PMC7708967_01
A 69-year-old female with splenic pseudoaneurysm secondary to a confirmed history of chronic pancreatitis, presenting with hematemesis, hemodynamic instability, and gastrointestinal bleed. Findings: Pre-contrast axial (a and b) and coronal (c) images of CT angiography of the abdomen and pelvis showed a collection (asterisk) inseparable from the pancreatic tail measuring 7.9 x 4.9 x 5.6 cm in three dimensions with peripancreatic inflammation. Small calcifications were detected surrounding the collection reflecting the pancreatic parenchyma consistent with the clinical history of chronic pancreatitis. Contrast-enhanced CT aortogram arterial phase axial (c and d) and coronal (f) images demonstrated shallow pooling of contrast along the superior aspect of the collection as evidenced by axial (e, arrow) and coronal (f, arrow) images, suggested of pseudoaneurysm of the splenic artery.
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F1
Pre-contrast CT [Figure 1a-c] identified pancreatic calcifications consistent with chronic pancreatitis and a well-circumscribed hypodensity focus occupying the expected location of the pancreatic tail. CT angiographic images [Figure 1d] revealed hyperattenuating material within the hypodense focus. Close inspection on the arterial phase images demonstrated a linear extravasation of contrast material [Figure 1e and f], and diagnosis of pseudoaneurysm arising from the splenic artery was made.
A 69-year-old female with splenic pseudoaneurysm secondary to a confirmed history of chronic pancreatitis, presenting with hematemesis, hemodynamic instability, and gastrointestinal bleed. Findings: Longitudinal gray scale transabdominal ultrasonography image (a) of the pancreatic region shows an anechoic lesion with posterior acoustic shadowing (asterisk) measuring 5.3 x 5.7 cm. Transverse color Doppler (b) sonogram demonstrated turbulent flow (red-blue) in the lesion. Thus, the structure should be vascular in its nature and is shown with the characteristic "yin-yang" sign (big arrow) compatible with pseudoaneurysm of the splenic artery as depicted by the magnified view (c). Note the pseudoaneurysm neck is illustrated (dashed lines). Color Doppler and spectral analysis (d and e) taken at the site of the pseudoaneurysm shows bidirectional blood flow of arterial (d, arrow) and venous flow (e, arrowhead) consistent with the to-andfro pattern. Ao: Aorta. Spl A: Splenic artery, PsA: Pseudoaneurysm.
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F2
Transabdominal ultrasound showed a 5.3 x 5.7 cm mass in the region of the pancreas [Figure 2a]. The mass was found with strong internal Doppler flow signals as demonstrated by the yinyang sign [Figure 2b] consistent with pseudoaneurysm. Color doppler flow image depicts the pseudoaneurysm and its neck to the splenic artery when chasing caudally [Figure 2c]. Follow up spectral analysis was performed that shows a bidirectional turbulent blood flow of a "to-and-fro" pattern of the pseudoaneurysm [Figure 2d and e].
Selective digital subtraction angiograms showing pre- and post-embolization of a splenic artery pseudoaneurysm. Findings: A pre-intervention angiogram of the celiac trunk (a) shows a large pseudoaneurysm (asterisk) arising from the splenic artery (SA). There is a jet of contrast material from the splenic artery into the pseudoaneurysm that is compatible with extravasation (a, red arrow). Delayed angiogram (b) showing contrast blush suggestive of active bleeding from the pseudoaneurysm (asterisk). Note the spleen parenchyma blush is noted. (c) DSA shows the proximal inflow (arrowhead) and distal outflow (curved arrow) of the splenic artery along with the neck (dashed arrow) and pseudoaneurysm itself (asterisk) is packed with microcoils. (d) A post-intervention arteriogram demonstrates the successful exclusion of pseudoaneurysm by coil embolization (blue arrow). CT: Celiac trunk, GEA: Gastroepiploic artery, DSA: Digital subtraction angiogram.
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F3
In the interventional radiology suite, a conventional diagnostic angiogram of the celiac axis and splenic artery shows a pseudoaneurysm at the junction of the proximal and mid third of the splenic artery [Figure 3a]. At the delayed catheter angiography depicts contrast blush within the pseudoaneurysm without contrast extravasation into the pancreatic duct, which suggest intermittent bleeding [Figure 3b]. Three additional microcoils (4 mm x 13 cm) were deployed into the inflow proximal splenic artery [Figure 3c]. Post embolization angiographic images of the splenic artery confirmed the successful exclusion of pseudoaneurysm by coil embolization [Figure 3d].
Findings: Digital subtraction angiogram shows that the neck of pseudoaneurysm is cannulated and detachable coils being deployed into the pseudoaneurysm (curved arrow). Note the distal splenic artery was embolized with coils (arrow) occluding the outflow tract since pseudoaneurysm is arising from splenic artery trunk, which has collateral supply.
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F4
The "sandwich" technique was elected by the interventional radiology team to embolized the distal and proximal flow to the pseudoaneurysm to avoid anterograde and retrograde perfusion [Figure 4].