Case Reports
Aortic Pseudoaneurysm Secondary to Celiac Plexus Block S u v r o S. Sett, M D , D a v i d C. T a y l o r , M D ,
Vancouver, British Columbia, Canada
Traumatic pseudoaneurysm of the abdominal aorta has been infrequently reported in the literature, We report a case of an infected pseudoaneurysm of the supraceliac aorta which we believe to be secondary to celiac plexus block performed for pain from chronic pancreatitis. The aneurysm was successfully repaired using a Dacron graft through a thoracoabdominal approach. The possible mechanism of aortic injury from celiac plexus block is discussed. (Ann Vasc Surg 1991;5:88-91). KEY WORDS:
Pseudoaneurysm; trauma; abdominal aorta; infection; pancreatitis.
postoperative course from this procedure was complicated by wound dehiscence. Initial examination revealed him to be malnourished. He was afebrile and normotensive. Examination of his abdomen revealed a nontender, ill defined, pulsatile epigastric mass. Ultrasound examination showed a retroperitoneal mass, 7 x 6 • 5 centimeters in the left upper quadrant. Computed tomography (CT) showed a pseudoaneurysm of the abdominal aorta (Fig. 1). Arteriography confirmed a pseudoaneurysm of the supraceliac aorta, immediately inferior to the diaphragm but not involving the superior mesenteric or celiac arteries (Fig. 2). Operative repair consisted of exposure of the aorta from the proximal descending thoracic portion to the aortic bifurcation through a left thoracoabdominal approach. On the left lateral aspect of the supraceliac abdominal aorta, there was a 10 cm pseudoaneurysm attached to the posterior wall of the stomach, the left hemidiaphragm, and the left lower lobe of the lung. There was no gross evidence of infection. The proximal and distal aorta were clamped without heparin and the aneurysm entered. A 2 x 1.5 cm, smooth-edged oval defect was present in the anterolateral wall of the aorta above the celiac axis. This was repaired using a knitted Dacron patch. Aortic cross-clamp time was 15 minutes. His postoperative course was prolonged because of previous malnutrition but without major complication. Subsequent cultures of the aneurysm wall grew Enterococcus. R e p e a t CT scan two months postoperatively showed an intact arterial repair. He was discharged on oral ampicillin for an indefinite period. He remains well one year following surgery.
Traumatic pseudoaneurysms of the abdominal a o r t a a r e r a r e , a t o t a l o f 20 c a s e s h a v i n g b e e n r e p o r t e d in t h e l i t e r a t u r e [1]. W e p r e s e n t a c a s e in which a pseudoaneurysm occurred after celiac p l e x u s b l o c k f o r p a i n c o n t r o l . W e b e l i e v e the a o r t i c injury w a s d i r e c t l y r e l a t e d to the c e l i a c p l e x u s block.
CASE REPORT A 49-year-old man, a reformed alcoholic, presented with a two week history of continuous pain across the left chest and abdomen. Three months prior to this admission, he had had a number of percutaneous celiac plexus blocks performed through a posterior approach with 50% alcohol to control severe pain from chronic pancreatitis. These were unsuccessful in controlling his pain, and he went on to have a pancreatojejunostomy and celiac ganglion neurect0mY two months prior to the current admission. His supraceliac aorta was surrounded by fibrous tissue but was otherwise normal at this time. His
From the Division of Vascular Surgery, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada. Reprint requests: Dr. D.C. Taylor, Department of Surgery, University of British Columbia, 3100-910 West lOth Avenue, Vancouver, British Columbia, Canada V5Z 4E3. 88
VOLUME 5 N o 1 - 199l
AORTIC P S E U D O A N E U R Y S M
89
Fig. 1. Computed tomography scan of abdomen showing aortic pseudoaneurysm (arrow) arising from anterolateral aspect of supraceliac aorta. DISCUSSION We believe this pseudoaneurysm of the aorta was the result of injury at the time of celiac plexus block. Traumatic pseudoaneurysms of the abdominal aorta are rare, 20 having been reported in the literature as reviewed by Chaikoff in 1985 [1]. The majority of these were secondary to penetrating trauma. One was associated with staphylococcal contamination. Twelve of 20 aneurysms were successfully repaired. These authors emphasized the use of CT and arteriography for preoperative assessment and adequate exposure using a thoracoabdominal incision. Although celiac plexus block for control of visceral pain is generally a safe procedure, there have been a number of significant complications reported. In a series of 100 patients who had celiac plexus block for pain from pancreatic cancer or chronic pancreatitis, Thompson and colleagues reported a 10% incidence of postural hypotension and one case of partial leg paralysis [2]. Moore and coworkers in a study of patients and corpses found the kidney to be iatrogenically punctured and pneumothorax to be a potential complication during this procedure [31.
We are not aware that the complication of aortic injury and pseudoaneurysm formation has been reported, but it is certainly plausible. Thompson and associates emphasized a technique of celiac plexus block whereby transmitted aortic pulsations along the needle tip and occasionally aortic puncture are used to localize the correct site for injection of 50 ml of 50% ethanol [2]. Others have used fluoroscopy and CT scanning for guidance [4,5]. The alcohol used to destroy the celiac plexus has a direct cytotoxic effect on tissue (dehydration of cells). It is likely in this case that inadvertent injection into or adjacent to the aortic wall caused pseudoaneurysm formation of the aorta. Although the pseudoaneurysm was contaminated with Enterococcus, we feel that this represents secondary infection of a preexisting aneurysm, rather than a primary mycotic aneurysm. There was no gross evidence of infection or tissue necrosis at the time of surgery and the organism cultured is not commonly associated with primary mycotic aneurysms. Given the low virulence of the organism cultured form the pseudoaneurysm and the difficulty of extraanatomic bypass of the aorta in this area, we feel that in situ repair was the best method of aortic reconstruction in this case. The safety of in situ aortic reconstruction in
90
AORTIC P S E U D O A N E U R YSM
ANNALS OF VASCULAR SURGERY
Fig. 2. Arteriogram showing aortic pseudoaneurysm (arrow) in AP (A) and lateral projections (B).
VOLUME 5 No 1 - 1991
AORTIC P S E U D O A N E U R Y S M
contaminated fields combined with long-term antibiotics in selected cases has been documented by Crawford and others [6-8]. We present this case as an unusual but very significant vascular complication of celiac plexus block.
4. 5.
6.
REFERENCES I. CHAIKOFF EL, SHAMBERGER RL, BREWSTER DL. Traumatic pseudoaneurysms of the abdominal aorta. J Trauma 1985;25(2): 169-173. 2. THOMPSON GE, MOORE DC, BRIDENBAUGH LD, et al. Abdominal pain and alcoholic celiac plexus nerve block. Anesth Analg 1977;56(1):1-5. 3. MOORE DC, BUSH WH, BENNETT LL. Coeliac plexus
7.
8.
mNNn
91
block: a roentgenographic anatomic study of technique and spread of solution in patients and corpses. Anesth Analg 1981 ;60(6):369-379. HEGEDIUS V. Relief of pancreatic pain by radiology-guided block. A JR 1979;133:1101-1103. FISCHIC J, GOLDING S, ROBBIE DS, et al. Unilateral computerized tomography guided celiac plexus block: a {echnique for pain relief. Anesth Analg 1983;38:498-503. CHAN FY, CRAWFORD ES, COSELLI JS, et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193-203. ATNIP RG. Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction. J Vasc Surg 1989;10:635-641. SEMEL L, SZMALC F, BREDENBERG CE. Management of suspected mycotic suprarenal aortic aneurysm. Ann Vasc Surg 1989;4:380-383.
Aortic Pseudoaneurysm Secondary to Celiac Plexus Block S u v r o S. Sett, M D , D a v i d C. T a y l o r , M D ,
Vancouver, British Columbia, Canada
Traumatic pseudoaneurysm of the abdominal aorta has been infrequently reported in the literature, We report a case of an infected pseudoaneurysm of the supraceliac aorta which we believe to be secondary to celiac plexus block performed for pain from chronic pancreatitis. The aneurysm was successfully repaired using a Dacron graft through a thoracoabdominal approach. The possible mechanism of aortic injury from celiac plexus block is discussed. (Ann Vasc Surg 1991;5:88-91). KEY WORDS:
Pseudoaneurysm; trauma; abdominal aorta; infection; pancreatitis.
postoperative course from this procedure was complicated by wound dehiscence. Initial examination revealed him to be malnourished. He was afebrile and normotensive. Examination of his abdomen revealed a nontender, ill defined, pulsatile epigastric mass. Ultrasound examination showed a retroperitoneal mass, 7 x 6 • 5 centimeters in the left upper quadrant. Computed tomography (CT) showed a pseudoaneurysm of the abdominal aorta (Fig. 1). Arteriography confirmed a pseudoaneurysm of the supraceliac aorta, immediately inferior to the diaphragm but not involving the superior mesenteric or celiac arteries (Fig. 2). Operative repair consisted of exposure of the aorta from the proximal descending thoracic portion to the aortic bifurcation through a left thoracoabdominal approach. On the left lateral aspect of the supraceliac abdominal aorta, there was a 10 cm pseudoaneurysm attached to the posterior wall of the stomach, the left hemidiaphragm, and the left lower lobe of the lung. There was no gross evidence of infection. The proximal and distal aorta were clamped without heparin and the aneurysm entered. A 2 x 1.5 cm, smooth-edged oval defect was present in the anterolateral wall of the aorta above the celiac axis. This was repaired using a knitted Dacron patch. Aortic cross-clamp time was 15 minutes. His postoperative course was prolonged because of previous malnutrition but without major complication. Subsequent cultures of the aneurysm wall grew Enterococcus. R e p e a t CT scan two months postoperatively showed an intact arterial repair. He was discharged on oral ampicillin for an indefinite period. He remains well one year following surgery.
Traumatic pseudoaneurysms of the abdominal a o r t a a r e r a r e , a t o t a l o f 20 c a s e s h a v i n g b e e n r e p o r t e d in t h e l i t e r a t u r e [1]. W e p r e s e n t a c a s e in which a pseudoaneurysm occurred after celiac p l e x u s b l o c k f o r p a i n c o n t r o l . W e b e l i e v e the a o r t i c injury w a s d i r e c t l y r e l a t e d to the c e l i a c p l e x u s block.
CASE REPORT A 49-year-old man, a reformed alcoholic, presented with a two week history of continuous pain across the left chest and abdomen. Three months prior to this admission, he had had a number of percutaneous celiac plexus blocks performed through a posterior approach with 50% alcohol to control severe pain from chronic pancreatitis. These were unsuccessful in controlling his pain, and he went on to have a pancreatojejunostomy and celiac ganglion neurect0mY two months prior to the current admission. His supraceliac aorta was surrounded by fibrous tissue but was otherwise normal at this time. His
From the Division of Vascular Surgery, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada. Reprint requests: Dr. D.C. Taylor, Department of Surgery, University of British Columbia, 3100-910 West lOth Avenue, Vancouver, British Columbia, Canada V5Z 4E3. 88
VOLUME 5 N o 1 - 199l
AORTIC P S E U D O A N E U R Y S M
89
Fig. 1. Computed tomography scan of abdomen showing aortic pseudoaneurysm (arrow) arising from anterolateral aspect of supraceliac aorta. DISCUSSION We believe this pseudoaneurysm of the aorta was the result of injury at the time of celiac plexus block. Traumatic pseudoaneurysms of the abdominal aorta are rare, 20 having been reported in the literature as reviewed by Chaikoff in 1985 [1]. The majority of these were secondary to penetrating trauma. One was associated with staphylococcal contamination. Twelve of 20 aneurysms were successfully repaired. These authors emphasized the use of CT and arteriography for preoperative assessment and adequate exposure using a thoracoabdominal incision. Although celiac plexus block for control of visceral pain is generally a safe procedure, there have been a number of significant complications reported. In a series of 100 patients who had celiac plexus block for pain from pancreatic cancer or chronic pancreatitis, Thompson and colleagues reported a 10% incidence of postural hypotension and one case of partial leg paralysis [2]. Moore and coworkers in a study of patients and corpses found the kidney to be iatrogenically punctured and pneumothorax to be a potential complication during this procedure [31.
We are not aware that the complication of aortic injury and pseudoaneurysm formation has been reported, but it is certainly plausible. Thompson and associates emphasized a technique of celiac plexus block whereby transmitted aortic pulsations along the needle tip and occasionally aortic puncture are used to localize the correct site for injection of 50 ml of 50% ethanol [2]. Others have used fluoroscopy and CT scanning for guidance [4,5]. The alcohol used to destroy the celiac plexus has a direct cytotoxic effect on tissue (dehydration of cells). It is likely in this case that inadvertent injection into or adjacent to the aortic wall caused pseudoaneurysm formation of the aorta. Although the pseudoaneurysm was contaminated with Enterococcus, we feel that this represents secondary infection of a preexisting aneurysm, rather than a primary mycotic aneurysm. There was no gross evidence of infection or tissue necrosis at the time of surgery and the organism cultured is not commonly associated with primary mycotic aneurysms. Given the low virulence of the organism cultured form the pseudoaneurysm and the difficulty of extraanatomic bypass of the aorta in this area, we feel that in situ repair was the best method of aortic reconstruction in this case. The safety of in situ aortic reconstruction in
90
AORTIC P S E U D O A N E U R YSM
ANNALS OF VASCULAR SURGERY
Fig. 2. Arteriogram showing aortic pseudoaneurysm (arrow) in AP (A) and lateral projections (B).
VOLUME 5 No 1 - 1991
AORTIC P S E U D O A N E U R Y S M
contaminated fields combined with long-term antibiotics in selected cases has been documented by Crawford and others [6-8]. We present this case as an unusual but very significant vascular complication of celiac plexus block.
4. 5.
6.
REFERENCES I. CHAIKOFF EL, SHAMBERGER RL, BREWSTER DL. Traumatic pseudoaneurysms of the abdominal aorta. J Trauma 1985;25(2): 169-173. 2. THOMPSON GE, MOORE DC, BRIDENBAUGH LD, et al. Abdominal pain and alcoholic celiac plexus nerve block. Anesth Analg 1977;56(1):1-5. 3. MOORE DC, BUSH WH, BENNETT LL. Coeliac plexus
7.
8.
mNNn
91
block: a roentgenographic anatomic study of technique and spread of solution in patients and corpses. Anesth Analg 1981 ;60(6):369-379. HEGEDIUS V. Relief of pancreatic pain by radiology-guided block. A JR 1979;133:1101-1103. FISCHIC J, GOLDING S, ROBBIE DS, et al. Unilateral computerized tomography guided celiac plexus block: a {echnique for pain relief. Anesth Analg 1983;38:498-503. CHAN FY, CRAWFORD ES, COSELLI JS, et al. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193-203. ATNIP RG. Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction. J Vasc Surg 1989;10:635-641. SEMEL L, SZMALC F, BREDENBERG CE. Management of suspected mycotic suprarenal aortic aneurysm. Ann Vasc Surg 1989;4:380-383.
