EUS-guided n-butyl-2-cyanoacrylate injection therapy for ruptured isolated left gastric artery pseudoaneurysm

Rupture visceral artery aneurysms (VAAs) are a life-threatening condition rarely occurring from left gastric artery accounting for 1%–4% of all VAAs.[1,2] Selective angiography mostly allows to perform coil embolization of the VAA. Some case reports of endoscopic ultrasound (EUS)-guided injection therapy were successful as an alternative if angiography failed by small caliber vessel or short neck of pseudoaneurysm.[3,4] We present a successful case of EUS-guided histoacryl injection for ruptured left gastric pseudoaneurysm.

A 55-year-old male was evaluated in admission for hematemesis. Computed tomography (CT) demonstrated saccular pseudoaneurysm through left gastric artery complicated by pancreatic pseudocyst [Figure 1a]. Endovascular therapy appeared inaccessible due to invisibly small-caliber feeder arteries of the pseudoaneurysm. After the informed consent, EUS was performed using linear echoendoscope (Olympus Tokyo Japan-GF-UCT260) for therapeutic embolization [Video 1]. After localizing the pseudoaneurysm, under color Doppler, super-thin feeder artery was visualized, and shortest puncture route was identified [Figure 1b]. We used histoacryl (n-butyl-2-cyanoacrylate) for embolic materials. One empty 1 mL syringe filled with 1 mL histoacryl and another 1 mL syringe filled with 0.5 mL normal saline were prepared. Using Expect™ 22G needle (Boston Scientific, MA, United States), pseudoaneurysm was punctured, and blood was then drawn into the syringe followed by 1.0 mL normal saline injection. Subsequently, 1.0 mL histoacryl injection was performed, instantly followed by 0.5 mL normal saline flush, confirming the pseudoaneurysm become echogenic resulting in solidification [Figure 1c]. The needle was removed when no color filling was seen inside the pseudoaneurysm. CT revealed complete embolization of the pseudoaneurysm in 2 months [Figure 1d]. There was no further episode of bleeding during the follow-up.

Figure 1.

(a) Computed tomography scan showed left gastric artery pseudoaneurysm (yellow arrow) without any visible feeder artery in the gastric wall. (b) EUS targeted left gastric artery pseudoaneurysm from the posterior side of stomach. Small-caliber feeder artery(*) was identified on color Doppler. (c) 1.0 mL histoacryl was injected and became solidifized in the pseudoaneurysm, instantly showing dense acoustic shaddow on EUS. (d) Computed tomography scan revealed complete embolization of the pseudoaneurysm in 2 months

Limitations of histoacryl instillation include the risk of distant thrombosis or allergic reactions,[5] although rare. The use of EUS-guided histoacryl injection provides a dynamic visualization of embolization of pseudoaneurysms in a real time. This report highlights the potential role of successful EUS-guided histoacryl embolization of pseudoaneurysm when inaccessible angiographically.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.