Transcatheter management of pseudoaneurysms complicating pancreatitis

Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis

BACKGROUND

There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms.

METHODS

Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I² 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I² 42%), 86% (95% CI-75-92%, I² 44%), and 88% (95% CI-83-91%, I² 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I² 0%)). Splenic infarction was the most common complication (n = 47).

CONCLUSION

Endovascular embolization is associated with a high technical and clinical success.

Safety and efficacy of transarterial embolisation for treatment of dorsal pancreatic artery haemorrhage

AIM

To evaluate the safety and efficacy of transarterial embolisation (TAE) of dorsal pancreatic artery (DPA) haemorrhage.

MATERIALS AND METHODS

Nineteen consecutive patients (M:F = 16:3, mean age 59.6 years) who underwent TAE of DPA in three tertiary medical centres between January 2001 to January 2020 were reviewed retrospectively. Angiographic features and the technical and clinical outcomes of TAE were analysed.

RESULTS

The clinical presentations were a bloody drain from the Jackson-Pratt drainage tube (n=8), melaena (n=7), abdominal pain (n=4), and haematochezia (n=3). Angiographic findings included pseudoaneurysm (n=14), contrast media extravasation (n=4), or abrupt cut-off of the arterial branch (n=1). The NBCA (N-butyl-cyanoacrylate; n=4), microcoils (n=4), and a combination of these agents (n=7) were used as embolic agents. The most common origin of the DPA in the present study cohort was the splenic artery (n=7), followed by the coeliac trunk (n=4), common hepatic artery (n=4), and superior mesenteric artery (n=4). Technical and clinical success rates were 100% and 84.2% (16/19), respectively. Of the three clinically unsuccessful cases, two patients were revealed to have newly developed bleeding from another artery. The other patient expired 1 day after the TAE procedure due to a progression of hepatic failure. In one patient, an asymptomatic non-target embolisation occurred in the right posterior tibial artery as a procedure-related complication. No major complications were observed.

CONCLUSION

TAE is safe and effective for the management of bleeding from the DPA. It is important to be aware of the DPA as a potential bleeding source, including the relevant clinical characteristics.

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.

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.

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

PURPOSE

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications.

METHODS

During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications.

RESULTS

Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient.

CONCLUSIONS

Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

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.

Endovascular treatment of visceral aneurysms and pseudoaneurysms: long-term outcomes from a multicenter European study

PURPOSE

To investigate the percutaneous endovascular management of visceral aneurysms (VA) and visceral pseudoaneurysms (VPA) treated in three European interventional radiology departments.

METHODS

Patient archives from the department's databases were examined and retrospectively analyzed. Patients diagnosed between 2000 and 2010 with VA and/or VPA, confirmed by computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography and treated exclusively with percutaneous endovascular methods, were included in the study. The study's primary end points were procedural technical success, target lesion reintervention rate, and periprocedural mortality rate. Secondary end points included major and minor complications rates.

RESULTS

The medical records of 54 patients (41 male, mean age 55 ± 18.1 years) with 58 VAs or VPAs and treated with various percutaneous endovascular therapeutic modalities were analyzed. In total, 21 VAs (mean diameter 49.4 ± 21 mm, range 20-100 mm) and 37 VPAs (mean diameter 25.1 ± 14.6 mm, range 8-60 mm) were treated. Procedural technical success was achieved in 100% of the cases, while target lesion reintervention rate was 6.1% (2 of 33) and 14.2% (3 of 21) in the VPA and VA groups, respectively. Mean clinical follow-up period was 19.1 ± 21.4 months. Overall periprocedural mortality rate was 3% (1 of 33) in the VPA group and 0% (0 of 21) in the VA group.

CONCLUSION

Percutaneous endovascular treatment of VAs and VPAs is safe and effective with low morbidity and mortality. There is a small but significant reintervention rate, particularly for true aneurysms; dedicated follow-up imaging is recommended. Successful aneurysm exclusion was achieved in all cases with a second procedure.

Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate

The purpose of this study is to evaluate the clinical efficacy of transcatheter embolization for pseudoaneurysms of peripheral arteries with n-butyl cyanoacrylate (NBCA). From November 2000 to February 2008, 17 patients with 18 pseudoaneurysms were treated by transcatheter embolization at our affiliated hospitals. The locations of the pseudoaneurysms were right hepatic artery (n=3), renal artery (n=5), splenic artery (n=2), gastroduodenal artery (n=2), common hepatic artery (n=1), pancreatic arcade (n=1), external iliac artery (n=1), internal iliac artery (n=1), internal thoracic artery (n=1), and left gastric artery (n=1). We assessed technical success rate, embolization methods, and clinical course in this study. The technical success rate was 94.4% (17/18 cases). Embolization methods were isolation (n=17) and packing (n=1). Only NBCA was used in 14 cases, both coils and NBCA were used in four cases. Six patients were in shock prior to the procedure, but all patients recovered immediately after embolization procedure including transfusion. None of the patients died of procedure-related factors or had notable postoperative complications, but three patients died within a week of the procedure because of deterioration of the underlying disease. In conclusion, transcatheter embolization of pseudoaneurysms with NBCA is a safe and effective technique for treatment.

Acute parent artery dissection as a complication of mesenteric endovascular coil embolisation for pancreatic pseudoaneurysm

We wish to highlight arterial dissection as an unusual complication during endovascular coiling of a pancreatic pseudoaneurysm. Immediate recognition and prompt corrective measures prevented progression of this serious condition. In our patient, angioplasty prevented further propagation of the dissection and preserved coeliac artery patency.

Vascular complications of pancreatitis: imaging and intervention

The objective of this study was to highlight technical challenges and potential pitfalls of diagnostic imaging, intervention, and postintervention follow-up of vascular complications of pancreatitis. Diagnostic and interventional radiology imaging from patients with pancreatitis from 2002 to 2006 was reviewed. We conclude that biphasic CT is the diagnostic modality of choice. Catheter angiography may (still) be required to diagnose small pseudoaneurysms. Endovascular coiling is the treatment of choice for pseudoaneurysms. Close clinical follow-up is required, as patients may rebleed/develop aneurysms elsewhere.

Thrombin injection of a pancreaticoduodenal artery pseudoaneurysm after failed attempts at transcatheter embolization

We describe a case of a pseudoaneurysm of the pancreaticoduodenal artery in a patient with history of cholecystectomy and chronic pancreatitis. Attempts at transcatheter coil embolotherapy failed because of vessel tortuosity. The lesion was then successfully treated by computed tomography-guided direct percutaneous injection of thrombin into the pseudoaneurysm. This technique may be a first line of treatment or a useful adjunct to transcatheter embolization technique.

Hepatic artery pseudoaneurysm: a report of seven cases and a review of the literature

PURPOSE

To analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature.

METHODS

We searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature.

RESULTS

There were five cases of HAP among 18,015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients.

CONCLUSION

Hepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.

Intercostal artery pseudoaneurysm due to stab wound

Intercostal artery pseudoaneurysm is extremely rare, and only six cases have been reported in the English literature. We describe a case of intercostal artery pseudoaneurysm due to a stab wound, review the literature, and discuss therapeutic modalities. Intercostal artery pseudoaneurysm is at risk for early rupture, and diagnosis before rupture is mandatory. Although embolization is considered to be a feasible therapeutic method, we would emphasize the significance of the anatomic features of the intercostal arteries: multiple blood supplies into the pseudoaneurysm, such as the anterior and posterior intercostal arteries, and musculophrenic artery.

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.

Endovascular treatment of visceral artery aneurysms

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Invasive radiology for pediatric trauma

Interventional radiology has assumed an expanded role in the management of the pediatric trauma patient. Transcatheter endovascular embolization for the polytraumatized and bleeding patient has proven to be effective and potentially life saving. Nonvascular interventional techniques can be applied to the pediatric trauma patient with curative or temporizing effects. The minimally invasive nature and rapidity of these procedures allows their emergent use in both the unstable and stable pediatric trauma patient.

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

OBJECTIVE

Erosion of pancreatic pseudocysts into adjacent vessels is a rare but highly lethal cause of intra-abdominal hemorrhage. Percutaneous angiographic embolization (PAE) of the bleeding artery has recently been advocated as the preferred therapy. This study was undertaken to survey the outcome after treatment of this complication and to make recommendations for its management.

METHODS

An 11-year retrospective analysis was performed of all patients treated at a large tertiary care referral center for visceral artery pseudoaneurysms associated with pancreatic pseudocysts.

RESULTS

From 1988 to 1998, 256 patients were admitted for complications of pancreatic pseudocysts. Sixteen patients (11 men and 5 women) were identified in whom a pseudocyst had eroded into a major blood vessel with hemorrhage or development of a false aneurysm. The mean age was 45 years (range, 23-67 years). Active bleeding was present in 13 patients, whereas three had evidence of recent hemorrhage. Ten of 16 patients initially underwent operative therapy, four elective and six emergency, whereas six stable patients were initially treated with PAE. Technical failures of the initial treatment or secondary complications required both therapeutic modalities in six patients, which resulted in 13 total surgical interventions and 10 PAEs. The surgical morbidity rate was 62% (8 of 13), whereas that of PAE was 50% (5 of 10). Three deaths occurred after emergency operations, two of which failed to stop the bleeding, accounting for all of the deaths in the series (3 [19%] of 16). A trend was noted toward increased death with necrotizing pancreatitis (P =.07) and emergency surgery (P =.06). Ranson's criteria were not found to be predictive of death in this series. Surgical drainage procedures were required in seven (44%) of 16 patients for infections (n = 3) or mass effect of the pseudoaneurysm (n = 3). The mean size of pseudoaneurysms that required operative intervention for secondary complications was 13.9 cm, compared with 7.7 cm for all others in the series (P =.046). Long-term follow-up was available in all 13 survivors at a mean of 44 months (range, 1-108 months).

CONCLUSIONS

The management of pancreatic pseudocyst-associated pseudoaneurysms remains a challenging problem with high morbidity and death rates. Operation and PAE play complementary management roles. PAE is recommended as the initial therapy for hemodynamically stable patients. Surgery should be reserved for actively bleeding, hemodynamically unstable patients; for failed embolization; and for other secondary complications such as infection or extrinsic compression.

Radiology in the diagnosis and therapy of gastrointestinal bleeding

Major breakthroughs in catheter and guidewire design as well as improvements in angiographic x-ray equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. For chronic or recurrent GI bleeding, when endoscopy is unrevealing or equivocal, barium studies, CT scanning, nuclear medicine studies, and angiography can help determine the cause of bleeding. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is extremely helpful in managing GI bleeding, particularly in high-risk patients or patients presenting as diagnostic dilemmas.

Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate

PURPOSE

To evaluate the clinical efficacy of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone.

MATERIALS AND METHODS

Ruptured pseudoaneurysms developed at the celiac trunk (n = 1), gastroduodenal artery (n = 2), pancreatic arcade (n = 1), hepatic artery (n = 3), renal artery (n = 1), and intercostal artery (n = 1) in nine patients. NBCA was mixed with iodized-oil (1:2) and injected via the 3-F microcatheter under fluoroscopic guidance, after the catheter was advanced close to the pseudoaneurysm. Coil embolization was performed to control blood flow before administration of NBCA in seven patients. NBCA was injected immediately after coil embolization in four patients. Embolization with NBCA was performed for recurrent bleeding that occurred within 1-21 days (mean, 10.7 days) after initial coil embolization in three patients. Two patients with peripheral pseudoaneurysms underwent embolization with NBCA alone.

RESULTS

The NBCA mixture was visible under fluoroscopy, and was useful in monitoring the embolization process and deciding the endpoint. Embolization was technically successful without major complications in all patients. Pseudoaneurysms and afferent and efferent arteries were eliminated immediately after embolization. Bleeding was stopped after embolization in all cases. Rebleeding did not occur in any patient during their follow-up periods of 0.7-69.5 months (mean, 17.9 months).

CONCLUSION

Embolization with NBCA is a feasible and useful treatment for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone.

Anchoring coil embolization in a high-flow arterial model: a pilot study

PURPOSE

To devise and test an occluding coil anchoring system to improve the safety of coil embolization.

MATERIALS AND METHODS

The anchoring system was attached to Gianturco embolization coils and investigated in 15 pigs. In the short-term studies, one 0.035-inch anchored coil (15-18 cm in length and 7-10 mm in diameter) was placed in the infrarenal portion of the abdominal aorta in each of 12 pigs with use of an 8-F catheter from the carotid approach. Aortography was performed before and up to 4 hours after coil placement. In the long-term studies, 0.028-inch anchored coils (8 cm in length and 5 mm in diameter) were placed in the left femoral and the right carotid arteries in each of three pigs with use of a 6-F catheter positioned from the right femoral approach. One week later, the animals were evaluated angiographically for coil migration and vascular occlusion.

RESULTS

Radiographically, the coils created a compact conglomerate on placement in all but one of the animals. No coil migration was noted during follow-up. Necropsy confirmed compact arrangement of the coils within the vessels and revealed effective anchoring of the device in all cases.

CONCLUSIONS

The anchoring coil has proved effective in making coil embolization safer, especially in a high-flow arterial model.

Nonoperative treatment for a ruptured pseudoaneurysm of the celiac trunk: report of a case

We report the case of a 67-year-old man in whom hemorrhage from a ruptured celiac trunk pseudoaneurysm, which occurred as a consequence of leakage at the site of gastroduodenostomy, was successfully controlled by transcatheter arterial embolization (TAE) with stainless steel coils and N-butyl cyanoacrylate (NBCA). The occurrence of a pseudoaneurysm of the celiac trunk associated with anastomotic leakage is etiologically rare. We compiled reports from the literature on TAE for ruptured aneurysms of the celiac trunk, and compared its therapeutic value with that of surgical treatment. Operative death occurred in 4 of a series of 43 patients with aneurysms of the celiac trunk that were surgically treated (9.3%). In 5 patients with ruptured aneurysms, the operative mortality rate was 40% (2/5). Conversely, while the unsuccessful rate of TAE therapy was 17% (1/6), the mortality rate was nil. The patient whose case is presented here was affected by methicillin-resistant staphylococcus aureus (MRSA) at the site of leakage and in the lung. Under septic conditions such as hemorrhage secondary to pancreatitis, the mortality rate of surgical therapy was 23%-29%, whereas the success rate of TAE therapy was 79% and the mortality rate was 4%. Based on these findings, it is suggested that TAE therapy is a viable alternative to surgery for patients even with ruptured pseudoaneurysms of the celiac trunk.

Arteriographic embolization of visceral artery pseudoaneurysms

The purpose of this study was to determine the safety and efficacy of transcatheter embolization in the management of bleeding visceral artery pseudoaneurysms. Eight patients (four women and four men) whose mean age was 61.0 years (range 44 to 77 years) underwent emergency transcatheter embolization for acute hemorrhage from a visceral artery pseudoaneurysm. Arteriographic technique was used to localize and selectively embolize these seven visceral artery pseudoaneurysms (three inferior pancreaticoduodenal, one gastroduodenal, two hepatic, and one splenic) by means of intravascular steel coils. Arteriography demonstrated visceral artery pseudoaneurysms in all eight patients. Acute hemorrhage was documented by endoscopy, falling hematocrit levels, CT scans, and arteriography. Successful embolization of these visceral artery pseudoaneurysms was achieved in seven (88%) of eight patients. In one patient embolization was not attempted because of a worsening clinical status, and this patient subsequently underwent emergency surgical resection. There was no significant morbidity associated with the procedures and seven patients remain asymptomatic with no further bleeding at a mean follow-up of 21.1 months (range 11 to 46 months). Arteriographic embolization of visceral artery pseudoaneurysms is a safe and highly successful technique for the effective identification and treatment of hemorrhage even in critically ill patients.

Retained contrast after embolization of a right gastric artery pseudoaneurysm

Pseudoaneurysms due to chronic pancreatitis can be a source of major gastrointestinal (GI) hemorrhage. Computed tomography (CT) is the primary diagnostic imaging modality for pancreatic pseudocysts associated with GI bleeding. Pseudoaneurysms and associated GI bleeding can be diagnosed and embolized with transcatheter techniques once the arterial anatomy is defined. CT is a useful modality for follow-up examination of the pseudocyst; the findings must be correlated with other procedures performed on these patients. On follow-up studies, contrast medium retained in the pseudocyst after embolization may falsely signal persistent bleeding into the pseudocyst.

Synchronous embolization of the gastroduodenal artery and the inferior pancreaticoduodenal artery in patients with massive duodenal hemorrhage

PURPOSE

To assess the efficacy and safety of synchronous embolization of the gastroduodenal artery (GDA) and inferior pancreaticoduodenal artery (IPDA) in patients with massive duodenal hemorrhage.

PATIENTS AND METHODS

All cases of synchronous embolization of the GDA and IPDA at the authors' hospital between 1980 and 1989 were retrospectively reviewed.

RESULTS

Bleeding was successfully controlled acutely in all six patients who underwent synchronous embolization. Clinical evidence of recurrent hemorrhage was found in two patients, but repeat angiography showed no extravasation of contrast material. Three patients died within 30 days of embolotherapy. In one patient who also received an infusion of vasopressin, postmortem evidence of pancreatic necrosis was found.

CONCLUSION

Synchronous embolization of the GDA and IPDA can be an effective treatment for continuing duodenal hemorrhage after failed endoscopic therapy in patients considered a poor surgical risk. The procedure should be undertaken only as a lifesaving measure due to the risk of pancreatic and duodenal necrosis.

Management of inferior pancreaticoduodenal artery aneurysms: a 4-year, single center experience

Inferior pancreaticoduodenal artery aneurysms are uncommon visceral artery aneurysms usually difficult to resect, and, if untreated, have a propensity to rupture with catastrophic results. We reviewed the clinical and treatment records of four patients encountered in our institution within the last 4 years. Three patients presented as bleeding emergencies from single aneurysms and were successfully treated by transcatheter embolization using coaxial technique and a variety of embolic agents. One nonemergent, asymptomatic patient had surgical resection of two inferior pancreaticoduodenal artery aneurysms due to unfavorable anatomy for embolization. Embolization therapy appears to be the treatment of choice in the emergency setting. Patients with unsuitable anatomy for embolization may still require surgical intervention.

Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases

PURPOSE

A retrospective study of 104 cases of arterial lesions related to pancreatitis was undertaken to examine the diagnostic and therapeutic benefits of arteriography compared with ultrasonography (US) and computed tomography (CT).

PATIENTS AND METHODS

Data were acquired from responses to a questionnaire. Eighty-seven patients were men, 17 were women (age range, 21-80 years; mean, 48 years). These lesions were usually revealed by hemorrhage (70 cases), pain (69 cases), or both (46 cases).

RESULTS

Arteriography was immediately positive in 90 of 93 patients in whom it was performed, but US and CT may also permit incidental discovery of silent lesions (17 cases). These lesions are often single (90%) and related to an arterial rupture in a pseudocyst (60%) or a pseudoaneurysm (48%). They involved the splenic (42%), the gastroduodenal (22%), and the small pancreatic arteries (25%). Of 32 cases in which embolization was performed, immediate success was achieved in all cases but bleeding recurred in 12 cases (37%). Treatment in 25 patients was a definitive success (78%), and five patients died of hemorrhage (16%).

CONCLUSION

Arteriography remains essential for diagnosis of arterial lesions, and embolization may be indicated as a stabilizing preoperative procedure and also for immediately stopping hemorrhage.

Direct aneurysm puncture and coil occlusion: a new approach to peripancreatic arterial pseudoaneurysms

A patient with pancreatitis complicated by a pseudoaneurysm in the pancreatic head was treated with a radiologic-surgical approach. At surgery, the phlegmon was exposed and treated by means of direct puncture and embolization with Gianturco coils under color Doppler flow imaging guidance.