Endovascular treatment of hemorrhage due to splenic artery injury in acute pancreatitis: case report

Abstracts

Splenic artery injury is a rare complication related to trauma, iatrogenic injury, and pancreatitis. Hemostasis can be made by identification of the vascular lesion through selective catheterism followed by embolization of the bleeding vessel. We report a case of a patient with biliary pancreatitis, who presented hemorrhage due to rupture of the splenic artery during a necrosectomy procedure and was successfully treated with selective embolization.

Pancreatitis; hemorrhage; embolization

A lesão arterial esplênica é uma rara complicação relacionada a situações como trauma, lesão iatrogênica e pancreatite. Hemostasia pode ser feita por identificação do foco do sangramento através de cateterismo seletivo seguido por embolização do ramo sangrante. Relata-se caso clínico de um paciente portador de pancreatite biliar que apresentou, durante procedimento de necrosectomia, hemorragia decorrente da ruptura da artéria esplênica, sendo, então, tratado com sucesso por embolização supersseletiva.

Pancreatite; hemorragia; embolização

CASE REPORT

Endovascular treatment of hemorrhage due to splenic artery injury in acute pancreatitis: case report

Alexandre de Tarso Machado^I; Ricardo Jayme Procópio^I; Franco Antônio Cordeiro Neves^II; Giovanni Menezes Santos^III; Marcelo Gomes Girundi^II; Cristina Toledo Afonso^IV; Tulio Pinho Navarro^V

^IRadiologista intervencionista e cirurgião endovascular, Membro do corpo clínico do Hospital Mater Dei (HMD), Belo Horizonte, MG, Brazil

^IICirurgião geral, Membro do corpo clínico do HMD, Belo Horizonte, MG, Brazil

^IIIAnestesiologista, Membro do corpo clínico do HMD, Belo Horizonte, MG, Brazil

^IVResidente de Cirurgia Vascular do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

^VCirurgião vascular e endovascular, Coordenador do Serviço de Cirurgia Vascular do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil

Correspondence

ABSTRACT

Splenic artery injury is a rare complication related to trauma, iatrogenic injury, and pancreatitis. Hemostasis can be made by identification of the vascular lesion through selective catheterism followed by embolization of the bleeding vessel. The case of a patient with biliary pancreatitis, who presented hemorrhage due to rupture of the splenic artery during a necrosectomy procedure and was successfully treated with selective embolization is reportted.

Keywords: Pancreatitis, hemorrhage, embolization.

Introduction

The disruption of the splenic artery as pancreatitis complication is a rare event, of multifactorial causation and potentially lethal. Angiography for identifying the bleeding focus and posterior superselective embolization of the injury appears as a highly successful theraputic modality, showing low mortality indexes.

Case description

A 51-year-old man, with no previous report of choleliths, pancreatitis and alcoholism, was admitted with acute biliary pancreatitis. He initially received a conservative treatment, evolving with cardiorespiratory instability, renal failure, extensive pancreatic necrosis, and peripancreatic collection increase. In the sixteenth day, he was referred to the surgery block and submitted to pancreatic sequestrectomy with alternative closure of abdominal cavity with Bogota bag.

Afterwards, four other interventions were performed to cavity revision and debridement. However, during the last procedure, the vascular injury occurred in the left retroperitoneal space with severe hypovolemic shock. Given the impossibility of surgical hemostasis, tamponade with compresses was chosen, and an emergency endovascular treatment was indicated.

Through the right common femoral access, left renal artery, gastroduodenal artery, upper mesenteric artery and splenic artery aortography and arteriographies were performed. During an angiographic study, an active bleeding from complex injury (at least in three points) was evidenced in the proximal segment of the splenic artery (Figures 1 and 2). To diminish the risk of 5F catheter disruption, a superselective catheterism was performed as far as the place of the injuries with a 2.4F microcatheter (Progreat^®, Terumo, Japan) and 0.014 guide microwire (Terumo, Japan). For splenic artery embolization, a 0.018" microspring, measuring 12 x 14 mm (Nestor^®, Cook Medical, USA), was used, occupying the whole injured area and serving as a basis for the tissular agent m-methyl cyanoacrylate (Hystoacril^®, B-Braun, Germany) applied, next, in the dilution with Lipidiol in a 1:1 concentration. (Figures 3 and 4).

Angiographic control confirmed the occlusion of the splenic artery proximal segment, preserving distal segments, with no signs of contrast extravasation (Figure 5).

During hospitalization period, no complications related to the procedure nor regression of bleeding occurred. However, given the severity of the underlying disease, the patient remained in critical state, being submitted to five other operations for debridement, compresses removal and laparotomy closure.

The patient was removed to the ward in the eighty-first day of hospitalization and discharged from hospital in the one hundred and fourth day.

Discussion

The main causes of hemorrhage resulting from the disruption of the splenic artery are pancreatitis, trauma, infection, peptic ulcer, post-surgical and iatrogenic complications. Nevertheless, most cases described occur in a pancreatitis context.^1-4 Its early diagnosis and intervention are directly related to better results.

The frequency of these complications in acute pancreatitis varies between 1.2 and 14.5%, being higher when compared to chronic pancreatitis, but with higher mortality rates (60% in acute against 22% in chronic).^6,7 Splenic, gastroduodenal and pancreaticoduodenal arteries are, in this order, the more commonly involved vessels, associated, respectively, to mortality rates of 20.5, 27.9 and 46.1%.^5,8,9

The splenic artery injury's pathogenesis in pancreatitis is multifactorial. One of its mechanisms involves inflammation and consequently pancreatic necrosis, leading to an extravasation of proteolytic enzymes and resulting in the weakening of the arterial wall. Another factor is the traumatic operatory technique, which may weaken the vessel's wall, exposing it to future damages caused by activated enzymes or strange bodies. Moreover, the prolonged use of intra-abdominal drains and compresses may aggravate the process. Finally, another pathogenic mechanism is the association with pseudocyst or peripancreatic abscess, causing vascular damages by the combination of ischemic necrosis, bacterial contamination, and enzymatic digestion by its contents.^1,2,10

Treatment may be conservative, surgical, or endovascular.^1,12,13 Endovascular treatment is the safer and more effective approach in comparison with open surgery, with a success rate of 79 to 100% and mortality between 12 and 33%.^1,2,8,13 In the presence of hemorrhage, surgery is frequently difficult, with complex anatomy and obscure source of bleeding, presenting high rates of intra and post-operative complications.^2,5,8,9

Endovascular techniques include embolization with Gelfoam, polyvinylalkohol (PVA) particles, spheres, springs, detachable balloon or tissular adhesive (glue).^2,11 A potential risk in using particulate agents (Gelfoam, PVA, or spheres) is that they may unintentionally flow to distal splenic circulation, causing splenic infarction or abscess.¹⁴

Springs are the agent of choice for occlusion of proximal and distal segments to arterial injury. In most cases, the springs alone are sufficient to produce the desired result. However, the big caliber of the splenic artery may require the use of multiple springs or the association of techniques with other embolizing agents, as the tissular adhesive (n-methyl cyanoacrylate), combined technique used in the case reported in this article. It is important to highlight that microcatheters are frequently necessary for distal placing of a spring or even for distal catheterization of an anfractuous artery. The use of coated stent, maintaining pervious arterial light, is another treatment option. It permits the maintenance of the splenic artery circulation; however, the technical difficulty intrinsic to the use of this device in an anfractuous vessel and the thrombosis after the stent implant are its main limitations.^1,8,9,11,14

The preservation of the splenic artery is desired, but there are cases in which occlusion is unavoidably necessary. In those, embolization is performed in the closer place to its origin, because the collateral blood circulation is generally sufficient to supply the spleen, avoiding the development of necrosis or abscess resulting from severe ischemia caused by a more distal embolization.^2,9,14

The occurrence of complications after endovascular treatment is related to the technique and the materials used; the knowledge of the anatomy and physiopathology of the disease to be treated; and the experience in performing the procedure. When there are complications, the following conditions are highlighted: persistence or regression of hemorrhage; post-embolization syndrome, characterized by pain, fever and leukocytosis, emerging soon after the onset of embolization and responding well to supportive measures; pancreatitis's exacerbation; splenic infarction or abscess; bowl ischemia; embolizing agent's migration, hematoma or pseudoaneurysm formation in the place of the puncture; and renal failure or allergy induced by the use of iodinated contrast.^10,11,14 The failure in stopping the bleeding may result from the failure in selectively catheterizing the vessel due to its anfractuousness or vasospasm. The regression of bleeding after a seemingly successful embolization has been described as resulting from the incomplete block or recanalization of the arterial bed. Reintervention in these situations is generally successful.¹¹ Persistency of fever and leukocytosis may suggest splenic abscess. The adequate use of antibiotics associated to ventilatory physiotherapy, avoiding the transformation of potential atelectasia in the left lung's basis into empyema, is generally effective for controlling the infection. In some situations, it may be necessary to perform the drainage of the abscess, which may be done via percutaneous access guided by ultrasound or computed tomography. Splenectomy is indicated in more severe cases, which did not respond to previous treatment.^6,7,14

Conclusion

The disruption of splenic artery in pancreatitis is a rare and potentially lethal condition. Endovascular approach allowed controlling the bleeding resulting from the vascular injury with a good outcome and low risk.

References

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Publication Dates

• Publication in this collection
  30 Apr 2010
• Date of issue
  2010

History

• Received
  12 May 2009
• Accepted
  22 Oct 2009