SIDS Hospital & Research CentreMS Surat, Gujarat, India
Jay Bapaye, MD1, Pankaj Desai, MS2, Mayank Kabrawala, MD3, Chintan Patel, MD3, Ritesh Prajapati, MD3 1Rochester General Hospital, Rochester, NY; 2SIDS Hospital & Research CentreMS, Surat, Gujarat, India; 3SIDS Hospital & Research Centre, Surat, Gujarat, India
Introduction: Here we describe a case of EUS guided glue + lipiodol injection for a bleeding pseudoaneurysm of pancreatoduodenal artery.
Case Description/Methods: 46 year old male with a history of hypertension, ischemic cardiomyopathy, chronic pancreatitis presented with hematemesis and malena. UGI scopy soon after admission revealed a small Mallory Weiss tear with severely edematous first and second duodenum medial wall. CECT abdomen revealed changes of acute on chronic pancreatitis with a pseudoaneurysm in the wall of 2nd part of duodenum arising from superior pancreatico duodenal artery. EUS with doppler revealed active bleed from pseudoaneurysm. After interventional radiology consultation, EUS guided therapy was planned. A mixture of 1.5 ml cyanoacrylate glue and 3 ml lipiodol was injected using a 19 G needle. 2.3ml of the mixture was injected under fluoroscopy control. EUS confirmed hemostasis. The patient was in left lateral position because the pseudoaneurysm came in a position to inject only in that position. We prefer supine position while injecting to control where the glue goes, which was not possible. Fluoroscopy showed that the pseudoaneurysm filled and some glue entered the feeding vessel and injection was stopped. Making the patient supine, we saw that some glue had extravasated into the common hepatic artery (CHA) and right gastroepiploic artery. Six hours post procedure he developed lactic acidosis with hepatitis. pH was 6.9, lactate 14, SGOT and SGPT were elevated > 20 times upper limit of normal, SGOT > SGPT, INR- 2, Bilirubin - 3mg/dl. He was treated with intravenous fluids, vasopressors and N acetylcysteine @150mg/kg/hr for 5 days. Patient improved gradually. CECT abdomen after 8 days showed occlusion of pseudoaneurysm with glue and lipiodol in CHA, GDA and right gastroepiploic artery with ischemic gall bladder. Patient was asymptomatic but cholecystectomy was performed. Patient recovered well in next 48 hours and was discharged. Follow up LFT were improving with normal Bilirubin and transaminases < 2 times upper limit of normal.
Discussion: Pseudoaneurysms in critical areas around the celiac trunk and gastroduodenal arteries can be treated with EUS guided glue and lipiodol injection. Lipiodol is advocated with glue for controlling the amount of injection under fluoroscopic guidance. Injection should be stopped as soon as the aneurysm and feeding vessel neck fills. Good fluoroscopy control in supine position while injecting is crucial prevent a lot of post procedure complications.
Disclosures: Jay Bapaye indicated no relevant financial relationships. Pankaj Desai indicated no relevant financial relationships. Mayank Kabrawala indicated no relevant financial relationships. Chintan Patel indicated no relevant financial relationships. Ritesh Prajapati indicated no relevant financial relationships.
Jay Bapaye, MD1, Pankaj Desai, MS2, Mayank Kabrawala, MD3, Chintan Patel, MD3, Ritesh Prajapati, MD3. P1758 - EUS-Guided Glue + Lipiodol Injection in Pseudoaneurysm of Pancreatoduodenal Artery, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.