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©The Author(s) 2023.
World J Gastrointest Surg. Aug 27, 2023; 15(8): 1574-1590
Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1574
Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1574
Table 1 Frequency and risk factors of vascular complications in patients with chronic pancreatitis in different studies
| Ref. | Number of patients (vascular complications/total CP patients) | Vascular complications | Risk factors |
| Udd et al[81], 2007 | 33/745 (4.4%) | PsA: 33 (4.4%) | - |
| Agarwal et al[20], 2008 | 34/157 (21.6%) | Splenic vein thrombosis: 34 (21.6%) | Pseudocyst (OR = 4.01) |
| Pandey et al[23], 2019 | 37/187 (19.7%) | Splenic vein thrombosis: 37 (19.7%) | Smoking (OR = 3.021). Pseudocyst (OR = 3.743) |
| Anand et al[21], 2020 | 166/1363 (12.2%) | Venous thrombosis: 132 (9.6%). PsA: 17/166 (1.24%). Both: 17 (1.24%) | Venous thrombosis: Alcohol (OR = 2.1); pseudocyst (OR = 4.6); inflammatory head mass (OR = 3.1). Pseudoaneurysms: Alcohol (OR = 3.49); pseudocyst (OR = 3.2) |
| Ru et al[22], 2020 | 89/3358 (2.6%) | Splenic vein thrombosis: 89 (2.6%) | Alcohol (OR = 1.28). History of AP (OR = 2.56). Diabetes mellitus (OR = 3.82). Pseudocyst (OR = 8.54) |
| Vujasinovic et al[17], 2021 | 33/394 (8.37%) | Venous thrombosis: 30 (7.6%). PsA: 3 (0.8%) | Alcohol (HR = 3.56). Pseudocyst (HR = 8.66) |
Table 2 Studies showing the frequency and site of venous thrombosis in chronic pancreatitis
| Ref. | Venous thrombosis | Distribution |
| Bernades et al[85], 1992 | 35/266 (13%) | SVT: 22 (8%) |
| PVT: 4% (10%) | ||
| SMVT: 3(1%) | ||
| Heider et al[28], 2004 | Venous thrombosis with chronic pancreatitis: 53 | SVT: 34 (64.3%) |
| SVT and SMVT: 10 (18.7%) | ||
| SVT and PVT: 3 (5.7%) | ||
| SVT, SMVT and PVT: 6 (11.3%) | ||
| Anand et al[21], 2020 | 149/1363 (10.9%) | SVT: 95 (63.8%) |
| PVT: 29 (19.4%) | ||
| SVT and PVT: 25 (16.8%) | ||
| Vujasinovic et al[17], 2021 | 30/394 (7.6%) | PVT: 2/30 (6.7%) |
| SVT: 16/30 (53.3%) | ||
| MVT: 1/30 (3.3%) | ||
| PVT and SVT: 3/30 (10.0%) | ||
| PVT and MVT: 2/30 (6.7%) | ||
| MVT and SVT: 4/30 (13.3%) | ||
| SVT, PVT, and MVT: 2/30 (6.7%) |
Table 3 Clinical consequences of venous thrombosis in patients with chronic pancreatitis in different studies
| Ref. | Varices | Splenomegaly | Clinical presentation |
| Bernades et al[85], 1992 (n = 266) | Esophageal: 2 (5%). Gastric: 4 (10%) | - | Hematemesis: 1. Melena: 1 |
| Sakorafas et al[29], 2000 (n = 34) | Gastroesophageal: 12 (35%) | - | Variceal bleed: 6/34 (17.6%) |
| Heider et al[28], 2004 (n = 53) | Overall gastroesophageal varices: 41/53 (77%). On CT: 40/53 (75.4%). On EGD: 11/36 (30.5%). Both CT and EGD: 10/36 (27.7%) | - | Gastric variceal bleed: 2 (4%) |
| Agarwal et al[20], 2008 (n = 34) | Varices: 11 /34. Gastric: 7/11 (64%). Esophageal: 4/11 (36%) | 13/34 (38%) | Variceal bleed: 5/34 (15%). Gastric variceal bleed: 3/5 (60%). PHG bleed: 2/5 (40%) |
| Pandey et al[23], 2019 (n = 157) | IGV: 7 (18.9%). GOV: 1 (2.7%) | - | Upper GI bleed: 7 (18.9%). Gastric variceal bleed: 3 (8.1%). Nonvariceal: 4 (10.8%) |
| Ru et al[22], 2020 (n = 3358) | Gastric: 45/89 (50.6%) | 50/3358 (1.5%) | Variceal bleed: 17/89 (19.1%). Melena: 13 (76.5%). Hematemesis: 10 (58.8%). Both: 8 (47%) |
| Anand et al[21], 2020 (n = 1363) | 43/149 (28.9%) | 27/149 (18.1%) | GI bleed: 21/149 (14.1%) |
| Vujasinovic et al[17], 2021 (n = 394) | 3/30 (10%) | 6/30 (20%) | GI bleed: 0/30. Intraabdominal bleed: 0/30 |
Table 4 Studies showing sites and clinical manifestations of arterial pseudoaneurysms in patients with chronic pancreatitis
| Ref. | Vascular complications | PsAs | Site- artery involved | Clinical presentation |
| Bergert et al[86], 2004 | 36/541 | 25/36 | Splenic: 8/25 (32%). Pancreaticoduodenal (superior or inferior): 7/25 (28%). Gastroduodenal: 4/25 (16%). Superior mesenteric: 2/25 (8%). Jejunal branches: 2/25 (8%). Left gastric: 1/25 (4%). Right colic: 1/25 (4%) | Acute abdominal pain: 12 (48%). Haemorrhagic shock: 10 (40%). Acute upper GI bleed: 9 (36%). Acute lower GI bleed: 3 (12%). Chronic anaemia: 3 (12%). Acute on chronic pancreatitis: 5 (20%) |
| Udd et al[81], 2007 | 33/745 | 33 | Gastroduodenal/pancreaticoduodenal: 19 (58%). Splenic or its branches: 14 (42%) | Abdominal pain: 22 (66.6%). GI bleed: 17 (51%) |
| Sethi et al[87], 2010 | Chronic pancreatitis with PsA: 16 | 16 | Splenic: 7 (43.7%). Hepatic: 3 (18.75%). Gastroduodenal: 2 (12.5%). Right gastric: 2 (12.5%). Left gastric: 1 (6.25%). Pancreaticoduodenal: 1 (6.25%) | Intraabdominal bleed: 2 (13%). GI bleed: 8 (50%). Occult bleed: 10 (63). Pain: 14 (88) |
| Mallick et al[88], 2019 | 27/380 | 27 | Gastroduodenal: 13 (48.2%). Splenic: 10 (37.1%). Superior mesenteric: 2 (7.4%). Left gastric: 1 (3.7%). Inferior pancreaticoduodenal: 2 (7.4%) | Hematemesis: 6/27 (22.2%). Melena: 17/27 (63.0%). PCD bleed: 1/27 (3.7%) |
| Zabicki et al[55], 2018 | Chronic pancreatitis with PsA: 15 | 15 | Splenic: 7/15 (46.7%). Common hepatic: 2/15 (13.3%). Right gastroepiploic: 2/15 (13.3%) | - |
| Anand et al[21], 2020 | 166/1363 (12.2%) | PsA: 34/1363 (2.5%). PsA alone: 17 (50%). PsA with VT: 17 (50%) | Splenic: 25/33 (75.7%). Gastroduodenal: 6/33 (18.2%). Inferior pancreatico-duodenal: 1/33 (3.0%). Left gastric: 1/33 (3.0%) | GI bleed: 22/34 (64.7%) |
| Vujasinovic et al[17], 2021 | 33/394 | 3/394 (0.8%) | Splenic: 2/3 (66.7). Left gastric: 1/3 (33.3) | Incidental finding: 3/3 (100%). Intraabdominal bleeding: 0/3 (0%) |
| Madhusudhan et al[68], 2021 | 56 patients of chronic pancreatitis | PsA: 61 | Splenic: 31/56 (55.3%). Gastroduodenal: 18/56 (32.1%). Inferior pancreaticoduodenal: 1/56 (1.7%). Colic: 1/56 (1.7%). Hepatic: 4/56 (7.1%). Left gastric: 5/56 (8.9%) | Upper GI bleed: 40/56 (71.4%). PCD bleed: 1/56 (1.7%). Pain: 4/56 (7.14%). Incidentally detected on imaging: 11/56 (19.6%) |
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 |
- Citation: Walia D, Saraya A, Gunjan D. Vascular complications of chronic pancreatitis and its management. World J Gastrointest Surg 2023; 15(8): 1574-1590
- URL: https://www.wjgnet.com/1948-9366/full/v15/i8/1574.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v15.i8.1574