Objectives

To identify the various vascular and nonvascular complications of severe acute pancreatitis (SAP)

To highlight the pivotal role of interventional radiology(IR) in the management of these complications

To describe the technique of percutaneous catheter drainage(PCD) and outline its key role in the multidisciplinary management of pancreatic collections

To illustrate the different techniques of endovascular and percutaneous management of vascular complications of SAP and elucidate their role according to the clinical setting

Background

SAP is characterized by persistent organ failure and pancreatic and/or peripancreatic necrosis and is associated with high rates of morbidity and mortality (20-30%)

Patients in late phase of disease (according to Revised Atlanta) are at high risk of developing secondary infection of pancreatic necrosis

Optimal treatment now consists of a “Step-up” approach with initial intensive conservative management, attempt to delay interventions for as long as possible, aggressive PCD as the first step, followed by minimally invasive endoscopic/ surgical necrosectomy

IR can also tackle most vascular complications thereby avoiding surgery

Imaging findings OR Procedure findings

The following will be described with illustrative cases:

PCD:

Goals of intervention

Timing of intervention

Pre-procedure evaluation

Image guidance and approach

Techniques and hardware

Complications of procedure and their management

Follow-up

Vascular complications

Endovascular techniques:

Embolization of pseudoaneurysm or feeding artery

Stent grafting of feeding artery

Embolization materials and techniques

Complications

Percutaneous Injections:

Injection of Thrombin

Use of Glue

Conclusion

Image guided interventions in appropriate cases result in better clinical outcomes and are an integral part in the multidisciplinary management of SAP

Purpose

The small bowel mesentery(SBM) and transverse mesocolon(TM) are part of the subperitoneal space, which are anatomically closely related to the pancreas and can undergo inflammatory changes in acute pancreatitis. The modified CTSI(mCTSI) assigns a single score to all peripancreatic changes together, while most other scoring systems do not consider them. Therefore, our aim was to study the degree of their involvement and correlate it with the severity of pancreatitis and clinical outcome of the patient.

Material and methods

In this IB approved prospective study, 110 patients (M:F::69:41, age range:19-75 years) with suspected acute pancreatitis underwent DECT examination in early disease onset. Two abdominal radiologists assessed and scored image data-sets independently. The involvement of SBM and TM was graded as 0(no involvement), 1(presence of fat stranding/increased density) and 2(presence of fluid collections/necrosis/vascular changes). Patients were followed up to assess the clinical outcome determined in terms of duration of hospital stay(HS), development of persistent organ failure(OF), need for any intervention (INT) and in-hospital mortality(MOR). Statistical analysis was done using Spearman’s rank correlation and Mann-Whitney U tests.

Results

Statistically significant correlation was found between mCTSI and parameters of clinical outcome(p<0.001). The correlation between mCTSI and grades of involvement of SBM and TM was highly significant(p<0.001). Significant correlation was found between TM involvement and all parameters of clinical outcome, while SBM involvement showed statistically significant correlation with HS and OF(p=0.033).

Conclusion

Increasing severity of involvement of SBM and TM may serve as a supplementary index to mCTSI for the prognostication of acute pancreatitis.

Objectives

To identify the various vascular and nonvascular complications of severe acute pancreatitis (SAP)

To highlight the pivotal role of interventional radiology(IR) in the management of these complications

To describe the technique of percutaneous catheter drainage(PCD) and outline its key role in the multidisciplinary management of pancreatic collections

To illustrate the different techniques of endovascular and percutaneous management of vascular complications of SAP and elucidate their role according to the clinical setting

Background

SAP is characterized by persistent organ failure and pancreatic and/or peripancreatic necrosis and is associated with high rates of morbidity and mortality (20-30%)

Patients in late phase of disease (according to Revised Atlanta) are at high risk of developing secondary infection of pancreatic necrosis

Optimal treatment now consists of a “Step-up” approach with initial intensive conservative management, attempt to delay interventions for as long as possible, aggressive PCD as the first step, followed by minimally invasive endoscopic/ surgical necrosectomy

IR can also tackle most vascular complications thereby avoiding surgery

Imaging findings OR Procedure findings

The following will be described with illustrative cases:

PCD:

Goals of intervention

Timing of intervention

Pre-procedure evaluation

Image guidance and approach

Techniques and hardware

Complications of procedure and their management

Follow-up

Vascular complications

Endovascular techniques:

Embolization of pseudoaneurysm or feeding artery

Stent grafting of feeding artery

Embolization materials and techniques

Complications

Percutaneous Injections:

Injection of Thrombin

Use of Glue

Conclusion

Image guided interventions in appropriate cases result in better clinical outcomes and are an integral part in the multidisciplinary management of SAP

Purpose

The small bowel mesentery(SBM) and transverse mesocolon(TM) are part of the subperitoneal space, which are anatomically closely related to the pancreas and can undergo inflammatory changes in acute pancreatitis. The modified CTSI(mCTSI) assigns a single score to all peripancreatic changes together, while most other scoring systems do not consider them. Therefore, our aim was to study the degree of their involvement and correlate it with the severity of pancreatitis and clinical outcome of the patient.

Material and methods

In this IB approved prospective study, 110 patients (M:F::69:41, age range:19-75 years) with suspected acute pancreatitis underwent DECT examination in early disease onset. Two abdominal radiologists assessed and scored image data-sets independently. The involvement of SBM and TM was graded as 0(no involvement), 1(presence of fat stranding/increased density) and 2(presence of fluid collections/necrosis/vascular changes). Patients were followed up to assess the clinical outcome determined in terms of duration of hospital stay(HS), development of persistent organ failure(OF), need for any intervention (INT) and in-hospital mortality(MOR). Statistical analysis was done using Spearman’s rank correlation and Mann-Whitney U tests.

Results

Statistically significant correlation was found between mCTSI and parameters of clinical outcome(p<0.001). The correlation between mCTSI and grades of involvement of SBM and TM was highly significant(p<0.001). Significant correlation was found between TM involvement and all parameters of clinical outcome, while SBM involvement showed statistically significant correlation with HS and OF(p=0.033).

Conclusion

Increasing severity of involvement of SBM and TM may serve as a supplementary index to mCTSI for the prognostication of acute pancreatitis.