IDDF2019-ABS-0115 Endoscopic ultrasound guided thrombin injection- an emerging therapy for visceral artery pseudoaneurysm

Abstract

Background Visceral artery pseudoaneurysm is a rare and potentially life-threatening vascular entity with a high mortality rate, conventionally managed with digital subtraction angiography with coil embolization or surgery. However, in cases where angiographic coil embolization is not possible due to technical reasons, computerized tomography/ultrasonography-guided thrombin injection remains a viable option. In our study, we intend to highlight the role of endoscopic ultrasound (EUS)-guided thrombin injection in the management of abdominal visceral artery pseudoaneurysm, which is either inaccessible by endovascular route or has a high surgical risk of complication. Aim To assess the efficacy of EUS guided thrombin injection in visceral artery pseudoaneurysm. Methods A prospective study was conducted at SMS Hospital, Jaipur from June 2015 to January 2019. All patients with pseudoaneurysm with a history of gastrointestinal bleed were consecutively enrolled. Data relating to demography, laboratory parameters, radiological imaging, pseudo aneurysm and endotherapy were analyzed. Results Sixteen patients with age 40 (25–58) years, 15 male and one female were studied. Etiology of pseudo aneurysm was chronic pancreatitis in 9 (56%), acute pancreatitis in 2 (12.5%), chronic liver disease in 2 (12.5%), Blunt trauma abdomen in 2 (12.5%) and idiopathic in 1 (6%) patients. The site of pseudo aneurysm was splenic artery in 9 (56%), hepatic artery in 4(25%) and gastroduodenal artery in 3(19%) patients. Median size of pseudo aneurysm was 2.2x2.2 cm (1.2x1.8 - 3.5x5.5 cm) and neck size of artery was 2.6mm (2.1–3.2mm). All patients presented with a history of hemetemesis and/or malena, two patients had hemobilia. Thrombin requirement was 400(300–1000) IU for loss of Doppler signals (figure 1). Computed tomography and EUS after 2 weeks, one month and 3 months showed an obliterated pseudo aneurysm. One patient required repeat thrombin injection after 2 weeks as there was an appearance of Doppler signal in pseudoaneurysm. One patient developed symptomatic splenic abscess after three weeks of procedure and required splenectomy. Technical success of procedure was 100%. Conclusions EUS-guided thrombin injection provides a new option for management of pseudoaneurysm especially in inaccessible by endovascular route and in patients having a high surgical risk.