Endoscopic Ultrasound-Guided Endotherapy for Visceral Artery Pseudoaneurysm: A Case Report and Systematic Review of the Literature.

Visceral artery pseudoaneurysms (VAP) develop following inflammatory pathology or trauma. Endovascular management remains the gold standard as per the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) standards. However, when endovascular therapy is not feasible, other modalities like percutaneous or endoscopic ultrasound (EUS)-guided embolization have also been utilized. Lately, EUS-guided procedures have been reported increasingly in the literature. We report a case of post-laparoscopic cholecystectomy cystic artery pseudoaneurysm complicated by associated biliary injury. It was initially managed with EUS-guided glue and coil embolization, but the patient developed recurrent bleeding with formation of a pseudoaneurysm-duodenal fistula. This complication was successfully salvaged with emergency surgery. Coexistent biliary injury was subsequently repaired with hepaticojejunostomy. We have performed a systematic review of the available literature to assess the current status of the EUS-guided endotherapy for VAP. A systematic review has been conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Handbook for Systematic Reviews and Interventions guidelines. Literature search showed 30 studies with 122 patients in whom VAP was managed by EUS-guided intervention. Studies primarily included case reports (n = 15), case series (n = 8), videos (n = 4), images (n = 2), and abstracts (n = 1). Most of the patients (108, 88.5%) were male, mean age of the cohort was 41.9 years (range: 18-73 years), chronic pancreatitis was the most common etiology, reported in 85 (69.7%) cases, splenic artery was the most commonly involved vessel, seen in 76 (61.8%) cases, and upper gastrointestinal bleeding was the most common presentation, reported in 83 (68%) cases. Unfavorable anatomy for angioembolization was the most common indication for EUS-guided endotherapy, reported in 26 (21.3%) cases, followed by failed angioembolization, which was reported in 19 (15.6%) cases. A combination of cyanoacrylate glue with coil was used in 70 (57.4%) patients during endotherapy. Pooled clinical success rate of EUS-guided endotherapy for VAP was 94.25% (95% confidence interval: 88.43-97.40%), with technical success rates approaching 100%. Pooled complication rate was 11.54% (95% CI: 6.11-19.29%), with recurrent bleeding in four (3.85%, 95% CI: 1.19-9.79%), and solid organ complications (infarct/abscess involving spleen and/or liver) in five (4.8%, 95% CI: 1.79-11.04%). Recanalization of pseudoaneurysm was noted in two patients (recurrence rate: 1.64%, 95% CI: 0.08-6.15%) on follow-up. Post-cholecystectomy cystic artery pseudoaneurysm is a rare complication. EUS-guided intervention is an evolving technique for the management of visceral artery pseudoaneurysm. There is limited and low-level evidence available at present to clearly define the role of EUS-guided endotherapy in the overall management of visceral artery pseudoaneurysm. EUS-guided intervention is a rescue therapy only for VAP at present; its first-line use (as in this case) is not supported. Endovascular management of visceral artery pseudoaneurysm remains the standard of care. Surgery remains the rescue intervention in cases where other interventions have failed.