Peripancreatic pseudoaneurysms: a management-based classification system

Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.

A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.

The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.

The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.