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Thrombin injection of a pancreaticoduodenal artery pseudoaneurysm after failed attempts at transcatheter embolization

2006; Elsevier BV; Volume: 43; Issue: 3 Linguagem: Inglês

10.1016/j.jvs.2005.11.051

1097-6809

Azad Ghassemi, Daniel Javit, Evan H. Dillon,

Vascular Procedures and Complications

We describe a case of a pseudoaneurysm of the pancreaticoduodenal artery in a patient with history of cholecystectomy and chronic pancreatitis. Attempts at transcatheter coil embolotherapy failed because of vessel tortuosity. The lesion was then successfully treated by computed tomography-guided direct percutaneous injection of thrombin into the pseudoaneurysm. This technique may be a first line of treatment or a useful adjunct to transcatheter embolization technique. We describe a case of a pseudoaneurysm of the pancreaticoduodenal artery in a patient with history of cholecystectomy and chronic pancreatitis. Attempts at transcatheter coil embolotherapy failed because of vessel tortuosity. The lesion was then successfully treated by computed tomography-guided direct percutaneous injection of thrombin into the pseudoaneurysm. This technique may be a first line of treatment or a useful adjunct to transcatheter embolization technique. Pancreaticoduodenal artery pseudoaneurysm is a very rare but potentially lethal complication of pancreatitis.1Chiou A.C. Josephs L.G. Menzoian J.O. Inferior pancreaticoduodenal artery aneurysm report of a case and review of literature.J Vasc Surg. 1993; 17: 784-789Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Iyomasa S. Matsuzaki Y. Hiei K. Sakaguchi H. Matsunaga H. Yamaguchi Y. Pancreaticoduodenal artery aneurysm a case report and review of the literature.J Vasc Surg. 1995; 22: 161-166Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 3Mandel S. Jaques P.F. Mauro M.A. Sanofsky S. Nonoperative management of peripancreatic arterial aneurysms A 10-year experience.Ann Surg. 1987; 205: 126-128Crossref PubMed Scopus (225) Google Scholar This lesion is traditionally treated noninvasively by percutaneous transcatheter embolization technique.4Golzarian J. Nicaise N. Deviere J. Ghysels M. Wery D. Dussaussois L. et al.Transcatheter embolization of pseudoaneurysms complicating pancreatitis.Cardiovasc Intervent Radiol. 1997; 20: 435-440Crossref PubMed Scopus (72) Google Scholar, 5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar, 6Mauro M.A. Jaques P. Transcatheter management of pseudoaneurysms complicating pancreatitis.J Vasc Interv Radiol. 1991; 2: 527-532Abstract Full Text PDF PubMed Scopus (70) Google Scholar There are few reports of successful treatment of splanchnic artery pseudoaneurysm by percutaneous thrombin injection (PTI).5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar, 7Luchs S. Antonacci V. Reid S. Pagan-Marin H. Vascular and interventional case of the day. Pancreatic head pseudoaneurysm treated with percutaneous thrombin injection.AJR Am J Roentgenol. 1999; 173: 833-834Crossref Scopus (16) Google Scholar, 8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar, 9Sparrow P. Asquith J. Chalmers N. US-Guided percutaneous injection of pancreatic pseudoaneurysm with thrombin.Cardiovasc Intervent Radiol. 2003; 26: 312-315Crossref PubMed Scopus (37) Google Scholar, 10Manazer J.R. Monzon R. Dietz P.A. Moglia R. Gold M. Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection.J Vasc Surg. 2003; 38: 600-602Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar We report a case of pancreaticoduodenal artery pseudoaneurysm secondary to pancreatitis that was successfully treated by using computed tomography (CT)-guided PTI after three failed attempts at percutaneous transcatheter embolization. A 77-year-old man presented with abdominal pain and melena. His medical history included hypertension, chronic pancreatitis, and cholecystectomy. A CT scan showed a 5.1-cm × 4.6-cm, well defined, ovoid, enhancing mass between the pancreatic head and the descending duodenum (Fig 1). The lesion was further evaluated by CT angiography of the upper abdomen that demonstrated a rounded, centrally slow-enhancing lesion. Communication between this lesion and the anteriorly located gastroduodenal artery was visible. Given the location and history of pancreatitis, this lesion most likely represented a pseudoaneurysm. During angiography, the celiac artery was selected with a 4FSos-Omni 3 catheter (AngioDynamics, Queensbury, NY). The Sos-Omni catheter was removed over the wire and a 4F Cobra glide catheter was advanced into the gastroduodenal artery. A Renegade high-flow microcatheter (Boston Scientific, Natick, Mass) was then advanced through the Cobra catheter to selectively cannulate a branch of the superior pancreaticoduodenal artery (Fig 2, A). Two 4-mm platinum micro-coils were deployed into the neck of the aneurysm from the superior pancreaticoduodenal approach. Evaluation of the superior mesenteric artery (SMA) angiogram after coil embolization revealed no definite filling of the pseudoaneurysm from branches of the inferior pancreaticoduodenal artery (Fig 2, B). On repeat CT angiography of the abdomen, the pseudoaneurysm remained patent. A second embolization procedure was performed. This time, however, the entire segment from the proximal right gastroepiploic artery to the mid-gastroduodenal artery was embolized with 4-mm and 5-mm platinum micro coils. The SMA was again catheterized, and no definite filling of the pseudoaneurysm was demonstrated. Follow-up CT angiography of the abdomen, however, demonstrated residual faint patency of the pseudoaneurysm (Fig 3, A). During a third attempt at embolization, a branch of the inferior pancreaticoduodenal artery was demonstrated to contribute flow to the pseudoaneurysm (Fig 3, B). Because of the tortuosity, a Tracker-325 microcatheter (Boston Scientific) could not be advanced up to the neck of the pseudoaneurysm. This vessel was not embolized more proximally owing to the concern of ischemia because the blood supply from the superior pancreaticoduodenal artery had already been compromised from earlier embolizations. After the embolization options had been exhausted, the decision was then made to perform a CT-guided PTI into the pseudoaneurysm. Ultrasound guidance could not be used to perform this procedure because overlying bowel gas obscured the lesion. The patient was placed in the left lateral decubitus position. A 20-cm 22-gauge needle containing an inner metallic stylet was advanced without aspirating between the right kidney and the transverse colon. The path of the needle was confirmed every 2 to 3 cm by rescanning until the tip of the needle was in the patent portion of the pseudoaneurysm (Fig 4, A). The needle should not be allowed to traverse through various structures with impunity because the risk of major organ-specific complications when fine needles (21-gauge or smaller) are used has been reported to be 0.1% to 2%.11Cardella J. Bakal C.W. Bertino R.E. Burke D.R. Drooz A. Haskal Z. et al.Quality improvement guidelines for image-guided percutaneous biopsy in adults.J Vasc Interv Radiol. 2003; 14: S227-S230Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In performing CT-guided pancreatic biopsies, Brandt et al12Brandt K.R. Charboneau J.W. Stephens D.H. Welch T.J. Goellner J.R. CT-and US-guided biopsy of the pancreas.Radiology. 1993; 187: 99-104PubMed Google Scholar reports 66 documented passes through overlying loops of bowel, including seven through the colon, without any side effects. Rothbarth et al13Rothbarth L.J. Redmond P.L. Kumpe D.A. Percutaneous transhepatic treatment of a large intrahepatic aneurysm.AJR Am J Roentgenol. 1989; 153: 1077-1078Crossref PubMed Scopus (34) Google Scholar treated a large intrahepatic aneurysm by direct percuatenous transhepatic injection of thrombin using a 22-gauge needle without major complications. However, to minimize complications, we try to avoid crossing bowel and solid organs unless absolutely necessary. Once the needle was in place, we injected thrombin at a concentration of 1000 U/mL for a total dose of 1300 U. In previous case reports of splanchnic artery pseudoaneurysms, a 500 U bolus dose of thrombin was used and repeated if part of the pseudoaneurysm was still patent.5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar, 7Luchs S. Antonacci V. Reid S. Pagan-Marin H. Vascular and interventional case of the day. Pancreatic head pseudoaneurysm treated with percutaneous thrombin injection.AJR Am J Roentgenol. 1999; 173: 833-834Crossref Scopus (16) Google Scholar, 8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar, 9Sparrow P. Asquith J. Chalmers N. US-Guided percutaneous injection of pancreatic pseudoaneurysm with thrombin.Cardiovasc Intervent Radiol. 2003; 26: 312-315Crossref PubMed Scopus (37) Google Scholar In these reports, an injection of 1000 U of thrombin was usually sufficient to achieve successful thrombosis of the pseudoaneurysm. Similarly, several studies examining the treatment of femoral artery pseudoaneurysms used a thrombin dose of 500 to 1000 U.14Kang S.S. Labropoulos N. Mansour M.A. Baker W.H. Percutaneous ultrasound guided thrombin injection A new method for treating postcatheterization femoral pseudoaneurysms.J Vasc Surg. 1998; 187: 464-466Google Scholar The size of the aneurysm and active bleeding can affect the amount of thrombin needed to achieve complete thrombosis.10Manazer J.R. Monzon R. Dietz P.A. Moglia R. Gold M. Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection.J Vasc Surg. 2003; 38: 600-602Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 14Kang S.S. Labropoulos N. Mansour M.A. Baker W.H. Percutaneous ultrasound guided thrombin injection A new method for treating postcatheterization femoral pseudoaneurysms.J Vasc Surg. 1998; 187: 464-466Google Scholar A final CT angiogram demonstrated no evidence of filling of the pseudoaneurysm. Total procedure time was 45 minutes, and there were no procedure-related complications. A follow-up CT scan obtained 4 months later demonstrated continued thrombosis of the pseudoaneurysm (Fig 4, B). Aneurysms of small splanchnic arteries are very uncommon. The pancreaticoduodenal arteries account for 2% of all splanchnic artery aneurysms.1Chiou A.C. Josephs L.G. Menzoian J.O. Inferior pancreaticoduodenal artery aneurysm report of a case and review of literature.J Vasc Surg. 1993; 17: 784-789Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Iyomasa S. Matsuzaki Y. Hiei K. Sakaguchi H. Matsunaga H. Yamaguchi Y. Pancreaticoduodenal artery aneurysm a case report and review of the literature.J Vasc Surg. 1995; 22: 161-166Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Pancreaticoduodenal aneurysms are among the most life-threatening aneurysms, with gastrointestinal hemorrhage occurring in 7% to 15%.3Mandel S. Jaques P.F. Mauro M.A. Sanofsky S. Nonoperative management of peripancreatic arterial aneurysms A 10-year experience.Ann Surg. 1987; 205: 126-128Crossref PubMed Scopus (225) Google Scholar Pseudoaneurysms at this location are more common than true aneurysms, secondary to pancreatitis.15Stanley J.C. Thompson N.W. Fry W.J. Splanchnic artery aneurysms.Arch Surg. 1970; 10: 689-697Crossref Scopus (348) Google Scholar Leakage of pancreatic enzymes from an inflamed pancreas results in enzymatic autodigestion of the arterial walls, with pseudoaneurysm formation.16Stabile B.E. Wilson S.E. Debas H.T. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis.Arch Surg. 1983; 118: 45Crossref PubMed Scopus (276) Google Scholar, 17Geokas M.C. The role of elastase in acute pancreatitis.Arch Pathol. 1968; 86: 135-141Google Scholar The wall of a pseudocyst can incorporate a visceral artery, converting it into a pseudoaneurysm. Hemorrhage from these pseudoaneurysms is associated with high mortality rate.16Stabile B.E. Wilson S.E. Debas H.T. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis.Arch Surg. 1983; 118: 45Crossref PubMed Scopus (276) Google Scholar The CT finding of contrast enhancement within or adjacent to a suspected pseudocyst or contiguous with a vascular structure is highly suggestive of pseudoaneurysm formation.18Burke J.W. Erickson S.J. Kellum C.D. Tegtmeyer C.J. Williamson B.R. Hansen M.F. Pseudoaneurysms complicating pancreatitis detection by CT.Radiology. 1986; 161: 447-450PubMed Google Scholar Other etiologies include atherosclerotic disease, fibrodysplasia, trauma, and congenital anomalies. Angiography may determine the vessel of origin of the pseudoaneurysm as well as provide definitive therapy through embolization with permanent embolic agents such as micro-coils. Both the superior and inferior pancreaticoduodenal arteries may need to be embolized to treat a pseudoaneurysm. Previous case reports in which both arteries were embolized have demonstrated no complications such as bowel or pancreatic ischemia.6Mauro M.A. Jaques P. Transcatheter management of pseudoaneurysms complicating pancreatitis.J Vasc Interv Radiol. 1991; 2: 527-532Abstract Full Text PDF PubMed Scopus (70) Google Scholar, 8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar Despite many successful reports of minimally invasive endovascular treatment of pancreaticoduodenal artery aneurysms,4Golzarian J. Nicaise N. Deviere J. Ghysels M. Wery D. Dussaussois L. et al.Transcatheter embolization of pseudoaneurysms complicating pancreatitis.Cardiovasc Intervent Radiol. 1997; 20: 435-440Crossref PubMed Scopus (72) Google Scholar, 5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar, 6Mauro M.A. Jaques P. Transcatheter management of pseudoaneurysms complicating pancreatitis.J Vasc Interv Radiol. 1991; 2: 527-532Abstract Full Text PDF PubMed Scopus (70) Google Scholar certain technical factors may preclude this treatment method. One of these factors is an inability to cannulate the vessel feeding the aneurysm.10Manazer J.R. Monzon R. Dietz P.A. Moglia R. Gold M. Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection.J Vasc Surg. 2003; 38: 600-602Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 19Chiang K.S. Johnson C.M. McKusick M.A. Maus T.P. Stanson A.W. Management of inferior pancreaticoduodenal artery aneurysms a 4-year, single center experience.Cardiovasc Intervent Radiol. 1994; 17: 217-221Crossref PubMed Scopus (35) Google Scholar In our case, the pseudoaneurysm was embolized from the superior pancreaticoduodenal artery; however, it could not be successfully embolized from a feeding branch of the inferior pancreaticoduodenal artery because of tortuosity. The pseudoaneurysm was finally successfully treated by a direct CT-guided percutaneous injection of thrombin. Percutaneous thrombin injection was pioneered by Cope and Zeit in 1986.5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar This initial series reported four patients treated for peripheral aneurysms by utilizing PTI. More recently, Luchs et al7Luchs S. Antonacci V. Reid S. Pagan-Marin H. Vascular and interventional case of the day. Pancreatic head pseudoaneurysm treated with percutaneous thrombin injection.AJR Am J Roentgenol. 1999; 173: 833-834Crossref Scopus (16) Google Scholar treated a pancreatitis-related pseudoaneurysm. The aneurysm was eventually treated by direct PTI using ultrasound guidance after a failed attempt at transcatheter embolization because of technical difficulties. The Table provides a review of the literature where a splanchnic artery pseudoaneurysm was treated by using thrombin injection along with the dosage of thrombin used. Kemmeter et al20Kemmeter P. Bonnell B. VanderKolk W. et al.Percutaneous thrombin injection of splanchnic artery aneurysm two case reports.J Vasc Interv Radiol. 2000; 11: 469-472Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar used fluoroscopic-guided PTI to treat two aneurysms arising from branches of the SMA. Similar to our case report, Chan et al8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar initially used transcatheter coil embolization, which appeared successful at angiography, but the final thrombosis of the pseudoaneurysm was achieved by direct PTI. It is therefore important to obtain a postembolization CT scan to assess for residual pseudoaneurysm patency regardless of the appearance of the postembolization angiographic images.Tabled 1Literature summary of splanchnic artery pseudoaneurysms treated with thrombinNumberTechniqueComplicationsDose (U)TSLuchs et al7Luchs S. Antonacci V. Reid S. Pagan-Marin H. Vascular and interventional case of the day. Pancreatic head pseudoaneurysm treated with percutaneous thrombin injection.AJR Am J Roentgenol. 1999; 173: 833-834Crossref Scopus (16) Google Scholar11TCE and US-guided PTINone1000Cope and Zeit5Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar11TCE and fluoro-guided PTINone1000Sparrow et al9Sparrow P. Asquith J. Chalmers N. US-Guided percutaneous injection of pancreatic pseudoaneurysm with thrombin.Cardiovasc Intervent Radiol. 2003; 26: 312-315Crossref PubMed Scopus (37) Google Scholar11US-guided PTINone1000Manazer et al10Manazer J.R. Monzon R. Dietz P.A. Moglia R. Gold M. Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection.J Vasc Surg. 2003; 38: 600-602Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar11CT-guided PTINone4000Chan et al8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar11TCE and CT-guided PTINone1000T, Treated; S, successful; TCE, transcatheter embolization; PTI, percutaneous thrombin injection; US, ultrasound; CT, computed tomography. Open table in a new tab T, Treated; S, successful; TCE, transcatheter embolization; PTI, percutaneous thrombin injection; US, ultrasound; CT, computed tomography. In hemodynamically stable patients, splanchnic pseudoaneurysms are often treated noninvasively by transcatheter embolization techniques using micro-coils. However, direct PTI is a relatively safe and effective method for treatment of splanchnic artery pseudoaneurysms. It also has lower associated cost and a shorter overall procedure time compared with endovascular embolization.8Chan R. David E. Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection.Cardiovasc Intervent Radiol. 2004; 27: 264-267PubMed Google Scholar Percutaneous thrombin injection can be both a first-line treatment and a useful adjunct to transcatheter embolization therapy when the pseudoaneurysm is not accessible by catheter technique. The decision whether to use transcatheter embolization or PTI to treat splanchnic artery aneurysms is made by what is determined to be the easiest approach on a case-by-case basis. A superficial aneurysm that is easily accessible by CT or ultrasound guidance may be approached first with PTI. We believe that transcatheter embolization may be safer than CT-guided PTI because real-time evaluation to the amount of thrombin being injected cannot be accomplished. Accordingly, ultrasound-guided PTI is therefore a safer and more preferred way to treat a splanchnic artery aneurysm because it allows for real-time evaluation of the patency of the aneurysm, thus preventing overinjection of thrombin. Ultrasound-guided PTI also allows visualization of the needle track in real time, which lowers the risk of bowel, vascular, or organ injury. However, ultrasound-guided PTI may be limited by overlying bowel gas obscuring the pseudoaneurysm. Further studies of short-term and long-term outcomes of thrombin injection to treat pseudoaneurysm are necessary.