Endoscopic ultrasonography-guided obliteration of a left inferior phrenic artery pseudoaneurysm in a patient with alcoholic chronic pancreatitis.

A 43-year-old man who was known to have alcoholic chronic pancreatitis presented with upper gastrointestinal bleeding (UGIB) with shock in September 2016. He was resuscitated with crystalloids and a blood transfusion. He underwent gastroduodenoscopy, colonoscopy, and computed tomographic angiography (CTA), but no source of bleeding was revealed. He had a second episode of UGIB in December 2017. CTA on this occasion revealed contrast extravasation, probably from the left inferior phrenic artery (LIPA) (▶Fig. 1). Digital subtraction angiography (DSA) confirmed the contrast leak from the LIPA (▶Fig. 2) but embolization could not be performed owing to dissection of the artery during wire manipulation. Percutaneous thrombin (500 units) was therefore injected using a trans-splenic approach under Doppler ultrasonography guidance (▶Fig. 3) with subsequent thrombosis of the pseudoaneurysm. The patient re-bled 1 month later and CTA showed a revascularized LIPA pseudoaneurysm. Because of the large size of the pseudoaneurysm and the previously failed DSA, endoscopic ultrasonography (EUS)-guided obliteration was planned. Linear EUS examination from the gastroesophageal junction showed a large pseudoaneurysm (3.6 ×2.3 cm). The pseudoaneurysm was punctured with a 19-gauge needle (Echo-19; Cook India) and 3mL undiluted N-butyl 2-cyanoacrylate glue (NBCA) was injected to completely obliterate the pseudoaneurysm including the feeding vessel (▶Video1). There has been no recurrence of bleeding during the subsequent 9 months of follow-up. Chronic pancreatitis-associated pseudoaneurysmal bleeding is well known. EUS has been reported as being useful both for the diagnosis and embolization of pseudoaneurysms [1]. The present case was unusual in many respects: (i) the involvement of the LIPA is rare with only one published report in chronic pancreatitis and the location of the pseudoaneurysm made it unsuitable for percutaneous intervention [2]; (ii) the pseudoaneurysm was large (>3 cm in size); and (iii) EUS-guided glue injection has been used infrequently. Because of the E-Videos