Clinical diagnosis
Case 53
Abdominal angiography was conducted for hemostasis. Celiac arteriography and superior mesenteric arteriography depict extravasation of contrast medium and pseudoaneyrysm (Figs 3A, 3B, 4A). Selective angiography of the first juejunal branch artery from superior mesenteric artery depicts dumbbell-shaped extravasation (Fig. 4B). Inferior pancreaticoduodenal artery branched from the first juejunal branch was super-selectively catheterized and embolization with NBCA was conducted. After embolization, superior mesenteric angiography depicted selective disappearance of the extravasaation of contrast medium (Fig. 5A). Subsequently, angiography of anterior superior pancreaticoduodenal artery branched from gastroduodenal artery depicts bar-like extravasation (Figs 3C to 3F). The microcatheter was super-selectively catheterized to the responsible branch of hemorrhage and embolization with NBCA was conducted (Figs 3G to 3I). Finally, because microaneurysm was confirmed to be present in the first jujunal branch, microcatheter was superselectively catheterized via superior mesenteric artery . Embolization with NBCA was conducted but resulted in insufficient occlusion (approximately a half) of pseudoaneurysm (Figs 5A to 5C) because of back flow from posterior superior pancreatico-duodenal artery branched from gastroduodenal artery. Then, again, posterior superior pancreatico-duodenal artery was tried to catheterize (Fig. 6) but during the catheterization, spasm occurred leading to be unable to reach the pseudoaneurysm (Fig. 7). As a result, a comple hemostasis was possibly completed.
【Progress】
The patient appealed backache for a few days and laboratory test revealed amylase elevated to 166 U/L, 1222 U/L and 136 U/L on Day 3, Day 4 and Day 6, respectively. The follow up enhanced CT on Day 6 showed localized pancreatitis in the retroperitoneum adjacent to the pancreas uncus tip.
【Discussion】
The trunk of inferior pancreatico-duodenal artery (IPDA) branches independently from superior mesenteric artery (SMA) in 40 % of all individuals (Fig. 8) and divides into anterior and posterior branches, forming two arcades surrounding pancreas head (Fig 8) (1 – 3). In 60 %, these branches have own separate origins, the common trunk or one of the divisions arises from the first jejuna artery branched from SMA (Fig. 9)(1 – 3). Based on the literature and our experiences, selective catherization of the IPDA will be unsuccessful unless anatomical variant is fully evaluated because it appears that the IPDA looks arising from the right side of the SMA when its arterial origin is the first jejuna artery (3). In our case, the trunk of the IPDA was confirmed to arise from the first jejunum artery in SMA angiography. The dumbbell-shaped extravasation of contrast medium came out from anterior inferior pancreaticoduodenal artery, one of the branch of IPDA, and the pseudoaneurysm came out from posterior inferior pancreaticoduodenal artery, one of the branch of IPDA (Fig. 9).
The main cause of the pancreatic bleeding is known to be from pancreatic pseudocyst. Pseudoaneurysm exists with 7 to 10 % in the patients with chronic pancreatitis (4, 5). The splenic artery is the most commonly involved followed by common hepatic artery and left gastric artery (4, 5). In our case, she had no past history of pancreatitis. Abdominal CT showed intact pancreas body and tail. The pseudoaneurysm was identified only at the uncus of the pancreas head. Further, the responsible arteries for pseudoaneurysm was the intrapancreatic branches of IPDA, ASPD and PSPD. Then, it is considered that the cause of the pancreatic bleeding in our case is not pancreatic pseudocyst. The pancreas hemorrhage is reported to be caused by pancreas serous cystadenoma (6), but it rarely occurs. In our case, she had experienced dissection of vertebral artery. Abdominal contrast-enhanced CT showed no evidence of dissection of the visceral arteries. Therefore, we could not identify the cause of pancreatic bleeding in our case. Cilostazole was given for approximately one month after transcatheter occlusion of dissected vertebral artery. Although cilostazole is reported to decrease the incidence of hemorrhagic stroke compared to aspirin (7), it might cause visceral hemorrhage.
We used NBCA for embolization of the responsible arteries of pancreatic hemorrhage. It is imperative to do the training how to use NBCA lipiodol. Immediately before usage of NBCA, 5 % glucose has to fill in a microcatheter using a three way cock because of the prevention of polymerization of NBCA (8, 9). Actually, when the dumbbell-shaped extravasation of contrast medium was tried to do embolization, 5 % glucose was infused without use of a three way stop cock. It induced instant occlusion at the catheter tip because the whole blood re-entered into catheter tip soon after infusion of 5 % glucose, leading to the only occlusion of the responsible artery and not accumulate to the dumbbell-shaped bleeding site. When the bar-like extravasation of contrast medium was tried to do embolization, 5 % glucose infusion with a three way stop cock was used to avoid bool-reentering, leading to the successful accumulation of NBCA to the bar-like extravasation. It is imperative to be used to the usage of NBCA embolization. Fortunately,we made a successful hemostasin for three bleeding sites.
【Summary】
We present a fifty two-year-old female with pancreas bleeding in the uncus of the pancreas head. The three hemorrhagic points are found from three responsible artekies: two branches of the IPDA, anterior inferior pancreatico-duodenal artery and posterior inferior pancreatico-duodenal artery: one branch of the anterior superior pancreaticoduodenal artery. Each artery was catheterized with a microcatheter and embolization with NBCA was conducted, leading to that angiography immediately after embolization showed disappearance of extravasation of contrast medium in each. As the complication, pancreatitis was found but its degree was transient and tolerable. We should keep in mind that the IPDA arises from the first jejunum artery rather than the direct arising from SMA.
【References】
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5.Adams DB, et al. Arterial hemorrhage complicating pancreatic pseudocysts: role of angiography. J Surg Res. 1993 Feb;54(2):150-6.
6.Ashkzaran H, et al. An unusual presentation of pancreatic serous cystadenoma with acute hemorrhage. JBR-BTR. 2007 Jan-Feb;90(1):44-6.
7.Uchiyama S, et al. Benefit of cilostazol in patients with high risk of bleeding: subanalysis of cilostazol stroke prevention study 2. Cerebrovasc Dis. 2014;37(4):296-303. doi: 10.1159/000360811. Epub 2014 May
8.Yonemitsu T, et al. Evaluation of transcatheter arterial embolization with gelatin sponge particles, microcoils, and n-butyl cyanoacrylate for acute arterial bleeding in a coagulopathic condition. J Vasc Interv Radiol 2009; 20(9): 1176-1187.
9.Ikoma A, et al. Ischemic effects of transcatheter arterial embolization with N-butyl cyanoacrylate-lipiodol on the colon in a swine model. Cardiovasc Intervent Radiol 2010; 33(5): 1009-1015.
2017.5.10
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