Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications

Gastrointestinal bleeding caused by splenic artery pseudoaneurysm in chronic pancreatitis: a case report and literature review

Pseudoaneurysm of the splenic artery is a rare vascular complication of chronic pancreatitis, with a high mortality rate. Haemorrhage and abdominal pain are the most common manifestations, and so far there are no literature reviews on the rare complication of splenic artery pseudoaneurysm due to chronic pancreatitis. Therefore, we describe a male patient with worsening haemochezia and upper abdominal pain, who had been hospitalized repeatedly for 'pancreatitis' 1 year ago, and relevant investigations confirmed a pseudoaneurysm of the splenic artery, which was successfully treated by transarterial embolization, and a literature review is also presented.

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.

Peripancreatic arterial pseudoaneurysm in the background of chronic pancreatitis: clinical profile, management, and outcome

BACKGROUND

Bleeding pseudoaneurysm (PSA) is a rare but potentially lethal complication of chronic pancreatitis (CP). It requires expeditious management by a multidisciplinary team. The study aims to report our experience with PSA in the background of CP.

METHODS

All the patients, who underwent intervention for CP-related PSA between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed.

RESULTS

Of the total 26 patients, 25 (96%) were men with a median age of 38 (11-63) years. The most commonly involved vessel was the splenic artery (n = 18, 69%). The interval between onset of GI bleed and intervention was 7 (0-120) days. Embolization was attempted in 11(42%) patients and was successful in six patients. Surgery was performed in 20 (77%) patients including five patients after failed embolization. The most commonly performed operation was distal pancreatectomy with splenectomy. The median operating time was 216 (115-313) minutes. The median intraoperative blood loss was 325 (100-1000) ml. Seventeen (85%) patients' required intraoperative blood transfusion. Four patients in the embolization group and five patients in the surgical group developed procedure-related complications. The most common postoperative complication was wound infection followed by pancreatic fistula. There was no procedure-related death. Over a median follow-up of 24 (6-122) months, no patient developed recurrent hemorrhage.

CONCLUSIONS

Both embolization and surgery play an important role in the management of PSA. The choice of procedure depends upon the local availability and feasibility of a particular technique.

Percutaneous direct puncture and embolization of vascularly inaccessible abdominal visceral pseudoaneurysms: A single-center experience and literature review

BACKGROUND

To evaluate the techniques, efficacy, and safety for treating vascularly inaccessible abdominal visceral pseudoaneurysms by direct puncture and embolization.

METHODS

A retrospective study of 5 consecutive patients who underwent percutaneous direct puncture embolization for intra-abdominal pseudoaneurysms in our institution between January 2009 and December 2016. Technical aspects, success, clinical outcome, and complications were discussed.

RESULTS

Four patients (80%) were men, and the mean age of all five patients was 57.2 years (range, 47-72 years). The mean diameter of the pseudoaneurysms was 2.5 cm (range, 1.9-3.4 cm). All the pseudoaneurysms were punctured under the imaging guidance of fluoroscopy, ultrasound, or computed tomography. Coils and glue were used in four of the patients, the remaining one with coil only. The mean injected glue volume was 1.5 (range, 0.8-2) mL. The overall technical and clinical success rate was 100% without major complications or mortality.

CONCLUSION

Our single-center experience and the literature review demonstrate that percutaneous direct puncture embolization is feasible and effective to serve as an alternative for treating abdominal vascular pseudoaneurysms when the traditional endovascular embolization fails. In this approach, fluoroscopy is the most needed guidance technique.

[Interventions for pancreatitis]

Approximately 20% of patients with acute pancreatitis develop complications that require surgical or radiological intervention. Radiology plays a central role, not only for imaging (course of the disease, detection of superinfection and their related complications, and development of necrosis) but also for the treatment of vascular and nonvascular complications. In the treatment of severe or necrotizing pancreatitis, a multidisciplinary staged approach with minimally invasive therapies such as endoscopic or percutaneous drainage should be used. Applying a sufficient number of drains of sufficient size, strict irrigation therapy under computed tomographic (CT) control and repositioning of the drains can successfully treat pancreatic and peripancreatic necrosis often without the need for subsequent surgical debridement. Arterial complications affect 1-10% of all patients with pancreatitis, most of which are ruptured pseudoaneurysms, which represent the most dangerous bleeding complication of pancreatitis and can be treated with a high technical success rate through embolization and/or use of an endovascular stent-graft.

Direct Percutaneous Puncture and Embolization of Visceral Pseudoaneurysm: Safety and Clinical Efficacy

Purpose The aim of the study is to assess the safety and clinical effectiveness of direct percutaneous embolization of visceral artery pseudoaneurysms.

Materials and Methods Retrospective analysis of patients who had undergone direct percutaneous embolization of visceral artery pseudoaneurysms between January 2012 and May 2017 was performed. The study included 26 patients with a mean age of 36 years (range 10–71 years). The indications for direct percutaneous embolization included the inability to catheterize endovascularly (n = 24) or prior embolization (n = 2) of the feeding artery. Patient demographics, details of the procedure, complications, and outcomes were evaluated. Patients were followed for a mean of 15 months to assess for recurrence of the pseudoaneurysms on ultrasound.

Results Splenic artery (n = 13), gastroduodenal artery (n = 4), right hepatic artery (n = 3), pancreaticoduodenal arteries (n = 3), left gastric artery (n = 2), and left hepatic artery (n = 1) were the embolized arteries. Etiology for pseudoaneurysm were pancreatitis (n = 20), trauma (n = 2), postoperative (n = 2), and few were incidentally detected (n = 2). N-butyl cyanoacrylate (NBCA) with lipiodol was used in 23 (88.4%) patients, coil in one (3.8%), and both coil and NBCA in two patients (7.7%). Embolization of the pseudoaneurysm was successful in all cases. No procedure-related complication was observed. Follow-up showed no recurrence of the pseudoaneurysm. Self-limiting splenic infarct was seen in six patients. Self-limiting abdominal pain was seen in all the patients with embolization with NBCA. One patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage.

Conclusion Direct percutaneous embolization is safe and effective in the treatment of visceral artery pseudoaneurysms and should be considered as an alternative in patients with a failed endovascular approach.

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.

Embolization coil migration in the stomach and spontaneous excretion: a case report and review of the literature

Embolization coil migration to the gastrointestinal tract is a rare complication. This report describes our experience of coil migration in the stomach and spontaneous excretion. A 77-year-old man, who was diagnosed with esophageal squamous cell carcinoma with multiple lymph node metastases, had a bleeding left gastric artery and splenic artery pseudoaneurysm associated with an abdominal lymph node mass, that was treated by coil embolization, after which the coil migrated into the stomach. Because there were no complications such as active bleeding or peritonitis, our patient was followed carefully, and excretion of the coil was documented. No standard management exists for migrated coils. Conservative treatment is an option, as in this case.

Endovascular embolization of arterial bleeding in patients with severe acute pancreatitis

Introduction

Severe acute pancreatitis (SAP) has a high mortality rate of 20% to 30%, with death often resulting from hemorrhage.

Aim

To investigate the role of digital subtraction angiography (DSA) and endovascular embolization in the management of arterial bleeding in SAP patients.

Material and methods

Seventy-six patients with SAP admitted to our hospital between January 2010 and May 2016 underwent DSA. DSA revealed arterial bleeding in 22 of these patients, who were treated with transcatheter endovascular embolization with coils and/or gelfoam particles. Patient demographics, angiographic features of vascular abnormalities, and outcomes of embolization were assessed.

Results

Arterial bleeding was the most common vascular abnormality (22/76 patients; 28.9%). DSA enabled the identification of 27 bleeding arteries in 22 patients. The splenic artery was the most commonly affected vessel (11/27; 40.7%). Among the 27 arteries treated with endovascular embolization, successful hemostasis was achieved in 96.3% (26/27). Two patients developed major complications (hepatic and splenic abscess). These patients were treated with abdominal catheter drainage and anti-infection measures and ultimately recovered. The mean interval between initial onset of SAP and angiographic diagnosis of arterial bleeding was 56 days. Rebleeding was diagnosed in 5 patients (5/22; 22.7%) during repeat angiography, with bleeding from new sites in four of these patients. The mean interval between successive angiography treatments was 38 days.

Conclusions

Endovascular embolization is a safe and effective method to localize bleeding arteries and achieve complete hemostasis in patients with SAP-related arterial bleeding.

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.

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.

Migrated embolization coil causes intestinal obstruction

Visceral artery pseudoaneurysm is a rare, potentially fatal entity, but proper identification and management with coil embolization can lead to good outcomes. Embolization coils can migrate to various destinations, causing delayed complications in several case reports. A case of small bowel obstruction due to migrated embolization coils from a gastroduodenal pseudoaneurysm 6 years after initial treatment is presented.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm

BACKGROUND AND AIMS

Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

AIM

To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms.

METHODS

Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's.

RESULTS

The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient.

CONCLUSIONS

Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.

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.

Endovascular treatment of visceral artery aneurysms and pseudoaneurysms with stent-graft: Analysis of immediate and long-term results

INTRODUCTION

The aim of this study is to analyze the safety and efficacy of stent-graft endovascular treatment for visceral artery aneurysms and pseudoaneurysms.

METHODS

Multicentric retrospective series of patients with visceral aneurysms and pseudoaneurysms treated by means of stent graft. The following variables were analyzed: Age, sex, type of lesion (aneurysms/pseudoaneurysms), localization, rate of success, intraprocedural and long term complication rate (SIR classification). Follow-up was performed under clinical and radiological assessment.

RESULTS

Twenty-five patients (16 men), with a mean age of 59 (range 27-79), were treated. The indication was aneurysm in 19 patients and pseudoaneurysms in 6. The localizations were: splenic artery (12), hepatic artery (5), renal artery (4), celiac trunk (3) and gastroduodenal artery (1). Successful treatment rate was 96% (24/25 patients). Intraprocedural complication rate was 12% (4% major; 8% minor). Complete occlusion was demonstrated during follow up (mean 33 months, range 6-72) in the 24 patients with technical success. Two stent migrations (2/24; 8%) and 4stent thrombosis (4/24; 16%) were detected. Mortality rate was 0%.

CONCLUSION

In our study, stent-graft endovascular treatment of visceral aneurysmns and pseudoaneurysms has demonstrated to be safe and is effective in the long-term in both elective and emergent cases, with a high rate of successful treatment and a low complication rate.

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

Background Long-term outcome after embolization of pancreatitis-induced pseudoaneurysm is not yet determined. Purpose To assess the long-term efficacy and patients' overall survival after embolization of pancreatitis-induced pseudoaneurysm. Material and Methods Patients referred for endovascular treatment of a pancreatitis-induced pseudoaneurysm between January 1998 and January 2014 were analyzed. Embolization procedures were performed by transcatheter techniques using different types of embolic agents. Demographic, technical-radiological, and clinical data were collected. Results Thirty-four patients were identified with a pancreatitis-induced pseudoaneurysm; the underlying disease was acute (n = 13; 38%) or chronic (n = 21; 62%) pancreatitis; seven patients (20.6%) had active bleeding when embolized, while in the remaining 27 patients (79.4%) the pseudoaneurysm was not bleeding. In all 34 patients, successful endovascular exclusion of the pseudoaneurysm was obtained after the first attempt. Minor complications occurred in 11 patients (30%); no major complications were noted. A new pseudoaneurysm on a different vessel was identified during follow-up in three patients (9%). In another patient (3%), the excluded pseudoaneurysm reopened during follow-up. All four recurrences occurred within the first 5 months after embolization. Long-term follow-up (mean, 6.6 years; range, 4 months-16 years) revealed estimated survival rates of 94%, 89%, and 75% after 2, 5, and 10 years respectively, without pseudoaneurysm-related death. Conclusion Catheter-directed embolization of pancreatitis-induced pseudoaneurysms is relatively safe and effective. Recurrence or new pseudoaneurysm formation was low and occurred within the first 6 months after embolization. Overall survival is high, with no pseudoaneurysm-related deaths.

Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution

PURPOSE

The aim of this study was to assess the outcome of endovascular intervention for pancreatitis-related hemorrhage at a single institution.

METHODS

From January 2000 to October 2012, thirty-seven patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications.

RESULTS

A total of 41 endovascular procedures were performed in 37 patients. The splenic artery (34.8%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (78.3%). Transcatheter embolization was performed in the majority of patients (95.1%), while two patients were treated with stent-grafts. Successful hemostasis without rebleeding was achieved in 34 patients (91.9%). Two cases of rebleeding were successfully treated by reintervention. Focal splenic infarction, which developed in eight patients, was either asymptomatic or accompanied by mild, transient fever. Splenic abscess was the only major complication occurring in three patients. Two of these patients died from resulting sepsis, while the third recovered after antibiotic treatment.

CONCLUSION

Endovascular management is effective for achieving hemostasis in patients with pancreatitis-related bleeding and demonstrates low recurrence and mortality rates.

Drug-Induced Acute Pancreatitis and Pseudoaneurysms: An Ominous Combination

Rupture of pseudoaneurysms is rare but can be life-threatening complications of acute or chronic pancreatitis, usually due to enzymatic digestion of vessel walls crossing peripancreatic fluid collections. We report the case of a 40 year-old female, with multisystemic lupus and anticoagulated for prior thrombotic events, admitted for probable cyclosporine-induced acute pancreatitis. Hemodynamic instability occurred due to abdominal hemorrhage from two pseudoaneurysms inside an acute peri-pancreatic collection. Selective angiography successfully embolized the gastroduodenal and pancreatoduodenal arteries. The hemorrhage recurred two weeks later and another successful embolization was performed and the patient remains well to date. The decision to restart anticoagulants and to suspend cyclosporine was challenging and required a multidisciplinary approach. Despite rare, bleeding from a pseudoaneurysm should be considered when facing a patient with pancreatitis and sudden signs of hemodynamic instability.

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.

Open versus Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms

BACKGROUND

Visceral artery aneurysms and pseudoaneurysms (VAAP) represent a rare and potential life-threatening disease with a documented incidence of 0.1-2.0%. Treatment options for VAAP vary from open approach with aneurysm excision, exclusion and revascularization to endovascular techniques. Aneurysm anatomy and pathogenesis dictate treatment choice. The purpose of this study was to compare the perioperative, short- and mid-term outcomes of open and endovascular approaches.

METHODS

Between January 2007 to April 2015, patients with VAAP who underwent surgical treatment, either by endovascular technique (endovascular surgery [EV] group) or by open surgery (OS group), were selected for analysis. Aneurysm's anatomy and pathogenesis dictated treatment choice. Demographic variables, surgical data, and postoperative follow-up were retrospectively analyzed. Preoperative computed tomography scans were evaluated for aneurysm characteristics.

RESULTS

A total of 296 consecutive patients were identified with VAAP. Surveillance without intervention occurred in 183 patients, and 113 underwent surgical treatment: 57 by EV technique and 56 by OS. The VAAP sites were: splenic (50.9/5.4%), renal (7.0/50%), superior mesenteric (7.0/7.1%), celiac (12.3/17.9%), hepatic (14.0/5.4%), gastroduodenal (7.0/7.1%), and pancreaticoduodenal (1.8/7.1%). Eight urgent surgeries occurred in EV and 5 in OS group (P = 0.39). Operative time and estimated blood loss were 122 ± 54 vs. 312 ± 157 min (P < 0.001) and 5 (interquartile range [IR], 0-50) vs. 550 (IR, 200-980) mL (P < 0.001) in groups EV and OS, respectively. The intraoperative and postoperative major complications, including end-organ infarction, and reinterventions were comparable between the groups. Transfusion of blood products was necessary in 12.3% (EV) and 42.9% (OS; P < 0.001). Median hospital length of stay was 1 (IR, 1-3) and 6 (IR, 4-9) days in groups EV and OS, respectively (P < 0.001). Short-term technical success was achieved in 98.2% (EV) and 96.4% (OS). During the median follow-up period of 16 (IR, 7.1-43.9) months, the clinical success was 91.2% and 92.9% (P = 0.74), and the overall survival was 94.7% and 96.4% (P = 1.0) in groups EV and OS, respectively.

CONCLUSIONS

Open and endovascular approaches have similar rates of technical and clinical success, as well as mortality during follow-up. However, periprocedural morbidity was significantly higher in cases treated by OS. Although longer-term follow-up is needed to access the durability of the endovascular treatment, initial successful outcomes and low reintervention rates make it a safe and feasible approach.

Sinister Splenic Artery Pseudoaneursym: A Rare Case of Unidentified Aetiology

Splenic Artery Pseudoaneurysms (SAP) are very rare. Giant SAPs are those which are more than 5 cm in diameter and are rarer. SAPs are usually caused by pancreatitis, trauma, surgery or other iatrogenic interventions, vasculitis, local infective or inflammatory processes. We report the successful surgical management of a giant SAP of unidentified aetiology. This case report highlights the significance that this entity may present atypically and hence, early recognition and aggressive management may be life saving.

Consensus guidelines on severe acute pancreatitis

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

"To-and-fro" waveform in the diagnosis of arterial pseudoaneurysms

Medical ultrasound imaging with Doppler plays an essential role in the diagnosis of vascular disease. This study intended to review the clinical use of “to-and-fro” waveform at duplex Doppler ultrasonography (DDU) in the diagnosis of pseudoaneurysms in the arterial vessels of upper and lower extremities, abdominal aorta, carotid and vertebral arteries as well as to review our personal experiences of “to-and-fro” waveform at DDU also. After receiving institutional review board approval, an inclusive literature review was carried out in order to review the scientific foundation of “to-and-fro” waveform at DDU and its clinical use in the diagnosis of pseudoaneurysms in various arterial vessels. Articles published in the English language between 2000 and 2013 were evaluated in this review study. Pseudoaneurysms in arterial vessels of the upper and lower extremities, abdominal aorta, carotid and vertebral arteries characterized by an extraluminal pattern of blood flow, which shows variable echogenicity, interval complexity, and “to-and-fro” flow pattern on color Doppler ultrasonography. In these arterial vessels, Duplex ultrasonography can demonstrate the degree of clotting, pseudoaneurysm communication, the blood flow patterns and velocities. Spectral Doppler applied to pseudoaneurysms lumen revealed systolic and diastolic turbulent blood flow with traditional “to-and-fro” waveform in the communicating channel. Accurate diagnosis of pseudoaneurysm by spectral Doppler is based on the documentation of the “to-and-fro” waveform. The size of pseudoaneurysm determines the appropriate treatment approach as surgical or conservative.

Percutaneous thrombin embolization of a pancreatico-duodenal artery pseudoaneurysm after failing of the endovascular treatment

Pancreatico-duodenal artery (PDA) pseudoaneurysms are rare vascular conditions with high mortality rates after rupture and they are frequently secondary to pancreatitis, surgery, trauma or infection. Due to the high risk of rupture and bleeding, it is mandatory to treat all pseudoaneurysms, regardless of their size or symptomatology. First option of treatment is open surgical repair, but it has high mortality rate, especially in hemodynamically unstable patients. In the recent years, percutaneous ultrasonography (US)- or computed tomography-guided thrombin injection was proposed as an alternative method for treating visceral aneurysms and pseudoaneurysms, but few reports described this therapy in case of peri-pancreatic pseudoaneurysms. We present a rare case of pseudoaneurysm of the PDA in a patient with no previous history of pancreatitis nor major surgery but with an occlusive lesion of the celiac axis. To the best of our knowledge this is the first reported case of PDA pseudoaneurysm successfully treated in emergency by single transabdominal US-guided injection of thrombin after failed attempts of percutaneous catheterization of the feeding vessel of the pseudoaneurysm.

Miscellaneous pharmaceutical agents in interventional radiology

Interventional radiologists employ a wide variety of drugs on a daily basis to improve patient experiences and outcomes during interventional procedures. The expectation is for the interventionalist to be well-versed in all pharmaceuticals used in the interventional suite. In this article, the authors review the following classes of common miscellaneous pharmaceutical agents used in interventional radiology: vasodilators, vasoconstrictors, antiemetics, bowel antiperistalsis agents, and prothrombotics.

Coil migration--a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms

INTRODUCTION

We describe a case of metallic, angiographic coil migration, following radiological exclusion of a gastroduodenal artery pseudoaneurysm secondary to chronic pancreatitis.

PATIENTS AND METHODS

A 55-year-old man presented to the out-patient clinic with chronic, intermittent, post-prandial, abdominal pain, associated with nausea, vomiting and weight loss. He was known to have chronic pancreatitis and liver disease secondary to alcohol abuse and previously underwent angiographic exclusion of a gastroduodenal artery pseudoaneurysm. During subsequent radiological and endoscopic investigation, an endovascular coil was discovered in the gastric pylorus, associated with ulceration and cavitation. This patient was managed conservatively and enterally fed via naso-jejunal catheter endoscopically placed past the site of the migrated coil. This patient is currently awaiting biliary bypass surgery for chronic pancreatitis, and definitive coil removal will occur concurrently.

CONCLUSIONS

Literature review reveals that this report is only the eighth to describe coil migration following embolisation of a visceral artery pseudoaneurysm or aneurysm. Endovascular embolisation of pseudoaneurysms and aneurysms is generally safe and effective. More common complications of visceral artery embolisation include rebleeding, pseudoaneurysm reformation and pancreatitis.

[Pancreatic tail pseudoaneurysm: percutaneous treatment by thrombin injection]

Visceral artery pseudoaneurysms secondary to acute and/or chronic pancreatitis are a relatively common and potentially serious complication. Endovascular techniques are the most currently accepted techniques, given the higher morbidity-mortality of surgery. The thrombosis of the pseudoaneurysm using an ultrasound-guided percutaneous thrombin injection is emerging as a useful option in those cases in which endovascular embolisation is not possible. We present the case of a patient with a pseudoaneurysm of the transverse pancreatic artery secondary to chronic pancreatitis, and successfully treated by administering percutaneous thrombin.

Current Management of Mesenteric Extrahepatic Arterioportal Fistulas: Report of a Case Treated With a Gastroduodenal Artery Stent Graft and Literature Review

Spontaneous arteriovenous fistulation of a pseudoaneurysm into superior mesenteric vein (SMV) has rarely been reported. We present the case of a 61-year-old woman who presented with a post pancreatic arterioportal fistula (APF) that was successfully managed by stent graft (SG) placement in the gastroduodenal artery (GDA). We also review the published experience of the endovascular management of mesenteric extrahepatic APFs. This review demonstrates the evolution from open surgical to endovascular management for majority of these patients.

Diagnosis and management of pseudoaneurysms: an update

"Pseudoaneurysm" is a term that describes disruption of an artery with patent flow in a defined space beyond the confines of the vessels. A pseudoaneurysm can involve any vascular bed and is usually associated with direct arterial injury or erosion of an artery by an adjacent tumor or inflammation. In this article, we discuss different clinical settings and various imaging modalities such as ultrasound, computerized tomography, magnetic resonance imaging, as well as conventional angiography used for the diagnosis of pseudoaneurysms. We also describe the role of newer endovascular, percutaneous, and traditional surgical approaches for the treatment of visceral and peripheral pseudoaneurysms in different clinical circumstances.

Left colic artery pseudoaneurysm from pancreatitis presenting as upper gastrointestinal hemorrhage

Visceral pseudoaneurysms resulting from pancreatitis occur in approximately 10% of cases. The present report describes a left colic artery pseudoaneurysm from pancreatitis presenting with active duodenal bleeding. Based on the clinical and endoscopic demonstration of duodenal bleeding, celiac and superior mesenteric arteriograms were initially obtained, and their findings were negative. Repeat arteriography, including an inferior mesenteric artery injection, demonstrated a left colic pseudoaneurysm with rupture into the pancreatic duct and retrograde flow into the duodenum. Because of inconsistent diagnostic yields for arteriography performed for pancreatitis-related bleeding, the authors recommend disciplined interrogation of all three major mesenteric vessels, unbiased by initial endoscopic findings, to reduce false-negative examination results and empiric embolization.

The use of thrombin in the radiology department

Thrombin is a naturally occurring coagulation protein that converts soluble fibrinogen into insoluble fibrin and plays a vital role in the coagulation cascade and in turn haemostasis. Thrombin also promotes platelet activation. In the last few years, there has been a rapid increase in the use of thrombin by radiologists in a variety of clinical circumstances. It is best known for its use in the treatment of pseudoaneurysms following angiography. However, there are now a variety of cases in the literature describing the treatment of traumatic, inflammatory and infected aneurysms with thrombin in a variety of locations within the human body. There have even been recent reports describing the use of thrombin in conventional aneurysms as well as ruptured aneurysms. Its use has also been described in the treatment of endoleaks (type II) following aneurysm repair. In nearly all of these cases, treatment with thrombin requires imaging guidance. Recently, thrombin has also been used as a topical treatment post-percutaneous intervention to reduce or stop bleeding. Most radiologists have only a limited knowledge of the pharmacodynamics of thrombin, its wide range of utilisation and its limitations. Apart from a few case reports and case series, there is little in the radiological literature encompassing the wide range of applications that thrombin may have in the radiology department. In this review article, we comprehensively describe the role and pathophysiology of thrombin, describing with examples many of its potential uses. Techniques of usage as well as pitfalls and limitations are also described.

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.

Multidetector CT appearances of splanchnic arterial pathology

Recent advances in multidetector computed tomography (MDCT) technology have enabled the production of high-resolution diagnostic images of the visceral vessels. The potential of MDCT in relation to splanchnic artery pathology is still being realized, but it already provides a credible quick, non-invasive, low-dose alternative to digital subtraction angiography. A variety of categories of splanchnic artery pathology are demonstrated, including stenosis and occlusion (due to extrinsic compression, mural thrombus, and atherosclerosis), aneurysms, dissection, and haemorrhage.