EUS guided embolization of a refractory splenic pseudoaneurysm. A 45-year-old female with decompensated alcoholic cirrhosis with portal hypertension, esophageal varices, loculated ascites, and large intra-abdominal and pelvic abscesses, with multiple percutaneous drainage procedures, presented as an outside hospital transfer to our institution for the management of a recurrent upper GI bleeding, her third episode in four months. At the outside institution, she had previously undergone multiple upper endoscopies, notable for large gastric and esophageal varices, portal hypertensive gastropathy, but no active intra-abdominal bleeding was noted. CT angiography demonstrated splenic arterial aneurysm and pseudoaneurysm, for which our interventional radiology service had performed gastric and perigastric variceal obliteration, as well as two splenic arterial embolizations prior to this current admission. At presentation, she was hemodynamically stable, with a hemoglobin of 7.1. A repeat CT abdomen and pelvis demonstrated a persistent splenic pseudoaneurysm, for which our interventional radiology service performed a third embolization. Unfortunately, post-embolization CT scan demonstrated a persistent pseudoaneurysm, with the patient requiring multiple transfusions. Due to continued transfusion requirements, in spite of the interventions by our interventional radiology service, the decision was made to perform US-guided splenic pseudoaneurysmal obliteration with thrombin and sionacrolate glue. Firstly, we tried to identify the splenic artery by use of power wave Doppler. Next, to identify the splenic pseudoaneurysm, we utilized color wave Doppler to identify the yin-yang sign, a sign created by the bidirectional flow of swirling blood within the pseudoaneurysm. Once identified, a 22-gauge FNA needle was advanced into the pseudoaneurysm. Contrast was then injected to confirm fluoroscopically the location of the aspiration needle within the pseudoaneurysm. 800 units of thrombin were then injected into the pseudoaneurysm. Color wave Doppler was used to confirm absence of flow within the pseudoaneurysm. Next, half a milliliter of sionacrolate glue was injected into the pseudoaneurysm. Upon completion of injection of the sionacrolate glue, careful withdrawal of the 22-gauge needle was performed with simultaneous flushing with sterile water. This is done to prevent clogging within the scope as well as the formation of a glue cast which can rupture and cause recurrent bleeding. Following successful embolization, the patient no longer had any transfusion requirement and has now demonstrated no recurrence of GI bleeding for the past nine months. Visceral arterial pseudoaneurysms are common sequelae of chronic pancreatitis occurring in about 10% of patients with a 50% risk of rupture and mortality of 14% to 50%. Typically this is treated with transcatheter arterial embolization with a technical success rate approaching 100% with similar clinical success with an adverse event profile of 6% to 24% splenic infarctions. In cases of splenic pseudoaneurysmal persistence in spite of transcatheter arterial embolizations, EUS-guided embolization has shown significant promise with 100% technical and clinical success rates. In these situations of refractory pseudoaneurysms, EUS-guided approaches are useful. The main technical challenge involves identification of the pseudoaneurysm. Identification of the yin-yang sign and also using the location of previous interventions such as coils help to serve as landmarks. Careful withdrawal of the FNA needle is imperative as any glue within the scope can result in the scope clogging and any glue cast at the site of injection can later rupture and cause recurrent bleeding. As such, we recommend that while the needle is being withdrawn, that sterile water be injected through the needle. We also recommend that the needle stay outside of the tip of the scope for at least 30 seconds to allow any glue that may be in the tip of the needle to dry. Thank you.

alcoholic cirrhosis

upper GI bleeding

EUS-guided embolization

pseudoaneurysm

Doppler techniques