A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.
A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.