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

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Abstract

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.

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References

  1. Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD. Management and outcome of haemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery. 2005;137:323–8.

    Article  Google Scholar 

  2. Hsu JT, Yeh CN, Hung CF, et al. Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis. BMC Gastroenterol. 2006;6:3–8.

    Article  Google Scholar 

  3. Stabile BE, Wilson SE, Debas HT. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis. Arch Surg. 1983;118:45–54.

    Article  CAS  Google Scholar 

  4. Mallick IH, Winslet MC. Vascular complications of pancreatitis. JOP. 2004;5:328–37.

    PubMed  Google Scholar 

  5. Marone EM, Mascia D, Kahlberg A, Brioschi C, Tshomba Y, Chiesa R. Is open repair still the gold standard in visceral artery aneurysm management? Ann Vasc Surg. 2011;25:936–46.

    Article  Google Scholar 

  6. Kalva SP, Yeddula K, Wicky S, Fernandez del Castillo C, Warshaw AL. Angiographic intervention in patients with a suspected visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery. Arch Surg. 2011;146:647–52.

    Article  Google Scholar 

  7. Van Langenhove P, Defreyne L, Kunen M. Spontaneous thrombosis of a pseudoaneurysm complicated pancreatitis. Imaging. 1999;24:491–3.

    Google Scholar 

  8. Sankaran S, Walt AJ. The natural and unnatural history of pancreatic pseudocysts. Br J Surg. 1975;62:37–44.

    Article  CAS  Google Scholar 

  9. Frey CF, Reber HA. Local resection of the head of the pancreas with pancreaticojejunostomy. J Gastrointest Surg. 2005;9:863–8.

    Article  Google Scholar 

  10. Nicholson AA, Patel J, McPherson S, Shaw DR, Kessel D. Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J VascInterv Radiol. 2006;17:1279–85.

    Article  Google Scholar 

  11. Balderi A, Antoneitti A, Ferro L, et al. Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience. Radiol Med. 2012;117:815–30.

    Article  CAS  Google Scholar 

  12. Balachandra S, Siriwardena AK. Systemic appraisal of the management of the major vascular complications of pancreatitis. Am J Surg. 2005;190:489–95.

    Article  Google Scholar 

  13. Udd M, Leppaniemi AK, Bidel S, Keto P, Roth WD, Haapiainen RK. Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis. World J Surg. 2007;31:504–10.

    Article  Google Scholar 

  14. Sethi H, Peddu P, Prachalis A, et al. Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis. Hepatobiliary Pancreat Dis Int. 2010;9:634–8.

    PubMed  Google Scholar 

  15. Manazer JR, Monzon JR, Dietz PA, Moglia R, Gold M. Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection. J Vasc Sur. 2003;38:600–2.

    Article  Google Scholar 

  16. Sparrow P, Asquith J, Chalmers N. Ultrasonic-guided percutaneous injection of pancreatic pseudoaneurysm with thrombin. Cardiovasc Intervent Radiol. 2003;26:312–5.

    Article  Google Scholar 

  17. Armstrong EM, Edwards A, Kingsnorth AN, Freeman S, Roobottom CA. Ultrasound guided thrombin injection to treat a pseudoaneurysm secondary to chronic pancreatitis. Eur J Vasc Endovas Surg. 2003;26:448–9.

    Article  CAS  Google Scholar 

  18. Krueger K, Zaehringer M, Lackner K. Percutaneous treatment of a splenic artery pseudoaneurysm by thrombin injection. J Vasc Intervent Radiol. 2005;16:1023–5.

    Article  Google Scholar 

  19. McErlean A, Looby S, Lee MJ. Percutaneous ultrasound-guided thrombin injection as first-line treatment of pancreatic pseudoaneurysm. Cardiovasc Intervent Radiol. 2007;30:526–8.

    Article  Google Scholar 

  20. Ward EVM, Buckley O, Doody O, Govender P, Conlon K, Torreggiani WC. Percutaneous thrombin embolization of a ruptured peripancreatic pseudoaneurysm. Digestion. 2007;76:188–91.

    Article  CAS  Google Scholar 

  21. Keeling AN, McGrath FP, Lee MJ. Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms. Cardiovasc Intervent Radiol. 2009;32:2–18.

    Article  CAS  Google Scholar 

  22. Lameris R, du Plessis J, Nieuwoudt M, Scheepers A, van der Merwe SW. A visceral pseudoaneurysm: management by EUS-guided thrombin injection. Gastrointest Endosc. 2011;73:392–5.

    Article  Google Scholar 

  23. Carrafiello G, Laganà D, Recaldini C, et al. Combined percutaneous thrombin injection and endovascular treatment of gastroduodenal artery pseudoaneurysm (PAGD): case report. Emerg Radiol. 2007;14:51–4.

    Article  Google Scholar 

  24. Parildar M, Oran L, Memis A. Embolization of visceral pseudoaneurysm with platinum coils and N-butyl cyanoacrylate. Abdom Imaging. 2003;28:36–40.

    Article  CAS  Google Scholar 

  25. Rossi M, Rebonato A, Greco L, Citone M, David V. Endovascular exclusion of visceral artery aneurysms with stent grafts technique and long term follow-up. Cardiovasc Intervent Radiol. 2008;31:36–42.

    Article  Google Scholar 

  26. Pasklipnsky G, Gasparis AP, Labropoupos N, et al. Endovascular covered stenting for visceral artery pseudoaneurysm rupture: report of 2 cases and a summary of disease process and treatment option. Vasc Endovasc Surg. 2008;42:601–6.

    Article  Google Scholar 

  27. Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Stent-graft placement for treatment of massive haemorrhage from ruptured hepatic artery after pancreaticoduodenectomy. World J Gastroenterol. 2010;16:3716–22.

    Article  Google Scholar 

  28. Bresler L, Boissel P, Grosdidier J. Major hemorrhage from pseudoaneurysms caused chronic pancreatitis: surgical therapy. World J Surg. 1991;15:649–53.

    Article  CAS  Google Scholar 

  29. de Perrot M, Berney T, Buhler L, Delgadillo X, Mentha G, Morel P. Management of bleeding pseudoaneurysms in patients with pancreatitis. Br J Surg. 1999;86:29–32.

    Article  Google Scholar 

  30. Reber PU, Patel AG, Baer HU, Triller J, Buchler MW. Acute hemorrhage in chronic pancreatitis: diagnosis and treatment options including superselective microcoil embolization. Pancreas. 1999;18:399–402.

    Article  CAS  Google Scholar 

  31. Boudghene F, L’Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol. 1993;4:551–8.

    Article  Google Scholar 

  32. Kianmanesh R, Benjelloun M, Scaringi S, et al. Fissure syndrome of a gastroduodenal artery pseudoaneurysm in contact with pseudocyst of the pancreas: rare, but serious complication of chronic pancreatitis. Gastroenterol Clin Biol. 2008;32:69–73.

    Article  CAS  Google Scholar 

  33. Ouaïssi M, Sielezneff I, Chaix JB, et al. Experience of two trauma-centers with pancreatic injuries requiring immediate surgery. Hepatogastroenterology. 2008;55:817–20.

    PubMed  Google Scholar 

  34. el Hamel A, Parc R, Adda G, Bouteloup PY, Huquet C, Malafosse M. Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis. Br J Surg. 1991;78:1059–63.

    Article  Google Scholar 

  35. Bender JS, Bouwman DL, Levison MA, Weaver DW. Pseudocysts and pseudoaneurysms: surgical strategy. Pancreas. 1995;10:143–7.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India

    Vikas Gupta, Santhosh Irrinki, Yashwanth Raj Sakaray, Vikash Moond, Thakur Deen Yadav & Jai Dev Wig

  2. Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India

    Rakesh Kochhar

  3. Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India

    Niranjan Khandelwal

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  1. Vikas Gupta
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  2. Santhosh Irrinki
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Correspondence to Vikas Gupta.

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VG, SI, YRS, VM, TDY, RK, NK, and JDW declare that they have no conflict of interest.

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Gupta, V., Irrinki, S., Sakaray, Y.R. et al. Treatment strategies for bleeding from gastroduodenal artery pseudoaneurysms complicating the course of chronic pancreatitis—A case series of 10 patients. Indian J Gastroenterol 37, 457–463 (2018). https://doi.org/10.1007/s12664-018-0897-y

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