Aneurysm

Rupture

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JOHN

Secondary

A. LINA,’

PAUL

to Transcatheter

JAQUES,

False aneurysms of the pancreatic and peripancreatic arteries are a well recognized complication of chronic pancreatitis due to proteolytic enzymatic digestion of the arterial wall. These false aneurysms can be a source of life-threatening hemorrhage. Three cases are reported in which attempted embollzatlons of these bleeding aneurysms resulted In rupture Into the gastrointestinal tract. Special precautions should be taken In such a procedure because of the Inherent weakness of the aneurysmal wall.

Case

dorsal

pancreatic

wedged ize

the

position, artery.

August

All authors:

1, 1978;

Department

after revision of Radiology. University accepted

of North

12,

material

small After

pieces

about

of Gelfoam

six

pieces

were used to embol-

were

injected.

contrast

into the lower common bile duct and (fig. 1 B), indicating rupture of the false

position in the After 5 days of

2

Case

A 34-year-old

black man with a long history

chronic pancreatitis was admitted and abdominal pain. Examination

episodes of upper with a hemoglobin

December

of contrast

no clinical deterioration or evidence for active hemorrhage, repeat angiography demonstrated occlusion of the dorsal pancreatic artery and nonfilling of the aneurysm.

Reports

with recurrent was admitted

and extravasation

aneurysm. The catheter was left in a wedged artery in the hope a thrombosis would develop.

a 4 cm

showed

black woman tract bleeding

artery

material flowed promptly then into the duodenum

and

A 37-year-old gastrointestinal

MANDELL

into the second part of the duodenum. Selective celiac arterial vasopressin infusion for 2 days resulted in clinical cessation of bleeding. The patient was returned to the angiographic suite for embolization of the feeding vessel to the aneurysm and selective dorsal pancreatic arteriography (fig. 1A). With the catheter in a

1

Received

VALERIE

level of 9.5 g/100 ml. The patient continued to deteriorate despite transfusions, and subsequently developed right upper quadrant pain with rebound tenderness. Surgery disclosed a dilated biliary tree and gallbladder filled with blood. After cholecystectomy, blood continued to drain from the T tube. Subsequent angiography revealed a false aneurysm of the

Various catheter techniques to induce vascular occlusion are becoming more and more widely practiced in a number of clinical circumstances [1-3]. The most common indication has been hemorrhage, particularly from chronic peptic ulceration, but more recently bleeding from vaginal, rectal, prostatic, and pelvic sources has also been controlled by transcatheter embolization. In addition, occlusion of a wide variety of aneurysms has been attempted. Three patients are reported in whom transcatheter embolization of peripancreatic pseudoaneurysms was attempted, and in whom the procedure was complicated by rupture of the aneurysms into the gastrointestinal tract. Case

AND

Embolization

pulsatile

false

right

aneurysms

upper

of the

arteries. Surgical obliteration rysm was accessible, and

of alcoholism

and

after 3 days of hematemesis revealed a tender abdomen quadrant

mass.

gastroduodenal

Angiography

and

splenic

was attempted, but neither aneuthe patient was returned to the

1978.

Carolina,

School

of Medicine,

Chapel

Hill.

North

Carolina

27514.

Address

reprint

requests

to P. Jaques. AJR 132:553-556, © 1979 American

April 1979 Roentgen Ray Society

553

0361 -803X/79/1324-0553

$0.00

LINA

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554

!;“

ET

AL.

AJR:132,

April 1979

:

Fig.

2.-Case

2. A,

Huge

pseudoaneurysm

of

gastroduodenal

artery.

B, After embolization, extensive extravasation of contrast material into third part of duodenum (arrowheads). C, After continued embolization, occlusion of gastroduodenal artery (arrow) and aneurysm.

vascular

suite

artery aneurysm rial extravasated

for attempted (fig. from

occlusion

of the gastroduodenal

2A). During embolization, contrast the aneurysm into the third portion

duodenum (fig. 26), indicating rupture. Continued resulted in occlusion of the gastroduodenal artery patient recovered uneventfully. Case

mateof the

embolization (fig. 2C). The

3

A 33 year-old chronic alcoholic tric pain, recurrent pancreatitis, evaluated

for

fluctuating

jaundice

with a long history of epigasand peptic ulcer disease was and

gastrointestinal

blood

loss. Exploratory celiotomy without prior angiography revealed an inflammatory mass in the head of the pancreas. In addition, the gallbladder was distended and contained numerous small black calculi. No active ulcer was found in the stomach or duodenum.

Vagotomy,

pyloroplasty,

and T tube

drainage

of the

common

bile

bleeding

from

which

duct

were

performed.

the common

demonstrated

a false

Postoperative

intermittent

prompted

angiography,

bile duct aneurysm

of

an

aberrant

right

hepatic artery arising from the superior mesenteric artery (fig. 3A). Embolization of the aneurysm with Gelfoam and autologous clot resulted in occlusion of the aberrant vessel and the aneurysm (fig. 3B). Follow-up angiography 1 week later demonstrated recanalization of the artery and reappearance of the aneurysm. A catheter was subselectively placed in a wedged position, and during attempts to reocclude the vessel the aneurysm ruptured into the biliary tree (fig. 3C). Hemobilia was noted through the T tube. Obliterative endoaneurysmorrhaphy and end-to-side choledochoduodenostomy were then performed to control hemorrhage. Surgery was successful and, after a stormy postoperative course complicated by septicemia, the patient was discharged.

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AJR:132.

April

POSTEMBOLIZATION

1979

ANEURYSM

RUPTURE

555

Fig. 3.-Case 3. A, Large pseudoaneurysm (arrows) of right hepatic B, After embolization, occlusion of artery (arrow) and aneurysm. C, After 1 week, further attempts to occlude reopened right hepatic artery false aneurysm resulted in rupture into biliary tree. artery.

Discussion

associated uing

Arterial aneurysms in the peripancreatic vessels are often visualized during angiography in patients with a history of pancreatitis [3]. These aneurysms apparently evolve after pancreatitis with digestion of arterial walls by the pancreatic enzymes. Such aneurysms present strong evidence that the patient has had pancreatitis, and carcinoma can be virtually excluded [3-5]. Because walls of these pseudoaneurysms are thin and weak, they are prone to rupture with life-threatening hemorrhage [3, 6-9]. Since they are relatively inaccessible and are often

or

with

local

previous

inflammation

pancreatitis,

disappointing. Of our three mately surgically accessible. Therefore, other methods, rial

occlusion,

may

be

secondary surgery

cases, such

attempted

is only

to contindifficult one

as transcatheter to

prevent

and

was

ultiarte-

significant

blood loss. However, these aneurysms are extremely fragile. In our three cases, this fragility was dramatically illustrated by their rupture into the gastrointestinal tract during embolization. Routine embolic materials (Gelfoam, autologous clot, Ivalon sponge) used in these cases require a substantial

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556

LINA

volume of fluid at a considerable pressure to facilitate their passage through the catheter. This exerts a very significant strain on the wall of the aneurysm, especially if the feeding vessel is small relative to catheter diameter. If the catheter is actually wedged in the vessel (cases 1 and 3), the whole of the injecting force is transmitted to the aneurysmal wall and rupture is likely. Therefore, on the basis of our experience and case material, we believe that these aneurysms require carefully controlled embolization, using minimal carrier fluid and only enough pressure to carry the embolus to the desired site. In this setting, other techniques of occlusion that do not require any carrier fluid may prove more appropriate. These include the Gianturco steel coil [10], transcatheter coagulation

[11],

adhesives

[13].

detachable

balloons

[12],

or polymerizing

ET AL.

AJR:132,

April 1979

titis. Acta Radio! [Diagn] (Stockh) 12 :34-48, 1972 5. Rentel SR, Redman HG, Joseph AR: Angiographic findings in pancreatitis.AJR 107:56-64, 1969 6. Schecter IM, Gordon HE, Passaro E: Massive hemorrhage of the celiac axis in pancreatitis. Am J Surg 128:301-305, 1974 7. Stanley JC, Freg CF. Miller TA, Lindenauer SM, Child CG: Major arterial hemorrhage. A complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg 111 :435440, 1976 8. Harris AD, Anderson JE, Goel MN: Aneurysms of the small pancreatic arteries. A cause of upper abdominal pain and intestinal bleeding. Radiology 15 : 17-20, 1975 9. Kadell BM, Riley FM: Major arterial involvement by pancreatic pseudocysts. AJR 99 : 632-636, 1967 10. Wallace S, Gianturco C, Anderson J, Goldstein HM, Davis JL, Bree AL: Therapeutic vascular occlusion using steel coil technique: clinical applications. AJR 127 : 381 -387, 1976 1 1 Phillips JF, Robinson AE, Johnsrude IS, Jackson DC: Experimental closure of arteriovenous fistula by transcatheter electrocoagulation Radiology 11:319-321, 1975 12. Kaufman SL, Strandberg JD, Barth KH, Gross GS, White RI: Therapeutic embolization with detachable silastic balloons. Long term effects in swine. Paper presented at the annual .

REFERENCES

.

HM, Medellin H, Ben-Menachem Y, Wallace 5: Transcatheter arterial embolization in the management of bleeding in the cancer patient. Radiology 115 :603-608, 1975 2. Grace DM, Pitt DF, Gold RE: Vascular embolization and 1. Goldstein

occlusion by angiographic techniques as an aid or alternative to operating. Surg Gyneco! Obstet 143:469-481, 1976 3. White A, Baum 5, Buranasiri S: Aneurysms secondary to pancreatitis. AJR 127:393-396, 1976 4. Boysen E, Tayler U: Vascular changes in chronic pancrea-

meeting

of the

Association

of University

Radiologists,

San

Antonio, May 1978 13. Goldman ML, Freeny PC, Tallman JM, Galambos JT, Bradley EL Ill, Salam A, Oen KT, Gordon IJ, Mennemeyer A: Transcatheter vascular occlusion therapy with isobutyl 2cyanoacrylate (bucrylate) for control of massive upper-gastrointestinal bleeding. Radiology 129 :41-49, 1978