A Complication Hanging by a Thread

Abstract

Question: A 75-year-old man presented with a 1-month history of mild abdominal pain and cramping, associated with weight loss (3 kg). He denied any nausea, vomiting, chills, diarrhea, or hematochezia. The patient reported no trauma. He had a history of ampullary adenocarcinoma treated with pancreaticoduodenectomy 2 years earlier. The postoperative course was marked by hemorrhagic shock owing to a splenic artery pseudoaneurysm that was successfully treated by trans-arterial embolization. On physical examination, the patient was afebrile and had normal vital signs. He had a slight tender abdomen on palpation. Blood tests revealed a C-reactive protein level of 20.2 mg/L (reference value, <3.5 mg/L) and a white blood cell count of 3670/mm3 with 87% neutrophils. Other laboratory tests were unremarkable. A contrast-enhanced computed tomography (CT) scan showed a status post embolization of the splenic artery with hyperattenuating embolic material (Figure A) and long thin hyperattenuating foreign bodies in the small bowel lumen (Figure B–D; the entire CT scan is provided as supplemental material) that were better assessed on a coronal maximum intensity projection view (Figure E). The small bowel wall was normal. There was no sign of bowel perforation, no fluid collection, and no sign of active or recent bleeding. The colon was normal. The pancreaticojejunal anastomosis was unremarkable. There was no evidence of tumor recurrence. What is the diagnosis? Look on page 55 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The pancreaticoduodenectomy was complicated with a pseudoaneurysm arising from the splenic artery (Figure F) that was successfully treated with transarterial embolization with steel wire coils. A postembolization CT scan showed complete occlusion of the lesion and the splenic artery (coronal view; Figure G). There was no bleeding recurrence, and the patient was discharged. The patient was regularly followed-up with a CT scan that showed no evidence of tumor recurrence and no modification of the embolization site. A multidisciplinary team recommended conservative management with no invasive procedure to remove the migrated coils. The patient spontaneously and painlessly evacuated the coils in stools 5 weeks after the diagnosis (Figure H). A contrast-enhanced CT scan performed 3 weeks later showed the evacuation of migrated coils, and the persistence of coils in the splenic artery (Figure I). The patient is currently asymptomatic and free from tumor recurrence. Complications of splenic artery embolization include splenic infarction (1%–2%), splenic abscesses, left pleural effusion (10%), or basal atelectasis (30%), and rarely portal thrombosis. Migration of coils is exceptional and has been described after embolization of splenic pseudoaneurysms owing to vascular coil erosion into the gastrointestinal tract.1Shah N.A. Akingboye A. Haldipur N. et al.Embolization coils migrating and being passed per rectum after embolization of a splenic artery pseudoaneurysm, "the migrating coil": a case report.Cardiovasc Intervent Radiol. 2007; 30: 1259-1262Crossref PubMed Scopus (36) Google Scholar, 2Tekola B.D. Arner D.M. Behm B.W. Coil migration after transarterial coil embolization of a splenic artery pseudoaneurysm.Case Rep Gastroenterol. 2013; 7: 487-491Crossref PubMed Scopus (21) Google Scholar, 3Takahashi T. Shimada K. Kobayashi N. et al.Migration of steel-wire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case.Surg Today. 2001; 31: 458-462Crossref PubMed Scopus (46) Google Scholar As previously reported, migration was a delayed complication (3 months to 10 years in the literature). Of note, several cases reported evidence of infection at the erosion site, which was not present here. Management depends on the extent of material migration and symptoms and ranges from conservative treatment to more invasive procedures (endoscopic or surgical retrieval). No evidence suggests that specific coils are more prone to secondary migration. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwMDVhZjJiODcwMzAzNjk2ZmI2YWIzMjUzYjdlYWQxOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgwMjM3NDk5fQ.LS386lU7wuNg_A2l4X5T61IP2FppVGq2DNjFd7aTwKDD2CnGpQETIi90YGkob6isNUAcHjGC4yhMDhQNo1DG5HKu1dFwUcd02ku-3-ijbtwufokHYbR9GkgBLJJrKiVWexXPcCmjZ80L7FxHY7cNGxrNvpL2raueVLp6qDpzbURZecPBVy2dgcAXpt6jsm1aasdWat3eZkIIzv_GjPqtCeiF2xd_C5fCUMsrsLpgVJRc4TUlfE7LeeevSOcSauQrdo1mVy7_4gMzUgxnWKEuzCzZQJNc2cgIvMo0DQPGSs8o2SDa7TKbqSjnpikBuxPR43PNpPDaTpv5tnSCsdVXbQ Download .mp4 (6.04 MB) Help with .mp4 files Video