Pancreatic Pseudoaneurysm Treatment & Management

  • Author: Faisal Aziz; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Nov 29, 2011
 

Medical Therapy

  • Although occasional reports have alluded to the spontaneous thrombosis of some pancreatic pseudoaneurysms, the current consensus holds that all these malformations should be treated to prevent the complication of bleeding. It is based on the fact that the natural history of visceral artery pseudoaneurysms is largely unknown.
  • Treatment options include the following:
    • Endovascular coil embolization
    • Covered stent placement
    • Percutaneous ultrasound-guided thrombin injection
    • Open surgical repair
  • Transarterial catheter angioembolization with or without endoscopic stent placement.
    • Endovascular coil embolization has been used extensively in the treatment of visceral artery pseudoaneurysms.[3, 4]
    • Angioembolization is considered much less invasive than surgery. The procedure can be completed quickly and is comfortable for the patient. It also allows the performance of surgery under optimal conditions.
    • The interventional approach has a reported success rate of 67-100% over the past few years.[7, 4]
    • Most authorities agree that embolization is appropriate when bleeding is diffuse or emanating from the pancreatic head, for unsuccessful surgery, or during postoperative bleeding.
    • Failure results from an inability to selectively catheterize the bleeding vessel or the misplacement or poor placement of embolization material.
    • In addition to rebleeding, complications of this procedure include rupture of the pseudoaneurysm during embolization, arterial perforation by the catheter, intestinal necrosis, and aortic thrombosis.
  • Percutaneous ultrasound guided thrombin injection has been used to successfully treat visceral artery pseudoaneurysms.[8, 9, 10] Suitable anatomic features, such as a narrow neck, are necessary to allow for a successful intervention without intravascular "leakage" of thrombin with distal embolization. Some advocate balloon inflation across the neck of the pseudoaneurysm to minimize this complication.[11]
Next

Surgical Therapy

  • Absolute indications for emergent exploratory laparotomy include hemodynamic instability and failure of endovascular techniques to control active hemorrhage.
  • Basic surgical techniques for controlling hemorrhage from a pancreatic pseudoaneurysm include arterial ligation on both sides of the bleeding sites, pancreatic resection, and intracystic/extracystic multiple ligatures.
  • Some pseudocyst drainage procedures have been frequently performed concomitantly with the primary hemostatic surgery.
Previous
Next

Preoperative Details

  • Manage the hemodynamically unstable patient in an emergent fashion. Approach the patient in a manner similar to that for a trauma patient.
  • First priority is securing the airway, followed by obtaining good peripheral access. As with trauma patients, at least two wide bore intravenous lines are preferable. Initial fluids of choice are isotonic crystalloids.
  • Send a type and cross of the blood to the blood bank, while the need for O-negative and type-specific blood transfusion is being assessed.
  • The patient's hemodynamic status and comorbid medical issues dictate the necessity for invasive hemodynamic monitoring.
  • Patients should undergo emergent celiotomy to control the bleeding pseudoaneurysm as soon as possible.
  • If the diagnosis of a ruptured pseudoaneurysm has been seriously entertained and the patient is hemodynamically stable, some studies may be performed before the patient enters the operating theater.
    • Performing a preoperative angiogram has several benefits (see image below). Identifying the bleeding vessel during surgery is difficult because of the friability, necrosis, and severe inflammation caused by pancreatitis. Also, because preoperative angiography identifies the bleeding vessel, it might dictate the optimal therapy. Preembolization angiogram depicting a splenic artePreembolization angiogram depicting a splenic artery pseudoaneurysm.
    • Performing arterial ligation or pancreaticoduodenectomy on bleeding vessels involving the pancreatic head has been demonstrated to carry a high mortality rate.
    • Furthermore, angiography might constitute an opportunity to gain temporary preoperative control over the bleeding vessel by performing transcatheter embolization, thus providing a time window for the surgeon to operate on a high-risk patient under optimum clinical conditions.
Previous
Next

Intraoperative Details

  • A generous midline incision is made from subxiphoid to pubis. Upon entering the peritoneal cavity, all four quadrants should be packed with lap packs. Lap packs are gradually removed from the least suspicious area for bleeding to the most suspicious area for bleeding.
  • Once adequate exposure is performed, direct attention toward the most common source of bleeding, mainly the peripancreatic vasculature.
  • Multiple effective measures to gain rapid control of the actively bleeding pseudoaneurysm have been described. These include manual tamponade, gauze packing, digital compression of the bleeding pseudoaneurysm or pseudocyst, and even supraceliac infradiaphragmatic cross-clamping of the aorta for brisk bleeding.
  • Institute these measures, especially in the actively bleeding, hemodynamically unstable patient, while aggressive volume resuscitation is being undertaken by the anesthesia team.
  • After establishing these initial measures, a more delicate and precise dissection can be performed in order to obtain definitive control of the bleeding vessels.
    • As previously mentioned, exposure of the bleeding site can sometimes be challenging because the surrounding inflammation from pancreatitis obscures the visual field.
    • Several adjunctive techniques have been listed to gain operative access to the bleeding pseudoaneurysm; these include gastrotomy, duodenotomy, and major gastrectomy.
  • Once the bleeding vessel is identified, the surgeon may perform one of several surgical methods to control the bleeding. The basic surgical principle is obtaining proximal and distal control of the blood vessel before trying to ligate or resect it.
    • Intracystic ligation without proximal/distal control or resection is not recommended because the friable tissues of the posterior pseudocyst wall do not hold sutures, and the feeding vessel that lies deep within the substance of the pancreas is still patent.
    • For treatment of the pseudocyst, several surgical options are available, ranging from resection to external or internal drainage methods.
Previous
Next

Postoperative Details

  • Carefully monitor the patient after surgery.
  • The occurrence of postresectional hemorrhage is well documented in the literature, with a reported incidence of 5-19% and a mortality rate of 6-58%. This may be the result of ongoing pancreatitis and continuous damaging of the arteries, iatrogenic trauma to the vessels, and/or inadequate control of the bleeding vessels.
  • While some surgeons have advocated surgical ligation of the bleeding vessel in the nonseptic patient and pancreatic resection in those with abscess or established fistula, interventional radiologists have strongly recommended angioembolization for postoperative hemorrhage (see image below). Postembolization angiogram depicting successful coPostembolization angiogram depicting successful coil embolization of the pseudoaneurysm.
Previous
Next

Follow-up

  • Despite few reports of resolution of pseudocysts with embolization alone, little long-term follow-up care is available for patients treated angiographically, particularly for patients who have underlying pathology that predisposes them to recurrent complications.
Previous
Next

Complications

  • As mentioned previously, the most serious and life-threatening complications of pseudoaneurysms are rupture and subsequent hemorrhage.
  • Bleeding is usually brisk but varies from short, repeated, and self-limiting episodes to massive hemorrhage requiring emergent laparotomy.
  • The frequency of arterial lesion hemorrhage during pancreatitis varies from 5-10%. However, when pseudocysts are present, the hemorrhage rate rises to 15-20% of cases.
  • The most common site of rupture is intracystic, and the incidence of spontaneous hemorrhage arising from a pancreatic pseudocyst reportedly ranges from 1.4-8.4%.
    • This bleeding can be localized in the cyst, causing sudden enlargement and abdominal pain, or bleeding can occur through the cyst into the pancreatic duct if a communication between these structures exists. (In this case, the patient will have gastrointestinal bleeding.)
    • Other sites of rupture include the biliopancreatic duct, peritoneal cavity, retroperitoneum, and sometimes direct erosion into the duodenum and other parts of the gastrointestinal tract.
  • Hemorrhage is a significant complication that carries a mortality rate of 13-40% and is almost always fatal if left unattended.
  • Other infrequent complications include arteriovenous fistula formation and extrahepatic biliary tract obstruction.
Previous
Next

Outcome and Prognosis

  • The mortality rate following surgical treatment of arterial hemorrhage of pancreatic origin ranges from 28-56%, primarily depending on the anatomic location of the pseudoaneurysm and not the surgical method.[12]
    • Surgical intervention for treatment of pseudoaneurysm in the head of the pancreas has a 43% mortality rate, but only a 16% mortality rate in the body or tail of the pancreas.
    • Patients treated with supportive measures have more than a 90% mortality rate.
  • The mortality rate with postoperative hemorrhage is nearly double (50-60%).
  • For pseudoaneurysms in the head of the pancreas, the surgical approach necessitates a Whipple procedure, which likely contributes to the higher mortality rate.
  • Embolotherapy has a high initial success rate (90-100%), although some reports indicate a recurrence rate of 37% and an overall mortality rate of 16%. Embolotherapy is the preferred initial therapy for bleeding originating from the head of the pancreas.
Previous
Next

Future and Controversies

  • A major controversy is whether transarterial catheter angioembolization should be the definitive approach or if it should always be followed by surgical intervention, especially if bleeding is located in the tail or body of the pancreas and/or is associated with a pseudocyst.
    • Some authors have found no rebleeding after seemingly successful angioembolization of the pseudoaneurysm.
    • Other authors have found statistically significant rebleeding rates, which necessitated surgical resection after embolization.
  • Another major controversy surrounding the operative management of the bleeding pseudoaneurysm is whether to perform arterial ligation or pancreatic resection.
    • Some authors have strongly advocated resection because it is technically easier to perform than ligation in an inflammatory milieu.[13]
    • Other authors have reported better outcome after performing proximal and distal arterial ligation and intracystic suture ligation.
  • A third controversy is the management of postoperative bleeding despite recent adoption of the operative option by more health care providers.
  • One article describes the percutaneous injection of thrombin into the head of the pancreas for treating pancreatic pseudoaneurysm, the significance, safety, and efficacy of which remain to be seen.[14]
Previous
 
Contributor Information and Disclosures
Author

Faisal Aziz  MD, Assistant Professor of Surgery, Division of Vascular & Endovascular Surgery, Department of Surgery, Penn State University College of Medicine, Hershey, PA

Faisal Aziz is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

John A Savino, MD  Professor of Surgery, Chairman, Director of Residency Program, Department of Surgery, New York Medical College; Director of Surgical Critical Care Fellowship, Director of Surgical Intensive Care Unit, Attending Surgeon, Westchester Medical Center

John A Savino, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Medical Society of the State of New York, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, and Surgical Infection Society

Disclosure: Nothing to disclose.

Mazen S Itani, MD, FACS  Private Practice in Vascular Surgery, Hackettstown Regional Medical Center

Mazen S Itani, MD, FACS is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Nabil Sumrani, MD  Associate Professor, Department of Surgery, Division of Transplantation Surgery, State University of New York Health Science Center at Brooklyn

Nabil Sumrani, MD is a member of the following medical societies: Central Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Alex Jacocks, MD  Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael A Grosso, MD  Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

  1. Shrikhande GV, Khan SZ, Gallagher K, Morrissey NJ. Endovascular management of superior mesenteric artery pseudoaneurysm. J Vasc Surg. Jan 2011;53(1):209-11. [Medline].

  2. James CA, Emanuel PG, Vasquez WD, et al. Embolization of splenic artery branch pseudoaneurysm after blunt abdominal trauma. J Trauma. May 1996;40(5):835-7. [Medline].

  3. Harvey J, Dardik H, Impeduglia T, et al. Endovascular management of hepatic artery pseudoaneurysm hemorrhage complicating pancreaticoduodenectomy. J Vasc Surg. Mar 2006;43(3):613-7. [Medline].

  4. Radeleff B, Noeldge G, Heye T, et al. Pseudoaneurysms of the common hepatic artery following pancreaticoduodenectomy: successful emergency embolization. Cardiovasc Intervent Radiol. Jan-Feb 2007;30(1):129-32. [Medline].

  5. Tessier DJ, Stone WM, Fowl RJ, et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg. Nov 2003;38(5):969-74. [Medline].

  6. Pilleul F, Beuf O. Diagnosis of splanchnic artery aneurysms and pseudoaneurysms, with special reference to contrast enhanced 3D magnetic resonance angiography: a review. Acta Radiol. Nov 2004;45(7):702-8. [Medline].

  7. Hyare H, Desigan S, Nicholl H, et al. Multi-section CT angiography compared with digital subtraction angiography in diagnosing major arterial hemorrhage in inflammatory pancreatic disease. Eur J Radiol. Aug 2006;59(2):295-300. [Medline].

  8. Szopinski P, Ciostek P, Pleban E, et al. Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement. Cardiovasc Intervent Radiol. Jul-Aug 2005;28(4):509-14. [Medline].

  9. Krueger K, Zaehringer M, Lackner K. Percutaneous treatment of a splenic artery pseudoaneurysm by thrombin injection. J Vasc Interv Radiol. Jul 2005;16(7):1023-5. [Medline].

  10. Kennedy RD, Clapp AJ, Potter DD, McKusick MA, Petersen BT, Friese JL. Percutaneous ultrasound-guided thrombin injection of a post-traumatic pancreatic pseudoaneurysm in a pediatric patient. Pediatr Surg Int. Oct 4 2011;[Medline].

  11. Patel JV, Weston MJ, Kessel DO, et al. Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection. Transplantation. May 27 2003;75(10):1755-57. [Medline].

  12. Bender JS, Levison MA. Massive hemorrhage associated with pancreatic pseudocyst: successful treatment by pancreaticoduodenectomy. Am Surg. Oct 1991;57(10):653-5. [Medline].

  13. Bender JS, Bouwman DL, Levison MA, et al. Pseudocysts and pseudoaneurysms: surgical strategy. Pancreas. Mar 1995;10(2):143-7. [Medline].

  14. Luchs SG, Antonacci VP, Reid SK, et al. Vascular and interventional case of the day. Pancreatic head pseudoaneurysm treated with percutaneous thrombin injection. AJR Am J Roentgenol. Sep 1999;173(3):830, 833-4. [Medline].

  15. Boudghene F, L'Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol. Jul-Aug 1993;4(4):551-8. [Medline].

  16. Bradley EL, Clements JL Jr, Gonzalez AC. The natural history of pancreatic pseudocysts: a unified concept of management. Am J Surg. Jan 1979;137(1):135-41. [Medline].

  17. Bresler L, Boissel P, Grosdidier J. Major hemorrhage from pseudocysts and pseudoaneurysms caused by chronic pancreatitis: surgical therapy. World J Surg. Sep-Oct 1991;15(5):649-52; discussion 652-3. [Medline].

  18. Brodsky JT, Turnbull AD. Arterial hemorrhage after pancreatoduodenectomy. The 'sentinel bleed'. Arch Surg. Aug 1991;126(8):1037-40. [Medline].

  19. Cahow CE, Gusberg RJ, Gottlieb LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts. Am J Surg. Apr 1983;145(4):534-41. [Medline].

  20. Clay RP, Farnell MB, Lancaster JR, et al. Hemosuccus pancreaticus. An unusual cause of upper gastrointestinal bleeding. Ann Surg. Jul 1985;202(1):75-9. [Medline].

  21. De Ronde T, Van Beers B, de Canniere L et al. Thrombosis of splenic artery pseudoaneurysm complicating pancreatitis. Gut. Sep 1993;34(9):1271-3. [Medline].

  22. Eckhauser FE, Stanley JC, Zelenock GB, et al. Gastroduodenal and pancreaticoduodenal artery aneurysms: a complication of pancreatitis causing spontaneous gastrointestinal hemorrhage. Surgery. Sep 1980;88(3):335-44. [Medline].

  23. El Hamel A, Parc R, Adda G, et al. Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis. Br J Surg. Sep 1991;78(9):1059-63. [Medline].

  24. Elton E, Howell DA, Amberson SM, et al. Combined angiographic and endoscopic management of bleeding pancreatic pseudoaneurysms. Gastrointest Endosc. Dec 1997;46(6):544-9. [Medline].

  25. Frey CF, Child CG, Fry W. Pancreatectomy for chronic pancreatitis. Ann Surg. Oct 1976;184(4):403-13. [Medline].

  26. Gadacz TR, Trunkey D, Kieffer RF Jr. Visceral vessel erosion associated with pancreatitis. Case reports and a review of the literature. Arch Surg. Dec 1978;113(12):1438-40. [Medline].

  27. Gambiez LP, Ernst OJ, Merlier OA, et al. Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg. Sep 1997;132(9):1016-21. [Medline].

  28. Hofer BO, Ryan JA Jr, Freeny PC. Surgical significance of vascular changes in chronic pancreatitis. Surg Gynecol Obstet. Jun 1987;164(6):499-505. [Medline].

  29. Huizinga WK, Kalideen JM, Bryer JV, et al. Control of major haemorrhage associated with pancreatic pseudocysts by transcatheter arterial embolization. Br J Surg. Feb 1984;71(2):133-6. [Medline].

  30. Khan TF, Ciancio G, Burke GW 3rd, et al. Pseudoaneurysm of the superior mesenteric artery with an arteriovenous fistula after simultaneous kidney-pancreas transplantation. Clin Transplant. Jun 1999;13(3):277-9. [Medline].

  31. Lee MJ, Saini S, Geller SC, et al. Pancreatitis with pseudoaneurysm formation: a pitfall for the interventional radiologist. AJR Am J Roentgenol. Jan 1991;156(1):97-8. [Medline].

  32. Lina JR, Jaques P, Mandell V. Aneurysm rupture secondary to transcatheter embolization. AJR Am J Roentgenol. Apr 1979;132(4):553-6. [Medline].

  33. Mandel SR, Jaques PF, Sanofsky S, et al. Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg. Feb 1987;205(2):126-8. [Medline].

  34. Marshall GT, Howell DA, Hansen BL, et al. Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis. Arch Surg. Mar 1996;131(3):278-83. [Medline].

  35. Morita R, Muto N, Konagaya M, et al. Successful transcatheter embolization of pseudoaneurysm associated with pancreatic pseudocyst. Am J Gastroenterol. Sep 1991;86(9):1264-7. [Medline].

  36. Sato N, Yamaguchi K, Shimizu S, et al. Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography. Arch Surg. Oct 1998;133(10):1099-102. [Medline].

  37. Shankar S, Russell RC. Haemorrhage in pancreatic disease. Br J Surg. Aug 1989;76(8):863-6. [Medline].

  38. Shapiro N, Brandt L, Sprayregan S, et al. Duodenal infarction after therapeutic Gelfoam embolization of a bleeding duodenal ulcer. Gastroenterology. Jan 1981;80(1):176-80. [Medline].

  39. Sharara AI, Le TH, Suhocki P, et al. Extrahepatic biliary obstruction resulting from a pancreatic pseudoaneurysm. Gastrointest Endosc. Aug 1995;42(2):176-7. [Medline].

  40. Stabile BE, Wilson SE, Debas HT. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis. Arch Surg. Jan 1983;118(1):45-51. [Medline].

  41. Stanley JC, Frey CF, Miller TA, et al. Major arterial hemorrhage: a complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg. Apr 1976;111(4):435-40. [Medline].

  42. Starling JR, Crummy AB. Hemosuccus pancreaticus secondary to ruptured splenic artery aneurysm. Dig Dis Sci. Sep 1979;24(9):726-29. [Medline].

  43. Stroud WH, Cullom JW, Anderson MC. Hemorrhagic complications of severe pancreatitis. Surgery. Oct 1981;90(4):657-65. [Medline].

  44. Trojanowski JQ, Harrist TJ, Athanasoulis CA, et al. Hepatic and splenic infarctions: complications of therapeutic transcatheter embolization. Am J Surg. Feb 1980;139(2):272-7. [Medline].

  45. Tsiotos GG, Munoz Juarez MM, Sarr MG. Intraabdominal hemorrhage complicating surgical management of necrotizing pancreatitis. Pancreas. Mar 1996;12(2):126-30. [Medline].

  46. van Berge Henegouwen MI, Allema JH, van Gulik TM, et al. Delayed massive haemorrhage after pancreatic and biliary surgery. Br J Surg. Nov 1995;82(11):1527-31. [Medline].

  47. Vanlangenhove P, Defreyne L, Kunnen M. Spontaneous thrombosis of a pseudoaneurysm complicating pancreatitis. Abdom Imaging. Sep-Oct 1999;24(5):491-3. [Medline].

  48. Waltman AC, Luers PR, Athanasoulis CA, et al. Massive arterial hemorrhage in patients with pancreatitis. Complementary roles of surgery and transcatheter occlusive techniques. Arch Surg. Apr 1986;121(4):439-43. [Medline].

  49. Wolstenholme JT. Major gastrointestinal hemorrhage associated with pancreatic pseudocyst. Am J Surg. Apr 1974;127(4):377-81. [Medline].

 
Previous
Next
 
Splenic artery angiogram demonstrating contrast (white arrow) extravasating into a pseudoaneurysm (black arrow).
A CT scan with intravenous contrast enhancement (arrow) within a pancreatic pseudocyst indicating the presence of a pseudoaneurysm.
Preembolization angiogram depicting a splenic artery pseudoaneurysm.
Postembolization angiogram depicting successful coil embolization of the pseudoaneurysm.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.