Discussion
SAP is uncommon. In a large case series from the Mayo Clinic, 10 SAPs were found during an 18-year period.2 Among previously reported cases, SAPs are most often caused by pancreatitis (52%) or trauma (29%)2 and are rarely caused by peptic ulcer disease. To the best of our knowledge, there are only nine reported cases of SAPs caused by peptic ulcers.2-10 Thus, for a patient with UGIB after pancreatitis or trauma, a ruptured SAP should be considered as a differential diagnosis. However, the diagnosis of SAP due to a peptic ulcer poses a significant challenge for a clinician. In contrast to true aneurysms, which involve all three layers (intima, media, and adventitia) of an arterial wall, pseudoaneurysms typically involve only the intima and media. Unlike true aneurysms, SAPs carry a much higher risk of rupture.3 Control of UGIB caused by ruptured SAPs is critical to the survival of patients since the mortality rate for this condition can reach 90% in untreated cases1 and the treatment strategies selected can determine whether patients live or die. Recently, retrospective studies and case reports involving multiple patients have discussed the use of REBOA for the treatment of non-traumatic hemorrhagic shock.11-13
In cases of traumatic shock and cardiopulmonary arrest, aortic occlusion with resuscitative thoracotomy (RT) is a method of temporizing distal hemorrhage while augmenting cerebral and coronary perfusion.14 REBOA is also widely performed in cases of traumatic shock and is minimally invasive compared with RT.14,15 Among patients in traumatic shock who did not require cardiopulmonary resuscitation before REBOA or RT, those who underwent REBOA had a significantly higher survival rate.14 There are two types of REBOA balloon management strategies: intermittent and partial. Intermittent REBOA occludes the aorta completely, occlusion time is limited to 35–40 min in the distal thoracic aorta,15 and the occlusion process involves repeated inflation and deflation of the balloon. In contrast, partial REBOA occludes the aorta partially to minimize ischemic injury caudal to the balloon, while maintaining cerebral and coronary perfusion. Although the retrospective studies included cases of hemostasis with REBOA, little consideration was given to the influence of balloon management in these cases. In our patient’s case, management by intermittent REBOA was useful, not only for maintaining cerebral and coronary artery perfusion, but also for securing the surgical field and identifying the source of the hemorrhage. Moreover, the durations of the complete occlusion times were 20 min and 5 min, respectively. Thus, the patient recovered without organ dysfunction. Since there are no conclusive indications as to whether partial or intermittent REBOA is better for balloon management, we propose that the choice of REBOA for balloon management should be based on the hemodynamics and bleeding characteristics of lesions. Future studies must aim to clarify the adaptation of REBOA for non-traumatic hemorrhage and to consider the type of REBOA balloon management used.