An Angiographic Treatment for a Pancreatic Pseudoaneurysm

1 Department of Gastroenterology-Internal Medicine, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Gastroenterology, Colentina Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Corresponding author: Mihai-Radu PAHOMEANU, Department of GastroenterologyInternal Medicine, Emergency University Hospital, Bucharest, ROmania. E-mail: paho93@gmail.com Abstract


INTRODUCTION
Pancreatic pseudoaneurysm is a visceral arterial pseudoaneurysm, with an estimated prevalence by several case series at around 1.3 to 10% of total acute pancreatitis complications 2 . Th e pancreatic pseudoaneurysm is caused by the communication between a pancreatic or peripancreatic artery with a pseudocyst that trough proteolytic enzymes is eroding into an artery. Compared with a true aneurysm, the wall of pseudoaneurysm Th e laboratory exam made at admission found elevated serum lipase and amylase. During his hospitalisation he presented an acute episode of arterial hypotension, acute anemia and haemodynamic instability for which it was performed an CT exam with arterial contrast. Th e CT scan identifi ed an intra-cystic-haemorrhage, measuring 5.1 cm on its largest diameter, located on the pancreaticoduodenal inferior artery. It was then decided to be transferred to University Emergency Hospital of Bucharest for evaluation.
Th e angiographic exam revealed a pseudoaneurysm on the inferior pancreaticoduodenal artery, classifi ed as type IIA2. It was then performed a embolization with a coil type VortX (Boston Scientifi c, USA) with no periprocedural complications that resulted in complete exclusion of the pseudoaneurysm from the circulation.
Patient was discharged 48 h post procedure.

DISCUSSION
Pancreatic pseudoaneurysm (PPA) carries a poor outcome. PPA is in fact a complication of acute pancreatitis, that compared to true aneurysms has a high rate of rupture (76.3% versus 3.1%) 11 and so it should be treated immediately. Several studies 4,12 have identifi ed a overall mortality rate in ruptured PPA ranging from 0 to 60%, the mortality rate being larger when the etiology is post-surgical than the one post-acute pancreatitis (31% vs. 4%). It is very hard to defi ne long-term strategies in this disease, due to the scarcity of the cases, but on short-term management most of the cases published after 2000 were treated through endovascular embolization (46-92%) 12,13 . Two studies have suggested that hemodynamically unstable patients can be managed successfully with endovascular interventions 15,16 .
Treatment options available today are: surgical, endovascular or percutaneous 5 . Th e endovascular treatment seems to be the fi rst choice nowadays, with success rates communication with the GI tract and the exposure to pancreatic juice at the bleeding site.
Th e main aetiology of pseudoaneurysm is acute pancreatitis but it can be also seen after biliopancreatic resection for cancer, local abscess or after pancreatic transplantation 1 .
Th e prognosis in this pathology depends a lot on the type of therapy applied. Treatment with supportive measures have an estimated mortality in excess of 90%, after surgical treatment is around 28 to 56% and after embolization therapy 16% 1 .
Physical examination is not specifi c, most of the patients being asymptomatic. In case of rupture the patient can present: abdominal pain, recurrent and intermittent, digestive haemorrhage, anemia of unexplained etiology and rapid enlargement of an otherwise stable pseudocyst 5 .
Angiography is the gold standard in determining diagnosis being also a mean of treatment. Also, CTA (CT angiography) or MRA (MR angiography) can be used in identifying the site of the lesion1.

CASE REPORT
A 40 years old male, heavy drinker and smoker, with multiple episodes of recurrent acute pancreatitis on a chronic pancreatitis was admitted to Colentina Hospital with upper abdominal pain, nausea and malaise. gelatin foam, polyvinyl alcohol, trisacryl gelatin microspheres, amplatzer vascular plugs, cyanoacrylate glue, ethylene vinyl alcohol copolymer and calcium alginate gel 14 . In case of an unsuited anatomy for endovascular procedure or failure of endovascular procedure the fi rst line of treatment should be the surgical one.
Th e prognosis of embolization therapy on pancreatic pseudoaneurysm, cited by the literature, indicates a successful technique in 77 to 100% of cases, rates resulted from several small retrospective studies made in the fi rst half of second decade of 21 th century 6-10 , r ecurrence rate of 37% and an overall mortality of 16% 1 .
Post procedure complications can arise in endovascular therapy, most commonly described being: local complications at the access site (thrombosis, embolism, hematoma, pain, cellulitis, infection or local pseudoaneurysms), contrast agent nephropathy, visceral ischemia, coil migration, post-embolization syndrome or intraprocedural pseudoaneurysm rupture.

CONCLUSIONS
Th e golden standard in PPA treatment is endovascular selective embolization. We successfully applied this approach in a young patient with a ruptured PPA.
Compliance with ethics requirements: Th e authors declare no confl ict of interest regarding this article. Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law. Informed consent was obtained from all the patients included in the study. ranging from 77% to 100%, 30 day aneurysm-related mortality 3.4% and periprocedural-related mortality 6.2% [7][8][9][10] . Several materials can be used in endovascular embolization, the most common ones being: coils,