THE GREAT HOUDINI

Resident: Marc Lim, MD

Attending: Shekher Maddineni, MD

Program/Department: Westchester Medical Center/New York Medical College/Department of Radiology

CHIEF COMPLAINT & HPI

▪Chief Complaint and/or reason for consultation ▪GI bleed

▪History of Present Illness ▪43M w/pancreatic adenocarcinoma s/p Whipple (2 months prior), complicated by recurrent pancreatitis due to ductal occlusion, presenting with one episode of hematemesis. He reports fatigue and lightheadedness. He denies prior episodes of hematemesis but states that he had an episode of dark, foul-smelling stool earlier in the day.

RELEVANT HISTORY

▪Past Medical History ▪Pancreatic adenocarcinoma

▪HIV (1992)

▪Insulin-dependent diabetes mellitus

▪Past Surgical History ▪Whipple

▪L total hip arthroplasty (trauma)

▪R femur ORIF (trauma)

▪Family & Social History ▪Denies EtOH, illicit drugs

▪Otherwise noncontributory

▪Review of Systems ▪( + ) Melena, fatigue, abdominal pain

▪( _ ) BRBPR

▪Medications ▪Etravirine, Raltegravir, Maraviroc (HIV)

▪Insulin, Creon, Omeprazole, Atorvastatin, Percocet

▪Allergies ▪NKDA

DIAGNOSTIC WORKUP

▪Physical Exam ▪Vitals: HR 104; BP 126/94; RR 14; T 99F

▪( + ) Abdomen was diffusely tender to palpation, bowel sounds hyperactive; pallor

▪( _ ) Abdomen nondistended, nontympanic. No hemorrhoids

▪Laboratory Data

9.0 137 | 103 | 18 10.02 >--------< 154 INR: 1 -------------------< 127 27.0 3.3 | 26 | 1.0

▪Other ▪Endoscopy performed; blood is seen in the bowel the level of the gastrojejunostomy but a source cannot be identified

DIAGNOSIS

▪Upper GI bleed ▪Differential diagnosis

▪Pseudoaneurysm

▪Arterioenteric fistula

▪Marginal ulcer

▪Anastomotic breakdown

QUESTION SLIDE

1) Which of the following is true regarding splanchnic artery aneurysms and pseudoaneurysms?

A: They are commonly caused by inflammatory conditions or trauma.

B: Open surgery is the preferred treatment modality.

C: They can safely be managed by observation.

D: Coil migration is a common complication of transcatheter coil embolization.

CORRECT!

1) Which of the following is true regarding splanchnic artery aneurysms and pseudoaneurysms?

A: They are commonly caused by inflammatory conditions or trauma.

B: Open surgery is the preferred treatment modality. Transcatheter arterial embolization has a 90% success rate.

C: They can safely be managed by observation. With a 25% chance of rupture and a subsequent 25-75% chance of mortality, treatment is generally advised.

D: Coil migration is a common complication of transcatheter coil embolization. There are fewer than one dozen case reports of coil migration from visceral arteries.

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT!

1) Which of the following is true regarding splanchnic artery aneurysms and pseudoaneurysms?

A: They are commonly caused by inflammatory conditions or trauma.

B: Open surgery is the preferred treatment modality. Transcatheter arterial embolization has a 90% success rate.

C: They can safely be managed by observation. With a 25% chance of rupture and a subsequent 25-75% chance of mortality, treatment is generally advised.

D: Coil migration is a common complication of transcatheter coil embolization. There are fewer than one dozen case reports of coil migration from visceral arteries.

CONTINUE WITH CASE

INTERVENTION

▪GI angiography with embolization therapy as warranted

CELIAC ANGIOGRAM

▪Celiac angiogram with a large pseudoaneurysm originating from the right hepatic artery (arrow)

COMMON HEPATIC ANGIOGRAM

▪Common hepatic angiogram with a large pseudoaneurysm originating from the right hepatic artery (arrow)

▪Note contrast in the bottom right of the image; this is within a loop of bowel and indicates communication with the pseudoaneurysm (arrow)

PSEUDOANEURYSM CATHETERIZATION & COILING

▪3 coils are deployed with 0.1 mL thrombin with subsequent occlusion of the pseudoaneurysm. Note the right hepatic artery is still patent.

CLINICAL FOLLOW UP

▪Six weeks later, the patient returns with recurrent GI bleeding…

CELIAC ANGIOGRAM

▪Previously embolized pseudoaneurysm coils are no longer visualized.

RIGHT HEPATIC ANGIOGRAM

▪There are two branches of the right hepatic artery with abrupt termination of the inferior branch and associated pseudoaneurysm

RIGHT HEPATIC ARTERY COILING

▪Coil embolization with occlusion of the right hepatic artery

▪Reconstitution of the right hepatic artery via collaterals from the left hepatic artery.

▪Pseudoaneurysm is no longer visualized.

SUMMARY & TEACHING POINTS

▪Splanchnic artery aneurysms and pseudoaneurysms have a 25% risk of rupture

▪Rupture carries at 25-75% risk of mortality

▪Causes

▪Chronic pancreatitis

▪Trauma

▪Acute pancreatitis

▪Postoperative complications

▪Peptic ulcer disease

▪Transcatheter arterial embolization has a 90% success rate in treatment

▪Complications:

▪Bleeding

▪Pseudoaneurysm recurrence

▪Postembolization syndrome

▪Infarction

▪Coil migration

SUMMARY & TEACHING POINTS

▪Coil migration ▪Rare complication

▪Reduced by occluding the afferent and efferent normal artery rather than filling the pseudoaneurysm

▪Treatment strategies for migrated coils are case-specific

REFERENCES

▪Skipworth JR, Morkane C, Raptis DA, et al. Coil migration: a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms. Ann R Coll Surg Engl. 2011;93:e19–e23.

▪Golzarian J, Nicaise N, Devière J, et al. Transcatheter embolization of pseudoaneurysms complicating pancreatitis. Cardiovasc Intervent Radiol.1997;20:435–440.

▪Pasha SF, Gloviczki P, Stanson AW, Kamath PS. Splanchnic artery aneurysms. Mayo Clin Proc. 2007;82:472–479.

▪Han YM, Lee JY, Choi IJ, et al. Endoscopic removal of a migrated coil after embolizatino of a splenic pseudoaneurysm: A case report. Clin Endosc. 2014; 47(2): 183-187.