U.S. guided glu-plus-lipidol injection in pseudoaneurysm of superior pancreatico-duodenal artery. These are our disclosures. A 46-year-old male with comorbidities, hypertension for 17 years, ischemic heart disease for 7 years, chronic pancreatitis for 1 year and history of heart failure in March 2021, presented with hematemesis and melena for 1 day. Patient had alcohol use disorder and last episode of acute chronic pancreatitis was on August 2020. His current medications include aspirin, decoxin, secubitril plus valsartan, isoprolol and rosuvastatin. On presentation, patient had tachycardia and hemoglobin of 9. After hemodynamic stabilization, upper GI endoscopy was done. It revealed small malaria-based tear with edematous D1 and D2 with no source of active bleed. CT angio-abdomen showed changes of acute on chronic pancreatitis with 12 by 13 mm pseudoaneurysm arising from superior pancreatico-duodenal artery. Interventional radiology opinion was taken. As the pseudoaneurysm was just beside the duodenal wall, U.S. guided angioembolization was planned and this was discussed with patient. U.S. showed a pseudoaneurysm measuring 16 by 14 mm with the classical Yin-Yang sign. Pseudoaneurysm was punctured with a 22 gauge needle. Mixture of glu and lipidol in the ratio of 1 is to 3 was injected into the pseudoaneurysm till the pseudoaneurysm and the feeding vessel was completely filled. 2.5 ml was required. On color doppler, there was complete obliteration of blood flow. On fluoroscopy, some glue was seen entering the common hepatic artery and right gastroepiploic artery. 6 hours post procedure, patient developed tachycardia, tachypnea and hypotension. Blood investigation showed severe lactic acidosis with severe hepatitis with pH of 6.97, lactate of 14, AST 1900, ALT 710, INR 2 and total bilirubin of 3 mg per deciliter. Alkaline phosphatase and GGT were normal. Hemodynamic stabilization was done and an acetyl cysteine infusion at 150 mg per kg per hour was given for 5 days. Patient improved with medical management. CECT abdomen repeated after 8 days revealed occlusion of previously seen pseudoaneurysm with glu and lipidol seen in common hepatic artery, gastrodiodenal artery, hepatic artery, right gastroepiploic artery with ischemic gallbladder necrosis with small perigallbladder collection. Clinically, patient had no fever, abdominal pain, guarding or rigidity. Surgical opinion was taken and laparoscopic cholecystectomy was done. On day 10 of initial presentation, patient is asymptomatic with near normal liver function tests. Injection of undiluted glu frequently leads to needle blockage and failure of therapy. This occurs due to reflux of blood into the needle. Undiluted glu has to be injected in short boluses with multiple needle punctures till complete obliteration of pseudoaneurysm. Dilution of glu with lipidol HH2 objective prevents needle blockage, allows steady glu injection till complete obliteration of pseudoaneurysm hence avoid multiple punctures. This however may come at a cost of increased chance of glu embolization as seen in this case where there was spillage of glu into the feeding vessel. This may be an additional advantage as blockage of feeding vessel avoids recurrence of bleed. Embolization in larger vessel can lead to complications as ischemic hepatitis and cholecystitis in this case. Lesser dilution with lipidol may achieve controlled glu delivery with lesser risk of embolization. In conclusion, EOS guided glu plus lipidol injection of peripancritic pseudoaneurysm is feasible. While use of undiluted glu may lead to needle blockage prior to glu reaching pseudoaneurysm and needle stuck in pseudoaneurysm, addition of lipidol allows controlled delivery of glu and avoids needle blockage but increases risk of embolization. Thank you.

gastrointestinal bleeding

pseudoaneurysm

angioembolization procedure

glue and lipidol mixture

complications post-procedure