Endoscopic ultrasound-guided embolization of a splenic artery pseudoaneurysm. We have no relevant disclosures for this presentation. A 45-year-old male with chronic pancreatitis secondary to alcohol use complicated by splenic vein thrombosis and gastric varices was admitted to an outside hospital in September of 2024 due to an upper GI bleed. The patient's history was significant for prior balloon-occluded retrograde transvenous obliteration in March of 2023. Initial CT scan on admission showed acute on chronic pancreatitis with a splenic artery pseudoaneurysm, but no active contrast extravasation. Each day was without active bleeding and the patient had no further reported bleeding during his hospitalization. Due to decreasing hemoglobin and acute onset abdominal pain, repeat CT angiography of the abdomen was performed and showed increasing size of his previously noted splenic artery pseudoaneurysm without extravasation. Interventional radiology at the outside hospital attempted selective embolization, but was unsuccessful, prompting transfer to our institution for higher level of care of an enlarging splenic artery pseudoaneurysm that had increased in size from 2.2 by 1.2 by 2.0 centimeters to 3.2 by 2.4 by 2.9 centimeters. Here we depict the patient's initial CT scan, which shows a 3-centimeter splenic artery pseudoaneurysm. The case was reviewed by interventional radiology who consulted GI due to the close proximity of the pseudoaneurysm to the gastric wall and concern for splenic infarction if IR-guided splenic artery embolization were attempted. Surgery was also engaged for consideration of splenectomy. However, after explaining the standard of care and alternative treatments to the patient, the decision was made to attempt EUS-guided embolization with additional surgical consent for splenectomy as a backup plan in the event of intraprocedural complications. Here we demonstrate turbulent flow within the pseudoaneurysm with the characteristic yin-yang sign. This image depicts pulse wave Doppler confirming pulsatile arterial flow within the pseudoaneurysm. After obtaining Doppler confirmation of the target and ensuring optimal window for intervention, a 22-gauge needle was used to puncture the saccular structure. Preparations were then made and 800 IU of thrombin was injected into the pseudoaneurysm. Following injection, we can see flow within the pseudoaneurysm begin to slow with eventual obliteration of all flow. Repeat Doppler evaluation was performed, which confirmed successful embolization of the pseudoaneurysm. A repeat CT angiography was performed the following morning and showed interval decrease in size of the pseudoaneurysm from 30 mm to 13 mm. The patient ultimately tolerated the procedure well and was without complications. He was discharged home later that day. Due to the risk of rupture, the Society for Vascular Surgery recommends treatment of aneurysms and pseudoaneurysms in the following scenarios. Non-ruptured splenic artery pseudoaneurysms of any size in patients of acceptable risk, non-ruptured splenic artery true aneurysms of any size in women of childbearing age, non-ruptured splenic artery true aneurysms greater than 3 cm in size with demonstrable increase in size or associated symptoms. The Society for Vascular Surgery suggests observation over repair for small, less than 3 cm in size, stable, asymptomatic splenic artery true aneurysms or those in patients with significant medical comorbidities or limited life expectancies. Treatment of splenic artery aneurysms and pseudoaneurysms can generally be accomplished by either open-surgical or endovascular approaches. Traditional endovascular approaches include deployment of coils and vascular plugs, injection of liquid embolic agents, placement of covered stents or flow-debriding stents, and injection of thrombin. Case reports have shown good success with EUS-guided therapy, which has historically involved coil and glue injection. Before non-traditional methods of treatment are pursued, multidisciplinary discussion is warranted given the concern for end-organ ischemia depending on the patient's anatomy and location of the vascular defect. In conclusion, our case demonstrates an effective use of an EUS-guided approach in the treatment of a splenic artery pseudoaneurysm using thrombin injection. EUS-guided treatment provides a radiation-free alternative approach for patients who are unwilling or unsuitable to undergo radiation, such as pregnant patients. Available literature has shown EUS-guided approaches to be technically and clinically effective. However, larger studies are needed to compare the long-term safety and efficacy of EUS-guided therapy versus traditional approaches before definitive recommendations can be made. Prior to attempting EUS-guided therapy, the standard of care and alternative approaches should be clearly explained with the patient, and multidisciplinary discussion should be employed.

chronic pancreatitis

splenic artery pseudoaneurysm

EUS-guided thrombin embolization

radiation-free alternative

interventional radiology