Case Report Direct Aneurysm Puncture and Coil Occlusion: A New Approach to Peripancreatic Arterial Pseudoaneurysmsl Paul Capek, MD Monica Rocco, MD John McGahan, MD Charles Frey, MD A patient with pancreatitis complicated by a pseudoaneurysm in the pancreatic head was treated with a radiologic-surgical approach.At sur- gery, the phlegmon was exposed and treated by means of direct punc- ture and embolization with Gianturco coils under color Doppler flow im- aging guidance. Index terms: Aneurysm, pancreatico- duodenal, 95.73 Aneurysm, therapy, 952.1299, 95.73 Pancreatitis, 770.291 JVIR 1992: 3:653-656 From the Departments of Radiology (P.C., J.P.M.) andsurgery (M.R., C.F.), University of California Davis Medical Cen- ter, 2516 Stockton Blvd, Ticon I1 Bldg, Sac- ramento, CA 95817. Received April 21, 1992; revision requested June 12; revision received July 8; accepted July 20. Address reprint requests to P.C., San Pedro Ra- diology, 1300 W 7th St, San Pedro, CA 90732-3594. ' SCVIR, 1992 PsEuDoANEuRYsM formation occurs in up to 10% of patients with chronic pancreatitis (1). These aneurysms have a propensity to rupture and are associ- ated with death from catastrophic ex- sanguination (2,3).In patients who survive immediate exsanguination, operative mortality is high and is de- pendent on the location of the pseudo- aneurysms, with those located in the pancreatic head associated with the highest mortality (4).More recently, angiographic embolization of feeding vessels has been used in conjunction with surgery in the management of these patients (5). In certain situations, endovascular occlusion is not possible due to abnormal vascular anatomy. Likewise, due to the intense, wide- spread inflammation, surgery alone is not able to safely achieve selective occlusion of the aneurysm. We report a combined radiologic-surgical proce- dure applied to a symptomatic pseu- doaneurysm that was not approach- able by the standard methods. After operative exposure, this aneurysm was treated by means of direct punc- ture and embolization with Gianturco coils under color Doppler flow imaging guidance. CASE REPORT A 52-year-old woman with a history of gallstone pancreatitis was trans- ferred to our institution with abdomi- nal pain, acute upper gastrointestinal bleeding, and multiple pancreatic pseudocysts. A color Doppler ultra- sound (US) scan demonstrated a 4-cm pseudoaneurysm posterior to a large pseudocyst in the head of the pancreas (Fig 1). A mesenteric arteriogram helped confirm the pseudoaneurysm in the pancreatic head, but the exact feed- ing vessel could not be identified. Fur- thermore, the celiac axis was occluded with corresponding dilatation of the pancreaticoduodenal arcades, which were supplied by the superior mesen- teric artery. Due to the extreme tortu- osity of the pancreatic-duodenal col- laterals, it was not possible to more selectively catheterize the potential feeding vessels (Fig 2). An attempt to catheterize the occluded celiac artery was unsuccessful. Several surgical approaches were considered, including revascularization of the celiac artery, pancreatoduode- nectomy, or a direct opening of the pseudocyst with an attempt to ligate the pseudoaneurysm. Revasculariza- tion of the celiac axis was considered high risk in the face of the often intense inflammation associated with a pseu- docyst. Neither pancreatoduodenec- tomy nor embolization of the inferior pancreaticoduodenal artery was feasi- ble, as these would interrupt the blood supply to the liver, spleen, and stom- ach. Opening the pseudocyst and ligat- ing the pseudoaneurysm had many risks-not the least of which was that in controlling the hemorrhage, the infe- rior pancreaticoduodenal artery, which supplied the liver, stomach, and spleen, might have been ligated. Therefore a plan was developed consisting of a com- bined surgical and radiologic approach to thrombose the aneurysm without interrupting the blood supply to the