Splenic Artery Pseudoaneurysm Complicating Pancreatitis

Abstract

A 62-year-old man with alcoholic cirrhosis was admitted for acute on chronic pancreatitis. During his last admission 3 months before, a CT scan had showed ascites as well as a 5.0-cm high-density posterior pancreatic tail fluid collection communicating with high-density material between the aorta and left renal vein (Fig. 1). The patient refused further workup and was discharged home. During this next admission, CT angiography showed an 8.6-cm partially thrombosed splenic artery pseudoaneurysm at the pancreatic tail and a subcapsular splenic fluid collection (Fig. 2). While awaiting intervention, the patient suddenly became pale and hypotensive. He died from a ruptured pseudoaneurysm leading to hemorrhage and acute hemodynamic collapse. Splenic artery pseudoaneurysm is a rare complication of pancreatitis and pancreatic pseudocysts. Other etiologies include peptic ulcer disease, trauma, and complications of surgical exploration. Release of pancreatic enzymes results in autodigestion of the vessel wall. Risk of rupture can be as high as 37%, with a mortality rate approaching 90% when untreated1. Early diagnosis and urgent treatment are imperative regardless of size or symptoms. Pseudoaneurysms may be mistaken for pseudocysts or other peripancreatic fluid collections on CT scan. High density within peripancreatic fluid collections should raise the suspicion of blood. Angiography offers a definitive diagnosis. Treatment options include transcatheter embolization, splenectomy with or without distal pancreatectomy, or splenic artery ligation alone. In our case, the patient likely had a pseudocyst with a concomitant bleeding pseudoaneurysm. The pseudoaneurysm progressed in size and led to fatal rupture. Figure 1 CT scan depicting a 5.0-cm high-density posterior pancreatic tail fluid collection communicating with high-density materialbetween the aorta and left renal vein. Figure 2 CT angiography depicting an 8.6-cm partially thrombosed splenic artery pseudoaneurysm at the pancreatic tail and a subcapsular splenic fluid collection.