British Journal of Radiology (2008) 81, e7-e10
© 2008 British Institute of Radiology
doi: 10.1259/bjr/33510361
Acute parent artery dissection as a complication of mesenteric endovascular coil embolisation for pancreatic pseudoaneurysm
T Mammen, MD1,
P Joseph, MS2,
V Sitaram, MS2 and
V Moses, MD1
Departments of 1 Radiology and 2 Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
Correspondence: Dr Thomas Mammen, Department of Radiology, Christian Medical College, Ida Scudder Road, Vellore, Tamilnadu 632004, India. E-mail: tom_mammen{at}yahoo.co.in
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Abstract
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We wish to highlight arterial dissection as an unusual complication during endovascular coiling of a pancreatic pseudoaneurysm. Immediate recognition and prompt corrective measures prevented progression of this serious condition. In our patient, angioplasty prevented further propagation of the dissection and preserved coeliac artery patency.
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Case report
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A 45-year-old man presented with massive haematemesis and melaena following a bout of acute exacerbation of chronic pancreatitis. The patient was on conservative treatment for idiopathic chronic pancreatitis, and had been in remission for the past 12 months. Oesophago-gastro duodenoscopy showed haemobilia. A clinical diagnosis of pancreatitc pseudoaneurysm with rupture into the gastrointestinal tract was considered.
A two-phase contrast CT study showed a gastroduodenal artery aneurysm, as well as features of acute on chronic pancreatitis (Figure 1
). The patient was haemodynamically stable and was scheduled for endovascular coil embolisation of the aneurysm.
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Figure 1. Contrast-enhanced CT showing a gastroduodenal artery pseudoaneurysm with features of acute chronic pancreatitis.
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A digital subtraction angiogram revealed a 2 cm pseudoaneurysm arising from the proximal gastroduodenal artery (Figure 2), with distal opacification of the superior pancreatic artery and the right gastroepiploic artery. There was arterial luminal narrowing proximal to the eccentric pseudoaneurysm. A superior mesenteric angiogram (Figure 3), performed to assess the pancreatic arcade, showed faint opacification of the pseudoaneurysm filling through the inferior pancreatic arcade. As the anatomy of the superior pancreatic arcade was favourable, as well as being close to the aneurysm, we decided to approach the aneurysm from the gastroduodenal artery. The gastroduodenal artery was cannulated with a 035 glide wire (Cook Incorporated, Bloomington, IN) and a glide 4F Yashiro catheter (Terumo, Tokyo, Japan). Because the gastroduodenal artery was of a good calibre (Terumo, Tokyo, Japan), coil embolisation was planned with the same glide catheter. The neck of the aneurysm was coiled with a 4 mmx3 cm 035 glide wire (Cook coil).
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Figure 2. Selective common hepatic angiogram showing a pseudoaneurysm from the proximal gastroduodenal artery.
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Figure 3. Superior mesenteric angiogram showing opacification of the pseudoaneurysm through the inferior pancreaticoduodenal artery arcade.
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A check angiogram performed to confirm aneurysm occlusion showed dissection of the gastroduodenal artery and no opacification of the aneurysm (Figure 4).
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Figure 4. Post-coiling common hepatic angiogram showing contrast within the false and true lumen of the dissected common hepatic artery.
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As treatment for the dissection, 5000 IU of heparin was given intravenously. The catheter was kept in place in the gastroduodenal artery and a second check angiogram was performed after an interval of 10 min. We were surprised to find proximal progression of the dissection up to the coeliac origin, with significant narrowing of the common hepatic artery (Figure 5). As the dissection was associated with impending coeliac artery occlusion, a 035 Terumo glide wire was flipped into the right hepatic artery along with the glide catheter. The wire was exchanged for an 035 guide wire (ZIndo), and a 10 min overlapping angioplasty was performed using a 7 mmx2 cm angioplasty balloon (Cordis Corporation, Miami Lakes, FL) from the coeliac origin up to the hepatic artery bifurcation (Figure 6). A post-angioplasty angiogram showed near total restoration of the coeliac artery lumen with good antegrade flow (Figure 7); pseudoaneurysm was not visualized. A post-coiling and post-angioplasty angiogram showed complete occlusion of the pseudoaneurysm, with the coil occluding the neck of the aneurysm. This was also confirmed by a superior mesenteric angiogram (Figure 8).
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Figure 5. Common hepatic artery angiogram showing significant luminal compromise owing to the progressing dissection.
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Figure 7. Post-angioplasty common hepatic artery angiogram showing near total restoration of the arterial lumen.
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Figure 8. Post-angioplasty superior mesenteric artery angiogram showing no opacification of the pseudoaneurysm.
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Doppler screening of the coeliac and hepatic arteries performed 12 h later showed preserved patency of the vessels and no flow in the pseudoaneurysm.
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Discussion
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The incidence of haemorrhagic complications in pancreatitis is 1.3% [1]. One of the most common causes of haemorrhage is bleeding from a pseudoaneurysm (61%); other causes include diffuse bleeding with pancreatic necrosis (19.5%) and haemorrhagic pseudocysts (9.5%) [1]. The primary investigation of choice in these patients is a biphasic CT study. This helps to evaluate the aetiology of the bleed, as well as plan further management.
Rupture of a pseudoaneurysm is associated with death in over 50% of affected patients [2]. Surgical treatment options for pseudoaneurysms include coeliotomy and ligation of the parent artery, or partial pancreatectomy with en-bloc removal of the pseudoaneurysm. The mortality associated with surgical management in such cases may be as high as 37% [3]. As these patients are often critically ill and the pseudoaneurysms lie close to vital anatomical structures, minimally invasive endovascular treatment has become the standard of care [3, 4].
Complications of endovascular embolisation are uncommon; however, Mauro and Jacques [5] and Boudghène et al [6] have reported splenic and intestinal infarction. Rupture of aneurysms during embolisation has also been reported; this is probably a result of the pressure exerted by injection of the embolic material and its carrier fluid [7]. So et al [8] have reported coeliac artery dissection during hepatic chemoembolisation.
We report a patient with dissection of the parent artery as a complication of endovascular coil embolisation of a pancreatic pseudoaneurysm. The parent artery dissection was noted during the post-coil embolisation check angiogram that was performed to confirm obliteration of the aneurysm. Iatrogenic dissections of the coeliac artery can occur as a result of mechanical intimal injury during manipulation of a guide wire or catheter and forceful injection of contrast material. Pre-existing arterial abnormalities, such as coeliac axis stenosis, and technical difficulties can also play a role [9].
We presume that, in our patient, coiling followed by contrast injection into the parent artery already rendered friable by pancreatitis could have damaged the endothelium, and post-coiling check angiograms could have initiated the retrograde dissection. The second check angiogram to reconfirm the problem may have propagated the dissection proximally to involve the common hepatic and coeliac arteries, causing significant arterial luminal narrowing. This situation was promptly identified and the patient was given a bolus of 5000 IU of heparin and treated with overlapping angioplasty with a 7 mmx2 cm angioplasty balloon (Cordis) from the coeliac origin to the hepatic artery, with the intention of tacking the retrograde progression of the flap. Being a retrograde dissection, the flap was well tacked by angioplasty, from the coeliac artery and extending distally into the hepatic artery, with good preservation of the arterial lumen. If the response to angioplasty had been sub-optimal, the option of stenting the parent artery, with the aim of preserving the lumen of the coeliac and hepatic arteries, would have been considered.
Iatrogenic antegrade coeliac artery dissections that occur during cannulation can be treated by a balloon fenestration technique with good results [8]. To our knowledge, retrograde parent artery dissection as a complication during mesenteric pseudoaneurysm coiling has not been reported in the English medical literature.
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Conclusions
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In conclusion, we reiterate the importance of our findings in light of the friable nature of mesenteric arteries in pancreatitis, and highlight arterial dissection as being one of the potential complications to anticipate during endovascular procedures in these patients. We hope that our experience of this difficult scenario and the treatment option we instituted in this case will be of benefit to interventionalists in a similar situation.
Received for publication May 16, 2006.
Revision received August 28, 2006.
Accepted for publication October 16, 2006.
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References
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- Balthazar EJ, Fisher LA. Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging. Pancreatology 2001;1:306–13.[CrossRef][Medline]
- Hemant D, Krantikumar R, Ashwin G, Rahul S, Suyash K. Transcatheter embolization as primary treatment for visceral pseudoaneurysms in pancreatitis: clinical outcome and imaging follow up. Ind J Gastroenterol 2004;23:56–8.
- Golzarian J, Nicaise N, Deviere J, Ghysels M, Wery D, Dussaussois L, et al. Transcatheter embolisation of pseudoaneurysms complicating pancreatitis. Cardiovasc Intervent Radiol 1997;20:435–40.[CrossRef][Medline]
- Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331–6.[Abstract/Free Full Text]
- Mauro MA, Jacques P. Transcatheter management of pseudoaneurysms complicating pancreatitis. J Vasc Intervent Radiol 1991;2:527–32.[Medline]
- Boudghène F, L'Herminé C, Bigot JM. Arterial complica-tions of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Intervent Radiol 1993;4:551–8.[Medline]
- Lina JR, Jaques P, Mandell V. Aneurysm rupture: secondary transcatheter embolization. AJR Am J Roentgenol 1979;132:553–6.[Abstract]
- So YH, Chung JW, Park JH. Balloon fenestration of iatrogenic coeliac artery dissection. J Vasc Intervent Radiol 2003;14:493–6.[Medline]
- Yoon DY, Park JH, Chung JW, Han JK, Han MC. Iatrogenic dissection of celiac artery and its branches during transcatheter arterial embolization for hepatocellular carcinoma: outcome in 40 patients. Cardiovasc Intervent Radiol 1995;18:16–9.[Medline]
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Abstract
Case report
