Purpose: To determine whether endovascular embolization of pseudoaneurysms complicating pancreatitis with microcoils was associated with better therapeutic outcome. Materials and Method: The prospective clinical study was carried out in the Department of Interventional Radiology for a period of 2 years extending from May 2010 upto August 2012 on 16 male patients in the age group of about 30 - 55 years, with each one of them having vascular complications as a sequel to pancreatitis, after obtaining well informed written consent from each one of them. Results: The outcome of the procedure was judged by the following parameters—a) Restoration of the blood pressure of the patient; b) Cessation of the hemetemesis and malena; c) Reduction in abdominal pain and discomfort and d) Overall improvement in the general condition of the patient. Each of the patients had been on follow up for at least 6 months, except 2 of them, with no new complaints in any of them. The procedure related mortality was none. Conclusion: Vascular complications of pancreatitis need immediate and accurate diagnosis and prompt treatment. Micro coil embolisation, is a minimally invasive technique which helps to exclude the pseudoaneurysm from the circulation and thus reduces the scope for massive life threatening internal hemorrhage, and is a better alternative to surgery.
Pancreatitis is one of the common conditions in patients presenting with acute abdominal pain. Severe pancreatitis occurs in 20% - 30% of all patients with acute pancreatitis and is characterized by a protracted clinical course, multiorgan failure, and pancreatic necrosis. Of the various complications of pancreatitis, vascular complications are one of the most dangerous life threatening ones. Vascular complications of acute pancreatitis include thrombosis, erosion of the vessel wall, and pseudoaneurysm formation [
The prospective clinical study was carried out in the Department of Interventional Radiology for a period of 2 years extending from May 2010 upto August 2012. It included total 16 male patients in the age group of about 30 - 55 years, with each one of them having vascular complications as a sequel to pancreatitis, and haven taken prior well informed written consent from each of them. The materials included routine angiography instruments like Gelco, Angiosheath, Terumo guide wires, Head hunter and Cobra catheters, Micro-catheters, Contrast agent and Embolization microcoils of varying sizes and the C arm machine.
The Inclusion criteria were:
• Patients with pancreatitis having complaints of repeated episodes of severe abdominal pain;
• Hemetemesis and Malena;
• Falling blood pressure.
The Exclusion criteria were:
• Patients who were unable to lie supine for long time;
• Patients with severe hemodynamic instability.
Total 16 male patients were included in the study. All were diagnosed to have pancreatitis with vascular complications in the form of pseudoaneurysm formation of varying sizes, and involving different branches of the celiac trunk and superior mesenteric artery as per individual case. The initial diagnosis was made with the help of plain and contrast enhanced CT scan and then conventional angiography was done for further diagnostic and therapeutic purpose. The table (
Initially through the right femoral arterial puncture, with help of 4 F Cobra catheter and guide wire assess was made inside the abdominal aorta. Then with cannulation of the celiac and superior mesenteric arteries was done as per the need. Initial check angiograms were taken to locate the site and number of the pseudoaneurysms. The check angiograms were carefully assessed for the location, size, number, neck size and rupture if present of the pseudoaneurysms and then the appropriate sizes and number of the microcoils were decided. Through the same route, microcoils of varying sizes as per the need were inserted carefully under DSA control to exclude the pseudo aneurysm from circulation. More than 3 microcoils were used in each case for the “sandwich technique” of coil embolization. In one of the cases of splenic artery pseudoaneurysm, all the inserted microcoils mi
grated distally at acute turn of distal splenic artery. The check angiography showed patent pseudoaneurysm with embolization of the distal splenic artery. Hence, whole of the splenic artery proximal to the microcoils was embolised using Glue (N-butyl Cyanoacrylate) mixed with lipiodol in equal proportion upto the splenic arterial origin. The microcoils prevented the glue from entering into the splenic parenchyma. In each of the cases post embolization check angiogram was taken to assess the success of embolization in the form of exclusion of the pseudoaneurysm from the circulation and non contrast filling of the parent artery (Figures 1(e), 2(c), 3(c), 4(c), 5(c) and 6(c)).
The pseudoaneurysm presented with rupture leading into haemorrhage into the peri-pancreatic collection (Figures 1(a)-(c)) as in the case of hepatic artery pseudoaneurysm, while it presented as hemetemesis and malena due to rupture into the gastrointestinal tract in some cases (Figures 2(a), 2(b) and 6(a)), while some were incidentally detected during scanning. Some of these pseudoaneurysms were relatively smaller in size (Figures 1(c), 1(d) and 2(b)), while in other cases they were larger in size (Figures 3(a), 3(b), 4(a), 4(b) and 5(a)).
The outcome of the procedure was judged by the following parameters:
1) Restoration of the blood pressure of the patient;
2) Cessation of the hemetemesis and malena;
3) Reduction in abdominal pain and discomfort;
4) Overall improvement in the general condition of the patient.
Usually the patients were kept admitted for 5 - 7 days after the procedure to see for any new procedure related complications. There was no such significant event noted, except for post embolization pain which resolved with
analgesics. Each of the patients had been on follow up for at least 6 months, except 2 of them, with no new complaints in any of them. The procedure related mortality was none.
A Pseudoaneurysm, also termed a false aneurysm, is a leakage of arterial blood from an artery into the surrounding tissue with a persistent communication between the originating artery and the resultant adjacent cavity, and contained by overlying media, adventitia or by soft tissue structures surrounding the injured vessels.
The etiology of these pseudoaneurysms may be varied, from inflammation, trauma to iatrogenic causes such as surgical procedures [
Sometimes these pseudoaneurysms may be asymptomatic and detected incidentally [
The diagnosis of pseudoaneurysms has been revolutionised by varying imaging modalities like duplex Doppler ultrasonography (US), magnetic resonance (MR) angiography and helical computed tomography (CT) angiography [6,12] although the conventional angiography remains the gold standard of reference [
Ultrasonography(US)—gray scale US demonstrates a hypoechoic cystic structure adjacent to supplying artery [4,14,15]. The various characteristics of the pseudoaneurysms that are to be assessed by US are the size of the sac, the connection of the sac to the artery, and the length and width of the neck [
CT Angiography—unenhanced CT scan may show low attenuation rounded structure arising from the donor artery, with surrounding high attenuation rim in cases of rupture. Contrast enhanced CT scan may show a contrast material filled sac [
MR Angiography—many new advances in the field of non contrast and contrast enhanced MRI Angiography have made the detection of subtle lesions possible. The advantages of MR Angiography include no iodinated contrast agent or ionising radiations [23,24], thus making it the investigation of choice in patients of renal failure and contrast allergy. The limitations of MRI Angiography include time consumption, not suitable in trauma patients and artifacts due to multiple causes.
Conventional Angiography—it remains the gold standard of reference for the diagnosis of pseudoaneurysm even today [22,24,25]. The advantages of conventional angiography include real time hemodynamic assessment of the vascular bed, exact measurement of the size of the sac and neck of the pseudoaneurysm [
Thus, all these imaging modalities are in fact complementary to each other in the final diagnostic and therapeutic procedures.
The risk of spontaneous rupture of extraorganic visceral pseudo aneurysm is very high regardless of their size and the mortality rate for such ruptures in morbid postsurgical patients approaches to about 100% [8,9,11]. Hence, definitive treatment should be administered in all such cases [9,19]. The traditional treatment of choice was surgical repair which was invasive and had higher morbidity and mortality rates [7,16,27]. In recent times various other treatment options have become available as a better alternative to surgery.
Endo-Vascular Management—the treatment option depends upon two important factors 1) size of pseudoaneurysmal neck and 2) expendability of the donor artery. If the donor artery is expendable, then the collateral supply is accessed. In case of no collateral supply, only proximal embolisaton of the parent artery is considered, but if the collateral supply is good, then both proximal and distal embolization of the parent artery with respect to the pseudoaneurysm is needed. If the artery is inexpendable, the neck size of the pseudoaneurysm is evaluated. In cases of narrow neck, embolization of the pseudoaneurysmal sac itself is considered, but if the neck is wide, then stent graft placement can be considered. In cases of the involvement of branches of the celiac trunk and superior mesenteric arteries especially due to pancreatitis, there is good collateral circulation [11,26] and so the “Sandwich technique” of embolization is used in which the embolization is done distally and then proximally with respect to the site of the pseudoaneurysm to prevent backflow from the collateral circulation [
Surgery—the various surgical procedures include resection and bypass procedure, arterial ligation, and partial and total organ removal [
The other possible therapeutic options are US guided compression and US guided percutaneous thrombin injection, which is usually suited for superficially located pseudoaneurysms [
Vascular complications of pancreatitis need immediate and accurate diagnosis and prompt treatment. It can be suspected on plain and contrast CT scan of the patient complaining of another episode of severe abdominal pain after recovery from initial pain of pancreatitis. Conventional angiography is done for further anatomic characterization and therapeutic management such as embolization. Micro coil embolisation, is a minimally invasive technique which helps to exclude the pseudoaneurysm from the circulation and thus reduces the scope for massive life threatening internal hemorrhage, and is a better alternative to surgery.