Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution.

Diagn Interv Radiol 2015; 21:140–147 INTERVENTIONAL RADIOLOGY © Turkish Society of Radiology 2015 ORIGINAL ARTICLE Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution Jinoo Kim, Ji Hoon Shin, Hyun-Ki Yoon, Gi-Young Ko, Dong Il Gwon, Eun-Young Kim, Kyu-Bo Sung PURPOSE The aim of this study was to assess the outcome of endovascular intervention for pancreatitis-related hemorrhage at a single institution. METHODS From January 2000 to October 2012, thirty-seven patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications. RESULTS A total of 41 endovascular procedures were performed in 37 patients. The splenic artery (34.8%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (78.3%). Transcatheter embolization was performed in the majority of patients (95.1%), while two patients were treated with stent-grafts. Successful hemostasis without rebleeding was achieved in 34 patients (91.9%). Two cases of rebleeding were successfully treated by reintervention. Focal splenic infarction, which developed in eight patients, was either asymptomatic or accompanied by mild, transient fever. Splenic abscess was the only major complication occurring in three patients. Two of these patients died from resulting sepsis, while the third recovered after antibiotic treatment. CONCLUSION Endovascular management is effective for achieving hemostasis in patients with pancreatitis-related bleeding and demonstrates low recurrence and mortality rates. From the Department of Radiology (J.K.), Ajou University, School of Medicine, Ajou University Hospital, Suwon, Korea; the Department of Radiology and Research Institute of Radiology (J.H.S.  jhshin@ amc.seoul.kr, H-K.Y., G-Y.K., G.I.G., K-B.S.), University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea; the Medical Device Development Center (E-Y.K.), KBIO Osong Medical Innovation Foundation, Chungbuk, Korea. Received 5 March 2014, revision requested, final revision received 25 August 2014, accepted 29 August 2014. Published online 23 January 2015. DOI 10.5152/dir.2014.14085 140 S erious bleeding complications have been reported to occur in up to 14.5% of patients with acute and exacerbated chronic pancreatitis and are potentially fatal when left untreated (1). Computed tomography (CT) serves an important role in the diagnosis of pancreatitis-related hemorrhage, demonstrating radiologic features such as the presence of hematomas, hemorrhagic pseudocysts, extravasation of contrast media or the formation of arterial pseudoaneurysms. Timely intervention, either surgical or endovascular, is essential in this clinical setting, especially for active bleeding or pseudoaneurysm formation. Even though the latter may sometimes be clinically silent, arterial pseudoaneurysms are widely considered to be life-threatening “time-bombs” due to their risk of rupture (2–4). The mortality rate of bleeding pseudoaneurysms has been reported to reach as high as 40% when managed conservatively (5). Endovascular treatment has advantages over surgery for managing complications related to pancreatitis. It is less invasive and can be performed in patients with comorbidities who are contraindicated for surgery. Even for those without surgical contraindications, surgery is often difficult owing to severe inflammatory change around the pancreas. Traditionally, the mainstay of endovascular treatment has been transcatheter embolization. More recently, stent-graft placement for exclusion of arterial rupture and pseudoaneurysms has gained popularity. Current literature suggests that such endovascular techniques are effective in achieving hemostasis in patients, and the outcomes are comparable or superior to those of surgery (2, 6, 7). However, despite the widespread popularity of endovascular treatment, the literature is mostly limited to case reports and small case series. We have performed a web-based search of the literature and have found a surprisingly limited number of publications comprising more than a handful of patients in a single study. By performing this retrospective, single-center study, we aim to provide firmer evidence in support of endovascular intervention as the first-line treatment for the management of pancreatitis-related hemorrhage. Methods Patients A retrospective review was performed for all patients who underwent endovascular treatment for vascular complications of pancreatitis from January 2000 to October 2012. Approval was given by our local ethics committee, and the requirement for informed consent was waived. We identified a total of 37 patients. In line with the trend at the authors’ institution, all patients but one underwent primary angiographic eval- uation and endovascular intervention before receiving any kind of surgery to manage the vascular complications. The only patient who received prior surgery underwent exploratory laparoscopy at another institution, which failed to identify the bleeding focus. Our study included two female patients and 35 male patients. The mean patient age was 52.0 years (age range, 19–85 years). We reviewed each patient’s medical documents in order to identify the underlying disease etiology, indications for treatment including clinical symptoms and laboratory findings, and documented any changes in the clinical course following embolization including procedure-related complications. Contrast-enhanced multiphase CT scans, obtained using a four-channel multidetector CT scanner (LightSpeed QX/I or LightSpeed Plus, GE Medical Systems) or a 16-channel multidetector CT scanner (Somatom Sensation 16, Siemens Healthcare), were available for all patients included in this study with the exception of a few patients who had undergone CT at outside institutions. The scan protocol was diverse due to the following reasons: first, while some patients underwent routine scans (usually including portal venous and delay phase scans) to find out the cause of nonspecified acute abdomen, others underwent CT to evaluate the site of bleeding, in which case, early arterial phase was included. Second, some of the patients had CT scans that were brought by the patients themselves from other hospitals. Third, the retrospective data was collected over a period of 10 years, during which the protocol has been adjusted several times. The images were reviewed on a picture archiving and communication system. The CT severity index was also assessed. Angiography and endovascular technique Digital subtraction angiography (DSA) and endovascular procedures (...truncated)