Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis

Clinical question
What are the immediate and long-term outcomes of percutaneous radiological interventions in patients with either acute or chronic pancreatitis associated with hemorrhagic complications?

Take away point
No significant difference in outcomes—including success rates, complications, and recurrences—between patients with acute or chronic pancreatitis who received percutaneous radiological treatment for their hemorrhagic events.

Reference
Kumble Seetharama Madhusudhan, MD, FRCR, Srikanth Gopi, DM, Anand Narayan Singh, MCh, Lokesh Agarwal, MS, Deepak Gunjan, DM, Deep N. Srivastava, MD, and Pramod Kumar Garg, DM. 08/2021. Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis. Journal of Vascular and Interventional Radiology. Volume 32, Issue 11, 1591-1600.

Click here for abstract

Study design
Retrospective, observational, cohort study.

Funding Source
No reported funding.

Setting
Tertiary Care Center, Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences (New Delhi, India).

Figure


Figure 1. Flowchart of the study. DSA: digital subtraction angiography, FU: follow-up.

Summary

Hemorrhagic events in cases of pancreatitis are relatively rare but can occur due to pseudoaneurysm formation, and are associated with high mortality rates. Invasive surgical intervention in such cases has high morbidity. Percutaneous embolization for patients with acute pancreatitis (AP) and chronic pancreatitis (CP) shows a high success rate but can be technically challenging. This study aimed to compare the immediate and long-term outcomes of percutaneous radiological interventions between patients with hemorrhagic complications associated with AP or CP.

The data for this retrospective cohort study was obtained from patients at a tertiary care center who received digital subtraction angiography (DSA) and endovascular intervention from January 2014 to March 2020. The mean age of patients for AP and CP were 36.5 ± 11.7 (78% [39/50] male) and 37.4 ± 11.9 (96% [54/56] male) respectively. DSA was performed via a transfemoral route. Angiography of the celiac, superior mesenteric, and inferior mesenteric arteries was performed in order to visualize the bleeding artery. The abnormal artery was then embolized using metallic coils (sandwich technique) or a mixture of glue and ethiodized oil. If endovascular embolization was unsuccessful, percutaneous embolization via ultrasound guidance was performed. Radiological interventions were correlated with clinical, angiographic, and embolization parameters. All data were analyzed using SPSS 21 software.

Technical success (complete occlusion of pseudoaneurysm or target artery) and clinical success (30-day absence of recurrent bleeding post-embolization) were not significantly different between the AP and CP groups. The overall technical success rate was 97.4% (114/117, 95% CI, 94.5-100.3%). The incidence of complications between the two groups was also not statistically different. In the AP group, 4 patients had complications post-embolization (2 splenic infarcts and 2 patients experiencing abdominal pain). In the CP group, 11 patients had complications (2 splenic infarcts, 4 splenic abscesses, and 5 patients experiencing abdominal pain). Incidence of complications was more commonly seen in older patients, female patients, bradycardic patients, and patients with a longer time-period between presentation and DSA. The higher rate of mortality in the AP group (50%, due to accompanying organ failure and sepsis) compared to the CP group (1.8%) was statistically significant (P < 0.001). The high mortality found in this study was attributed to all patients having severe presentation, with 1 or more organ failure. No significant impact was found for the embolization parameters impact on complications, recurrence of hemorrhage, and mortality. Most post-embolization patients did not experience symptoms during follow-up, and did not experience any unfavorable long-term impacts.

Commentary

This study conducted a detailed intermediate and long-term outcome comparison of interventional radiology embolization procedures in patients with hemorrhagic acute and chronic pancreatitis. Success, complications, and recurrence were comparable in the two groups. The high mortality observed in the hemorrhagic acute pancreatitis group was largely attributed to organ failure and sepsis.

Therefore, despite higher mortality rates observed in the hemorrhagic acute pancreatitis group, high technical and clinical success rates of percutaneous embolization support its use in this high-risk high-mortality population. Some questions remain to be addressed. For example, how would the comparison look like in a lower-acuity clinical setting (i.e. less severe cases or in patients without organ failure). Would a risk stratification system for acute pancreatitis help us in identifying patients who are more likely to develop hemorrhagic complications and therefore should receive aggressive fluid collection drainage. management?

Post Author
Malik Ata
Medical Student
University of Illinois College of Medicine – Chicago

Edited and formatted by @NingchengLi

Interventional Radiology Resident

Dotter Institute, Oregon Health and Science University

Prevalence of and Factors Associated with Arterial Aneurysms in Patients with Hereditary Hemorrhagic Telangiectasia: 17-Year Retrospective Series of 418 Patients

Clinical question
What is the prevalence of and characteristics associated with the presence of aneurysms in patients with hereditary hemorrhagic telangiectasia (HHT)?

Take away point
Compared to the general population, the prevalence of intracranial and visceral arterial aneurysms is higher in this specific cohort with HHT. Older age, unrelated AVMs and ACVRL1 mutation were associated with having an aneurysm.

Reference
Prevalence of and Factors Associated with Arterial Aneurysms in Patients with Hereditary Hemorrhagic Telangiectasia: 17-Year Retrospective Series of 418 patients (2021). Ring, N., et al. Journal of Vascular and Interventional Radiology, Volume 32: 1661-1669.

Click here for abstract

Study design
Retrospective, observational and descriptive study.

Funding Source
No funding.

Setting
Single center; HHT Center of Excellence

Figure

Summary

Hereditary Hemorrhagic Telangiectasia (HHT) is a genetic disorder characterized by vascular malformations and defined by the Curaçao criteria. Diagnosis requires inclusion of three out of four criteria: (1) recurrent epistaxis, (2) mucocutaneous telangiectasia (3) visceral lesions and (4) having a first-degree with HHT. The most well-known associated genetic mutations involve the transforming growth factor-beta (TGF-β) signaling pathway and the Endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) pathways. The TGF- β pathway has been shown to be involved in vascular remodeling and subsequent abnormal angiogenesis. Case reports suggest an increased risk of arterial aneurysms within the HHT population. This study seeks to estimate the prevalence and location of arterial aneurysms and identify any associated clinical and demographic characteristics associated with aneurysms in patients with HHT.

The study was performed at a single center, which is established as a center of excellence. A total of 418 patients with HHT were identified via chart review. The presence and characteristics (eg size, number and location) were collected. Regression modeling was performed to evaluate the following potential associations, which are known to be associated with an increased risk of aneurysms: older age, male sex, smoking, alcohol, hypertension, hyperlipidemia, genetic mutations, the presence of arteriovenous malformations unrelated to aneurysms and HHT-related genetic mutations.

Out of 418 patients, 43 (10.3%) patients had at least one aneurysm, with a total of 73 aneurysms. Eighteen (4.3%) had intracranial aneurysms and twenty patients had visceral aneurysms (4.8%), which included splenic, renal, hepatic and pancreatic aneurysms. Less than two percent were pulmonary aneurysms unrelated to AVM’s, thoracic aortic aneurysm and coronary artery aneurysms. Please see figure one for a case with multiple arterial aneurysms. Of the Curaçao criteria, only the presence of unrelated aneurysms was statistically significant. The mean Curaçao score was significantly higher in patients with aneurysms. Patients with an ACVRL1 mutation had the highest rate of arterial aneurysms (20.0%). Results from the regression analysis demonstrated presence of the ACVRL1 mutation, unrelated AVMs and older age significantly associated with having at least one aneurysm.

Meta-analyses describe the prevalence of intracranial aneurysms as 1.8-3.2% in patients without comorbidities, compared to 4.3% of patients in the present study. Prevalence of visceral artery aneurysms in the general population is 0.1-2.0%, compared to 4.8% of patients in the present study. 

A particular limitation discussed within this study surrounds the association between an unrelated AVM and an unrelated arterial aneurysm. Due to this finding, the patients underwent additional screening and may have been more likely to have an incidental aneurysm discovered. The nature of the study, single center and retrospective, limits the conclusions. The benefits of screening require further research, as the study underscores the uncertainties surrounding screening for brain AVMs in patients with HHT.

Commentary

This study demonstrates a higher rate of intracranial and visceral arterial aneurysms in their cohort of HHT patients when compared to the general population. As discussed by the authors, the largest limitation is comparing these results to the general population. The rate of aneurysms in the general population is based on research that excluded “comorbidities”. What comorbidities did they exclude and were these excluded in the present study? HHT is not an isolated diagnosis and so the small, though significant, percentage difference between the two groups could possibly be explained by comorbidities. The single-center nature of the study may also limit the conclusion regarding increased aneurysms among patients with the ACVRL1 mutation. Given HHT is an autosomal dominant genetic disorder, the same mutation may be expressed in one family living in a similar geographic area. The higher percentage of patients with ACVRL1 mutation may have allowed increased power to reach significance. 

Overall this is an excellent foundational paper for future prospective studies. Establishing an appropriate comparison group would likely strengthen the conclusions and help develop screening applications regarding frequency, age initiation, and risk stratification. 

Post Author
Marissa Stumbras, MD
Interventional Radiology Resident, PGY3
Oregon Health & Science University
@MarissaStumbras

Edited and formatted by @NingchengLi

Interventional Radiology Resident

Dotter Institute, Oregon Health and Science University