Peripancreatic pseudoaneurysms: a management-based classification system

Abstract

Background Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.MethodsA systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.ResultsThe demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60 %. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56 %) and hepatic failure (19 %). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.ConclusionThe management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Surgical Treatment of Splenic Artery Pseudoaneurysm with Digestive Tract Communication - Presentation of Two Cases

“…(2,9,11,18) Gambiez et al (19) presented in his study that the majority of his patients were surgically treated and no signs of recurrent bleeding were present after definitive pancreatic surgery. He also concluded that angiographic methods might associate other severe complications such as necrosis of the duodenum or the development of spleen abscesses.…”

“…A single procedure of embolization or stenting has a high rate of failure and often several attempts are done in order to completely manage the aneurysm. (2) These specialized procedures are highly dependent on the endowment of the medical facility in which the patient is treated. Ideally for the patient is to receive treatment in an angio-surgical-setting under general anesthesia.…”

“…Pang et al (2) classified peri-pancreatic pseudo-aneurysms in accordance with the type of artery involved, communication with gastrointestinal tract and exposure to pancreatic juices, in order to ease up proper management. (2) If the patient is stable and can be transported, definitive treatment must be applied in high-volume centers for pancreatic surgery because of better resources, higher expertise and better intensive care management. Here the patient can benefit from several types of treatment:…”

“…If the first episode is self-controlled the risk of recurrent bleeding is present and can occur days to years after the initial presentation. (2) Their optimal treatment is controversial and no consensus is present. Only small series of cases are described in literature so a standard way of treatment isn't described.…”

“…Selective trans-catheter arterial embolization and arterial stenting are modern ways of care but are these treatments of curative intent or a bridge therapy towards curative surgical treatment? (2) Case report 1 55 year-old male with childhood history of accidental swallowing of acid, type II diabetes with oral medication since 2012, and a known episode of acute pancreatitis in December 2015, is investigated in a territorial hospital for hematochezia. At that time the patient presented with a hemoglobin level of 7 g/dl, so vivid hematic resuscitation was initiated.…”