Endoscopic ultrasound guided coil embolization of a refractory pseudoaneurysm. Here are our disclosures. A 30-year-old male with a past medical history of alcohol use disorder and severe necrotizing pancreatitis complicated by Waldorf necrosis presented with 14 episodes of hematemesis. He reported fatigue, lightheadedness, and inability to ambulate independently due to these symptoms. His vitals were notable for tachycardia with a heart rate of 143. He was pale in appearance and nearly lethargic. His lactate was noted to be 5.7, and his hemoglobin was only 3.4. He was transfused three units of packed red blood cells. CT angiography of the abdomen was performed. Here you can see evidence of a peripancreatic collection with known Waldorf necrosis measuring 3.2 centimeters in size. This was only 2.7 centimeters in size three weeks prior. Active extravasation of contrast was noted in this large collection consistent with bleeding from a large pseudoaneurysm measuring 1.8 centimeters in size. Interventional radiology was urgently consulted. An angiogram was performed with the plan for embolization. However, despite exhaustive efforts with multiple instruments, the suspected culprit vessel, a branch of the posterior inferior pancreaticoduodenal artery, could not be easily opacified or accessed, and the procedure was therefore terminated. Despite being visualized, the pseudoaneurysm could not be intervened upon during this exam. The patient had melana and one episode of hematokesia overnight. At that point, advanced endoscopy was consulted. A multidisciplinary discussion was performed involving the patient's family, the ICU team, advanced endoscopy, and interventional radiology. The plan was to proceed with endoscopy and possible endoscopic ultrasound intervention on this pseudoaneurysm. An upper endoscopy was performed under general anesthesia. There was no evidence of esophageal varices. Diminutive gastric varices were seen in the fundus on retroflexion. With advancement of the scope into the duodenum, fresh blood was seen emerging from the major papilla consistent with hemosuchus pancreaticus. An endosonographic exam was then performed with a linear echoendoscope. A 35-millimeter collection was seen consistent with the known Waldorf necrosis with a dense 18-millimeter pseudoaneurysm that was confirmed by Doppler. Using endoscopic, endosonographic, and fluoroscopic guidance, the thick-walled necrotic cavity was punctured using a 19-gauge fine needle aspiration needle. With difficulty given endoscope tip angulation, one 0.035-inch embolization coil measuring 12 millimeters by 14 centimeters was deployed within the vessel with immediate depletion of flow. An absorbable gelatin sponge slurry was also injected around the coil as a secondary measure to ensure complete obliteration of the vessel. A small tail of the coil could be seen emerging from the duodenal wall. The procedure was uncomplicated, and the patient tolerated it all very well. He was observed for 48 hours following the procedure with no signs of ongoing bleeding and a consistently rising hemoglobin. He was prescribed a three-day course of periprocedural prophylaxis. On follow-up one month later, he denied any bleeding episodes, lightheadedness, or abdominal discomfort. He was back to work for the first time in many months. Repeat labs were notable for a hemoglobin of 13. Repeat CT andrography six weeks after discharge confirmed complete obliteration of the large pseudoaneurysm in the head of the pancreas. The endoscopically placed coil can be seen as the hyperechoic circular structure on this imaging. The patient has had no recurrent bleeding for one year. Pseudoaneurysms are traditionally treated using a catheter-based transarterial intervention. This approach is not always feasible. This video demonstrates EUS-guided coil embolization, which may be a safe and effective option for the treatment of pseudoaneurysms.

EUS-guided coil embolization

pseudoaneurysm

hematemesis

necrotizing pancreatitis

alcohol use disorder