Bleeding pancreatic pseudoaneurysms: management by angioembolization combined with therapeutic endoscopy.

Background: Bleeding pancreatic pseudocysts (PPCs) are a rare but lethal complication of pancreatitis. Transcatheter arterial embolization (TAE) is the first-line treatment of acute hemorrhage, but consensus on the definitive management of bleeding PPCs is lacking. The aim of this study was to evaluate the safety and efficacy of the combination of TAE and therapeutic endoscopy in the treatment of bleeding PPCs.
Methods: Patients with acute or chronic pancreatitis treated for bleeding PPCs in Helsinki University Hospital during 2004-2014 comprised the study group. Inpatients with acute necrotizing pancreatitis were excluded. Patients underwent TAE as the primary treatment to control the bleeding. Therapeutic endoscopy performed on an outpatient visit after TAE allowed the definitive treatment of PPCs.
Results: A total of 58 patients underwent TAE. Re-bleeding rate (<30 days) was 15.5 %, necessitating re-embolization on seven and surgical intervention on two patients. Overall, TAE success rate was 96.6 %. Mortality rate (<30 days) was 3.4 %. Of the 58, 47 patients were followed up for their PPCs in our unit. PPCs resolved spontaneously in 13 (27.1 %). The remaining 34 had an endoscopic treatment attempt with endoscopic draining performed on 32 and unsuccessful cannulation on two (5.9 %). Of the 32 patients with initially successful endoscopy, 7 (21.9 %) needed an additional drainage procedure (six non-surgical and one surgical). Overall success rate of non-surgical management was 91.5 %. Post-endoscopy mortality rate (<30 days) was 2.9 %. Our follow-up continued for 15 (1-75) months. By the time of data retrieval, 35 of 58 patients had died with alcohol liver disease being the most common cause of death. Five-year survival estimate was 63 %.
Conclusions: Bleeding pancreatic pseudoaneurysms require non-surgical management. We need more data on the optimal timing of therapeutic endoscopy and on the role of empirical embolizations.