Splenic Artery Pseudoaneurysm Complicating Pancreatitis

Abstract

A 62-year-old man with alcoholic cirrhosis was admitted for acute on chronic pancreatitis. During his last admission 3 months before, a CT scan had showed ascites as well as a 5.0-cm high-density posterior pancreatic tail fluid collection communicating with high-density material between the aorta and left renal vein (Fig. 1). The patient refused further workup and was discharged home. During this next admission, CT angiography showed an 8.6-cm partially thrombosed splenic artery pseudoaneurysm at the pancreatic tail and a subcapsular splenic fluid collection (Fig. 2). While awaiting intervention, the patient suddenly became pale and hypotensive. He died from a ruptured pseudoaneurysm leading to hemorrhage and acute hemodynamic collapse. Splenic artery pseudoaneurysm is a rare complication of pancreatitis and pancreatic pseudocysts. Other etiologies include peptic ulcer disease, trauma, and complications of surgical exploration. Release of pancreatic enzymes results in autodigestion of the vessel wall. Risk of rupture can be as high as 37%, with a mortality rate approaching 90% when untreated 1 . Early diagnosis and urgent treatment are imperative regardless of size or symptoms. Pseudoaneurysms may be mistaken for pseudocysts or other peripancreatic fluid collections on CT scan. High density within peripancreatic fluid collections should raise the suspicion of blood. Angiography offers a definitive diagnosis. Treatment options include transcatheter embolization, splenectomy with or without distal pancreatectomy, or splenic Figure 2. CT angiography depicting an 8.6-cm partially thrombosed splenic artery pseudoaneurysm at the pancreatic tail and a subcapsular splenic fluid collection.Figure 1. CT scan depicting a 5.0-cm high-density posterior pancreatic tail fluid collection communicating with high-density materialbetween the aorta and left renal vein. JGIMAuthor contributions MP, AS, and AA treated the patient and were responsible for writing the paper and looking up the background references. AA was responsible for overall coordination and final proofreading. All the above-mentioned authors read and approved the final manuscript.

Management of Giant Splenic Artery Aneurysm

“… 7 , 14 , 18 The third trimester of pregnancy is the period with the highest risk. 1 Our literature survey revealed that among the 78 giant SAA cases, 8 had cirrhosis, 13 , 18 , 23 , 41 , 47 , 56 , 64 , 65 2 had portal hypertension, 14 and 1 had a history of pregnancy, 66 which are possible predisposing conditions for SAA. Relatively rare risk factors are splenomegaly, medial fibrodysplasia, arteritis, collagen vascular disease, polyarteritis nodosa, systemic lupus erythematosus, anomalous splenic artery origin, α 1 -antitrypsin deficiency, and inflammatory and infectious diseases.…”

Spleen-preserving surgical treatment of splenic artery aneurysm secondary to chronic pancreatitis and primary biliary cholangitis

“…Splenic artery aneurysms are up to 4 times more common in females while overall incidence increases to 10% in patients > 60 years and in patients with portal hypertension [12,13]. Spontaneous rupture is associated with high mortality, up to 40% for true aneurysms, and even 90% for PSAs [8,9,10]. In patients with intraperitoneal SAA rupture, acute abdomen and hypovolemic shock, splenectomy and SA ligation are mostly performed [14,15].…”

“…Pancreatitis, on the other hand, has been associated with SA pseudoaneurysm development with high risk of rupture up to 40% and mortality up to 90% [10,16]. It has been proposed that in the case of pancreatitis, pancreatic enzymes are responsible for destruction of arterial wall architecture and disintegration of elastic tissues, leading to formation of pseudoaneurysm [17].…”

“…Pseudoaneurysms of SA are rare, more prone to rupture than true aneurysms and mostly associated with pancreatitis, trauma, iatrogenic cause or rarely peptic ulcer disease [9]. Pancreatitis has been linked with PSA formation of SA [10,11] due to destruction of arterial wall by pancreatic enzymes causing inflammation, fragmentation of elastic tissue and consequent PSA formation, however true SAA associated with pancreatitis hasn't been described yet. We are presenting the first case of true SAA in a patient with chronic pancreatitis and primary biliary cholangitis successfully treated by surgical excision and arterial reconstruction.…”

Characteristics and Surgical Outcomes of the Patients With Atraumatic Splenic Rupture

“…Splenic infarction occurs in case of occlusion of the splenic vascular supply, leading to tissue ischemia and necrosis. Thromboembolism is the most common cause of splenic infarctions [12][13][14][15]. Splenic infarction may be due to arterial or venous occlusion.…”