Large Pseudoaneurysm Research Articles

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.

Interventional Closure of a Large Pseudoaneurysm of the Ascending Aorta in a Patient after Lung Transplantation

Pseudoaneurysm of the ascending aorta is a rare but life-threatening complication in patients undergoing cardiac surgery.1 Surgical repair of pseudoaneurysms remains the standard treatment. Nevertheless, for patients with extensive aneurysms, urgent indication or renal failure, surgical therapy comes with a high perioperative morbidity and mortality.2 Interventional occlusion of the aneurysmal sac may represent an alternative therapy for inoperable patients.

Hemobilia: an unusual and life threatening complication of laparoscopic cholecystectomy

Hemobilia though rare, occurs due to abnormal vascular and biliary communication established as a result of trauma, gallstones, neoplasms, inflammatory process and vascular disorders. It can rarely complicate a laparoscopic cholecystectomy as a result of hepatic artery injury, clip migration, clip erosion, diathermy and subsequent arteriobiliary fistula, or pseudoaneurysm eroding into the extra hepatic bile ducts. A 34 years female underwent laparoscopic cholecystectomy for cholelithiasis, suffered bile leak that settled on by 13th postoperative day, met with sudden right upper abdominal pain and hypovolemic shock on 15th postoperative day due to massive hemobilia arising out of rupture of pseudoaneurysm of the right hepatic artery into the biliary system. Urgent CT Angiography showed a large pseudoaneurysm of right hepatic artery branch with adjacent small collection, IHBR and CBD dilatation suggestive of hemobilia. Emergency CT guided trans-arterial hepatic artery embolization done to control hemobilia and save the patient. An immediate CT angiography for early diagnosis, in all postoperative laparoscopic cholecystectomy cases with suspicion of hemobilia due to an underlying hepatic artery pseudoaneurysm, followed by CT guided trans-arterial hepatic artery embolization forms the gold standard management in such patients.

Lessons learned from clinical outcome and tumor features of patients underwent selective artery embolization due to postoperative bleeding following 2076 partial nephrectomies: propensity scoring matched study.

To evaluate the clinical and tumor characteristics in patients undergoing selective artery embolization (SAE) for bleeding after partial nephrectomy (PN). We retrospectively evaluated patients who underwent SAE from 2076 patients who underwent PN. The clinical and tumor characteristics of these patients were analyzed using entire data and propensity score matching (PSM). 76 patients who underwent PN (control, n = 38 patients; SAE, n = 38) were enrolled in PSM. SAE was performed in 41 patients who underwent open (19/1171), laparoscopic (4/60), and robot-assisted PN (18/845). The median period from PN to SAE was 12days (interquartile range 8-24day). The most common symptom of 31 (75.61%) patients was gross hematuria, followed by flank pain (3/41). Follow-up imaging revealed large pseudoaneurysm in 7 asymptomatic patients. The main reason for SAE on angiography was pseudoaneurysm (32/41), followed by arteriovenous fistula (5/41). Technical and clinical success was achieved in all patients. There was no statistical difference in the estimated glomerular filtration rate after 1year, surgical methods, or baseline characteristics between the two groups. Conversely, there was statistically significant difference in ischemic time in the entire data and PSM. In the embolization group, renal masses showed statistically significant endophytic (p = 0.006) and posterior (p = 0.028) characteristics. SAE is an effective method for controlling postoperative bleeding while preserving renal function after PN. And, we suggest more attentive postoperative surveillance about vascular complications in patients with longer ischemia time or renal masses with endophytic and posterior locations.

Umbilical artery catheter, aortic dissection, carotid cannulation, and pseudoaneurysm in a neonate: A tale of propagating pathology

Arterial dissections are uncommon in neonates. Complications include thrombosis, bleeding, dissection, aneurysm and pseudoaneurysm. We report an unusual case of multisite pathology (dissection and pseudoaneurysm) following common vascular interventions. A term neonate with antenatal diagnosis of congenital heart block secondary to maternal lupus deteriorated clinically at 5 days of life. He was found to have an abdominal aortic thrombus secondary to abdominal aortic dissection, following umbilical arterial catheter placement. Attempted percutaneous treatment was complicated by dissection of the left common carotid artery and formation of a large pseudoaneurysm. Neonatal lupus is associated with weakened vessel wall which may be vulnerable to injury from line placement and endovascular interventions. Various options are available to manage arterial dissection, thrombus, and pseudoaneurysm, but consequences of these options need to be carefully weighed to minimize further complications.

Giant left ventricular pseudoaneurysm: a rare acute complication of radiofrequency catheter ablation for premature ventricular contraction

BackgroundRadiofrequency catheter ablation is approved effective therapy for premature ventricular contraction. However, the rare but serious complication such as pseudoaneurysm should be given more attention. It is life-threatening due to the high risk of rupture. Only few cases have been reported in the literature. We herein report a huge acute left ventricular pseudoaneurysm after catheter ablation therapy.Case presentationA 69-year-old man underwent radiofrequency catheter ablation for premature ventricular contraction at a local hospital. The patient developed shock the second day after ablation. A chest computed tomography (CT) scan showed pericardial effusion. Pericardiocentesis was performed, and the puncture fluid was a bloody pericardial effusion. The transthoracic echocardiogram revealed an 9- × 4-cm giant pseudoaneurysm with a cystic structure in the left ventricular inferior wall near the mitral annulus along the left atrium. The pseudoaneurysm was connected to the left ventricular cavity through a 8-mm neck, and the lumen was filled with systolic and diastolic blood flow. The patient underwent three-dimensional transesophageal echocardiography. The pseudoaneurysm and the tract was clearly visible. Emergency surgery was performed to resect the pseudoaneurysm. A bovine pericardial patch was placed on the neck of the pseudoaneurysm. Echocardiographic examination confirmed the absence of cardiac lesions after the operation.ConclusionsIt is rare to see such a large pseudoaneurysm after radiofrequency catheter ablation. Clinicians should be allert to the potential risks to patients in the process of an effective treatment. Echocardiography plays an important role in the prompt diagnosis and prognosis of this disease. Emergency surgery is a better method for treatment of huge pseudoaneurysm.

Large left ventricular apical pseudoaneurysm: a multimodal imaging approach guiding successful diagnosis and surgical management.

Large left ventricular apical pseudoaneurysm: a multimodal imaging approach guiding successful diagnosis and surgical management.

Iatrogenic giant left anterior descending coronary artery pseudoaneurysm with contained perforation following percutaneous coronary intervention

Giant iatrogenic coronary pseudoaneurysms are very rare. Left untreated, they may cause serious adverse outcome. We present a case of a male patient with recurrent NSTEMIs and coronary interventions who developed a large LAD artery pseudoaneurysm with contained rupture. He underwent excision of the large proximal LAD pseudoaneurysm, excision of the previous LAD stent, ligation of proximal LAD, and coronary artery bypass grafting with LIMA-LAD graft. He subsequently recovered and was stable on follow up. In conclusion, an aggressive surgical strategy, though difficult, is likely the best means of management for lasting benefit.

A dreadful complication of peritonsillar abscess drainage managed endovascularly

A 11 year female presenting with sorethroat and diagnosed as peritonsillar abscess ,drained outside under aseptic precautions lead to bleeding, later presented with hemiparesis with DSA revealing a large pseudoaneurysm formation in ipsilateral carotid with patchy infarcts on CT. At emergency repeat bleeding occurred and patient started deteriorating following which the patient was managed by endovascular parent vessel occlusion following which she recovered gradually with regaining normal strength in paretic limbs within a few days . The case highlights the dreadful complication of peritonsillar abscess drainage as well as its endovascular management.

Large Traumatic Skull Base Internal Carotid Artery Pseudoaneurysm managed With Endovascular Flow Diversion: 2-Dimensional Operative Video.

We present a case of a traumatic skull base internal carotid artery (ICA) pseudoaneurysm treated with endovascular flow diversion stenting. The patient was a 27-year-old male who was involved in a motorcycle accident suffering multiple traumatic injuries including a large skull base fracture that extended through the carotid canal. Computed tomography angiography revealed a 2-cm right ICA pseudoaneurysm. Once the patient was stable, a digital subtraction angiography demonstrated enlargement of the pseudoaneurysm. After his other injuries were addressed by trauma and orthopedic surgery, at day 9 after his initial injury, the patient was loaded with aspirin and clopidrogel in preparation for stent reconstruction of his ICA injury. Under conscious sedation and systemic heparinization, the patient underwent endovascular reconstruction of the large pseudoaneurysm using telescoping flow diversion stents. Immediate intra-aneurysm flow stasis was observed. No procedure-related complications occurred. The patient did well and at last follow-up remained neurologically intact.

An Odd Case of Melena: Chronic Celiac Artery Dissection and Hepatic Arterioduodenal Fistula

AbstractWe present the case of a 54-year-old chronic alcoholic man who presented to the emergency department with intermittent melena for 3 days. Imaging revealed a large dissecting pseudoaneurysm of the common hepatic artery with an arterioduodenal fistula in the second part of the duodenum. The pseudoaneurysm and fistula were managed with refined interventional techniques, and supply to the hepatic arteries was salvaged. In cases of melena that are difficult to diagnose through traditional means, early imaging and interventional management can prove beneficial and improve short-term survival.

Repeated Percutaneous Thrombin Injections as Treatment of a Large Iatrogenic Pseudoaneurysm in the Artery Supplying a Haemodialysis Arteriovenous Fistula

Repeated Percutaneous Thrombin Injections as Treatment of a Large Iatrogenic Pseudoaneurysm in the Artery Supplying a Haemodialysis Arteriovenous Fistula

A Pseudo to Pseudo Connection: Pseudoaneurysm Draining Into the Pseudocyst

Pseudohemobilia or Hemosuccus Pancreaticus (HP) is a rare cause of gastrointestinal (GI) bleeding from an aneurysm of peripancreatic vessels that ruptures into a pancreatic pseudocyst, and blood travels through the pancreatic duct as a conduit entering the GI tract through the ampulla of Vater. We are highlighting a case of a 65-year-old female with past medical history of chronic pancreatitis who presented with multiple episodes of dark tarry stools for one day. Her vitals were stable and systemic examination was unremarkable. Laboratory evaluation was only significant for a hemoglobin of 6.7mg/dl and Doppler ultrasound of the abdomen revealed a 8.3 cm ovoid echogenic structure in the midline near the superior mesenteric artery with bidirectional flow suggesting a pseudoaneurysm raising suspicion for communication with pseudocysts. Contrast-enhanced CT showed multiple pancreatic pseudocysts connecting with a large 7.9 x 7.5 cm pseudoaneurysm close to the pancreatic head. (Figure 1) Emergent angiography was done revealing a large pseudoaneurysm arising from the middle part of the gastroduodenal artery with contrast extravasation into pseudocyst depicting active hemorrhage. (Figure 2) The pseudoaneurysm was embolized by microvascular plug (MVP) devices. Post-embolization angiogram showed preservation of hepatic arterial supply and patent portal vein with good flow towards the liver. (Figure 3) Sandblom first coined the name “hemosuccus pancreatitis” in 1970. (1) It's a rare and potentially lethal cause of GI bleed found mostly in men. (2) Most common cause of HP is the chronic recurrent pancreatitis resulting in pancreatic pseudocysts formation. (3) Pseudocyst induced pressure necrosis and autodigestion by pancreatic enzymes from repeated episodes of pancreatitis weaken the surrounding vessel walls and result in the formation of the pseudoaneurysms. (3) Rupture of these pseudoaneurysms into pseudocysts or sometimes directly into the pancreatic duct heralds GI bleed. This poses a diagnostic and management challenge due to the novelty of the condition and difficulty of diagnosing it with endoscopy because of the intermittent nature of the bleeding. Angiography is considered to be the gold standard as it not only serves a diagnostic role but also as a therapeutic modality. (4) Physicians should keep a high index of suspicion for HP in high-risk patients with a normal endoscopy.1359.tif Figure 1: Contrast-enhanced CT scan of the abdomen reveals a 7.9 x 7.5 cm mass adjacent to the pancreatic head. High-density area(arrow) corresponds to active hemorrhage in the pseudoaneurysm.

All That Bleeds! Visceral Artery Pseudo Aneurysm as a Rare Cause of Recurrent Fresh Gastrointestinal Bleeding

Visceral artery aneurysm and pseudoaneurysm are rare with incidence of 0.1-2%.We report a case of pancreato-duodenal artery pseudoaneurysm presenting as recurrent upper and lower GIB. CASE PRESENTATION: A 57 year old male with past history of COPD, hypertension, GERD, chronic hepatitis C,and alcohol abuse, presented with diffuse abdominal pain.His symptoms started nearly two weeks prior with hematemesis and lower GIB. An upper endoscopy and colonoscopy failed to identify source of bleeding.Two days later he had another episode of fresh upper and lower GI bleeding. Repeat endoscopy revealed no source.On third occassion patient reported diffuse abdominal pain, followed by mild nausea,vomiting and large amount of fresh blood hematemesis and bleeding per rectum. Abdominal CT angiogram revealed acute on chronic pancreatitis, atrophy of pancreatic body and multiple pseudocysts.A 4.6x3.2 cm pseudoaneurysm anterior to splenic artery anatomically was located in close proximity to posterior gastric wall with possible erosion. During endovascular repair a small branch of gastro-duodenal artery was identified as vessel of origin. Multiple micro-catheter coils were used to fill and obliterate the sac and feeding vessel. At six month follow up pseudoaneursym was stable on imaging. DISCUSSION ETIOLOGY: True aneurysms are caused by hypertension, atherosclerosis,and connective tissue disease.Two-thirds of VAPA are secondary to pancreatitis and leaking of proteolytic enzymes.PRESENTATION:Most cases present with vague abdominal symptoms.If ruptured, patients present with anemia and hemodynamic instability.DIAGNOSIS:Color Doppler can display inflow and outflow of blood in sac, known as “yin-yang sign”.Transcatheter angiography remains gold-standard for diagnosis as it can provide definitive diagnosis, has highest sensitivity (100%) and therapeutic potential.TREATMENT: Treatment is indicated if a visceral aneurysm size is >2cm. Women of child bearing age or pregnant should also undergo treatment.A pseudoaneurysm must be treated immediately as rate of expansion is much rapid(76.3% vs 3.1%). Treatment options include endovascular(stent,embolization),percutaneous thrombin injection,and surgery(vessel ligation,arterial bypass,sac exclusion). CONCLUSION:This case reports highlights importance of including VAA and VAPA in differential diagnosis of GI bleeding and use of alternative diagnostic modalities when endoscopy and colonoscopy fail to reveal a source of bleeding.1954_A Figure 1. Non contrast CT Abdomen showing extensive pancreatic destruction1954_B Figure 2. Contrast enhanced CT showing a large pseudoaneurysm in proximity of posterior gastric wall1954_C Figure 3. Intra operative angiogram before and after the endovascular repair.

Is Expanding Heart Always Serious?

Left Ventricular Pseudo Aneurysm (LVPA) is a rare complication occurs in population that carries the risk. Clinical presentation of a large LVPA can be variable which make the diagnosis challenging. Given the high risk of death in such cases, high clinical suspicion in addition to the use of proper diagnostic modality may reduce the mortality rate & guide the management decision. Echocardiogram is considered the proper investigation tool to screen, diagnose the presence of LVPA & identify the high-risk feature of rupture. In this review will present catastrophic echocardiographic features in unusual clinical case presentation of a patient with large LV pseudo aneurysm presented with ischemic stroke & background of diabetes & hypertension.

Treatment of large renal allograft arterial pseudoaneurysm with in situ cold perfusion, ex vivo vascular reconstruction and reimplantation

Background: Pseudoaneurysm after renal transplantation is a rare but serious complication. Case Presentation: We report a case of a 76-year-old man who presented six weeks after kidney transplant with a large pseudoaneurysm arising from the renal artery anastomosis, causing renal vein compression and renal allograft dysfunction. Prior to the removal of the transplanted kidney, an in situ cold perfusion of the allograft was performed. The pseudoaneurysm was repaired ex vivo and the renal artery was reconstructed. External iliac vein was reconstructed with deceased donor interposition allograft, and the kidney was then re-implanted. The patient recovered with immediate allograft function. Conclusions: Successful surgical management of a large renal allograft arterial pseudoaneurysm involves avoidance of dissection of the pseudoaneurysm, utilization of in situ cold perfusion and en-bloc removal of the kidney together with pseudoaneurysm, and pseudoaneurysm incision and vascular bypass reconstruction ex vivo

Spontaneous Fatal Rupture of a Large Pseudoaneurysm within a Renal Angiomyolipoma following Incomplete Embolization in a Patient with Bilateral Renal Angiomyolipomas

Angiomyolipoma (AML)—a frequently seen solid renal tumor—is the most common benign tumor of the kidney. It was considered to be hamartomatous in origin and is now considered to be a member of the family of perivascular epithelioid cell (PEComa).[1] Classically thought to be associated with tuberous sclerosis that is an autosomal dominant disease with TSC1 or TSC2 gene mutation, around 80% AMLs may present sporadically.[1] They are also seen in patients with lymphangiomyomatosis and included in its diagnostic criteria.[2] Clinically, the tumor has myriad of presentations ranging from being completely asymptomatic at the time of diagnosis to abdominal pain, hematuria, recurrent urinary tract infection, and intratumoral bleed that can be occasionally massive requiring urgent embolization or nephrectomy.[3] On ultrasound AMLs appear as markedly hyperechoic to hypoechoic depending on the fat content. Though they are more frequently echogenic compared with renal cell carcinoma, overlap in imaging features can occur.[4] On color Doppler, pseudoaneurysms are seen as anechoic structure showing internal turbulent to-and-fro motion.[5] On computed tomographic (CT) scan, the diagnosis of renal AML depends on the detection of intralesional fat.[6]

Initial non-contrast scan at time of admission shows large pseudoaneurysm at the arch proximal to stent graft

Initial non-contrast scan at time of admission shows large pseudoaneurysm at the arch proximal to stent graft

A patient with lower gastrointestinal bleeding: common history, very uncommon cause, minimally invasive treatment

An 81-year-old patient with significant cardiac comorbidities, a history of sigmoid resection 6 years ago, and iliac bypass surgery 19 years ago presented with mild hematochezia for the previous 3 days. While hemodynamically stable at first, he developed massive bleeding during preparation for colonoscopy and underwent a short course of cardiopulmonary resuscitation. Colonoscopy revealed no active bleeding but a protuberance of the colonic wall and a coagulation clot. In ultrasonography immediately after endoscopy, a large aneurysm was diagnosed and diagnosis of an iliaco-colonic fistula was assumed. CT scan demonstrated a large pseudoaneurysm of the distal anastomosis after iliaco-iliac bypass. With endovascular treatment, the original lumen of the iliac artery could be recanalized, and 2 covered stents were placed to cover both anastomosis of the prosthetic bypass leading to a complete shutdown of bypass perfusion. A double-barreled transversostoma was established to minimize contamination of the aneurysmal sac. Seven months after these procedures, the patient is well and free of infection.Though aorto- or iliaco-colonic fistula after aortic or iliac surgery are very rare, endoscopists should be aware of their possibility. A high index of clinical suspicion in patients with prior abdominal vascular bypass surgery should prompt rapid imaging studies, possibly before endoscopy. In critically ill patients, endovascular treatment may be a suitable alternative and result in a favorable outcome.

Aortoesophageal fistula and arch pseudoaneurysm after removing of a swallowed chicken bone: a case report of one-stage hybrid treatment

BackgroundAortoesophageal fistula (AEF) and arch pseudoaneurysm are rare complications induced by a foreign body, and considerable controversy remains regarding the appropriate management strategies. We herein report a successful one-stage hybrid treatment in a patient with AEF and arch pseudoaneurysm.Case presentationThe patient, a 40-year-old man, presented to the emergency room because of intense retrosternal discomfort for 3 days and hematemesis for 3 h. The esophagoscopy and thoracic enhanced computed tomography (CT) showed two irregular mural ulcers in the esophagus and a large saccular pseudoaneurysm at the aortic isthmus, respectively. The laboratory examinations confirmed no widespread inflammation and infection. We have successfully performed a successful one-stage hybrid treatment for this patient. Six-month follow-up shows the patient is in good condition and the esophagoscopy reveals the two mural ulcers had completely healed.ConclusionThe treatment decision-making process should depend upon the patients’ specific situations. Our case suggest the one-stage hybrid treatment could be an valuable alternative in some selected patients.