Cas cliniques

DOI of or1Departme

Uruguay.2Departme

University of t3Vascular

CorrespondSurgery, PastUruguay, E-m

Ann Vasc SurDOI: 10.1016/� Annals of V�Edit�e par ELS

Faux an�evrysme de l’art�ere gastroduod�enalesecondaire �a une pancr�eatite chronique

Mauricio A. Volpi,1,2 Eduardo Voliovici,1,2 Fernando Pinato,1,2 Fernando Sciuto,3 Luis Figoli,1

Marcelo Diamant,1,2 Luis R. Perrone,1 Montevideo, Uruguay

Bien que les faux an�evrysmes soient une complication rare de la pancr�eatite chronique, ils sontpotentiellement s�erieux en raison des �ev�enements qu’ils peuvent causer et des difficult�es diag-nostiques. Historiquement, ils �etaient trait�es chirurgicalement, par la ligature et/ou la r�esection ; desproc�edures endovasculaires percutan�ees mini-invasives n’ont �et�e pr�esent�ees qu’au cours de laderni�ere d�ecennie. Cet article rapporte le cas d’un patient avec une pancr�eatite chroniquepr�esentant une h�emorragie digestive haute grave provoqu�ee par la rupture d’un faux an�evrysme del’art�ere gastroduod�enale. Le patient a �et�e trait�e avec succ�es par embolisation s�elective.

The pseudoaneurysm that occurs as a consequence

of chronic pancreatitis is associated with a signifi-

cant morbimortality because of its potential compli-

cations and the diagnostic and therapeutic issues it

usually poses.1

These type of vascular events develop in the sple-

nic artery, the stomachic coronary artery, and the

gastroduodenal artery; even the superiormesenteric

artery or the common hepatic artery2,3 may be

impaired, with severe upper gastrointestinal bleed-

ing being the main complications resulting in a high

mortality rate.1

Inchronicpancreatitis, the incidenceofhemorrha-

gic complications increases to approximately 3%.4

Technological development and the advances in

the percutaneous endovascular diagnostic and

iginal article: 10.1016/j.avsg.2010.03.034.

nt of Vascular Surgery, Pasteur Hospital, Montevideo,

nt of Surgery, Pasteur Hospital, School of Medicine,he Republic, Montevideo, Uruguay.

Intervention Center (CEDIVA), Montevideo, Uruguay.

ence : Mauricio A. Volpi, MD, Department of Vasculareur Hospital, Larravide 2458, Montevideo 11400,ail: mavolpi@yahoo.com

g 2010; 24: 1136.e7-1136.e11j.acvfr.2011.05.008ascular Surgery Inc.EVIER MASSON SAS

therapeutic techniques have succeeded in reducing

morbimortality.5,6

At present, the selective embolization of pseu-

doaneurysms provides a noninvasive tool to

manage a disorder that used to be under the

domain of surgery, with a significant reduction of

morbimortality.6,7

CASE DESCRIPTION

The patient is a 69-year-old man, alcoholic, former

smoker, and hypertensive. He had a history of

long-standing epigastric pain treated with proton

pump inhibitors.

The patient presented with hematemesis and

melena, which were significant enough to show

evidence of hemodynamic effect. The patient was

lucid, but anemic, with a fine radial pulse of 100

beats per minute and a blood pressure of 100/60

mm Hg. The abdominal examination showed no

elements suggesting peritoneal irritation. However,

the rectal digital examination revealed the presence

of melena, when a painless and pulsatile 7 cm mass

was reported to be palpable at the level of the

epigastrium.

The nasogastric tube yielded 250mL of dark blood

with clots (hematocrit, 31.3%; hemoglobin, 10.9 g/

dL). Al-though the patient was resuscitated with

crystalloids, he started bleeding again after 3 hours of

1228.e1

Fig. 1. Abdominal CT scan: heterogeneous solid mass

with a diameter of 5 cm involving the gastric antrum and

the head of the pancreas; the epicenter of the lesion

could not be determined. The intravenous contrast

showed filling of the mass, certifying its vascular origin.

Fig. 2. Panoramic arteriography of the abdominal aorta:

mass showing vascular opacification on the midline,

somewhat shifted to the right (tip of the arrow).

1228.e2 Cas cliniques Annales de chirurgie vasculaire

admission, resulting in gleaming red blood in the

nasogastric tube. The laboratory testing reflected

the hemodynamic effect of the hemorrhage, with the

hematocrit level decreasing to 22.4% and hemo-

globin to 7.8 g/dL. Moreover, the fiberoptic gas-

troscopy showed deformation of the antrum, which

appeared retracted toward the lesser curvature,

showing thickened erythematous folds that extended

to the pylorus, causing the previously mentioned

deformation. There is a raised lesion inwhat seems to

be submucosa, as well as erosion of the anterior wall

mucosa, with oozing bleeding. Hemostasis was

achieved using 1/10,000 adrenaline.

The computed tomography (CT) scan perfor-

med with oral and intravenous contrast to assess

the nature of the mass showed a solid, heteroge-

neous 5-cm mass involving the gastric antrum

and the head of the pancreas; however, the epi-

center of the lesion could not be determined.

The pancreas was enlarged and it presented intra-

parenchymal calcifications and dilation of the

duct of Wirsung.

The mass filled with intravenous contrast, attest-

ing to the vascular origin of the lesion (Fig. 1).

A panoramic arteriography of the abdominal

aorta was performed using a femoral approach and

a 5-F pigtail catheter (Torcon NB� Advantage

Catheters, Cook� Cook Medical, Inc, Bloomington,

IN). Next, a selective arteriography of the celiac

trunk and gastroduodenal artery was performed

using a Cobra 2, 5-F catheter (Glidecath� Catheters

COBRA II, Terumo Corp, Tokyo, Japan), with a

.038-inch guidewire, and nonionic, low osmolality

contrast.

The panoramic arteriography showed a mass

with vascular opacification on the midline, slightly

shifted to the right (Fig. 2).

The selective injection of the celiac trunk and the

gastroduodenal artery revealed the irregular lumen

of the latter artery, with filling of the distal part of

the mass. The diagnosis revealed that the pseudo-

aneurysm was caused by the rupture of the wall in

the middle portion of the artery, immediately proxi-

mal to the origin of a pancreaticoduodenal arcade.

However, there was no evidence of arteriovenous

fistulas (Fig. 3).

The same diagnostic catheter was used for the

selective embolization of the gastroduodenal artery

using 0.35-inch stainless steel embolization coils

(Cook� Stainless Steel Embolization Coils. Cook

Medical, Inc, Bloomington, IN). Three coils were

3 mm in diameter and 40 mm in length, whereas a

fourth coil had a diameter of 4 mm and length of 30

mm. A sandwich technique was used for proximal

placement of distal coils at the level of the neck of

the pseudoaneurysm (Fig. 4). The patient responded

well; the gastrointestinal tract bleeding did not

relapse and the patient was discharged 4 days after

the intervention.

The gastrointestinal endoscopy that was perfor-

med 30 days after discharge detected no evidence

of gastroduodenal lesions, whereas the abdominal

CT scan performed after 5 months showed no chan-

ges in the size of the pseudoaneurysm, which was

still thrombosed by the coils, without any contrast

inside its sac (Fig. 5).

Fig. 3. Selective injection of the gastroduodenal artery

showing an irregular lumen and filling of the distal sec-

tion of the mass; diagnosis of pseudoaneurysm caused by

the rupture of the wall in the middle of the artery.

Fig. 4. Selective embolization of the gastroduodenal

artery with stainless steel fibrilar coils (Cook� Stainless

Steel Embolization Coils; Cook Medical Inc, Bloo-

mington, IN) - the ‘‘sandwich technique.’’

Fig. 5. The control abdominal CT scan performed at

5 months revealed the pseudoaneurysm thrombosed by

the coils, with no evidence of contrast in its sac.

Vol. 24, No. 8, 2010 Cas cliniques 1228.e3

DISCUSSION

Chronic pancreatitis is an inflammatory condition

characterized by morphological and functional

lesions of the gland that are usually irreversible

and progressive, with both exocrine and endocrine

involvement of the pancreas. Histologically, it inclu-

des intraglandular fibrosis, acinar destruction, and

lymphocytic infiltration.8

The vascular complications of chronic pancreati-

tis are the main cause of morbimortality and are pri-

marily caused by the hemorrhage resulting from the

erosion of a pseudoaneurysm, with ischemic and

venous complications.3 Pseudoaneurysms are an

uncommon complication of chronic pancreatitis,

with its incidence ranging from 10 to 17%.9

Although the sequence of events leading to the

occurrence of a pseudoaneurysm in chronic pan-

creatitis is not well understood, some of the events

are thought to be similar to the changes that occur

in acute pancreatitis.3 At the early stages of chro-

nic pancreatitis, there is predominance of recurring

bouts of pancreatitis; the mechanisms involved

result from the inflammatory process.10,11

The vascular changes that can be attributed to the

disease include the splitting of the internal elastic

lamina and subsequent necrosis of the vessel wall,

which can lead to the thrombosis or rupture of the

vessel. These events occur as a consequence of the

proteolytic action of the pancreatic enzymes, prima-

rily elastase.10,11

Two types of aneurysms have been reported in

association with pancreatitis. True aneurysms are

created when the inflammatory process causes

the partial digestion of the arterial wall, destroying

the elastic tissue of the tunica media. False aneu-

rysms or pseudoaneurysms develop when a pseu-

docyst is incorporated as a part of the arterial

wall.12

The spleen artery is the most commonly involved

vessel, accounting for 30-50% of the cases of arterial

pseudoaneurysms in chronic pancreatitis, particu-

larly because of its anatomic location.13,14 The fre-

quency of pseudoaneurysms of the gastroduodenal

artery ranges from 10 to 20% and the pan-

creaticoduodenal arteries are involved in 10%of the

cases.2,3,13,14

Most of the patients suffering from chronic pan-

creatitis with pseudoaneurysms are asymptomatic,

1228.e4 Cas cliniques Annales de chirurgie vasculaire

and they are usually diagnosed through imaging

work-ups.14

However, when they are symptomatic, their cli-

nical presentation cannot be distinguished from a

bout of pancreatitis, unless it is complicated.1,2,4,15

It can also present as a painful pulsatile mass.14

The most complicated forms may have a different

clinical expression depending on the location of the

pseudoaneurysm rupture. It may break into a hol-

low viscus, particularly into the duodenum, causing

a severe upper gastrointestinal hemorrhage. It can

also rupture into a pseudocyst, resulting in a retro-

peritoneal hemorrhage, or in the duct of Wirsung,

causing the so-called hemosuccus pancreaticus.1

The pseudocysts related to chronic pancreatitis are

usually intrapancreatic and occur secondary to the

obstruction of one of the branches of the pancreatic

tree. The association of both processes (pseudocyst

and pseudoaneurysms) is because of the fact that the

subsequent expansion of the pseudocyst would

promote the erosion of the intra- and peripancreatic

arteries. Another alternative origin of pseudocysts is

similar to that of acute pancreatitis, that is, resulting

from episodes of acute exacerbation of the disease,

andwith necrosis itself as the cause of the damage of

the vascular wall.6

In all, 3% of the patients with pseudoaneurysms

present with hemorrhage. Balthazar reports it as a

late complication, occurring 2-3 years after the

first episode of pancreatitis on an average, after

repeated acute bouts in patients with chronic

pancreatitis.16

The rupture of a pseudoaneurysm in the gastroin-

testinal tract is a life-threatening event, which is

associated with a mortality rate of approximately

75%; the patient presents with a severe upper gas-

trointestinal bleeding, and the upper digestive

endoscopy fails to determine the cause of

diagnosis.17

The CT scanwith intravenous contrast locates the

lesion and reveals the intracystic hemorrhage9,18

(Fig. 1). A selective arteriography of the celiac trunk

is indicated as an elective procedure in any patient

presenting with digestive bleeding and suffering

from chronic pancreatitis, both for diagnostic and

therapeutic purposes.6,7,9,19

The classical management of ruptured pseudo-

aneurysms used to be surgical and was associated

with a high morbimortality; however, because of

the development of imaging techniques and percu-

taneous procedures, there are now many reports of

patients treated successfully with endovascular per-

cutaneous therapy. The procedure has a low morbi-

mortality,19 and its efficacy rate ranges from 70 to

100%.9,20

The transcatheter selective embolization of the

pseudoaneurysm has become the treatment of

choice for pseudoaneurysms, regardless of the pre-

sence or absence of complications.7,9,19,20-22

Thematerial used for embolization varies, includ-

ing particles (alcohol polyvinyl foam, powder or gel-

foam sheets, microfibrilar collagen), metallic bodies

(platinum or stainless steel coils), liquids (hystoa-

cryl, ethanol, sodium tetradecyl sulfate [sotrade-

col�]), or even balloons.7 These materials may be

placed in the aneurysmatic sac to preserve arterial

patency, or in the artery from which the pseudo-

aneurysm originates, occluding both structures.

Under such circumstances, and whenever possible,

the ‘‘sandwich’’ technique is the one preferred to

occlude the artery proximally and distally to the

aneurysm, thereby preventing both downstream

and upstream filling. This was the technique used in

the present case (Fig. 4).

The most frequent complication is the recurrence

of hemorrhage, which is usually caused by the

proximal occlusion without the distal closure of

the artery, resulting in the retrograde filling of the

pseudoaneurysm through collateral vessels, thus

reproducing the initial symptomatology.6

The subsequent CT scan control performed for

the patient in this study showed the therapeutic

effectiveness of the targeted embolization of the

upper gastrointestinal bleeding caused by the pseu-

doaneurysms of the gastroduodenal artery (Fig. 5).

REFERENCES

1. Bradley E. Complications of chronic pancreatitis. Surg Clin

North Am 1989;69:481-497.

2. Boudghene F, L’Hermine C, Bigot JM. Arterial complica-

tions of pancreatitis: diagnosis and therapeutic aspects in 104

cases. J Vasc Interv Radiol 1993;4:551-558.

3. Mendelson RM, Anderson J, Marshall MM, Ramsay D.

Vascular complications of pancreatitis. ANZ J Surg 2005;75:

1073-1079.

4. Bretagne J, Heresbach D, Darnault P, et al. Pseudo-

aneurysms and bleeding pseudocysts in chronic pancreatitis:

radiological findings and contribution to diagnosis in 8 cases.

Gastrointest Radiol 1990;15:9-16.

5. Van Sonnenberg E, Wittich GR, Casola G. Complicated

pancreatic inflammatory disease: diagnostic and therapeutic

role of interventional radiology. Radiology 1985;155:

335-340.

6. Ochoa Labarta LM, Garcı́a Guti�errez JA, Rueda Vicente J,

et al. Radiologı́a intervencionista en las complicaciones

vasculares de la pancreatitis cr�onica: seudoaneurisma de la

arteria gastroduodenal. Cir Esp 2000;67:506-509.

7. Funaki B. Endovascular intervention for the treatment of

acute arterial gastrointestinal hemorrhage. Gastroenterol

Clin North Am 2002;31:701-713.

8. Baker R, Fischer J. El dominio de la cirugı́a. Cuarta edici�on,Vol 2. Buenos Aires, Argentina: M�edica Panamericana, 2004.

pp 1503-1512.

Vol. 24, No. 8, 2010 Cas cliniques 1228.e5

9. de Perrot M, Berney T, B€uhler L, et al. Management of

bleeding pseudoaneurysms in patients with pancreatitis. Br J

Surg 1999;86:29-32.

10. Freedman SD. New concepts in understanding the patho-

physiology of chronic pancreatitis. Int J Pancreatol 1998;

24:1-8.

11. Ammann RW. The natural history of alcoholic chronic

pancreatitis. Intern Med 2001;40:368-375.

12. Patel SB, Shah SR, Shah SS, et al. Case report: pseudo-

aneurysm from gastroduodenal artery associated with

chronic pancreatitis; an unusual complication. Indian J

Radiol Imaging 2003;13:311-313.

13. Walter JF, Chaung VP, Bookstein JJ, et al. Angiography of

massive heamorrhage secondary to pancreatic disease.

Radiology 1977;124:337-342.

14. Pasha SB, Gloviczki P, Stanson AW, Kamath PS.

Splanchnic artery aneurysms. Mayo Clin Proc 2007;82:

472-479.

15. Izaguirre Loro~no M, Estallo Laliena L, Vega de C�eniga M,

et al. Aneurismas y pseudoaneurismas peripancre�aticoscomplicados. Angiologı́a 2007;59:73-78.

16. Balthazar EJ, Fisher LA. Hemorrhagic complications of

pancreatitis: radiologic evaluation with emphasis on CT

imaging. Pancreatology 2001;1:306-313.

17. Jenkins AP, El Omar MM, Booth JC, et al. Recurrent gas-

trointestinal bleeding associated with chronic pancreatitis.

Gut 1995;36:314-316.

18. P�erez C, Llauger J, Pallard�o Y, Sanchı́s E, Sabat�e JM.

Radiologic diagnosis of pseudoaneurysms complicating

pancreatitis. Eur J Radiol 1993;16:102-106.

19. Kakizawa, Toyota N, Naito A, et al. Endovascular therapy for

abdominal pseudoaneurysms: analysis from technical and

clinical aspects. Acta Radiol 2006;1:28-36.

20. Chong CN, Lee KF,Wong KT, et al. Ruptured gastroduodenal

artery pseudoaneurysm as the initial presentation of chronic

pancreatitis. Am J Surg 2009;197:e38-e40.

21. Sessa C, Tinelli G, Porcu P, et al. Treatment of visceral artery

aneurysms: description of a retrospective series of 42

aneurysms in 34 patients. Ann Vasc Surg 2004;18:695-703.

22. Germanos S, Soonawalla Z, Stratopoulos C, Friend PJ.

Pseudoaneurysm of the gastroduodenal artery in chronic

pancreatitis. J Am Coll Surg 2009;208:316.