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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by Punit Mahajan
Contributed by Punit Mahajan
Endovascular management of a pseudoaneurysm of a branch of middle colic artery as a complication of acute pancreatitis
Endovascular management of a pseudoaneurysm of a branch of middle colic artery as a complication of acute pancreatitis
Introduction:
Introduction:
Visceral artery aneurysms of middle colic artery branches are extremely rare, accounting for less than 2% of all visceral artery aneurysms (1). The pseudoaneurysms have been associated with pancreatitis, abdominal trauma, septic emboli, iatrogenic injuries, penetrating duodenal ulcers, and malignancies (2). The complicated clinical presentations and high incidence of rupture make it difficult to diagnose and treat. They often rupture into the gastrointestinal tract and result in life-threatening gastrointestinal haemorrhage (3). Here we report an interesting case of pseudoaneurysm in a patient with pancreatitis..
Visceral artery aneurysms of middle colic artery branches are extremely rare, accounting for less than 2% of all visceral artery aneurysms (1). The pseudoaneurysms have been associated with pancreatitis, abdominal trauma, septic emboli, iatrogenic injuries, penetrating duodenal ulcers, and malignancies (2). The complicated clinical presentations and high incidence of rupture make it difficult to diagnose and treat. They often rupture into the gastrointestinal tract and result in life-threatening gastrointestinal haemorrhage (3). Here we report an interesting case of pseudoaneurysm in a patient with pancreatitis..
Case presentation
Case presentation
A 25-year-old male presented in EMR with several months of intermittent abdominal pain that worsened over 3–4 days, he also had black colour stools for 5 days and vomiting bilious in nature since a day. As a part of initial work up haemoglobin was 9 gm % and USG were suggestive of acute pancreatitis and pseudocyst in left lumbar region which was later confirmed by elevated levels of amylase and lipase. Patient was admitted and was on conservative management and pig tail insertion was performed in the pseudocyst. On 3rd day of admission patient had lower GI bleed of approximately 500 ml. Post bleed haemoglobin was 7.8 gm %. He had at least two similar episodes within next 8 hours with hemodynamic alterations in form of tachycardia and falling blood pressure. Patient was stabilized with fluid resuscitation and ionotropic supports. He underwent CECT Abdomen and Pelvis to rule out cause of GI bleed as a complication of pancreatitis. However, on CT scan no obvious arterial phase contrast extravasation or pseudoaneurysm was appreciated. Findings of acute edematous pancreatitis with extensive inflammatory changes and pseudocyst was confirmed on CT scan and pseudocyst was noted in the lesser sac with a pig tail catheter in situ. In view of dropping haemoglobin due to blood loss Digital subtraction angiography of gastro intestinal vasculature was planned. Selective angiography of celiac artery, superior and inferior mesenteric artery was performed using 5F SIM 2 catheter system. SMA angiogram revealed middle colic artery branch showing a small focal pseudoaneurysm in its terminal portion. The middle colic artery was selectively cannulated using PROGREAT microcatheter and coil embolization of the branch and associated pseudoaneurysm, via a superior mesenteric artery approach was performed using 18-14-3 pushable coils. Post coil embolization angiogram shows exclusion of pseudoaneurysm from the circulation. Patient recovered well and was discharged to home three days post procedure.
A 25-year-old male presented in EMR with several months of intermittent abdominal pain that worsened over 3–4 days, he also had black colour stools for 5 days and vomiting bilious in nature since a day. As a part of initial work up haemoglobin was 9 gm % and USG were suggestive of acute pancreatitis and pseudocyst in left lumbar region which was later confirmed by elevated levels of amylase and lipase. Patient was admitted and was on conservative management and pig tail insertion was performed in the pseudocyst. On 3rd day of admission patient had lower GI bleed of approximately 500 ml. Post bleed haemoglobin was 7.8 gm %. He had at least two similar episodes within next 8 hours with hemodynamic alterations in form of tachycardia and falling blood pressure. Patient was stabilized with fluid resuscitation and ionotropic supports. He underwent CECT Abdomen and Pelvis to rule out cause of GI bleed as a complication of pancreatitis. However, on CT scan no obvious arterial phase contrast extravasation or pseudoaneurysm was appreciated. Findings of acute edematous pancreatitis with extensive inflammatory changes and pseudocyst was confirmed on CT scan and pseudocyst was noted in the lesser sac with a pig tail catheter in situ. In view of dropping haemoglobin due to blood loss Digital subtraction angiography of gastro intestinal vasculature was planned. Selective angiography of celiac artery, superior and inferior mesenteric artery was performed using 5F SIM 2 catheter system. SMA angiogram revealed middle colic artery branch showing a small focal pseudoaneurysm in its terminal portion. The middle colic artery was selectively cannulated using PROGREAT microcatheter and coil embolization of the branch and associated pseudoaneurysm, via a superior mesenteric artery approach was performed using 18-14-3 pushable coils. Post coil embolization angiogram shows exclusion of pseudoaneurysm from the circulation. Patient recovered well and was discharged to home three days post procedure.
Fig 1
Fig 1
Fig 2
Fig 2
Fig 3
Fig 3
IMAGE 1: Celiac Artery Angiogram
IMAGE 1: Celiac Artery Angiogram
IMAGE 2: Superior Mesenteric Artery Angiogram
IMAGE 2: Superior Mesenteric Artery Angiogram
IMAGE 3: Magnified image of superior mesenteric artery angiogram showing small pseudoaneurysm in one of the left branches of middle colic artery.
IMAGE 3: Magnified image of superior mesenteric artery angiogram showing small pseudoaneurysm in one of the left branches of middle colic artery.
There was significant drop in Hemoglobin,PT INR was normal. The patient was shifted to the angio suite for interventional treatment
There was significant drop in Hemoglobin,PT INR was normal. The patient was shifted to the angio suite for interventional treatment
Fig 4
Fig 4
Fig 5
Fig 5
Fig 6
Fig 6
IMAGE 4: Selective angiogram of the middle colic artery using SIM 2 catheter suspicious for pseudoaneurysm in one of the branches.
IMAGE 4: Selective angiogram of the middle colic artery using SIM 2 catheter suspicious for pseudoaneurysm in one of the branches.
IMAGE 5: Selective angiogram of the middle colic artery using microcatheter the presence of pseudoaneurysm is confirmed.
IMAGE 5: Selective angiogram of the middle colic artery using microcatheter the presence of pseudoaneurysm is confirmed.
IMAGE 6: Selective angiogram of the branch of middle colic artery using microcatheter.
IMAGE 6: Selective angiogram of the branch of middle colic artery using microcatheter.
Fig 7
Fig 7
Fig 8
Fig 8
Fig 9
Fig 9
IMAGE 7 : Coil embolization using push able coils 18-14-6.
IMAGE 7 : Coil embolization using push able coils 18-14-6.
IMAGE 8: Post coil embolization angiogram shows exclusion of pseudoaneurysm from the circulation
IMAGE 8: Post coil embolization angiogram shows exclusion of pseudoaneurysm from the circulation
IMAGE 9: CT scan done for follow up of pseudocyst showing multiple coils in position along the middle colic artery branch.
IMAGE 9: CT scan done for follow up of pseudocyst showing multiple coils in position along the middle colic artery branch.
By coaxial technique microcatheter is introduced through balloon and sclerosant agent(lipiodol:setrol:Air, 1:2:3) was injected slowly (figure 6). After 2hrs complete deflation of balloon was done (figure7). Check left renal venogram was done showed patent renal vein (figure8).post procedure APG was done showed complete obliteration of gastric varices (figure 9). Catheters and sheaths were removed patient was shifted to recovery room and observed,then shifted to ward.Folloup CT and fluroscopy was done after 2 weeks to evaluate the degree of thrombosis of gastric varices and screening for potential complications(figure 10).
By coaxial technique microcatheter is introduced through balloon and sclerosant agent(lipiodol:setrol:Air, 1:2:3) was injected slowly (figure 6). After 2hrs complete deflation of balloon was done (figure7). Check left renal venogram was done showed patent renal vein (figure8).post procedure APG was done showed complete obliteration of gastric varices (figure 9). Catheters and sheaths were removed patient was shifted to recovery room and observed,then shifted to ward.Folloup CT and fluroscopy was done after 2 weeks to evaluate the degree of thrombosis of gastric varices and screening for potential complications(figure 10).
Discussion :
Discussion :
Aneurysms of the splanchnic artery are extremely rare with an incidence of about 0.2% of the population (4). Pseudoaneurysms can occur after pancreatitis, abdominal trauma, septic emboli, iatrogenic injuries, penetrating duodenal ulcers, and malignancies, and they often rupture into the gastrointestinal tract (2,3). The mortality has been reported as greater than 25% (6). Abdominal ultrasonography, CT, and magnetic resonance imaging are useful in detecting aneurysms. Angiography plays a vital role and is considered the gold standard for diagnosis of aneurysms. The risk of rupture of pseudoaneurysm is not dependent on the size.
Aneurysms of the splanchnic artery are extremely rare with an incidence of about 0.2% of the population (4). Pseudoaneurysms can occur after pancreatitis, abdominal trauma, septic emboli, iatrogenic injuries, penetrating duodenal ulcers, and malignancies, and they often rupture into the gastrointestinal tract (2,3). The mortality has been reported as greater than 25% (6). Abdominal ultrasonography, CT, and magnetic resonance imaging are useful in detecting aneurysms. Angiography plays a vital role and is considered the gold standard for diagnosis of aneurysms. The risk of rupture of pseudoaneurysm is not dependent on the size.
There are 3 layers of vessels in true aneurysms (endothelium, muscularis and adventitia), the most common etiology is atherosclerosis and the symptoms are present in 70 to 90% of cases. False aneurysms or pseudoaneurysms are defined as missing complete arterial walls lined by adventitia or perivascular tissue and arises from the weakening of the arterial wall caused by trauma, including surgical trauma or by proteolytic action as as in this case. Because of that, almost all cases of pseudoaneurysms are symptomatic and display greater risk of rupturing than true aneurysm
There are 3 layers of vessels in true aneurysms (endothelium, muscularis and adventitia), the most common etiology is atherosclerosis and the symptoms are present in 70 to 90% of cases. False aneurysms or pseudoaneurysms are defined as missing complete arterial walls lined by adventitia or perivascular tissue and arises from the weakening of the arterial wall caused by trauma, including surgical trauma or by proteolytic action as as in this case. Because of that, almost all cases of pseudoaneurysms are symptomatic and display greater risk of rupturing than true aneurysm
The major treatments for pseudoaneurysms consist of surgery or angiographic embolization. Surgery used to be the accepted gold standard for treatment of pseudoaneurysms. Angiography plays a crucial role in making accurate diagnosis, with the additional benefit of therapy in some cases (10). For example, once the source of haemorrhage is identified on angiography, percutaneous transcatheter angiographic embolization is recommended in hemodynamically stable patients. Compared with surgery, endovascular embolization is a less invasive and shorter procedure with a good success rate and associated with a shorter hospital stay (11). However, the risk of endovascular interventions should be considered. Reported complications include migration of coils, aneurysmal rupture, aneurysmal reperfusion, inadvertent occlusion of other vessels, and infection. (7)
The major treatments for pseudoaneurysms consist of surgery or angiographic embolization. Surgery used to be the accepted gold standard for treatment of pseudoaneurysms. Angiography plays a crucial role in making accurate diagnosis, with the additional benefit of therapy in some cases (10). For example, once the source of haemorrhage is identified on angiography, percutaneous transcatheter angiographic embolization is recommended in hemodynamically stable patients. Compared with surgery, endovascular embolization is a less invasive and shorter procedure with a good success rate and associated with a shorter hospital stay (11). However, the risk of endovascular interventions should be considered. Reported complications include migration of coils, aneurysmal rupture, aneurysmal reperfusion, inadvertent occlusion of other vessels, and infection. (7)
In this case, the patient was successfully treated with the accurate diagnosis and effective coil embolization. Clinicians should consider the possibility of ruptured pseudoaneurysms in patients with active gastrointestinal bleeding. The familiarity of this disease and appropriate treatments will save lives timely.
In this case, the patient was successfully treated with the accurate diagnosis and effective coil embolization. Clinicians should consider the possibility of ruptured pseudoaneurysms in patients with active gastrointestinal bleeding. The familiarity of this disease and appropriate treatments will save lives timely.
The initial determination of treatment approach for patients with visceral artery pseudoaneurysms should be based largely on their hemodynamic status. Hemodynamically stable patients should undergo angiography with therapeutic embolization if possible. Surgical management may be considered for hemodynamically unstable patients, those with failed embolization, or when angiographic capabilities are not available. (8)
The initial determination of treatment approach for patients with visceral artery pseudoaneurysms should be based largely on their hemodynamic status. Hemodynamically stable patients should undergo angiography with therapeutic embolization if possible. Surgical management may be considered for hemodynamically unstable patients, those with failed embolization, or when angiographic capabilities are not available. (8)
Embolization can be achieved with coils, particulate materials such as polyvinyl alcohol or gel foam, N-acetyl cyanoacrylate or a combination of these agents.(8 , 9) Technical success is considered when perfusion of the pseudoaneurysm ceases no contrast extravasation is visualized.(8 , 9) As an alternative to embolization, a stent graft may be deployed across the abnormal vessel to allow distal organ perfusion, while excluding the pseudoaneurysm from circulation.(8) Stents cannot be used if there is not sufficient vessel length on either side of the pseudoaneurysm, if there is significant vessel tortuosity, or a correctly sized stent graft is not available.(10)
Embolization can be achieved with coils, particulate materials such as polyvinyl alcohol or gel foam, N-acetyl cyanoacrylate or a combination of these agents.(8 , 9) Technical success is considered when perfusion of the pseudoaneurysm ceases no contrast extravasation is visualized.(8 , 9) As an alternative to embolization, a stent graft may be deployed across the abnormal vessel to allow distal organ perfusion, while excluding the pseudoaneurysm from circulation.(8) Stents cannot be used if there is not sufficient vessel length on either side of the pseudoaneurysm, if there is significant vessel tortuosity, or a correctly sized stent graft is not available.(10)
The technical success rates of endovascular intervention in two different studies ranged from 98–100%. (8 and 10) Interestingly, there was no correlation between overall survival and the success of the embolization performed, although the sample sizes of the studies are small. In contrast, only low numbers of blood transfusion products needed prior to angiography are associated with better survival. Complications of embolization include end-organ infarction, post-embolization syndrome, re-bleeding and reperfusion of the pseudoaneurysm. (9) Contraindications to endovascular intervention include the need to maintain patency of the feeding vessel or the presence of collaterals near or arising from the pseudoaneurysm. In these instances, a stent graft or surgical intervention may be needed. (10)
The technical success rates of endovascular intervention in two different studies ranged from 98–100%. (8 and 10) Interestingly, there was no correlation between overall survival and the success of the embolization performed, although the sample sizes of the studies are small. In contrast, only low numbers of blood transfusion products needed prior to angiography are associated with better survival. Complications of embolization include end-organ infarction, post-embolization syndrome, re-bleeding and reperfusion of the pseudoaneurysm. (9) Contraindications to endovascular intervention include the need to maintain patency of the feeding vessel or the presence of collaterals near or arising from the pseudoaneurysm. In these instances, a stent graft or surgical intervention may be needed. (10)
Surgical intervention includes pseudoaneurysm resection with revascularization, or pseudoaneurysm ligation with or without end organ resection. (10) Postoperative morbidity and mortality is higher in patients treated with surgery, making endovascular approaches more appealing when possible. (8,10)
Surgical intervention includes pseudoaneurysm resection with revascularization, or pseudoaneurysm ligation with or without end organ resection. (10) Postoperative morbidity and mortality is higher in patients treated with surgery, making endovascular approaches more appealing when possible. (8,10)
The choice of which embolic to use is based on several factors, including underlying pathology if known, lesion location, and operator experience. GELATIN: Known by various names, most commonly Gelfoam (Pfizer, Inc.), gelatin has been used in interventional procedures for decades. There are a variety of methods by which it can be administered that affect mostly the size of the particle when injected. A small sheet of Gelfoam is frequently cut by the operator to the desired size and agitated in varying concentrations of contrast before injection. Recently, precut and calibrated gelatin (EmboCube, Merit Medical Systems, Inc.) has been made available to introduce consistency and reduce preparation time. An added benefit of gelatin is its possible resorption over weeks, thereby making it a potentially “temporary” embolic agent. Gelatin generally embolizes distally and, therefore, has a higher risk of ischemia, particularly if smaller calibers are used. It can be used as an adjunct to coil embolization to enable a more rapid thrombosis of a coil pack.
The choice of which embolic to use is based on several factors, including underlying pathology if known, lesion location, and operator experience. GELATIN: Known by various names, most commonly Gelfoam (Pfizer, Inc.), gelatin has been used in interventional procedures for decades. There are a variety of methods by which it can be administered that affect mostly the size of the particle when injected. A small sheet of Gelfoam is frequently cut by the operator to the desired size and agitated in varying concentrations of contrast before injection. Recently, precut and calibrated gelatin (EmboCube, Merit Medical Systems, Inc.) has been made available to introduce consistency and reduce preparation time. An added benefit of gelatin is its possible resorption over weeks, thereby making it a potentially “temporary” embolic agent. Gelatin generally embolizes distally and, therefore, has a higher risk of ischemia, particularly if smaller calibers are used. It can be used as an adjunct to coil embolization to enable a more rapid thrombosis of a coil pack.
N-butyl cyanoacrylate (NBCA) is a radiolucent monomer used in conjunction with ethiodized oil and/or, less often, tantalum powder for embolotherapy in nonneurovascular interventions. NBCA rapidly polymerizes on contact with ionic medium and bonds with adjacent structures. It is highly thrombogenic and bacteriostatic, making it an ideal candidate for the control of GI hemorrhage; however, use in GI hemorrhage is off-label. Its use is limited by a lack of stable control and operator familiarity with its deployment. The availability of the intravascular formulation may be limited to sites with neurovascular interventions. The polymerization of NBCA is controlled by dilution with ethiodized oil, and depending on this, it can be formulated to provide a more proximal embolization. It can also be used to help thrombose a large aneurysm or pseudoaneurysm when coiling alone is insufficient.
N-butyl cyanoacrylate (NBCA) is a radiolucent monomer used in conjunction with ethiodized oil and/or, less often, tantalum powder for embolotherapy in nonneurovascular interventions. NBCA rapidly polymerizes on contact with ionic medium and bonds with adjacent structures. It is highly thrombogenic and bacteriostatic, making it an ideal candidate for the control of GI hemorrhage; however, use in GI hemorrhage is off-label. Its use is limited by a lack of stable control and operator familiarity with its deployment. The availability of the intravascular formulation may be limited to sites with neurovascular interventions. The polymerization of NBCA is controlled by dilution with ethiodized oil, and depending on this, it can be formulated to provide a more proximal embolization. It can also be used to help thrombose a large aneurysm or pseudoaneurysm when coiling alone is insufficient.
Coils come in two broad categories: pushable and detachable. Pushable coils are the dominant embolic agent used in both upper and lower GI hemorrhage. The main limitation of coils is malposition or nontarget coil migration. This limitation can be somewhat mitigated by the use of detachable coils, which allow for coil formation and final positioning prior to deployment. Additionally, detachable coils are available in longer lengths compared to pushable coils. This also helps compensate for the increased cost associated with detachable coils, because one long detachable coil could be used in place of several shorter pushable coils. Coil embolization is considered a more proximal form of embolization as the embolic device does not generally migrate into the bowel mucosa and ischemia is a rare complication.
Coils come in two broad categories: pushable and detachable. Pushable coils are the dominant embolic agent used in both upper and lower GI hemorrhage. The main limitation of coils is malposition or nontarget coil migration. This limitation can be somewhat mitigated by the use of detachable coils, which allow for coil formation and final positioning prior to deployment. Additionally, detachable coils are available in longer lengths compared to pushable coils. This also helps compensate for the increased cost associated with detachable coils, because one long detachable coil could be used in place of several shorter pushable coils. Coil embolization is considered a more proximal form of embolization as the embolic device does not generally migrate into the bowel mucosa and ischemia is a rare complication.
Ethylene-vinyl alcohol copolymer (EVOH) (Onyx, Medtronic) is indicated for the treatment of neurovascular arteriovenous malformation; its use in the GI tract is off-label. Its two formulations allow for more proximal or distal embolization as needed. However, as a whole, the territory affected by embolization is more distal than that of coils. Onyx requires at least 20 minutes of agitation before use and it is best to start agitation at the beginning of a case in which it may be used. Like NBCA, there is a small risk of catheter adherence to the extruded material as well as nontarget embolization. The risk for ischemia is generally higher than that of coils.
Ethylene-vinyl alcohol copolymer (EVOH) (Onyx, Medtronic) is indicated for the treatment of neurovascular arteriovenous malformation; its use in the GI tract is off-label. Its two formulations allow for more proximal or distal embolization as needed. However, as a whole, the territory affected by embolization is more distal than that of coils. Onyx requires at least 20 minutes of agitation before use and it is best to start agitation at the beginning of a case in which it may be used. Like NBCA, there is a small risk of catheter adherence to the extruded material as well as nontarget embolization. The risk for ischemia is generally higher than that of coils.
Most commonly composed of polyvinyl alcohol or acrylic polymer impregnated with porcine gelatin, particle embolics are available in a range of sizes. The target vascular territory for embolization can therefore be selected by choosing an appropriate size: larger for more proximal embolizations and smaller when a more distal vascular territory is desired. In GI hemorrhage, particles are most useful for the treatment of tumors, in which careful selection of the feeding vessels can often provide a palliative treatment in the acute setting when options are limited (10)
Most commonly composed of polyvinyl alcohol or acrylic polymer impregnated with porcine gelatin, particle embolics are available in a range of sizes. The target vascular territory for embolization can therefore be selected by choosing an appropriate size: larger for more proximal embolizations and smaller when a more distal vascular territory is desired. In GI hemorrhage, particles are most useful for the treatment of tumors, in which careful selection of the feeding vessels can often provide a palliative treatment in the acute setting when options are limited (10)
The pseudoaneurysms of the middle colic artery ruptured into the bowel, causing life-threatening haemorrhage are extremely rare. The patient was successfully treated by effective coil embolization. The report of this case may arise awareness among clinicians regarding pseudoaneurysms as a possible cause of gastrointestinal bleeding.
The pseudoaneurysms of the middle colic artery ruptured into the bowel, causing life-threatening haemorrhage are extremely rare. The patient was successfully treated by effective coil embolization. The report of this case may arise awareness among clinicians regarding pseudoaneurysms as a possible cause of gastrointestinal bleeding.
References
References
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