Removing lumen-apposing metal stent stopped bleeding from splenic artery pseudoaneurysm during transmural drainage of walled-off pancreatic necrosis

A 45-year-old man with a walled-off pancreatic necrosis underwent endoscopic ultrasound (EUS)-guided transmural drainage using a lumen-apposing metal stent (LAMS) owing to infection and gastric outlet obstruction [1]. His clinical history included previous necrotizing pancreatitis with a splenic vein thrombosis and a laparoscopic cholecystectomy. Chronic medication included proton pump inhibitors.

Both the initial computed tomography (CT) scan ([Fig. 1]) and the EUS ([Fig. 2]) showed a collection with a liquid component and some necrotic areas inside (about 30 %), near the body/tail of the pancreas and in close contact with the splenic artery. A double pigtail stent was also initially placed to avoid the collapse of the cavity and contact with the internal flange of the LAMS [2].

Fig. 1 Computed tomography scan showed a collection of about 8.6 × 6 cm with a liquid component of 4 to 6 cm and some necrotic areas inside, near the body/tail of the pancreas.

Fig. 2 Endoscopic ultrasound showed the collection was in close contact with the splenic artery.

He was admitted again 1 month later with melena, anemia, and a drop in hemoglobin levels from 13.6 to 7.2 g/dl. Esophagogastroduodenoscopy (EGD) showed migration of the double pigtail stent. Fluoroscopy showed a collection size reduction of 2 to 3 cm. During the EGD, arterial bleeding started from the wall below the internal flange of the LAMS, probably coming from the splenic artery ([Video 1]). We therefore decided to remove the LAMS.

Video 1 Bleeding from a splenic artery pseudoaneurysm was stopped by removing the lumen-apposing metal stent.

Computed tomography angiography was then performed, showing irregularities along the profile of the splenic artery, as from small pseudoaneurysm and without spills as in active bleeding ([Fig. 3 a]). The subsequent selective arteriography of the celiac tripod ([Fig. 3 b]) did not confirm these irregularities. Hence, it was collectively decided to perform only the diagnostic study and to pursue close clinical and laboratory follow-up. No further signs of gastrointestinal bleeding were observed, and hemoglobin levels were stable.

Fig. 3 a Computed tomography angiography revealed a small pseudoaneurysm of the splenic artery, without spills as in active bleeding. b Selective arteriography of the celiac tripod did not confirm the pseudoaneurysm.

A new CT angiography 2 weeks later confirmed the presence of the known pseudoaneurysm of the splenic artery in the mid-distal area. The splenic artery embolization was therefore carried out ([Fig. 4]).

Fig. 4 The main splenic artery is embolized with a 14-mm Vascular Plug II and a Gianturco spiral with good results. Collaterally, a small branch adjacent to the pseudoaneurysm is also embolized at the origin.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Walter D, Will U, Sanchez-Yague A. et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 2015; 47: 63-67
• 2 Bang JY, Hasan M, Navaneethan U. et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut 2017; 66: 2054-2056

Publication History

Article published online:
08 October 2020