Vascular complications of chronic pancreatitis and its management

Table 5 Studies showing types of intervention and its outcomes in patients with chronic pancreatitis with pseudoaneurysms

Ref.	Patients	Presentation	Intervention for PsA	Outcomes	Complications
Bergert et al[86], 2004	Chronic pancreatitis: 541. Bleed: 36	Acute bleed with haemorrhagic shock: 10/36 (27.7%). GI bleed: 12 (33.3%). Acute severe abdominal pain: 12 (33.3%)	PsA: 25/36 (69.4%). Angioembolization: 9(47%). Surgery: 16 (53%)	Higher rebleeding rate after surgery (25% vs 11% after embolization)	Deaths after surgery: 2. Deaths after embolization: 1
				On follow-up, one patient presented with a left hepatic artery PsA 18 mo post embolization of the gastroduodenal artery	Hospital mortality determinants: Haemorrhagic shock and amount of blood transfusion required
Balachandra et al[89], 2005	Total PsA: 214. Spontaneous: 160. Postoperative: 40. CP: 40. Pseudocyst: 135. AP: 39	GI bleed: 147 (69%). Intra-abdominal bleed: 30 (14%)	Angiographic embolization attempted: 115 (66%). Successful: 85 (74%). Surgery: 62 (30%)	Among angiography group: 55 (37%) had subsequent surgery; 94 (63%) underwent embolization. In 30 (48%) of the 62 patients undergoing surgery as first intervention require: Angiography: 21/30; re-operation: 9/30	-
Hsu et al[90], 2006	CP with PsA-9	-	Arterial embolization: 5. Surgical intervention: 9	Success rates: Embolization: 20% (1/5). Surgery: 88.9% (8/9)	Mortality: Surgery (0). Post embolization [1 (sepsis)]
Zyromski et al[61], 2007	PsA: 24 in pancreatitis. Acute on chronic pancreatitis: 22 (91.6%). Acute pancreatitis: 2 (8.6%). Most common etiology: Alcohol (79%)	GI bleed: 7 (29%). Increasing abdominal pain: 15 (62%)	Coil embolization: 23. Covered stent: 1	Repeat embolization: 1	-
Udd et al[81], 2007	Chronic pancreatitis: 745. PsA: 33	GI bleed: 17. Abdominal pain: 22. Bleeding confined to the pseudocyst: 9 (27%). Peritoneal bleed: 5 (15%). Retroperitoneal bleed: 3 (9%)	Angioembolization attempted: 23/33 (70%). Technical failure: 7 cases. Vessel not visualized: 3. Surgery: 4/5 cases with bleeding into the peritoneal cavity	Angioembolization success rate: 22/33 (67%). Re-embolization for recurrent bleed: 3. Success rate: 16/20 (80%) when the pseudocyst in head region and 50% when splenic artery was the source of bleed. Follow-up of surgical cases (14 mo): no rebleed or surgical intervention	4 complications in the embolization procedure: Coil pushed to the MPD: 1 (endoscopically removed); dissection of the bleeding artery: 1; coil pushed into the iliac artery: 1; PsA at inguinal puncture: 1; mortality: 1
Tulsyan et al[91], 2007	Visceral aneurysms: 90. PsA: 28	-	Coil embolization: 96%. N-butyl-cyanoacrylate (glue): 19%	Endovascular treatment technically successful: 98%. Secondary interventions for persistent flow: 1. Recurrent bleeding from previously embolized aneurysms: 2	Postembolization syndrome developed: 3 (6%). 30-d mortality: 4 (8.3%)
Kim et al[92], 2015	Total cases: 37. Chronic pancreatitis: 31	-	41 procedures. Transcatheter embolization: 39 (95.1%). Stent-grafts: 2	Successful haemostasis: 34 (91.9%). Rebleed: 2 (treated by reintervention)	Focal splenic infarction: 8. Splenic abscess: 3 (2/3 died from sepsis)
Zabicki et al[55], 2018	Chronic pancreatitis with PsA: 15	-	Microcoils: 5. Bovine thrombin: 5. Squid embolization: 1. Stent graft: 1. Coil + vascular plug: 1. Thrombin and coil embolization with splenectomy: 1. Squid embolization with splenectomy: 1	Complete exclusion of PsA from systemic circulation: 14/15(93.3%). Reintervention: 1. No recanalization at the follow-up CT after 1 to 3 wk	Splenic ischemia requiring splenectomy: 2 cases. No mortality at 30 d
Mallick et al[88], 2019	Chronic pancreatitis: 380	PsA: 27	Endovascular coiling: 13 (48.2%). Endovascular glue: 3 (11.1%). Endovascular coiling + glue: 1 (3.7%). Percutaneous thrombin injection: 8 (29.6%). Conservative management: 1 (3.7%). Surgery: 1 (3.7%)	Technical success of embolization: 17/21 (80.9%). Clinical success of embolization: 16/17 (94.1%). Rebleed: 4 (14.8%)	Major complications of embolization: 1 (3.7%). Death: 1 (3.7%)
Madhusudhan et al[68], 2021	56 patients of chronic pancreatitis with 61 PsAs	Upper GI bleed: 40/56 (71.4%)	Embolization: 59/61 lesions. Technical success rate: 96.7%. Clinical success rate: 83.9%	Recurrent bleed: 9 (16.1%) (stopped spontaneously in 6/7, one expired). 49 patients followed up for a mean duration of 24.1 mo. Late recurrence of bleeding from a different artery- 4 patients (mean duration of 5.4 mo)	Major complications: 6 (10.7%). Splenic infarcts: 2/6. Splenic abscesses: 4/6
			Agents used for obliteration: Coils: 24; glue: 15; coils + glue: 15; gel foam: 2; others: 3		Minor complications: Abdominal pain: 5 (8.9%); mortality rate: 1/56 (1.8%)
Dhali et al[93], 2022	26 patients with CP with PsA	Upper GI bleed: 25 (96%). Incidental detection: 1 (4%)	Embolization: 11 (42%). Coil embolization: 10 (91%), followed by injection of glue in one patient (9%). Surgery: 20 (77%) including 5 patients after failed embolization	Embolization failed: 3 (27%). Rebleed from embolised PsA: 2 (18%). Over a median follow-up of 24 (6-122) mo, none had rebleed	Embolization-induced complications: 4/11 (36%). Colonic ischemia: 1. Splenic infarct: 1. Splenic abscess: 1. Acute renal failure: 1. The most common postoperative complication was wound infection followed by pancreatic fistula. No procedure-related death

AP: Acute pancreatitis; CP: Chronic pancreatitis; CT: Computed tomography; GI: Gastrointestinal; MPD: Main pancreatic duct; PsA: Pseudoaneurysm.