From Pseudocyst to Pseudoaneurysm: A Complex Pancreatic Vascular Emergency Managed With a Multi-stage Interventional Radiology Approach.

Acute-on-chronic pancreatitis is frequently complicated by the formation of pancreatic pseudocysts (PPs). Haemorrhage within a pseudocyst is a life-threatening event, typically resulting from the development of a pseudoaneurysm (PA) involving adjacent arterial structures. First-line treatment is endovascular embolization, an interventional radiology (IR) approach. However, if embolization fails, remaining treatment options are severely limited, as surgery is often considered high-risk or unfeasible. We present a case of chronic pancreatitis complicated by a haemorrhagic PP complicated by PA formation of several adjacent vessels within the pancreatic head. The patient was successfully managed with multiple embolization sessions, performed by IR, the only viable treatment option in this scenario. A 43-year-old man with a history of alcohol-related liver cirrhosis (Child-Pugh B), alcoholic hepatitis, and recurrent chronic pancreatitis presented with melaena. Computed tomography (CT) imaging revealed a pseudocyst in the pancreatic head containing internal haemorrhage, with active bleeding from multiple arterial feeders within the pancreaticoduodenal arcade (PDAA). Five direct angiography sessions were required. A large amount and combination of coils as well as large volumes of glue (Glubran II; GEM S.r.l., Lucca, Italy), and stent placement were all necessary to achieve complete occlusion of all feeding vessels causing bleeding within the PP. Surgical intervention would have necessitated a pancreaticoduodenectomy in a hostile operative field, with prohibitively high morbidity and mortality. Endovascular embolization remains the treatment of choice for PA in the setting of haemorrhagic pancreatic pseudocysts. This case highlights the life-saving role of IR, particularly when surgical options are unfeasible. It also emphasizes the importance of timely escalation, multidisciplinary decision-making, and advanced embolization techniques. Notably, this is the first reported case of a persistently haemorrhagic PP successfully managed with a multi-stage interventional radiology approach incorporating Glubran II, coils, thrombin, and covered stent deployment. Given the rarity of the condition and the effectiveness of the treatment, this case describes an evolving endovascular strategy finding application in a highly complex clinical scenario.