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Background There is limited literature on the role of percutaneous transhepatic biliary drainage (PTBD) as an adjunct to endoscopic retrograde cholangiopancreatography (ERCP). This study evaluates the role of PTBD in patients with failed ERCP or post-ERCP cholangitis. Methods Retrospective evaluation of clinical and intervention records of patients with biliary obstruction referred for PTBD following failed ERCP or post-ERCP cholangitis was performed. The cause of biliary obstruction, baseline serum bilirubin, white blood cell (WBC) count, serum creatinine, and procalcitonin were recorded. Technical success and clinical success (resolution of cholangitis, reduction in bilirubin levels, WBC count, creatinine, and procalcitonin) were assessed. Results Sixty-three patients (35 females, mean age 51.4 years) were included. Indications for ERCP included malignant causes in 47 (74.6%) cases and benign causes in 16 (25.4%) cases. Indications for PTBD were failed ERCP in 21 (33.3%) and post-ERCP cholangitis in 42 (66.7%). PTBD was technically successful in all patients. Clinical success rate was 68.2% in the overall group. Mild hemobilia was noted in five (7.9%) patients. There were no major complications or PTBD related mortality. Cholangitis and acute kidney injury resolved following PTBD in 63.1% and 80% of the patients, respectively. Total serum bilirubin reduced by 47.8% and 69.4% after one week and one month of the PTBD, respectively. The average fall in procalcitonin was 5.17 ng/mL after one week of the PTBD. Conclusion PTBD is an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis.

Hepatic artery pseudoaneurysm in postcholecystectomy choleduodenal fistula is an extremely rare but clinically significant complication. A 52-year-old male presented with hematemesis and melena several weeks after open cholecystectomy for complicated gallstone disease. Upper gastrointestinal endoscopy revealed bleeding from the choledochoduodenal fistula site. On computed tomography angiography, a small right hepatic artery pseudoaneurysm close to fistula site was identified. Endovascular embolization failed due to nonopacification of the proximal right hepatic artery. Endoscopic ultrasound-guided embolization was also unsuccessful due to the small size of the aneurysm and inadequate visualization. Following this, percutaneous n-butyl cyanoacrylate glue was successfully injected into the pseudoaneurysm. The patient recovered and was planned for hepaticojejunostomy to restore biliary continuity.

Within healthcare generally, patients who self-harm can experience stigma and inequitable medical care. Previous studies have suggested that patients with small self-harm burn injuries may not be treated equally in comparison to non-intentional injuries. Furthermore, there is an absence of literature related to surgical outcomes for self-harm burn injuries. A retrospective cohort study of an adult burns service's outpatient attendances over a four-year period was completed. Self-harm burn injuries were identified and hospital medical records were used to extract demographic, burn injury, treatment and outcome information. 94 self-harm burn injuries in 58 patients presented over the study period. Of those who presented with self-harm burn injuries, 29 % (n = 17) of patients presented on more than one occasion, 54 % (n = 50) of wounds were managed surgically and 80 % (n = 36) of full thickness injuries were managed surgically. The post-operative course and healing time was similar to what would be expected after non-intentional burn injuries. In 93 % (n = 54) of all patients presenting with self-harm burn injuries, there was no reported tampering or non-compliance. There was no tampering or non-compliance in 94 % (n = 47) of those with self-harm burn injuries when wounds were treated surgically. The findings support the view that self-harm burn injuries should be treated in the same way as non-intentional burn injuries and that similar outcomes from treatment can be expected. However, further research is needed to explore this systematically.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in acute pancreatitis (AP) are associated with development and worsening of organ failures and poor prognosis. Limited studies suggest that contrast-enhanced computed tomography (CECT) can predict the presence of IAH/ACS. We aimed to study clinical profile of patients with AP and IAH and identify predictive factors of IAH on CECT abdomen. Consecutive patients admitted with moderately severe and severe acute pancreatitis (SAP) were recruited. Clinical and radiological data were recorded prospectively. Intra-abdominal pressure was measured via a urinary catheter to document the presence of IAH/ACS. CECT abdomen was done within the first week of admission and various features that may predict the presence of IAH were studied. Thirty-seven patients (24 SAP) (mean age: 39.78 ± 13.43 years and 67.6% males) with AP were studied. The most common etiology was alcohol (37.7%). IAH developed in 54.05% of patients; patients with IAH had significantly higher bedside index of severity in AP (BISAP), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score, persistent acute lung injury (ALI), persistent acute kidney injury (AKI), persistent cardiovascular failure (CVSF), intensive care unit (ICU) stay, and mortality. Among the CT predictors, patients with IAH more commonly had moderate-gross ascites (60% vs. 23.5%, p-value − 0.026), a pancreatic necrosis of > 50% (50% vs. 17.6%, p-value − 0.04), and a round belly sign (RBS) (50% vs. 5.9%, p-value 0.03). On multivariate analysis, only RBS was predictive of IAH (odds ratio 12.6, 95% confidence interval 1.3–124.2, p-value 0.03). The sensitivity, specificity, positive predictive value, and negative predictive value for RBS were 50%, 94.12%, 90.9%, and 61.54%, respectively. Presence of RBS, moderate-gross ascites, and pancreatic necrosis of > 50% on CECT can predict the presence of IAH in these groups of patients.

Infected pancreatic necrosis (IPN) is associated with poor outcomes. The present study looked at incidence of infection and predictors, if any, in these collections.This prospective observational study was done between July 2019 and October 2020. Symptomatic patients of acute necrotic collections and walled-off necrosis of pancreas requiring drainage were included. Necrotic fluid and blood were analyzed for growth of organisms.Sixty-two patients were included. The mean age was 36.8 years (standard deviation, 11.5 years). Male-female ratio was 4:1. Alcohol was the most common etiology. Infection was noted in 44 of the 62 patients (70.9%) and bacteremia noted in 23 of the 62 patients (37%). Escherichia coli was the most common organism in necrotic collections and Staphylococcus was the most common organism isolated from blood culture. The patients with Modified Computed Tomography-Severity Index of 8 of higher ( P0.001) had significant association with IPN but not with bacteremia. However, splanchnic vein thrombosis ( P = 0.022) was significantly associated with development of IPN as well as bacteremia on both univariate and multivariate analysis.Escherichia coli and Staphylococcus were the most common organisms grown from necrotic collections and blood respectively. Presence of splanchnic vein thrombosis was a significant factor for development of IPN and bacteremia on univariate as well as multivariate analysis.

Renal Doppler to assess renal resistive index (RRI) is an attractive option to prognosticate acute kidney injury (AKI) in acute pancreatitis (AP) as it is feasible within scope of point-of-care ultrasound. However, RRI has been infrequently evaluated in AP.Prospectively study diagnostic and prognostic performance of RRI in patients with AP.75 patients with AP were prospectively enrolled and followed till recovery/death. All patients were subjected to renal Doppler and RRI was compared between patients with and without AKI.Thirty six patients developed AKI and 39 patients did not develop AKI. AKI network stage 1, 2 and 3 AKI was seen in 7(19.4%), 12(33.3%) and 17 (47.2%) patients respectively. Prognostic scoring done at admission by SIRS, modified marshal score, and BISAP scores, as well as duration of hospitalization and mortality rates were significantly higher in patients with AKI. Mean peak systolic velocity and RRI at upper, middle and lower poles of bilateral kidneys were comparable between patients with and without AKI. The RRI was abnormal in 46 (66.6%) patients and it was0.6 in 35/46 (76%) and0.7 in 11/46 (24%) patients respectively. RRI0.6 was observed in 16 (53.3%) and 19 (48.7%) patients with and without AKI respectively (p = 0.80). RRI0.7 was observed in 4 (53.3%) and 7 (48.7%) patients with and without AKI respectively (p = 0.74).AKI is associated with poor prognosis in AP. RRI on renal Doppler at admission seems to have poor diagnostic as well as prognostic performance for AKI in patients with AP.

Objectives Renal pseudoaneurysms are multifactorial in origin, and angioembolization remains the mainstay of treatment. Few case reports have also described percutaneous embolization using glue or thrombin. Our study aimed to evaluate the predictors of active bleed by analyzing their etiology, morphology, imaging features, and treatment adopted. To the best of our knowledge, this is the largest such study done in India. Methods This was a retrospective study of patients treated for renal pseudoaneurysms between 2014 and 2019. We reviewed their clinical data, treatment modalities used, and clinical outcomes. We also assessed computed tomography angiography (CTA) and conventional angiography images. Results A total of 79 patients (54 males and 25 females) were included in the study. The mean age was 39.5 years (range 15–83 years). The most common cause was renal biopsy, followed by surgery. Of these, three patients (3.9%) had more than one lesion and 57% of pseudoaneurysms were seen in lower polar arteries. Active contrast extravasation was seen in 15.2% (n = 12) of the patients and 21.5% (n = 17) showed lobulations in CT and digital substraction angiography. The mean size of the pseudoaneurysms was 1.17 cm (SD 0.7); 22.8% of pseudoaneurysms were wide necked. The embolization was approached by endovascular (89.9%), percutaneous (10.1%), or both (1.3%) routes. Embolization was performed using microcoils (78.5%), gel foam (12.7%), N-butyl cyanoacrylate glue (8.9%), polyvinyl alcohol (8.9%), and thrombin (5.1%) either as a single agent or in combination. The technical success was achieved in all cases after the first procedure. Pseudoaneurysms with a wide neck (p = 0.03) and lobulations (p = 0.002) were associated with active contrast extravasation. Episodes of rebleeding were seen at a younger age (p-value = 0.02). Conclusion Minimally invasive methods remain the cornerstone in the management of renal pseudoaneurysms with high success rates. The morphology of pseudoaneurysms can help predict the risk of active bleeding and decide the type of intervention. Direct percutaneous injection into the aneurysm sac is an alternate technique and should be considered when an endovascular approach is challenging.

To assess the efficacy and outcome of percutaneous thrombin injection in treatment of visceral arterial pseudoaneurysms (PAs) in a selective group of patients.Retrospective review of the institutional database showed 19 cases of visceral arterial pseudoaneurysms that were treated with percutaneous ultrasound-guided thrombin injection between January 2014 and December 2019 (13 men and 6 women). Of the pseudoaneurysms, 36% were due to pancreatitis, 35% were iatrogenic, 21% were infective and 8% traumatic. Most of the pseudoaneurysms arose from the hepatic artery (27%) followed by the splenic artery (26%) and renal artery (21%). Mean sac size of the pseudoaneurysms was 23 mm (range, 8 -40 mm). Technical success was defined as absence of flow within the PAs on follow-up ultrasonography (USG) 24 h and 3 days after thrombin injection.Overall technical success was seen in 10/19 patients. Technical success of thrombin injection was higher in cases of distal branch PAs as compared to main vessel PAs (9/13 vs. 1/6). Success rates were higher with smaller (23mm) pseudoaneurysms (7/12) as compared to larger ones (3/7). There were no procedure-related complications.Ultrasound-guided percutaneous thrombin injection is a novel method of treating visceral pseudoaneurysms as a painless, cheap and radiation-free procedure. However, further large-scale studies are needed to prove the efficacy in treating visceral pseudoaneurysms.

Background and Aims: Previous studies have shown that patients with extra-pancreatic necrosis (EPN) alone are associated with better outcomes than patients with pancreatic necrosis (PN) in acute pancreatitis (AP). The natural history and drainage outcome of pancreatic collections resulting from PN vs. EPN has not been studied. Methods: Clinical records of a prospectively maintained cohort of AP patients who underwent endoscopic drainage of walled of necrosis (WON) were reviewed. Computed tomography (CT) done on day 4 to 7 of illness was reviewed to identify EPN alone (Group 1) or PN with or without EPN (Group 2). Group 1 and 2 were compared for WON characteristics, as well as outcome and adverse effects of endoscopic drainage. Results: Seventy-one patients in Group 2 (57 males; mean age 38.6±11.5 years) were compared with sixteen patients in Group 1 (12 males; mean age 34.5±10.8 years). WON developing in Group 2 were significantly larger (11.7±2.8 cm vs. 9.5±2.03 cm) with higher solid necrotic debris (30.4±9.8% vs. 13.7±7.2%). Endoscopic transmural drainage of WON associated with PN required a greater number of direct endoscopic necrosectomy (DEN) sessions along with a longer time for resolution. The time taken for resolution correlated with size (r=0.629, p

Although gastrointestinal dysfunction is common in patients with acute pancreatitis, its impact on the outcome of disease has not been adequately studied. The present study was conducted to study the frequency of gastrointestinal failure (GIF) as well as its effect on outcome in patients with acute pancreatitis. Patients with acute pancreatitis admitted in our unit were prospectively studied. Gastrointestinal dysfunction and intra-abdominal pressures were measured daily till their resolution, and gastrointestinal failure score was calculated. Baseline parameters including various severity scores were noted. The patients were followed till clinical recovery or death. Sixty-four patients (mean age 41.52 ± 16.28 years; 45 (70.3%) males) were prospectively studied. Forty-five (70.3%) patients had severe disease, and 18 (28.1%) patients succumbed to illness. GIF was present in 31 (48.4%) patients. The median duration of GIF was 5 (range 1–20) days. The presence of GIF was significantly associated with mortality (p value

The development of endoscopic ultrasound (EUS)-guided drainage techniques and lumen-apposing metal stents (LAMS) has markedly reduced the complication rate of endoscopic transmural drainage of pancreatic collections and made these procedures safer and more effective. Despite its improved safety profile, various types of complications, some even life-threatening, can occur after EUS-guided drainage of pancreatic fluid collections. Stent maldeployment/migration, bleeding, gastrointestinal perforation, and air embolism are important complications of EUS-guided drainage of pancreatic collections. Delayed complications weeks after the procedure, such as bleeding and buried LAMS due to the presence of prolonged indwelling transmural stents, have also been described. Careful patient selection, with proper assessment of the size, solid necrotic content and location of the collection, as well as an in-depth understanding of various risk factors that predict complications, are important for a safer and more effective endoscopic transmural drainage. For a better clinical outcome, it is important for the endoscopist to know about various complications of EUS-guided drainage of pancreatic collections, as well as their appropriate management strategies.

Percutaneous catheter drainage (PCD’s) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.

Background Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study. Methods In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase. Results There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase. Conclusion Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.

Background and Objective: Pancreatic fluid collections in early phase of illness

Gastrointestinal fistulization (GIF) is a rare and potentially fatal complication of acute necrotizing pancreatitis (ANP). There is paucity of data on clinical course and outcome of GIF in walled of necrosis (WON). To evaluate frequency, clinical as well as imaging findings and outcome of spontaneous symptomatic GIF in patients with WON. Retrospective analysis of database of patients with asymptomatic WON on regular follow-up over last six years to identify patients with symptomatic GIF. Out of 138 patients with asymptomatic WON seen during the study period, 16 (11.5%) patients (all males; mean age 41.7 ± 9.9 years) developed symptomatic GIF. The mean size of WON in patients who developed GIF was 9.5 ± 2.4 cm, and fistulization occurred after 65.1 ± 17.8 days of the onset of ANP. The site of fistulization was stomach, duodenum, jejunum, colon, and esophagus in seven (43.7%), five (31.2%), one (6.2%), two (12.5%), and one (6.2%) patients, respectively. GIF resulted in spontaneous resolution in two patients (stomach 1 and esophagus 1). The remaining patients with gastric (six patients) and duodenal (five patients) fistulization were successfully treated endoscopically by placing multiple plastic stents in the necrotic cavity after balloon dilatation of the fistulous tract. Patients with colonic fistulization required surgery. None of the patients succumbed to the illness. Symptomatic GIF of WON usually occurs within the first three months of onset of ANP. It commonly occurs in either stomach or duodenum and can be successfully managed endoscopically.

Background Preeclampsia is associated with greater narrowing of the airway than normal pregnancy, but it is not known if these changes worsen during labor and delivery. The aim of the study was to evaluate the airway during and after labor in women with or without preeclampsia. Methods Twenty-five normal and 25 severely preeclamptic pregnant women in early labor were recruited in this single-center, prospective, case-control study. Airway assessment was performed (a) before active labor (b) within one hour of delivery and (c) 24–48 h postpartum. The Mallampati grade was the primary outcome. Sonographic measurements of tongue thickness, anterior neck soft tissue at the level of the hyoid bone and the vocal cords, thyromental distance, and neck circumference, were secondary outcomes. Results The Mallampati score increased from the pre-labor to the post-labor period in both preeclamptic and normotensive patients ( P =0.001 and P =0.002 respectively). A significant difference in tissue thickness at the hyoid level was observed between preeclamptic and normotensive patients pre-labor ( P =0.035), post-labor ( P =0.05) and postpartum ( P =0.05). There was no significant difference in thyromental distance or neck circumference between groups at any time. The total duration of labor and a Mallampati change by one grade correlated (Spearman correlation coefficient 0.473). Conclusion Airway sonography may provide useful bedside anatomical information for prediction of difficult laryngoscopy. The change in airway dimensions and the Mallampati score during labor may persist for 48 h postpartum in both groups. Those with prolonged labor are more susceptible to changes in airway dimensions.

Persistent hyperinsulinemic hypoglycemia in adults is most commonly caused by insulinomas, which pose a diagnostic challenge to physicians, surgeons, and radiologists and require multimodality imaging for precise localization and staging. PET tracers such as F-FDOPA and glucagon-like peptide 1 receptor analogs have been used for imaging insulinomas. Glucagon-like peptide 1 receptor analogs have recently shown promising results in preoperative localization of these tumors, as all insulinomas express glucagon-like peptide 1 receptors. Ga-DOTA-Exendin PET and MRI done in the present case helped in precise localization and management of the culprit lesion, whereas contrast-enhanced CT and F-FDOPA PET failed to do so.

Background & objective: It has been shown that the combined use of alcohol before radiofrequency ablation (RFA) helps to augment the therapeutic advantage of RFA. The present study was conducted to compare the outcome of treatment with RFA alone and RFA with alcohol as ablative technique in patients with small hepatocellular carcinomas (HCCs), who were not candidates for surgery. Methods: Fifty patients with chronic liver disease and concurrent HCC were enrolled in this prospective study. The patients were treated with either RFA alone (n=25) or RFA combined with alcohol (n=25). Patient outcome was evaluated, and the tumour recurrence and survival of the patients were assessed in the two groups. Results: The survival rates at six months in patients who completed at least six months of follow up were 84 and 80 per cent in patients treated with RFA alone and combination therapy, respectively. During the follow up period, 11 and four patients treated with RFA alone showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at one to 18 months of the follow up period. The distant recurrences occurred at 6-36 months of the follow up period. During the follow up period, eight and six patients treated with combination therapy showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at 1.5-15 months during the follow up period. The distant intrahepatic recurrences occurred at 6-72 months during the follow up period. Interpretation & conclusions: No significant difference was seen between the survival time of the patients treated with RFA alone and RFA with alcohol as well as in the local recurrences and distant intrahepatic recurrences in RFA compared to RFA and alcohol group patients. Combined use of RFA and alcohol did not improve the local tumour control and survival in patients with HCC compared to RFA alone.

Background Renal pseudocysts (RP) are rare and we know little about their presentation and management. In the present case series, we present the pertinent clinico-radiological features as well as the role of endoscopic drainage in symptomatic RP. Methods A retrospective analysis was performed of patients with RP seen in our unit over the last 12 years. Patient symptoms, imaging findings and details of endoscopic or endoscopic ultrasound (EUS)-guided drainage procedures were evaluated. Results Eight patients with RP (7 male; mean age: 33.1 years) were studied. Seven patients had underlying chronic pancreatitis (calcific in 3), predominantly alcohol-related. The mean size of the RP was 8.5 cm. All patients presented with abdominal pain and none had urinary complaints. The RP could be well detected on both contrast-enhanced computed tomography and EUS. None of the patients had significant debris on EUS. Five patients were treated with combined transmural and transpapillary drainage, 2 patients were treated with transpapillary drainage alone, while combined percutaneous and transpapillary drainage was performed in 1 patient. All patients had partial disruption of the main pancreatic duct and a bridging transpapillary endoprosthesis was successfully placed. The RP resolved in all patients within 2-6 weeks and no patient required surgery. There were no complications and no patient had recurrence of RP over a follow-up period of 3-118 months. Conclusion RP are usually associated with abdominal pain and do not cause renal symptoms. Endoscopic drainage is a safe and effective minimally invasive management option for RP.

External pancreatic fistulae (EPF) associated with complete pancreatic duct (PD) disruption leading on to disconnected pancreatic duct syndrome (DPDS) is a therapeutic nightmare usually requiring surgery. However, spontaneous closure also has been reported. There is paucity of data on the natural history of EPF associated with DPDS.To retrospectively study outcome of conservative treatment in patients with low output (200 ml/day) EPF with DPDS following percutaneous or surgical intervention in acute necrotising pancreatitis (ANP).The data of patients of low output EPF with DPDS treated conservatively in our unit over last 5 years was retrospectively analysed. Their clinical course, complications as well as time taken for fistula closure was retrieved.33 patients (27 males; mean age: 40.5 ± 9.3 years) of low output EPF and DPDS were studied. 31 patients developed EPF following percutaneous drainage (PCD) and 2 patients developed fistula following surgery. The drain fluid amylase ranged from 1600 to 32,000 IU/l and site of disruption was neck, proximal body and distal body in 4, 16 and 13 patients respectively. EPF closed spontaneously in all patients within 88.2 ± 63.46 days. PCD slipped out in 2 patients and led to formation of pseudocyst in 1 patient that was treated endoscopically. There has been no recurrence in any patient over follow up of 32.5 ± 21.9 months.Low output EPF developing post PCD or surgery in patients with DPDS following ANP closely spontaneously in majority of patients within 3 months with good long term outcome.

Aim: To evaluate the feasibility and outcome of percutaneous glue embolisation as primary treatment for pseudoaneurysms in selective patients.Material and methods: A review of the pseudoaneurysm ca...