Endovascular treatment of a hepatic artery pseudoaneurysm associated with gastrointestinal tract bleeding

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1 Endovascular treatment of a hepatic artery pseudoaneurysm associated with gastrointestinal tract bleeding Tryfon Vainas, MD, PhD, a Elisabeth Klompenhouwer, MD, b Lucien Duijm, MD, PhD, b Xander Tielbeek, MD, PhD, b and Joep Teijink, MD, PhD, a,c Eindhoven and Maastricht, The Netherlands Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding from the pancreatic duct originating from aneurysms or pseudoaneurysms of peripancreatic arteries. It is a life-threatening cause of gastrointestinal bleeding that should always be considered in patients with prolonged or intermittent obscure gastrointestinal blood loss, or both, especially in patients with pancreatic disorders or prior pancreatic surgery. We demonstrate an endovascular treatment strategy in a patient with a common hepatic pseudoaneurysm and upper gastrointestinal tract bleeding, with preserved flow in the hepatic artery. This treatment consisted of a covered stent placement in the hepatic artery, followed by transcatheter coil embolization of collateral feeding arteries. (J Vasc Surg 2012;55: ) Visceral artery pseudoaneurysms (VAPA) are rare but life-threatening complications of intra-abdominal inflammatory or infectious processes or traumatic events. The risk of VAPAs stems from bleeding into the peritoneal cavity or retroperitoneal space. Occasionally, VAPAs may erode into the gastrointestinal (GI) or biliopancreatic tract, causing GI tract bleeding. 1 The mainstay of treatment of VAPAs consists of bleeding control and is achieved by coil-embolizations of the aneurysm or surgical resection of the vascular lesion. 3 We present a patient with occult persistent upper GI tract blood loss secondary to a common hepatic artery (CHA) pseudoaneurysm. The patient was treated by covered stent graft placement in the HA and adjuvant coil embolization of collateral feeding arteries to the aneurysm. This case illustrates the challenges associated with localizing the source of GI tract bleeding, the vital role of computed tomography angiography (CTA) in the detection of visceral artery pseudoaneurysms and associated intra-abdominal and extravascular pathologies, as well as the importance of endovascular techniques in the treatment of these patients. CASE REPORT A 62-year-old man was admitted to a district general hospital with melena and a low hemoglobin level of 2.4 mmol/l. The patient was hemodynamically stable and was resuscitated with intravenous fluids and blood transfusions. His medical history was From the Departments of Surgery a and Radiology, b Catharina Hospital Eindhoven, Eindhoven; and the Department of Epidemiology, Caphri Research School, Maastricht University, Maastricht. c Competition of interest: none. Reprint requests: Dr Joep A. Teijink, Catharina Hospital, Department of Surgery-Vascular Surgery, PO Box 1350, 5602 ZA Eindhoven, The Netherlands ( joep.teijink@catharina-ziekenhuis.nl). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest /$36.00 Copyright 2012 by the Society for Vascular Surgery. doi: /j.jvs unremarkable except for treatment of Helicobacter pylori-positive peptic ulcers 6 months before the events. An esophagogastroduodenoscopy (EGD) at admission revealed a copious amount of blood in the stomach and duodenum, with no obvious source of bleeding. Two repeat EGDs and a colonoscopy failed to identify the bleeding source. An abdominal CT scan with arterial-phase contrast revealed a CHA pseudoaneurysm. The patient received 4 units of packed red cells and was transferred to our hospital for further treatment. At arrival, the patient was hemodynamically stable, with a hemoglobin of 5.6 mmol/l. A repeat CT scan revealed, besides the CHA pseudoaneurysm, signs of chronic pancreatitis with calcifications throughout the pancreatic parenchyma (Fig 1, A and B). Considering the presence of blood in stomach and duodenum, without any evident bleeding source on repeated EGDs, the negative colonoscopy, and the radiologic evidence of chronic pancreatitis, a hemosuccus pancreaticus (HP) was suspected. Angiography through a right transfemoral approach and selective catheterization of the celiac trunk confirmed the presence of the CHA pseudoaneurysm (Fig 1, C). An 8F guide catheter was placed into the celiac trunk, and the CHA was crossed with a coronary ALLstar wire (Guidant Nederland BV, Nieuwegein, The Netherlands). The pseudoaneurysm was excluded from the circulation by the placement of an Advanta 8 38 covered stent (Atrium Europe, Mijdrecht, The Netherlands) in the CHA extending into the proper HA, thus covering the origin of the gastroduodenal artery (GDA). Arterial flow to the liver was preserved (Fig 2, A and B). In the ensuing days, the patient s hemoglobin did not exceed 6.0 mmol/l, despite further transfusions with 6 units of packed cells. A subsequent CT scan showed persistent flow in the pseudoaneurysm through superior mesenteric artery branches (Fig 2, C). By catheterization through the right groin, a 5F pigtail catheter (Cordis, Europe, Waterloo, Belgium) was positioned in the proximal part of the abdominal aorta and an aortogram was performed. After cannulation of the superior mesenteric artery, the GDA was opacified and contrast extravasation into the pseudoaneurysm was seen through two branches; one 1145

2 1146 Vainas et al JOURNAL OF VASCULAR SURGERY April 2012 Fig 1. Computed tomography angiography (A) coronal and (B) sagittal views show irregular pancreas with gross calcification as sign of chronic pancreatitis and blush from hepatic artery into the false aneurysm (arrow). C, Digital subtraction angiography of selective catheterization of the hepatic artery shows filling of the false aneurysm. proper HA side branch, just distal of the previously placed stent graft, and one GDA side branch (Fig 3, A). A 2.7F Progreat microcatheter (Terumo Europe, Heverlee, Belgium) was introduced, and the HA side branch was embolized using 11 Platina microcoils (Tornado, 4-2/4-3/6-2; Cook, Bloomington, Ind). By pulling back the microcatheter, four microcoils (Tornado, 6-2; Cook) were placed in the distal part of the GDA. Completion angiogram showed successful exclusion of the aneurysm (Fig 3, B). After the procedure the patient s hemoglobin remained stable. He was released from the hospital 3 days later. Follow-up CTA of the abdomen at 1 day, 2 weeks, and 3 months showed complete obliteration of the pseudoaneurysm and a patent HA (Fig 3, C). DISCUSSION VAPAs are uncommon but potentially lethal pathologic entities caused by trauma and intra-abdominal inflammatory or infectious processes. VAPAs carry a high risk of rupture and bleeding, which is not related to their size, and should therefore be treated promptly. 2

3 JOURNAL OF VASCULAR SURGERY Volume 55, Number 4 Vainas et al 1147 Fig 2. A, Digital subtraction angiography and (B) computed tomography angiography after stent placement show the false aneurysm of the hepatic artery is successfully excluded from the circulation after placement of a covered stent. C, Persistent arterial flow is shown in the false aneurysm by filling of the aneurysm by branches of the superior mesenteric artery. VAPAs differ from true visceral artery aneurysms in their clinical presentation and anatomic localization. 3 Patients with VAPA are more frequently symptomatic at presentation, displaying GI bleeding, hemobilia, or hypovolemic shock secondary to rupture, and are more likely to have a history of retroperitoneal or intra-abdominal inflammation or malignancy, arterial trauma, or biliary tract manipulation. Most VAPAs affect the celiac axis and its branches, whereas true aneurysms are mostly seen at the splenic artery. 3 Currently available data on open repair of visceral aneurysms comes from small case series and does not distinguish between true and false aneurysms. 3 Mortality rates for elective and emergency open repair of visceral artery aneurysms are 5% to 25%. 4 Open surgical repair of VAPAs is fraught by the associated intra-abdominal inflammation or infection, pancreatic and hepatobiliary disease, or acute hemodynamic instability at presentation, all of which elevate the morbidity and mortality of VAPA repair. It is in this context that endovascular management seems particularly useful. 5 Endoluminal ablation of VAPA with coils or

4 1148 Vainas et al JOURNAL OF VASCULAR SURGERY April 2012 Fig 3. A, Selective catheterization of the superior mesenteric artery shows filling of the false aneurysms. B, The supplying and draining branches are occluded by coil embolization. C, Follow-up computed tomography angiography after 3 months shows shrinking and complete obliteration of the pseudoaneurysm and a patent hepatic artery. glue has proven technically successful and provided excellent short-term and long-term results. 6 Nevertheless, aneurysm sac repressurization and endorgan ischemia remain a concern. Sac reperfusion occurs in approximately 10% of patients but reperfusion rates of 4% to 41% have been reported. 7 Mostly, repeat endovascular procedures suffice to achieve complete obliteration of the aneurysm sac. Vigorous postprocedural monitoring is mandatory after endoluminal ablation of VAPA to prevent clinical sequelae from sac reperfusion. Partial end-organ infarction after endoluminal ablation of VAA may be seen in 30% to 40% of patients but rarely bears significant clinical consequences. 3,7 Nonetheless, embolization of aneurysms affecting the major arterial supply to vital organs should be avoided. Kasirajan et al 8 proposed three types of aneurysm morphology that are favorable for endoluminal ablation: (1) saccular aneurysms with narrow neck, (2) fusiform aneurysms with adequate collateral flow, and (3) aneurysms of a vessel supplying an organ that has multiple arterial sources. Endovascular polytetrafluoroethylene-covered stent graft placement offers exclusion of the visceral aneurysm

5 JOURNAL OF VASCULAR SURGERY Volume 55, Number 4 Vainas et al 1149 while preserving flow through the affected artery. Case reports describing placement of stent grafts in the superior mesenteric, splenic, and hepatic artery have proven the technical feasibility of this treatment, but longer observations are necessary to assess the durability of this solution. Vessel tortuosity, small caliber size, and proximal and distal neck size mismatch may limit the application of stent graft technology. The significance of type II endoleaks through potentially numerous side branches also needs to be established. Because pseudoaneurysms may develop secondary to infectious processes, endovascular treatment with stents and coils may herald septic complications. Considering the often-symptomatic presentation of VAPAs, we believe that bleeding control should prevail and possible infection be monitored. In a series of eight VAPAs treated with coil embolization, no septic complications were noted. 8 Erosion of VAPA into the biliodigestive tract or pancreatic duct represents a diagnostic and clinical management challenge. In the present patient, a HA pseudoaneurysm was detected, but the source of GI tract bleeding could not be identified by endoscopy or CTA. Although the pseudoaneurysm may have eroded into the GI tract or common bile duct, the CT finding of chronic pancreatitis with calcifications of the pancreatic parenchyma suggested that blood might have reached the GI tract through the pancreatic duct, making a diagnosis of HP possible. HP is characterized by intermittent upper GI bleeding presenting as melena, hematemesis, or hematochezia associated with epigastric pain. 9,10 The intermittent nature of the symptoms makes diagnosis difficult. Endoscopy rarely reveals active bleeding from the ampulla of Vater but rules out other sources of GI bleeding. Contrast-enhanced abdominal CT scans 11 and angiographies 10 readily identify peripancreatic aneurysms and pseudoaneurysms, but leakage of contrast into the pancreatic duct and GI tract is usually not seen in these studies. 12 Similarly, repeated OGDs failed to identify a bleeding source in our patient. The diagnosis was suspected by the presence of a CHA pseudoaneurysm within the calcified pancreatic parenchyma on CT scan. CONCLUSIONS Our case represents, to our knowledge, the first attempt to treat a patient with a CHA pseudoaneurysm and associated GI tract bleeding with a polytetrafluoroethylene-covered stent and adjuvant coil embolization of collateral feeding arteries. REFERENCES 1. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997;77: Tessier DJ, Stone WM, Fowl RJ, Abbas MA, Andrews JC, Bower TC, et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg 2003;38: Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83; Discussion: Carr SC, Mahvi DM, Hoch JR, Archer CW, Turnipseed WD. Visceral artery aneurysm rupture. J Vasc Surg 2001;33: Sachdev-Ost U. Visceral artery aneurysms: review of current management options. Mt Sinai J Med 2010;77: Gabelmann A, Görich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9: Sachdev U, Baril DT, Ellozy SH, Lookstein RA, Silverberg D, Jacobs TS, et al. Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg 2006;44: Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular management of visceral artery aneurysm. J Endovasc Ther 2001;8: Lermite E, Regenet N, Tuech JJ, Pessaux P, Meurette G, Bridoux V, et al. Diagnosis and treatment of hemosuccus pancreaticus: development of endovascular management. Pancreas 2007;34: Mandel SR, Jaques PF, Sanofsky S, Mauro MA. Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg 1987;205: Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson BR, Hansen MF. Pseudoaneurysms complicating pancreatitis: detection by CT. Radiology 1986;161: Vimalraj V, Kannan DG, Sukumar R, Rajendran S, Jeswanth S, Jyotibasu D, et al. Haemosuccus pancreaticus: diagnostic and therapeutic challenges. HPB (Oxf) 2009;11: Submitted May 4, 2011; accepted Nov 22, 2011.