Bleeding giant pseudoaneurysm non-visualized on arterial phase imaging: Endoscopic ultrasound-guided angioembolization to the rescue.

A 51-year-old man, with known diabetes and coronary artery disease and a history of acute pancreatitis, presented with melena for 1 day. Investigations revealed anemia (hemoglobin 6.8 gm/dl) with tachycardia. After initial resuscitation, computed tomography (CT) angiography was done. In the arterial phase, no extravasation or aneurysm was noted ([Fig. 1]). However, in the venous phase, contrast filling was noted with a giant pseudoaneurysm measuring 7.2 × 6.2 × 9.7 cm, likely arising from the splenic vessel ([Fig. 2]). The patient, being a poor candidate for radiological endovascular therapy (non-visualization on arterial phase, narrow neck) as well as surgery (multiple comorbidities), was planned for endoscopic ultrasound (EUS)-guided angioembolization. EUS-guided localization of the aneurysm was done and Doppler showed turbulent blood flow in the giant pseudoaneurysm ([Fig. 3]). It was punctured with a 19-G needle (EZ Shot3 Plus; Olympus Medical, Tokyo, Japan) and blood aspirated to confirm the position. After flushing the needle with saline, four Nester coils (20 mm × 14 cm) were deployed one after the other. Using this coil-complex as a scaffold, 4 ml of cyanoacrylate glue was injected. The coil-glue cast formed caused thrombosis of the blood contents, which gradually increased in size and slowed the intravascular turbulence ([Fig. 4] ). On further observation for another 1 minute, the whole aneurysm showed formation of an echogenic thrombus with minimal flow ([Video 1]). A repeat EUS 48 hours later showed complete obliteration of the pseudoaneurysm with no flow ([Fig. 5]), and CT revealed coil artifacts with no filling in the venous phase. At the 1-year follow-up, the patient was doing fine with no further bleeding episodes.