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.