Artery Pseudoaneurysm Research Articles

Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study.

Mechanical endovascular thrombectomy (EVT) is an increasingly relied-on treatment for clot retrieval in the context of ischemic strokes, which otherwise are associated with significant morbidity and mortality. Despite several known risks associated with this procedure, there is a high degree of technical heterogeneity across both centers and operators. The most common procedural complications occur at the point of transfemoral access (the common femoral artery), and include access-site hematomas, dissections, and pseudoaneurysms. Other interventional fields have previously popularized the use of ultrasound to enhance the anatomical localization of structures relevant to vascular access and thereby reducing access-site complications. In this study, the authors aimed to describe the ultrasound-guided EVT technique performed at a large, quaternary neurovascular referral center, and to characterize the effects of ultrasound guidance on access-site complications. A retrospective chart review of all patients treated with EVT at a single center between January 2013 and August 2020 was performed. Patients in this cohort were treated using a universal, unique, ultrasound-guided, single-wall puncture technique, which bears several theoretical advantages over the standard technique of arterial puncture via palpation. There were 479 patients treated with EVT within the study period. Twenty patients in the cohort were identified as having experienced some form of access-site complication. Eight (1.67%) of these patients experienced minor access-site complications, all of which were groin hematomas and none of which were clinically significant, as defined by requiring surgical or interventional management or transfusion. The remaining 12 patients experienced arterial dissection (n = 5), arterial pseudoaneurysm (n = 4), retroperitoneal hematoma (n = 2), or arterial occlusion (n = 1), with only 1.04% (5/479) requiring surgical or interventional management or transfusion. The authors found an overall reduction in total access-site complications as well as minor access-site complications in the study cohort compared with previously published randomized controlled trials and observational studies in the recent literature. The findings suggested that there may be a role for routine use of ultrasound-guided puncture techniques in EVT to decrease rates of complications.

Transarterial embolization with N-butyl 2-cyanoacrylate for the treatment of recurrent secondary post-tonsillectomy hemorrhage

BackgroundPostoperative hemorrhage is a potential complication of tonsillectomy, and early diagnosis and adequate management are mandatory to prevent hemorrhagic shock. The aim of this study was to assess the safety and efficacy of transcatheter embolization of recurrent post-tonsillectomy hemorrhage by using N-butyl 2-cyanoacrylate.ResultsWe performed a retrospective analysis of the medical records, imaging findings, technical details, and clinical outcome of eight patients with delayed post-tonsillectomy hemorrhage who underwent endovascular embolization. All patients were followed up; technical and clinical successes of treatment were evaluated. All patients had arterial pseudoaneurysm as a source of bleeding. The injured artery was facial artery in four patients, lingual artery in three patients, and linguofacial trunk in one patient. All lesions were treated by endovascular embolization using NBCA glue. All patients were successfully embolized with no clinical complications. In one patient with pseudoaneurysm at the ostium of the facial artery, after filling the pseudoaneurysm with glue, inadvertently proximal reflux into the adjacent part of the external carotid artery (ECA) occurred leading to its occlusion with no related immediate or delayed complication.ConclusionEndovascular embolization is an effective and almost safe procedure in the management of recurrent post-tonsillectomy bleeding. In such cases, we can use NBCA glue with certain precautions as an effective appropriate embolizing agent.

Endovascular treatment of visceral aneurysms and pseudoaneurysms.

Visceral artery aneurysm (VAA) is a rare and potentially life-threatening condition, defined as true artery aneurysms and pseudoaneurysms of splanchnic circulation and renal artery. This study reports our experience in the diagnosis and endovascular treatment of visceral artery aneurysms (VAAs) over a 10-year period. Between 2008 and 2018, a total of 24 VAAs in 21 patients were diagnosed by clinical symptoms and a combination of imaging techniques, such as Doppler ultrasound, computed tomography angiogram, and catheter angiogram. All patients underwent endovascular treatment to exclude aneurysms. Oral antiplatelet medicine was administered, and imaging examination was performed during follow-up. Technical success was achieved in all 21 patients, and no periprocedural complications occurred. Endovascular coiling alone was employed in 10 aneurysms. Coiling was combined with gelfoam in 2 aneurysms. Coiling was assisted by stent in 4 aneurysms. Covered stents were deployed in 8 aneurysms individually. Clinical symptoms disappeared or highly improved in all patients after treatment. None of the patients showed recurrent symptoms after discharge. However, two cases with new aneurysms after 6 and 8 months, respectively, and one case with in-stent thrombosis after 12 months were reported during follow-up. This study may justify the efficacy of percutaneous endovascular coil embolization and stent deployment. It also provides beneficial experience about how to choose appropriate various endovascular strategies based on both clinical symptoms and aneurysm anatomy condition.

Iatrogenic Pseudoaneurysm after Laparoscopic Bilateral Inguinal Hernia Surgery: Treatment with Endovascular Coil Embolization

Although laparoscopic interventions have provided significant achievements in hernia surgery, they may cause complications such as pain, hematoma, intestinal injuries, testicular complications, and sometimes arterial pseudoaneurysms. Arterial pseudoaneurysms are a very rare complication of laparoscopic inguinal hernia surgery. Pseudoaneurysms have serious various causes such as inflammation, trauma, and iatrogenic injury. The patient was diagnosed with bilateral inguinal hernia and a laparoscopic total extra-peritoneal repair was completed. Pelvic bleeding developed on the first postoperative day. A pseudoaneurysm that was 80x70x50 cm was detected in an abdominal computer tomography angiography. In this case because of having high rate morbidity and mortality of open surgery, we selected endovascular angioembolization instead of open surgery in the treatment of pseudoaneurysm which occurred after laparoscopic inguinal hernia surgery

Role of Multi Detector Computed Tomography in Evaluation of Vascular Complications of Pancreatitis: A Cross-sectional Study

Introduction: The involvement of the blood vessels around the pancreas in pancreatitis may result in devastating complications. The proteolytic enzymes secreted by the inflamed pancreas can directly erode the walls of arteries in and around the pancreas, resulting in haemorrhage or pseudoaneurysms formation. On the other hand, the inflamed tissue may compress or thrombose adjoining veins. Multidetector Computed Tomography (MDCT) serves as an excellent tool for diagnosis and evaluation of complications of pancreatitis and can detect most vascular complications. Aim: To evaluate the MDCT findings of vascular complications associated with pancreatitis. Materials and Methods: This cross-sectional study was conducted on 60 patients at the Department of Radiology in the Tertiary Care Hospital attached to Mysore Medical College and Research Institute, Mysore, India for 12 months from 1st August 2019 to 31st July 2020. Each patient was subjected to unenhanced and contrast-enhanced CT to characterise the vascular complications associated with pancreatitis. The results were tabulated and evaluated descriptively by Microsoft excel 2016 and presented in figures and tables. Results: Of the 60 patients included, Splenic Vein Thrombosis (SVT) was seen in 39 (65%), followed by Portal Vein (PV) thrombosis in 17 (28.3%), Superior Mesenteric Vein (SMV) thrombosis in 14 (23.3%), all the three vein thrombosis was seen in 7 (11.6%) and arterial pseudoaneurysms was seen in 3 (5%). Conclusion: Vascular complications in pancreatitis are not uncommon but should be evaluated in all cases of pancreatitis. Contrast-enhanced CT is the main imaging modality for originally identifying local complications. SVT is one of the most frequently found vascular complications seen in patients of pancreatitis.

Endovascular treatment experience on arterial pseudoaneurysms: a presentation of three cases

En los ultimos anos con la llegada del tratamiento endovascular, se ha visto una importante disminucion de la morbimortalidad de pacientes con pseudoaneurismas arteriales. Continua siendo controversial su uso en un contexto de infeccion. El objetivo de este trabajo es reportar la experiencia del servicio en el manejo endovascular de pseudoaneurismas arteriales infecciosos (PAI). Un estudio retrospectivo y observacional, incluye pacientes con diagnostico de pseudoaneurisma infeccioso arterial tratados de forma endovascular en nuestro centro en un periodo de dos anos, de junio 2016 a junio 2018.

Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study.

Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. Level IV, Cadaveric study.

S1530 A Catastrophic Complication of Pancreatic Adenocarcinoma

INTRODUCTION: Gastrointestinal bleeding (GIB) is often times a medical emergency. Determining the source of bleed is important for management and treatment. Some common causes of upper GIB are known as peptic ulcers, Mallory-Weiss tears, esophageal varices, and gastric cancer. A less frequent cause of GIB occurs due to an extremely rare disease called hemosuccus pancreaticus (HP), defined as bleeding from ampulla of Vator through the pancreas. HP is caused by pancreatitis, arterial pseudoaneurysms, and pancreatic tumors causing bleeding from the pancreatic duct or adjacent vessels such as the splenic or gastric artery. We present a rare case of HP causing massive upper GIB in a patient with known pancreatic adenocarcinoma. CASE DESCRIPTION/METHODS: We describe a case of a 79 year old male with history of melena and stage IV pancreatic adenocarcinoma who presented to the hospital for fatigue. Upon arrival the patient was hypotensive and tachycardic. He complained of extreme generalized weakness above his baseline. He appeared pale with icteric sclera and conjunctival pallor. Intravenous fluids were started. Significant lab values showed hemoglobin 7.4 g/dL, which was 2 grams less from outpatient labs 1 day prior. Therefore, 1 unit of packed red blood cells was initiated. During the interview, he had sudden onset of profuse hematemesis and systolic pressure decreased to 60 mmHg. Patient was started on massive transfusion but blood pressure continued to fall and he went into cardiac arrest requiring cardiopulmonary resuscitation. Return of systemic circulation was achieved after 8 minutes. After stabilization, an esophagogastroduodenoscopy revealed active bleeding from the duodenal papilla, requiring endovascular treatment. Notably, there was recent sonographic evidence of tumor invasion into the celiac trunk likely causing rupture of a splenic pseudoaneurysm into the pancreatic duct causing HP. Despite interventional embolization, hemodynamic compromise continued leading to demise. DISCUSSION: HP remains a clinical and diagnostic challenge. The acuity of bleed can be massive and mortality rate remains high. The importance of this report is to include HP as a differential diagnosis, especially in patients with known pancreatic adenocarcinoma. A common manifestation of HP is melena, and if detected early in these patients, prior to massive bleeding with hemodynamic instability, it can allow safe intervention and life saving measures. The gold standard for diagnosis and treatment of HP remains angiography.Figure 1.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.Figure 2.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.

Cutaneous nerve-conscious surgical repair of vascular access-related aneurysm assisted by anatomical ultrasonography in hemodialysis patients.

Background:The superficial runoff veins anatomically run alongside the cutaneous nerves in the volar forearm. Consequently, the surgical repair of vascular access (VA)-associated venous aneurysms attached to the cutaneous nerves could cause intraoperative nerve injury. Therefore, we proposed a cutaneous nerve-conscious VA-related aneurysmal repair assisted by nerve ultrasonography. This ultrasonography aids in the preoperative examination of the courses of the nerves neighboring the aneurysm.Methods:Sixteen consecutive patients who underwent surgical revisions of VA-related aneurysms (14 venous aneurysms and two arterial pseudoaneurysms) were enrolled. The locations of aneurysms derived from preexisting arteriovenous fistulas included 11 radiocephalic arteriovenous fistulas in the wrist or distally, three radiocephalic arteriovenous fistulas at the antecubital fossa, and two brachiocephalic arteriovenous fistulas at the antecubital fossa or in the distal upper arm. A preoperative ultrasonographic scan of the cutaneous nerve trunks that ran peripherally toward and along the aneurysms was attempted to avoid nerve injuries during operations. Basically, the aneurysms were resected from the proximal to the distal ends after being separated from the preserved adjacent nerves.Results:The cutaneous nerve trunks that coursed toward and along the aneurysm could be identified by preoperative ultrasonography and could be preserved intraoperatively based on ultrasonographic findings in all patients. In four patients, the cutaneous nerve branch was unexpectedly or intentionally severed for a seamless surgical process because the nerve branch that divided from the cutaneous nerve trunk was strongly attached to the aneurysm. They subsequently suffered from hypoesthesia, but did not experience neuropathic pain.Conclusion:Preoperative ultrasonographic examination of the cutaneous nerve facilitated the intraoperative prevention of cutaneous nerve injury in VA-related aneurysmectomy. Nerve-sparing VA surgery assisted by preoperative nerve ultrasonography based on the understanding of topological anatomy might contribute to the reduction in postoperative neuropathy and enhance comfort in the daily life of hemodialysis patients.

Endovascular Occlusion of Giant Posttraumatic Pseudo-Aneurysm of Superior Mesenteric Artery Connected to Mesenteric Arteriovenous Fistula.

The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding.Materials and Methods.A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography — revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32×35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient’s past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder — Amplatzer Vascular Plug II (USA), 14×10 mm in size.Results.A unique endovascular intervention — transcatheter occlusion of pseudo-aneurysm and AVF separation — was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect.Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms.

Introduction:Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI).Materials and Methods:Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed.Results:A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI.Conclusion:Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Idiopathic Intrahepatic Artery Aneurysm Presenting as Acute Hemorrhagic Cholecystitis

Intrahepatic artery aneurysm or pseudoaneurysm is an unusual condition encountered clinically that accounts for a very small part of all visceral artery aneurysm cases. True incidence of primary or spontaneous intrahepatic artery aneurysm is difficult to be verified and has been rarely reported. For intrahepatic artery aneurysm/pseudoaneurysm, the diagnosis and management are challenging owing to the lower incidence and occult or various presentations. Due to the insidious course, patients with such aneurysms often have a higher risk of rupture, sometimes causing a catastrophic bleeding situation. Herein, we present a case of a 20-year-old woman with idiopathic left intrahepatic artery aneurysm with initial presentation mimicking acute hemorrhagic cholecystitis. Following laparoscopic cholecystectomy, intermittent upper gastrointestinal bleeding occurred. At the second radiologic study, left lateral-superior subsegmental hepatic artery aneurysm was detected. After endovascular treatment, the patient recovered without complications. To avoid delayed diagnosis, we suggest that hepatic artery aneurysm/pseudoaneurysm should always be considered when there is no usual cause of upper gastrointestinal tract bleeding.

P1425Complication rate and incidence of esophageal injury after minimally invasive convergent procedure for treatment of atrial fibrillation

Abstract Funding Acknowledgements None Introduction Convergent procedure is a minimally invasive surgical approach for treatment of atrial fibrillation (AF) combining epicardial and endocardial radiofrequency (RF) ablation. However, there is conflicting data regarding the rate of major complications after convergent treatment of AF. Apart from common complications the esophageal injury incidence after convergent procedure is not well documented. Purpose Our aim was to assess major complication occurrence after convergent procedure with additional emphasis on the incidence of esophageal injury. Methods One hundred forty-seven consecutive patients (113 male, mean age 59 ± 9 years, BMI 29 ± 5 kg/m2) with persistent (122, 83%) and paroxysmal (25, 17%) AF were treated with convergent procedure that included epicardial RF ablation with coagulation devices (12 lesions, each for 90 s, with 30 W power), combined with endocardial RF catheter ablation for pulmonary vein isolation. The approach for epicardial ablation was diaphragmatic pericardial window through subxiphoid incision. Infusion of cooled saline into the pericardial space during epicardial ablations and monitoring of esophageal temperature with temperature probe were additional precautions to avoid esophageal overheating. All patients had endoscopy of the esophagus at least 2 days after the procedure to assess for presence of esophageal injury. Adverse events resulting in additional intervention or causing long-term disability were defined as major complication. Results During short-term follow-up (minimum of 5 months) major complication rate was 6.1%. Three patients had cardiac tamponade, 4 had abdominal bleeding, 1 had ischemic stroke and 1 had arterial pseudoaneurysm. Esophageal mucosal lesions were observed in 11 patients (7.5%) that did not result in major complication. All lesions were followed with additional endoscopies and resolved without any intervention. Conclusions Complication rate after minimally invasive convergent procedure for treatment of AF in our patient cohort is low. Prevention of esophageal overheating resulted in absence of major esophageal injury.

Stent graft treatment for ruptured pseudoaneurysms of the splanchnic arteries after pancreaticoduodenectomy: a case report

BackgroundHemorrhage due to a ruptured splanchnic pseudoaneurysm followed by the formation of a postoperative pancreatic fistula is the most severe complication of a pancreatectomy, sometimes leading to a fatal outcome. Stent graft placement to control the hemorrhage due to the pseudoaneurysm is a validated treatment option, but once the stent graft is infected, infection control is complicated. We report a case of a ruptured pseudoaneurysm of the splanchnic artery after pancreaticoduodenectomy to evaluate the stent graft treatment.Case presentationA 77-year-old man underwent pylorus-preserving pancreaticoduodenectomy for suspected distal bile duct cancer. Hemorrhage from a pseudoaneurysm of the common hepatic artery due to the formation of the pancreatic fistula was detected on postoperative day 9, and a stent graft was successfully placed with the preservation of hepatic arterial blood flow. On postoperative day 12, new-onset hemorrhage from a pseudoaneurysm of the right hepatic artery developed, and a stent graft was similarly placed, but immediately occluded. Refractory pancreatic and biliary fistulas developed and required continuous drainage. On postoperative day 85, computed tomography revealed the presence of air within the latter stent graft, which indicated infection of the stent graft. The patient died due to sepsis caused by the graft infection.ConclusionStent graft placement for the treatment of hemorrhage of a pseudoaneurysm secondary to a postoperative pancreatic fistula, following pancreaticoduodenectomy, is an effective treatment option as it achieves immediate hemostasis and maintains end-organ perfusion. However, stent graft infection is the most detrimental complication.

A RARE COMPLICATION OF A COMMON PROCEDURE: PULMONARY ARTERY PSEUDOANEURYSM SECONDARY TO RIGHT HEART CATHETERIZATION

Pulmonary artery aneurysms and pseudoaneurysms are rare entities resulting from various etiologies including congenital, acquired and iatrogenic. Prompt recognition, diagnosis and treatment is required to reduce mortality. An 80 year old female presented for further evaluation of dyspnea two months

Percutaneous Endoscopic Treatment of Complicated Delayed Bleeding Postpercutaneous Nephrolithotomy: A Novel Suggestion.

Background: Delayed bleeding after percutaneous nephrolithotomy (PCNL), which may occur within the first 3 weeks postoperatively, is a life-threatening complication that may result from arteriovenous fistula and arterial pseudoaneurysm. Angioembolization is the standard treatment when these patients develop hemodynamic instability despite conservative measures. Contrast hypersensitivity and renal insufficiency, however, contraindicate angiogram and subsequent embolization; in these patients, alternative methods such as the one described in this study may help in resolving the renal hemorrhage. Case Presentation: In this case series, we report the effective management of post-PCNL hemorrhage with nephroscopy and nephrostomy and drainage and tamponade because angioembolization was not feasible. Conclusion: Delayed bleeding after PCNL may be managed conservatively with nephrostomy drainage and tamponade when angioembolization is not feasible.

Utility of ultrasound in acute pancreatitis.

Ultrasound plays an essential role in the initial evaluation of patients with suspected or confirmed acute pancreatitis. In addition to evaluation of the pancreatic parenchyma, ultrasound is used for assessment of the gallbladder, biliary tree, peripancreatic tissues, and regional vascular structures. While enlarged and edematous pancreas are classic sonographic features of acute pancreatitis, the pancreas may appear sonographically normal in the setting of acute pancreatitis. Nonetheless, sonographic evaluation in this setting is valuable because assessment for etiologic factors such as gallstones or evidence of biliary obstruction are best performed with ultrasound. Complications of pancreatitis such as peripancreatic fluid collections, venous thrombosis, or arterial pseudoaneurysm can be identified with careful and focused ultrasound examination. Knowledge of various scanning techniques can help to mitigate some of the commonly encountered barriers to sonographic visualization of the pancreas and right upper quadrant structures. Ultrasound can also be used for guidance of percutaneous treatment such as drainage of fluid collections or pseudoaneurysm thrombosis. Difficulty in differentiating edematous from necrotizing pancreatitis can be mitigated with the use of contrast-enhanced ultrasound to assess pancreatic parenchymal enhancement.

3002 Several Endoscopies Later, Hemosuccus Pancreaticus Comes to Light

INTRODUCTION: Hemosuccus pancreaticus (HP) is an extremely rare cause of upper gastrointestinal bleeding occurring in an estimated one in 1,500 cases. HP is believed to occur through a vascular malformation within the splenic artery leading to intermittent bleeding within the pancreatic duct. The most common causes of HP are due to chronic inflammatory changes from pancreatitis, pseudocysts, or pancreatic malignancy. HP is a challenging diagnosis due to intermittent bleeding, difficulty in localizing anatomical structures, and vague clinical symptoms. Clinically, patients present with vague abdominal pain and intermittent gastrointestinal bleeding not often visualized on EGD, which make diagnosis extremely challenging. Upper GI bleeding can have different etiologies, including but not limited to, peptic ulcer disease, varices, Mallory-Weiss tears, and angioectasis. A rare form of upper GI bleeding can be caused by HP, which is described as bleeding from the pancreatic duct via the Ampulla of Vater. Here we present a case of Hemosuccus Pancreaticus after ruling out common causes. CASE DESCRIPTION/METHODS: 45-year-old male with medical history significant for chronic pancreatitis complicated by enlarging pancreatic cysts and alcoholic cirrhosis, who presented with melena, left upper quadrant pain, and significant acute blood loss anemia. Patient had several admissions to our facility and underwent several endoscopic procedures without an obvious etiology. During endoscopy on his most recent admission, blood was seen oozing from the ampulla concerning for HP. Patient then had diagnostic angiography by IR notable for distal aneurysm formation communicating with the distal pancreatic duct. Once patient had been discharged, patient had another episode of syncope and was transferred to another facility where he had ultrasound-guided right common femoral artery arteriogram with subsequent coiling of a large pseudoaneurysm arising from the inferior pancreatic artery. DISCUSSION: Hemosuccus Pancreaticus is a rare entity but can be seen in patients with chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. HP occurs when a direct communication is formed between the pancreatic duct and a vessel after a pancreatic cyst or malignancy erodes into an arterial pseudoaneurysm. Given the fact that this diagnosis is rare and can be potential life-threatening with the rupture of the pseudoaneurysm, it is imperative for physicians to be familiar with the pathology, presentation, and appropriate management of HP.

The Evolution of Endovascular Management of Extracranial Carotid Artery Aneurysms and Pseudoaneurysms

Introduction: Extracranial carotid artery aneurysms and pseudoaneurysms (ECCAs) are rare pathologies with various etiologies, presentations, and management strategies. Historically, open aneurysm resection and arterial repair have been the gold standard management of ECCAs. Our study examines the evolving experience with endovascular management of ECCAs. Methods: We performed a literature review of multiple studies on endovascular and open management of carotid artery aneurysms and pseudoaneurysms. Conclusions: Endovascular stenting is technically feasible and clinically effective for the treatment of carotid artery aneurysms and pseudoaneurysms. Further follow-up is required regarding long-term safety and efficacy.

Outcomes of Ligation without Revascularization in Pseudoaneurysms of Peripheral Arteries in Intravenous Drug Users

Management of pseudoaneurysms in intravenous drug users is complex and challenging due to an associated infection and unavailability of autologous vein grafts. Here we observe the outcomes of ligation and local debridement as a primary modality of treatment in this subset of patients with pseudoaneurysms. This is a descriptive cross sectional study of 15 patients over a period of 4 years who presented with pseudoaneurysm of peripheral artery from intravenous drug use. In this study, we describe the presentations and management outcomes in 15 patients with peripheral arterial pseudoaneurysmfrom IV drug use. The most common site involved was common femoral artery among 12 (80%) patients followed by superficial femoral artery among 8 (13.3%) patients and external iliac artery in 1 (6.7%) patient. Twelve (80%) patients were having signs of infection. All patients underwent surgical intervention which comprised of excision of pseudoaneurysm and ligation of artery without revascularization among 12 (80%) patients and with revascularization with autologous venous graft among 3 (20%) patients. There was no mortality or a major bleeding requiring re-exploration. None of the patients developed limb ischemia necessitating amputation.One patient with femoral artery ligation without revascularization at one year of follow up is having claudication on brisk walking.There was one saphenous vein graft thrombosis in immediate postoperative period. With the use of ligation without revascularization technique, there was no mortality or major bleeding requiring re-exploration. None of the patients developed limb ischemia necessitating amputation so this treatment modality seems promising in treatment of pseudoaneurysms in intravenous drug users.