A 45-year-old man with a walled-off pancreatic necrosis underwent endoscopic ultrasound (EUS)-guided transmural drainage using a lumen-apposing metal stent (LAMS) owing to infection and gastric outlet obstruction [1]. His clinical history included previous necrotizing pancreatitis with a splenic vein thrombosis and a laparoscopic cholecystectomy. Chronic medication included proton pump inhibitors.
Both the initial computed tomography (CT) scan ([Fig. 1]) and the EUS ([Fig. 2]) showed a collection with a liquid component and some necrotic areas inside (about 30 %), near the body/tail of the pancreas and in close contact with the splenic artery. A double pigtail stent was also initially placed to avoid the collapse of the cavity and contact with the internal flange of the LAMS [2].
Fig. 1 Computed tomography scan showed a collection of about 8.6 × 6 cm with a liquid component of 4 to 6 cm and some necrotic areas inside, near the body/tail of the pancreas.
Fig. 2 Endoscopic ultrasound showed the collection was in close contact with the splenic artery.
He was admitted again 1 month later with melena, anemia, and a drop in hemoglobin levels from 13.6 to 7.2 g/dl. Esophagogastroduodenoscopy (EGD) showed migration of the double pigtail stent. Fluoroscopy showed a collection size reduction of 2 to 3 cm. During the EGD, arterial bleeding started from the wall below the internal flange of the LAMS, probably coming from the splenic artery ([Video 1]). We therefore decided to remove the LAMS.
Video 1 Bleeding from a splenic artery pseudoaneurysm was stopped by removing the lumen-apposing metal stent.
Qualität:
Computed tomography angiography was then performed, showing irregularities along the profile of the splenic artery, as from small pseudoaneurysm and without spills as in active bleeding ([Fig. 3 a]). The subsequent selective arteriography of the celiac tripod ([Fig. 3 b]) did not confirm these irregularities. Hence, it was collectively decided to perform only the diagnostic study and to pursue close clinical and laboratory follow-up. No further signs of gastrointestinal bleeding were observed, and hemoglobin levels were stable.
Fig. 3 a Computed tomography angiography revealed a small pseudoaneurysm of the splenic artery, without spills as in active bleeding. b Selective arteriography of the celiac tripod did not confirm the pseudoaneurysm.
A new CT angiography 2 weeks later confirmed the presence of the known pseudoaneurysm of the splenic artery in the mid-distal area. The splenic artery embolization was therefore carried out ([Fig. 4]).
Fig. 4 The main splenic artery is embolized with a 14-mm Vascular Plug II and a Gianturco spiral with good results. Collaterally, a small branch adjacent to the pseudoaneurysm is also embolized at the origin.
Endoscopy_UCTN_Code_CPL_1AL_2AD
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