EUS guided thrombin injection of pseudo and true aneurysm of a branch of splenic artery. These are our disclosures. 64 year old male patient presented with abdominal pain for 7 days. There was no history of nausea, vomiting or fever. Patient had past history of open appendicitomy one year back, following which he developed post-operative islet structure, for which right hemicolectomy with terminal islet resection and double-barrel stoma, followed by stoma cruiser at one month later was done. Patient was relatively asymptomatic for one year post-procedure. On presentation, his pulse was 86 per minute. Blood pressure was 190 by 100 mmHg. On examination, there was right hypochondriac tenderness. In the view of hypertensive urgency, patient was started on labetalol infusion. Blood investigations revealed hemoglobin of 6.5, total leukocyte count of 15.8, bilirubin of 3.2 mg per deciliter, ALT 359 IU per liter and INR of 1.2. Ultrasound abdomen revealed a 17 x 15 x 6 cm large right subdiaphragmatic and right lobar intrahepatic hematoma with minimal hemoperitoneum and a 6 x 5 cm aneurysm from the body of pancreas. CT angiogram of the abdomen showed a 24 mm microaneurysm in the liver bed vasculature and in both kidneys, pancreas, spleen, suggestive of changes of polyarthritis nodosa. A 12 x 10 x 4 cm intraparenchymal hematoma was seen in the right lobe of liver communicating with a large 18 x 12 x 12 right subdiaphragmatic hematoma which was suggestive of a ruptured segment 7 artery pseudoaneurysm. A large 6 x 5 cm aneurysm was seen in the pancreatic body on CT angiogram. PENCA, CENCA, ANA and HBSAG were negative. Patient satisfied ACR diagnostic criteria for polyarthritis nodosa. A decision to manage pancreatic pseudoaneurysm was taken as it was large with high probability of rupture. Feeder vessel was a branch of splenic artery and approaching it by transarterial route was not possible. Hepatic hematoma was likely due to true aneurysmal bleed from segment 7 artery or its branches. No active ooze was seen during the scan. Hence, a decision to manage intraparenchymal hematoma conservatively was taken. Endoscopic ultrasound revealed a 5 x 6 cm pseudoaneurysm in midbody with a partial thrombus in it. A true aneurysm was seen inside the pseudoaneurysm but was mistaken as splenic artery. The pseudoaneurysm was punctured with a 22-gauge needle. reconstituted thrombin 1 ml along with a protein in and 1 ml of fibrinogen was injected till there was obliteration of Doppler signal For reconstitution, the fibrinogen powder was dissolved with aprotinine solution and thrombin powder with calcium chloride was dissolved in distilled water. The reconstituted fibrinogen with aprotinine and thrombin solution was simultaneously injected in equal proportion using an applicator system provided. Repeat CT angiogram abdomen done post procedure showed partially thrombosed pancreatic pseudoaneurysm with a patent true aneurysm inside the pseudoaneurysm. The true aneurysm was arising from the third order branch of splenic artery. Repeat endoscopic ultrasound done three days later showed completely thrombosed pancreatic pseudoaneurysm along with a feeding true aneurysm at the distal end of the pseudoaneurysm. One ml of thrombin was injected with a 22 gauge needle and the aneurysm was blocked completely till Doppler signal was obliterated. Repeat CT angiogram of abdomen done post 2 endoscopic procedures revealed completely thrombosed pancreatic aneurysm with no evidence of other true aneurysm. On 8th day post admission liver function tests were completely normal and hemoglobin was 11.3. Patient had significant clinical improvement and was discharged in stable condition. 2 months follow up there was reduction in size of the pseudoaneurysm. When conventional angiography fails due to inaccessible vascular territory i.e. small caliper vessel or short neck of pseudoaneurysm or an angiographically occult pseudoaneurysm, U.S. guided occlusion of visceral artery pseudoaneurysm has been successfully described. U.S. has advantage over CT and transabdominal ultrasound due to close vicinity to mesentric vessels. U.S. provides dynamic information which CT fails to provide. Pre canalization after initial successful thrombosis is a limitation and requires follow up imaging and re-intervention. Thank you.

abdominal pain

polyarthritis nodosa

pseudoaneurysm

pancreas

thrombin injection