EUS-GUIDED COIL EMBOLIZATION AND THROMBIN INJECTION OF BLEEDING GASTRO-DUODENAL ARTERY PSEUDOANEURYSM

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. The most common clinical presentation is gastrointestinal haemorrhage secondary to rupture of the aneurysm.

A 50-years-old male had an episode of acute pancreatitis one month back. He presented with melena, requiring six units of blood transfusions. After hemodynamic resuscitation, the patient underwent upper gastrointestinal endoscopy to know the etiology of upper GI bleeding. Upper GI endoscopy showed bulge with overlying ulceration in second part of duodenum. Side viewing endoscopy showed a pulsatile bulge with overlying large ulcer. Ultrasound abdomen showed pseudoaneurysm of size 3.8 × 5.6 cm arising from GDA artery. CECT abdomen with angiography showed a saccular pseudo-aneurysm of size 4 × 6 cm in relation to GDA. EUS from duodenal bulb showed a pseudo-aneurysm of size 4.1 × 5.8 cm arising from GDA. Radiological or EUS guided interventions were considered. The advantages and disadvantages of both procedures were explained. The patient selected the option of EUS guided coil embolization.

Results:

Under EUS and fluoroscopy guidance, five coils of 10 mm size were placed within pseudoaneurysm through 19-Gauge EUS needle. After coil embolization, contrast injection into pseudoaneurysm showed partial filling of pseudoaneurysm. Review EUS one day after coil embolization showed high flow in the pseudoaneurysm. Around 30% of pseudoaneurysm was obliterated. On 3 rd day, 6 ml of human thrombin was (3000 IU) injected during second session of intervention in six boluses of 500 unit each. After thrombin injection high velocity flow was confined to the neck and periphery of pseudoaneurysm. Further 2 ml of thrombin was injected. Immediately after thrombin injection, colour Doppler EUS showed complete obliteration of pseudoaneurysm. Two weeks later, repeat EUS showed completely obliterated pseudoaneurysm with no flow.

Conclusions:

This case shows the practical problems of EUS guided coil embolization of pseudoaneurysms.