European Journal of Cardiovascular Medicine

Pancreatitis is a disorder characterized by inflammation of the pancreas secondary to variable etiologies, with the most common being gallstones and alcohol abuse.

Pancreatitis represents a significant clinical entity characterized by inflammatory destruction of pancreatic parenchyma, leading to the premature activation and release of proteolytic enzymes. Acute pancreatitis can be classified into mild, moderate, and severe based on organ failure and its duration (greater than 48 h or less than 48 h) and the  presence or absence of local complications¹.

This pathological process results in both localized tissue damage and systemic complications. The disease spectrum encompasses acute inflammatory episodes and chronic fibrotic changes, with vascular complications representing particularly severe manifestations that substantially increase morbidity and mortality. ²  It is estimated that one-quarter of patients with pancreatitis may develop vascular complications.¹

However, in 20–30% of cases, the pancreatitis can be severe and associated with potentially life-threatening complications such as extensive pancreatic necrosis, pancreatic abscess formation, multi-organ failure, and development of peripancreatic vascular complications.³

Contemporary radiological literature demonstrates that approximately 25-35% of pancreatitis patients develop vascular complications, as evidenced by multiple CT-based studies. These complications arise through several mechanisms: (1) direct enzymatic erosion of vascular walls, (2) perivascular inflammation, and (3) compression by pseudocysts or necrotic collections. The vascular manifestations exist along a severity continuum, ranging from clinically silent venous thrombosis to life-threatening arterial pseudoaneurysm rupture, with mortality rates exceeding 50% in cases of hemorrhagic complications.⁴

Modern cross-sectional imaging, particularly multiphasic MDCT, has revolutionized the detection and characterization of these vascular complications. The arterial phase optimally demonstrates pseudoaneurysms and arterial involvement, while the portal venous phase is essential for evaluating venous thrombosis and collateral circulation.⁵

The critical importance of early radiological identification cannot be overstated, as underscored by Mortelé et al. ¹⁴ in their study, which showed that delayed diagnosis of vascular complications increases mortality rate significantly. Furthermore, Heider et al. ⁶ established that timely intervention based on CT findings significantly improves outcomes in cases of splanchnic vein thrombosis and arterial complications.

AIMS AND OBJECTIVES

Primary Objectives

The primary aim of this retrospective study was to comprehensively evaluate vascular complications associated with both acute and chronic pancreatitis in patients presenting to a tertiary care center. The study specifically focused on identifying, characterizing, and analyzing the spectrum of vascular involvement that occurred as a consequence of pancreatic inflammation. Given that vascular complications represented one of the most serious and potentially life-threatening sequelae of pancreatitis, affecting approximately 25% of patients according to contemporary literature, this investigation aimed to provide detailed insights into the prevalence, patterns, and clinical significance of these complications in the local population.

Secondary Objectives

The secondary objective was to characterize and categorize the specific types of vascular involvement encountered in pancreatitis patients. This included the systematic identification and classification of venous thrombotic events, arterial complications such as pseudoaneurysm formation and arterial thrombosis, and other associated vascular abnormalities. The study aimed to determine the relative frequency of different vascular complications, identify the most commonly affected vessels, and document any patterns of multivessel involvement. Additionally, the investigation sought to evaluate the effectiveness of multiphase computed tomography in detecting and characterizing these vascular complications, thereby establishing the diagnostic utility of advanced cross-sectional imaging in the management of pancreatitis patients.

Study Design and Setting

This retrospective observational study was conducted at Basaveshwara Medical College, Chitradurga, over a period of 18 months. The study received approval from the institutional ethical committee prior to commencement, ensuring adherence to established research ethics guidelines and patient confidentiality protocols. The investigation was designed as a comprehensive analysis of all patients diagnosed with acute or chronic pancreatitis during the study period, with particular emphasis on identifying and characterizing associated vascular complications through advanced imaging techniques.

Sample Size and Study Population

The study encompassed a total sample size of 126 patients who were diagnosed with either acute or chronic pancreatitis during the 18-month study period. This sample size was determined based on the patient population presenting to the institution during the specified timeframe, representing consecutive cases that met the established inclusion criteria. The study population was identified through systematic review of the institutional database, ensuring comprehensive capture of all eligible cases within the designated study period.

Inclusion Criteria

The inclusion criteria were carefully established to ensure a homogeneous study population while maintaining clinical relevance. Patients were included if they had received a confirmed diagnosis of either acute or chronic pancreatitis, with the diagnosis being established through clinical presentation and subsequently confirmed radiologically using triple-phase multidetector computed tomography (MDCT). The study included patients across all age groups, encompassing pediatric, adult, and geriatric populations, as evidenced by the age range from 0 to over 60 years represented in the final cohort. A critical inclusion requirement was that all patients had undergone multiphase contrast-enhanced CT imaging, specifically including arterial, portal venous, and excretory phases, which was essential for accurate assessment of vascular complications.

Additionally, all included patients were hospitalized at Basaveshwara Medical College within the defined 18-month study period, ensuring temporal consistency and standardization of care protocols across the study population. Complete imaging data availability was another essential inclusion criterion, requiring that patients had undergone comprehensive imaging studies including axial, coronal, sagittal, and three-dimensional reformatted images sufficient for thorough vascular assessment. This comprehensive imaging requirement ensured that adequate data was available for detailed evaluation of potential vascular complications.

Exclusion Criteria

The exclusion criteria were designed to eliminate potential confounding factors and ensure the reliability of study findings. Patients were excluded if they had not undergone contrast-enhanced CT imaging, as this was fundamental to accurate visualization and characterization of vascular complications. Cases with poor-quality or incomplete imaging studies were systematically excluded, including those with significant motion artifacts or missing arterial or venous phases that would prevent adequate evaluation of vascular structures.

Patients with known pre-existing vascular disorders unrelated to pancreatitis were excluded to avoid diagnostic confusion and ensure that identified vascular complications were directly attributable to the pancreatic inflammatory process. This included conditions such as pre-existing portal vein thrombosis secondary to cirrhosis, known vasculitis, or other systemic vascular diseases that could confound the interpretation of imaging findings. Similarly, patients with concurrent malignancies involving the pancreas or peripancreatic vasculature were excluded to eliminate the possibility of secondary vascular involvement unrelated to pancreatitis.

Cases with inadequate medical records or lack of clinical correlation were also excluded, particularly instances where CT findings could not be appropriately correlated with the clinical diagnosis of pancreatitis. This exclusion criterion ensured that all included cases had sufficient clinical documentation to support the radiological findings and maintain the integrity of the diagnostic process.

Diagnostic Methodology

The diagnostic approach employed a standardized triple-phase MDCT protocol that was consistently applied across all study participants. The imaging protocol commenced with an initial non-contrast basal scan, followed by sequential contrast-enhanced phases including arterial, portal venous, and excretory phases. This multiphase approach was specifically designed to optimize visualization of different vascular structures and pathological processes, with each phase providing complementary information essential for comprehensive vascular assessment.

Thin contiguous CT images were systematically acquired in the axial plane, providing high-resolution cross-sectional anatomy. These axial images were subsequently processed to generate coronal and sagittal reformations, as well as three-dimensional reformatted images, creating a comprehensive multiplanar imaging dataset. This multiplanar approach enhanced the detection and characterization of vascular complications by providing multiple perspectives and improving spatial understanding of complex anatomical relationships.

Image Analysis and Data Collection

The retrospective analysis involved systematic evaluation of triple-phase CT scans and associated radiological reports from all 126 identified patients. The image analysis focused specifically on the detection and characterization of vascular complications among the study population, employing standardized criteria for identifying various types of vascular involvement. The assessment included comprehensive evaluation for venous thrombosis affecting different vessel territories, arterial complications such as pseudoaneurysm formation, arterial thrombosis, and other vascular events that could be attributed to the pancreatic inflammatory process.

Each case underwent detailed review by experienced radiologists familiar with pancreatic imaging and vascular complications. The analysis involved systematic examination of all imaging phases, with particular attention to vessel patency, enhancement patterns, and morphological abnormalities. Venous thrombosis was identified based on filling defects within vessel lumens, lack of contrast enhancement, and associated collateral vessel formation. Arterial complications were assessed through evaluation of vessel wall integrity, identification of focal dilatations suggestive of pseudoaneurysm formation, and detection of luminal narrowing or occlusion indicative of thrombotic processes.

Data Management and Statistical Analysis

Data collection and management were performed using Microsoft Excel software, which facilitated systematic tabulation and organization of patient demographics, imaging findings, and vascular complications. The database was designed to capture comprehensive information including patient age, gender, type of pancreatitis, specific vascular complications identified, vessel territories involved, and associated findings such as collateral circulation and secondary organ changes.

Statistical analysis employed descriptive statistics appropriate for the retrospective observational study design. Results were presented using frequencies and percentages to characterize the distribution of vascular complications within the study population. The analytical approach focused on determining the prevalence of different types of vascular complications, identifying patterns of vessel involvement, and characterizing associated findings that accompanied these vascular manifestations. This descriptive statistical methodology provided clear insights into the spectrum and frequency of vascular complications encountered in the study population, facilitating comparison with existing literature and contributing to the understanding of these important clinical entities.

Demographic Distribution

In this retrospective study of 126 patients with acute or chronic pancreatitis, the majority were male (87.3%), with the highest incidence observed in the 20–40 years age group (46.8%). The 40–60 years group accounted for 32.5% of cases, while patients below 20 years constituted 13.5%. Only 7.2% of patients were above 60 years, and notably, no female patients were observed in this age group. This male predominance and concentration in younger to middle-aged adults reflected common epidemiological patterns in pancreatitis, particularly in alcohol-related cases.

Venous Thrombosis Distribution

Out of 126 patients with pancreatitis, 27 patients (21%) were found to have venous thrombosis, representing a significant vascular complication. Among these, isolated splenic vein thrombosis was the most common, observed in 15 patients (50%), likely due to the anatomical proximity of the splenic vein to the inflamed pancreas. Isolated portal vein thrombosis was seen in 4 patients (13%), while isolated superior mesenteric vein thrombosis was rare, affecting only 1 patient (3%). Combined involvement of portal and splenic veins occurred in another 4 cases (13%), while portal vein with superior mesenteric vein and triple vessel involvement were less frequent, found in 1 (3%) and 2 (6.5%) patients respectively. These findings underscored the predominance of splenic vein thrombosis in pancreatitis-associated vascular complications and highlighted the potential for multifocal venous involvement in more severe cases.

Arterial Complications

Arterial complications were observed in 3 patients (2.4%) in the study. The splenic artery was the most commonly involved vessel, affected in 2 cases, while the common iliac artery was involved in 1 case. No cases of arterial involvement were noted in the gastroduodenal artery or superior mesenteric artery. Among the arterial complications, pseudoaneurysm formation was the predominant finding, occurring in 2 patients, both involving the splenic artery, with one case associated with a surrounding hematoma indicating a possible contained rupture or leak. One patient presented with arterial thrombosis, specifically in the common iliac artery, causing significant luminal narrowing.

Associated Vascular Findings

Among the patients with vascular complications in pancreatitis, several important associated vascular abnormalities were observed. Periportal collaterals were the most common, present in 15 patients, reflecting the development of alternate venous pathways likely due to chronic venous obstruction and portal hypertension. Chronic thrombosis was identified in 4 patients, suggesting long-standing venous compromise and the potential for complications like cavernous transformation. Cavernoma formation, characterized by a network of dilated collateral veins replacing a thrombosed portal vein, was seen in 1 patient, representing a classic late sequela of portal vein thrombosis. Additionally, varices were noted in 2 patients, indicating the development of portal hypertension and posing a risk for potential gastrointestinal bleeding.

Associated Abdominal Findings

Several abdominal findings commonly associated with vascular complications of pancreatitis were observed in the patient cohort. Ascites was the most frequent, present in 30 patients (23.8%), likely resulting from portal hypertension, systemic inflammation, or pancreatic fluid leakage. Splenomegaly was seen in 28 patients (22.2%), often secondary to splenic vein thrombosis or increased portal pressure. Hepatomegaly was noted in 20 patients (15.8%), which may have reflected underlying venous congestion or coexisting alcohol-related liver injury. Additionally, chronic liver disease was diagnosed in 5 patients (3.9%), further compounding the vascular and hemodynamic burden in these individuals.

Figure 1: Short segment non enhancing focus in splenic vein-Partial Thrombosis

Figure 2: Right branch of portal vein shows absence of contrast filling, with peripheral rim of contrast flow in the Portal vein at its confluence.

Figure 3: Short segment thrombosis of right common iliac artery just before the bifurcation causing 70-80% luminal narrowing

Figure 4: A 4 cm diameter contrast enhancing mass in the left abdomen is demonstrated by means of helical CT.

Vascular complications are serious consequences of pancreatitis that require careful patient evaluation, diagnostic workup for assessment of the risk, deciding the management of patients, type of treatment, and its benefits .Vascular complications in pancreatitis, including venous thrombosis and pseudoaneurysms, are well-documented in radiology literature.

In our study of 126 patients with pancreatitis, 23% of patients had vascular complications arterial and venous) of which 3 were arterial and 27 were venous.

The incidence of splenic vein thrombosis was the highest(50%) ,followed by portal vein thrombosis (13%) and superior mesenteric vein thrombosis and a combination of all three. In a study conducted by Vujasinovic,7  a similar incidence of 53.3% was reported. These findings align with prior studies, such as those by Balthazar et al. and Heider et al, who reported splenic vein thrombosis as the most frequent vascular complication due to its anatomical proximity to the inflamed pancreas.(21,6) Splenic vein thrombosis (50%) was the predominant type, consistent with Sakorafas et al., who attributed this to direct inflammatory compression and enzymatic erosion of the vessel wall1. The portal vein (13%) and superior mesenteric vein (SMV, 3%) were less frequently involved, similar to findings by Pieterman et al., who noted that extensive thrombosis (PV+SV+SMV) was rare but carried a higher risk of portal hypertension 23.

Our results are comparable to a meta-analysis by Ahmed et al., which reported a 20-25% incidence of venous thrombosis in pancreatitis, with splenic vein involvement in ~40-60% of cases 6. However, our study had a lower incidence of SMV thrombosis (3% vs. 10-15% in prior studies), possibly due to differences in disease severity or imaging protocols.

Pseudoaneurysm occurred in 0.015% of patients, which involved the splenic artery. Butler et al in systematic review and meta analysis on the efficacy of the endovascular embolization of PA in chronic pancreatitis showed a pooled incidence rate of PA to be 0.03% with the most common site being the splenic artery (37.7%)9

The incidence of vascular complications was predominantly in the male population between the ages of 20-40 years.

We identified portosystemic collaterals in 50% of patients.

None of our patients with splenic vein thrombosis and varices experienced gastrointestinal bleeding, which contrasts with the findings of the systematic review and meta-analysis by Butler et al., which reported an aggregate rate of gastrointestinal bleeding associated with these conditions 12.3%.9

Anand et al. also reported a low incidence of gastrointestinal bleeding (3.5%), suggesting that the presence of collaterals may reduce the risk of bleeding. This aligns with our findings, as 50% of our patients developed abdominal collateral vessels, and 2 patients developed varieces ,which could explain the absence of variceal bleeding.

• Associated findings: Splenomegaly (22.2%) and ascites (23.8%) were common, likely secondary to portal hypertension from venous obstruction, as described by Gore et al. 14
• Hepatomegaly (15.8%) and chronic liver disease (3.9%) were also noted, possibly due to prolonged venous congestion or comorbid alcohol-related liver disease, as seen in studies by Mallery et al. 8
• Ascites (23.8%) was observed, likely secondary to portal hypertension or pancreatic inflammation, as described by Mortelé et al. (Radiology, 2004)3

Clinical Implications and Management Considerations

• Early MDCT diagnosis is crucial to prevent complications like variceal hemorrhage or mesenteric ischemia.1
• Anticoagulation remains controversial but may be beneficial in acute SMV thrombosis 11.
• Endovascular or surgical intervention is indicated for pseudoaneurysms or bleeding varices. 12

Zamboni et al. emphasized that early-phase CT angiography improves pseudoaneurysm detection, which was not a major finding in our study but remains a critical consideration.13.

This study highlights the significant prevalence (21%) of vascular complications in pancreatitis, with splenic vein thrombosis (50%) being the most common, followed by portal vein

(13%) and superior mesenteric vein (3%) thrombosis. The findings reinforce that MDCT with multiphase imaging is indispensable for early detection, characterization, and management of these complications, which can range from asymptomatic thrombosis to life-threatening sequelae like variceal hemorrhage or mesenteric ischemia.

The high incidence of collateral circulation (55.5%) and varices underscores the risk of portal hypertension in chronic cases, necessitating close radiological surveillance. Additionally, splenomegaly (22.2%) and ascites (23.8%) were frequent associated findings, further emphasizing the systemic impact of pancreatitis-induced vascular pathology.

In summary, radiologists and clinicians must maintain a high index of suspicion for vascular complications in pancreatitis, leveraging advanced cross-sectional imaging to guide timely intervention and improve patient outcomes. Early identification through CT imaging can facilitate prompt intervention, potentially reducing morbidity and mortality.

Future prospective studies with larger cohorts are needed to further stratify risk factors and optimize management.

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