Management Options in Visceral Artery Pseudo Aneurysms - A Critical Analysis at a Tertiary Care Refferal Center.

INTRODUCTION : Aneurysms of visceral arteries are unusual, although they have been reported with increasing frequency in recent years. Their prevalence has been estimated at 0.2%-1% in the general population. Splenic artery aneurysms (SAAs) are the most common type (60%) followed by hepatic(20%) ; superior mesenteric (5%) ; celiac trunk (4%) ; smaller celiac branches (gastric, pancreaticoduodenal, and gastroepiploic) (4%) ; and jejunal, ileal, and colic arteries(3%). They are clinically important because of the high complication rate associated with their rupture.Aetiological factors include atherosclerosis, trauma, surgery, inflammation, infection and congential anomalies. These lesions are traditionally treated primarily by surgical means, but with the advent of newer imagining modalities, trans-catheter embolization is now emerging as a safe procedure. A gastrointestinal surgeon is likely to encounter aneurysms of splanchnic vessels in one of the following situations: (1) Incidental discovery of an aneurysm of a visceral artery or vein ; (2) A false aneurysm of visceral artery as a consequence of adjacent gastrointestinal pathology ; (3) A gastrointestinal complication of an abdominal aneurysm. AIM OF STUDY : To analyze the varied clinical presentation of bleeding visceral artery pseudo aneurysms and to highlight the need for increased awareness of such a rare clinical entity and a potentially lethal complication in patients presenting with obscure / overt gastro intestinal bleeding in the background of pancreatitis, liver trauma and previous pancreatic / biliary surgery. To asses the central role of mesenteric angiography in the management of pseudo- aneurysmal bleed. To evaluate the safety, efficacy and clinical outcome of non-surgical and surgical treatment options (embolization, ligation, resection) for pseudo aneurysmal bleeding from visceral arteries with an intent to draw inferences and to setup management guide lines/protocol. CONCLUSION : A high index of suspicion is essential for early prompt diagnosis of pseudoaneurysmal bleed with expeditious investigations and timed therapy in all patients presenting with obscure / overt gastrointestinal / intra abdominal bleeding particularly in the background of pancreatitis and liver trauma and in the postoperative setting of pancreatic / biliary surgery in order to reduce the morbidity and mortality. Non invasive imaging such as Colour Doppler Ultrasound, multislice Helical CT and CT angiography are useful in establishing, the early diagnosis of pseudoaneurysm. Surgery and PTAE play complementary management roles. Selective/Super-selective angiographic trans-catheter coil embolization should be considered as the first line treatment of choice in all patients presenting with sentinel or massive pseudoaneurysmal bleeding after adequate resuscitation because,(1)it is a safe ,minimally invasive and effective alternative therapy to surgery (2) it can achieve temporary hemostasis and sometimes even permanent hemostasis, (3) it allows hemodynamic stabilization and prevents the need for an urgent high risk surgery(converting a high risk emergency surgery with its attended high morbidity / mortality into an elective surgery with a more favourable outcome), (4) it has an impressive therapeutic success rate coupled with a negligible morbidity and mortality, (4) it is also prudent to regard angiographic embolization as“buying time” for careful disease re-evaluation in order to avoid inappropriate surgery in an emergency situation. Surgery should be reserved only for (i) actively bleeding lesions unsuitable for angioembolization with significant haemodynamic instability caused by and exsanguinating / torrential haemorrhage that obviates the need for angiography(ii) Unsuccessful / failed / non availability of therapeutic angiographic embolization. (iii) secondary complications such as extrinsic compression or sepsis