9 vs. 5.4±5.2 days) and mortality (41.7% vs. 10.7%) were significantly higher in patients who suffered haemorrhage. Seven of the 13 with major bleeding had pseudoaneurysms-4 were embolized, 4 needed surgery including 1 embolization failure. Seven with intraabdominal bleeding required surgical intervention, 2 had successful embolization and 3 had expectant management. CT severity index and surgical intervention, were significantly associated with intraabdominal bleeding. Organ failure, presence of pseudoaneurysm and surgical intervention were associated with major bleeding.

Conclusions

Hemorrhage in SAP was associated with increased morbidity and mortality. Infected necrosis accentuated the degradation of the vessel wall, which predispose to hemorrhage. Luminal bleeding may be indicative of erosion into the adjacent viscera by the pseudoaneurysm.

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.