Successful embolization of a bleeding pseudoaneurysm of the celiac tripod

Abstract

A 70-year-old alcoholic man with a 10-year history of recurrent pancreatitis was hospitalized owing to an acute episode of active gastrointestinal bleeding with hematemesis and melena. The patient was pale and emaciated. Fresh blood was aspirated from the stomach. Transfusions were necessary, as hemoglobin levels had dropped to 4.9 g/dL and hematocrit to 14%. Serum alkaline phosphatase was normal (80 U/L) along with serum bilirubin and calcium. Serum amylase was slightly increased (190 U/L). Physical examination revealed a pulsatile epigastric mass. Upper gastrointestinal endoscopy revealed blood clots in the stomach but the site of bleeding was not detected. A selective visceral angiogram was therefore carried out, and it showed a large saccular cavity arising from celiac trunk (Fig. 1). Steel coil embolization both of the celiac trunk and its efferent branches (ie, splenic, hepatic, and left gastric artery) was then performed in order to exclude the hemorrhagic region from the backflow through collaterals (Fig. 2). Definitive bleeding control was achieved, avoiding a major surgical procedure, as the patient did not experience any further bleeding. Repeat angiography performed 6 months after embolization showed complete revascularization of the liver and the spleen through collaterals emerging from the superior mesenteric artery, while the pseudoaneurysmatic cavity was still fully embolized and excluded from arterial circulation (Fig. 3). At a recent clinical follow-up (11 months after embolization) the patient was doing well, having experienced no bleeding recurrence nor significant abdominal pain. Ultrasound color Doppler study showed complete occlusion of the pseudoaneurysm and laboratory data were within normal limits.