Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis

Background Arterial pseudoaneurysm formation in pancreatitis is a rare complication. The optimal treatment modality is controversial. Operative treatment and interventional treatment, either alone or as a temporizing method with a later operation, are options. Methods In this single-center, patient-based cohort study, we managed 35 patients (8 with necrotizing pancreatitis and 27 with chronic pancreatitis) with bleeding pseudoaneurysms treated over a period of 10.5 years with a median follow-up of 4.6 years. Angiography was performed depending on the patient's hemodynamic condition. Results Angiography had a sensitivity of 96% for 26 patients. Angiographic embolization as primary treatment was performed in 16 patients (61% embolization rate); there were 2 rebleeding complications. No patients required intervention for embolization complications after discharge. Nineteen patients (54%) underwent an operation, 9 urgently without angiographic evaluation. The overall mortality rate for the 35 patients was 20% (19% for embolization, 21% after an operation). For necrotizing pancreatitis, an advantage of angiographic embolization was observed (mortality in 2/5 vs 2/3 after surgery). Ligation or repair of the bleeding vessel was complicated by higher rebleeding rates (6/13) than partial pancreatectomy (1/6). Conclusions Concerns that angiographic embolization is unable to provide definitive hemostasis in both acute and chronic pancreatitis are unfounded. In the operative treatment of chronic pancreatitis, partial pancreatectomy is superior to vessel ligation, depending on the patient's general condition and degree of pancreatic inflammation. We propose an algorithm for the management of arterial pseudoaneurysms in the setting of pancreatitis.