Open Thrombin Injection Of Inaccessible Splenic Artery Pseudoaneurysm
Brendan Jones, MD, Matthew Cunningham-Hill, MD, Pamela Zimmerman, MD.
WVU Hospital, Morgantown, WV, USA.
DEMOGRAPHICS: A 50 year old female with a history of chronic pancreatitis, diabetes mellitus type 1, venous thromboembolism, and migraine headaches. No history of alcohol abuse.
HISTORY: The patient initially developed recurrent episodes of pancreatitis following a partial gastrectomy and cholecystectomy in 2021. She presented to an outside facility with three days of nausea, vomiting, and epigastric abdominal pain which she reported differed from her usual pancreatitis related pain. A CT scan of the abdomen was obtained demonstrating a 3.5 cm splenic artery pseudoaneurysm which had not been visualized on a CT scan from one month prior. The scan also re-demonstrated a 5.2 x 2.8 cm pseudocyst adjacent to the stomach
PLAN: Due to the symptomatic nature of the pseudoaneurysm and the rapid increase in size with concern for the possibility of rupture the decision was made to take the patient to the operating room for endovascular repair. Unfortunately, due to the tortuosity of the splenic artery in the setting of chronic pancreatitis access could not be obtained. An exploratory laparotomy was performed and again, due to inflammation from the pancreatitis access to the retroperitoneum was difficult to achieve without significant risk and blood loss. The aneurysm was then located with ultrasound and thrombin was injected to induce clotting. Repeat CT scan on post-operative day three confirmed that the pseudoaneurysm had clotted off.
DISCUSSION: Splenic artery aneurysms are rare, despite the splenic artery being the most commonly affected visceral artery. A pseudoaneurysm is a rare complication of pancreatitis and may be confused with a pseudocyst. Prompt recognition and treatment is imperative to prevent rupture which can carry a mortality rate of 90%, In a hemodynamically stable patient the aneurysm case be treated endovascularly via embolization or stenting. Hemodynamic instability requires more rapid access and repair via exploratory laparotomy. As pseudoaneurysms are likely to arise in the setting of pancreatitis open surgery to correct the issue can be fraught with danger. When access to the retroperitoneum is difficult in the setting of adhesive disease and inflammatory tissue, direct thrombin injection under ultrasound guidance can serve as a bail out procedure.
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