Ultrasound guided thrombin injection to treat a pseudoaneurysm secondary to chronic pancreatitis

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

We analyzed our experience with management of gastroduodenal artery (GDA) pseudoaneurysms associated with chronic pancreatitis using a multidisciplinary approach. We treated 10 patients with GDA pseudoaneurysms (all men, aged 24-62 year) who underwent treatment during April 1998 to December 2016. All had presented with recent hematemesis and/or melena. Hemodynamically, stable patients were initially subjected to transcatheter embolization or radiologically guided thrombin injection. Recurrence of bleeding within 48 h was taken as failure. Emergency surgery was done for hemodynamic instability and recurrent bleeding, and elective surgery was carried out as per specific indications. Ten interventional procedures were performed in nine patients, while one was directly subjected to surgery. Angioembolization was done in five patients (with success in four) and thrombin injection in five patients (including one with embolization failure; with success in three). Six patients underwent surgery, two on emergency basis, for hemodynamic instability and recurrent bleeding in one each, and four for definitive treatment of pancreatitis/associated complication. One patient died while the other nine survived and well with no recurrence of bleeding during follow up (6 months to 10 years). Management of GDA pseudoaneurysms requires a multidisciplinary approach. Pseudoaneurysms with narrow neck are suitable for thrombin injection while those with wide neck should be subjected to angioembolization. Emergency surgical treatment is reserved for non-surgical failures, and choice between trans-ductal or trans-cystic approach is based on the location of the aneurysm.

Endoscopic ultrasound-guided thrombin injection for management of visceral artery pseudoaneurysm: A novel approach

Visceral artery pseudoaneurysm is a rare and potentially life-threatening vascular entity with a high mortality rate, conventionally managed with digital subtraction angiography with coil embolization or surgery. However, in cases where angiographic coil embolization is not possible due to technical reasons, computerized tomography (CT)/ultrasonography-guided thrombin injection remains a viable option as described in the literature. In this case series, we intend to highlight the role of endoscopic ultrasound-guided thrombin injection in the management of abdominal visceral artery pseudoaneurysm, which is either inaccessible by endovascular route or have high surgical risk of complication.

Endovascular management of pancreatitis-related pseudoaneurysms: A review of techniques

Objectives

To present the various techniques used in the management of pancreatitis-related pseudoaneurysms of visceral vessels.

Methods

The retrospective clinical study was carried out at the Department of Diagnostic and Interventional Radiology at Poznan University of Medical Sciences from 2011 to 2016. The fifteen patients included in the study were diagnosed with pseudoaneurysms of visceral arteries, as a complication of chronic pancreatitis. The diagnosis was made using contrast-enhanced computed tomography, followed by angiography. On admission, all patients were symptomatic, with varying degrees of abdominal pain. One patient was haemodynamically unstable. Treatments with endovascular techniques were analysed, along with their efficacy and outcomes. Coil embolisation was performed in 5 patients. Stent graft was used in 1 patient. Liquid embolic agents were used in 7 cases, of which 5 patients were treated with thrombin injection and 2 with Squid. A combination of techniques was used in 2 patients.

Results

The most common artery affected by pseudoaneurysm formation was the splenic artery (7/15; 46.7%), and the size of the pseudoaneurysms ranged from 27 mm to 85 mm. Primary technical success was achieved in 14 out of 15 patients (93.3%). One patient required reintervention. Two patients required splenectomy after embolisation due to splenic ischemia. No recanalisation was present at the follow-up computed tomography performed after 1 to 3 weeks, and no mortality was observed within 30 days.

Conclusion

Vascular complications of pancreatitis require accurate diagnosis and immediate treatment. Endovascular intervention is highly effective and is the preferred treatment option. The technique used is determined based on vascular anatomy and the patient’s haemodynamic status.

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.

Ultrasound-guided percutaneous thrombin for the management of superior mesenteric artery pseudoaneurysm

Visceral aneurysms are a well-recognized and potentially fatal occurrence in the event of rupture. Endovascular occlusion using stent grafting or embolization is often favorable over high-risk open surgical repair. However, interventional mesenteric angiography may not always be feasible or successful. We present an emergency case of successful occlusion of a large peripancreatic pseudoaneurysm using a single percutaneous injection of thrombin under ultrasound guidance alone after both laparotomy and mesenteric angiography had failed to identify and control bleeding. In this case and review of the current evidence, we propose an effective alternative first-line treatment strategy in these complex patients.

Image-guided percutaneous splenic interventions

In the spleen, image-guided interventional procedures such as biopsy and catheter drainage have not been widely performed because of the perceived increased risk of complications. The ability of image-guided biopsy to allow tissue diagnosis of a focal splenic mass without the need for splenectomy is the driving force behind use of this procedure in oncology patients. The literature on image-guided splenic biopsy suggests that the highest biopsy yield is achieved with core biopsy and the lowest complication rate is achieved with fine-needle aspiration. Image-guided catheter drainage is an effective alternative to splenectomy for management of infected splenic collections. In clinical practice, image-guided splenic biopsy, fluid aspiration, and catheter drainage have high success rates. Image-guided alcohol ablation is effective in treatment of splenic cysts. The literature on splenic radiofrequency ablation (RFA) is sparse; therefore, further studies are needed to determine the role of RFA in management of splenic neoplasms and hypersplenism. Image-guided percutaneous thrombin injection can be used to treat splenic artery pseudoaneurysms. Awareness of the correct interventional techniques and their limitations is important for safe performance of image-guided percutaneous splenic interventions.

Percutaneous ultrasound-guided thrombin injection of a post-traumatic pancreatic pseudoaneurysm in a pediatric patient

Non-operative management for blunt injuries to the proximal pancreas has become increasingly common. A bleeding pseudoaneurysm in the setting of a traumatic pancreatic pseudocyst presents a morbid operation. We present the case of a 15-year old with a grade V pancreatic injury that developed a bleeding pseudoaneurysm successfully treated with percutaneous ultrasound-guided thrombin injection.

[Pseudoaneurysm of the hepatic artery: rare complication of chronic pancreatitis]

Bleeding from a pseudoaneurysm is a rare complication of chronic pancreatitis. We present two cases of ruptured pseudoaneurysms of the hepatic arteries. The first case involved a pancreatic pseudocyst that ruptured in the duodenum and the second resulted in an intrahepatic hematoma that compressed the bile tract causing secondary hemobilia. Angiographic embolization was the primary treatment in both cases, with surgery for the first patient and later radiological drainage in the second. The hemorrhage was controlled in both cases despite the severe prognosis and high mortality in these cases.

Treatment of a splenic artery pseudoaneurysm by endoscopic ultrasound-guided thrombin injection

We present a case of a splenic artery pseudoaneurysm secondary to pancreatitis that was successfully treated by transgastric injection of thrombin under endoscopic ultrasound guidance. There has been no recurrence on follow-up CT angiography, and thus complex surgery or endovascular intervention has been avoided.

Percutaneous ultrasound-guided thrombin injection as first-line treatment of pancreatic pseudoaneurysm

Pancreatic pseudoaneurysms are a rare but potentially fatal complication of pancreatitis. Surgical intervention and transcatheter embolization are not always feasible therapeutic options. In this report we present a case of a pseudoaneurysm secondary to pancreatitis which, despite being angiographically invisible, was successfully embolized with a single ultrasound-guided percutaneous injection of thrombin.

CT-guided percutaneous thrombin injection for treatment of an inferior pancreaticoduodenal artery pseudoaneurysm

We present a case of an inferior pancreaticoduodenal artery pseudoaneurysm treated by computed tomography (CT)-guided percutaneous injection of thrombin. As far as we are aware, we present the first documented case of successful long-term (9 months) follow-up with no evidence of recurrence.

Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

Percutaneous treatment of a splenic artery pseudoaneurysm by thrombin injection

Pseudoaneurysms in the visceral arteries are rare complications of pancreatitis. In the reported case, a 42-year-old man with a splenic pseudoaneurysm was successfully treated by computed tomography (CT)-guided direct thrombin injection into the pseudoaneurysm lumen. Selective catheterization of the splenic artery had proven technically impossible. During the procedure, contrast medium was injected via a pigtail catheter into the aorta for planning, correct positioning of the needle tip, and control imaging after injection. CT examinations 1 day, 3 weeks, and 6 months after treatment demonstrated complete occlusion shrinkage of the pseudoaneurysm, and the patient was symptom-free.