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Tamura Y, Kiyosue H, Ikeda O, Hayashi H, Sasaki G, Hirai T. Endovascular Treatment of Unruptured Pancreatic Arcade Aneurysms. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03824-8. [PMID: 39117888 DOI: 10.1007/s00270-024-03824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/24/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE This study aimed to assess the safety and efficacy of endovascular treatment of unruptured pancreatic arcade aneurysms in a single-center series. MATERIALS AND METHODS The electronic medical records of patients who underwent endovascular treatment for unruptured pancreatic arcade aneurysms between 2011 and 2022 at our tertiary center were retrospectively reviewed. The presence of celiac artery stenosis/occlusion; aneurysm number, location, and size; endovascular technique; procedure-related complication incidence; and clinical outcomes were assessed. RESULTS Twenty-three patients (12 men and 11 women; mean [range] age, 63.8 [45-84] years) with 33 unruptured pancreatic arcade aneurysms were identified. Celiac artery stenosis/occlusion coexisted in 17 (74%) patients. Five (21%) patients had multiple aneurysms. The median aneurysm size was 9.3 mm (range, 4-18 mm). Seven, 6, 6, 5, 4, 3, and 2 aneurysms were located in the gastroduodenal, dorsal pancreatic, anterior superior pancreaticoduodenal, inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal, posterior superior pancreaticoduodenal, and anterior inferior pancreaticoduodenal arteries, respectively. Four (15%) and 22 (85%) aneurysms were treated with endosaccular packing alone and coil embolization with endosaccular packing and parent artery occlusion, respectively, with resulting exclusion from arterial circulation. The remaining 7 aneurysms coexisting with larger aneurysms in other peripancreatic arteries were observed without embolization because they were small and for preserving collateral blood flow to the celiac artery. The treated aneurysms did not rupture or recur during the follow-up period (median, 40 months). CONCLUSION Endovascular treatment is a safe and effective treatment for unruptured pancreatic arcade aneurysms. LEVEL OF EVIDENCE 3, non-controlled retrospective cohort study.
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Affiliation(s)
- Yoshitaka Tamura
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chou-Ku, Kumamoto, 8608556, Japan.
| | - Hiro Kiyosue
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chou-Ku, Kumamoto, 8608556, Japan
| | - Osamu Ikeda
- Department of Cardiovascular Surgery and Catheter Less Invasive EVT Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hidetaka Hayashi
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chou-Ku, Kumamoto, 8608556, Japan
| | - Goh Sasaki
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chou-Ku, Kumamoto, 8608556, Japan
| | - Toshinori Hirai
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chou-Ku, Kumamoto, 8608556, Japan
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Karanasios E, Ragab Z, Cavenagh H, Stather P, Ali T. Characteristics and Trends in Median Arcuate Ligament Syndrome (MALS) Associated Visceral Artery Aneurysms: A Systematic Descriptive Review of the Literature. Vasc Endovascular Surg 2024; 58:512-522. [PMID: 38271562 DOI: 10.1177/15385744241229842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P = .84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P = .02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management.
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Affiliation(s)
| | - Zeyad Ragab
- Speciality Registrar- Radiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Harry Cavenagh
- Speciality Registrar- Radiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Philip Stather
- Consultant Vascular Surgeon, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Tariq Ali
- Consultant Interventional Radiologist, Norfolk and Norwich University Hospitals, Norwich, UK
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Ghoneim B, Nash C, Akmenkalne L, Cremen S, Canning C, Colgan MP, O'Neill S, Martin Z, Madhavan P, O'Callaghan A. Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review. Vascular 2024; 32:162-178. [PMID: 36071691 DOI: 10.1177/17085381221124991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite being rare, pancreaticoduodenal artery aneurysms (PDAAs) carry a risk of rupture of up to 50% and are frequently associated with coeliac artery occlusion. METHODS PubMed and Embase databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines. RESULTS We present the case of a 2 cm pancreaticoduodenal artery aneurysm pre-operative angiography demonstrated that the coeliac artery was occluded and the pancreaticoduodenal artery was providing collateral blood supply to the liver. Treatment was a staged hybrid intervention inclusive of an aorto-hepatic bypass using a 6 mm graft, followed by coil embolisation of the aneurysm. We also present a systematic review of the management of PDAAs. Two hundred and ninety-two publications were identified initially with 81 publications included in the final review. Of the 258 peripancreatic aneurysms included, 175 (61%) were associated with coeliac artery disease either occlusion or stenosis. Abdominal pain was the main presentation in 158 cases. Rupture occurred in 111 (40%) of patients with only ten (3.8%) cases being unstable on presentation. Fifty (18%) cases were detected incidentally while investigating another pathology. Over half the cases (n=141/54.6%) were treated by trans arterial embolisation (TAE) alone, while 37 cases had open surgery only. Twenty-one cases needed TAE and a coeliac stent. Seventeen cases underwent hybrid treatment (open and endovascular). Sixteen cases were treated conservatively and in 26 cases, treatment was not specified. CONCLUSION PDAAs are commonly associated with coeliac artery disease. The most common presentation is pain followed by rupture. The scarcity of literature about true peripancreatic artery aneurysms associated with CA occlusive disease makes it difficult to assess the natural history or the appropriate treatment. Revascularisation of hepatic artery is better done with bypass in setting of median arcuate ligament compression and occluded celiac trunk.
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Affiliation(s)
- Baker Ghoneim
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Connor Nash
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Liga Akmenkalne
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Sinead Cremen
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Catriona Canning
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Mary P Colgan
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Sean O'Neill
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Zenia Martin
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
| | - Prakash Madhavan
- Department of Vascular Surgery, St James Hospital, Dublin, Ireland
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Borges AP, Antunes C, Donato P. Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization. Abdom Radiol (NY) 2023; 48:1415-1428. [PMID: 36801957 PMCID: PMC10115732 DOI: 10.1007/s00261-023-03844-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization. METHODS Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis. RESULTS MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases. CONCLUSIONS In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.
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Affiliation(s)
- Ana Paula Borges
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal.
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal.
| | - Célia Antunes
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
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Vani K, Calligaro KD, Maloni K, Madden N, Troutman DA, Dougherty MJ. Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience. Vasc Endovascular Surg 2021; 55:684-688. [PMID: 34008440 DOI: 10.1177/15385744211017112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years. METHODS We retrospectively reviewed our prospectively maintained registry between January 1, 1992 - March 30, 2020. RESULTS We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity. CONCLUSION Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.
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Affiliation(s)
- Kunal Vani
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Krystal Maloni
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Nicholas Madden
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Douglas A Troutman
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
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Mori A, Inoue S, Orikasa H, Yoshimoto T, Konishi H. Coronary Artery Fistula Aneurysm: Pathological Analysis After Surgery. Cureus 2021; 13:e14903. [PMID: 34113513 PMCID: PMC8183465 DOI: 10.7759/cureus.14903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
An asymptomatic 75-year-old woman was identified with a 40-mm-sized, round-shaped lesion beside the pulmonary artery on computed tomography (CT). Coronary angiography showed a coronary artery fistula (CAF) with an aneurysm branching from the left anterior descending artery toward the pulmonary artery. The CAF aneurysm (CAFA) was resected and coronary artery bypass graft surgery using the left internal thoracic artery was performed successfully. Pathological analysis revealed that medial depletion similar to segmental arterial mediolysis (SAM) may contribute to aneurysm formation.
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Affiliation(s)
- Atsuo Mori
- Cardiovascular Surgery, Kawasaki Municipal Hospital, Kawasaki, JPN
| | - Shinya Inoue
- Cardiovascular Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, JPN
| | - Hideki Orikasa
- Pathology, Kawasaki Municipal Kawasaki Hospital, Kawasaki, JPN
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Chaer RA, Abularrage CJ, Coleman DM, Eslami MH, Kashyap VS, Rockman C, Murad MH. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg 2020; 72:3S-39S. [DOI: 10.1016/j.jvs.2020.01.039] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/18/2022]
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Blood flow modification might prevent secondary rupture of multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis stenosis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:41-45. [PMID: 32072085 PMCID: PMC7016350 DOI: 10.1016/j.jvscit.2019.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/13/2019] [Indexed: 12/18/2022]
Abstract
A pancreaticoduodenal artery arcade aneurysm (PDAA) is rare and often associated with celiac axis stenosis by the median arcuate ligament. Although rupture risk of the PDAA is not related to its size, treatment guidelines are absent. Here we describe a 59-year-old woman with multiple ruptured PDAAs associated with celiac axis stenosis who was successfully treated with coil embolization. As follow-up computed tomography revealed rapid expansion of residual PDAAs and new gastric artery dissection, median arcuate ligament resection was followed by aorta-common hepatic artery bypass, which resulted in aneurysmal regression. Blood flow modification might prevent secondary rupture of PDAA associated with celiac axis stenosis.
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Kimura N, Matsui K, Shibuya K, Yoshioka I, Naruto N, Hoshino Y, Mori K, Hirano K, Watanabe T, Hojo S, Sawada S, Okumura T, Nagata T, Noguchi K, Fujii T. Metachronous rupture of a residual pancreaticoduodenal aneurysm after release of the median arcuate ligament: a case report. Surg Case Rep 2020; 6:34. [PMID: 32016595 PMCID: PMC6997311 DOI: 10.1186/s40792-020-0784-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Multiple pancreaticoduodenal artery aneurysms in association with median arcuate ligament syndrome (MALS) are relatively rare. A treatment option, such as a median arcuate ligament (MAL) release or embolization of the aneurysms, should be considered in such cases, but the treatment criteria remain unclear.
Case report
A 75-year-old man was transferred to our hospital because of a ruptured pancreaticoduodenal aneurysm. Emergency angiography showed stenosis of the root of the celiac axis (CA), a ruptured aneurysm of the posterior inferior pancreaticoduodenal artery (PIPDA), and an unruptured aneurysm of the anterior inferior pancreaticoduodenal artery (AIPDA). Coil embolization of the PIPDA was performed. Five days after embolization, the gallbladder became necrotic due to decreased blood flow in the CA region, and an emergency operation was performed. We performed a cholecystectomy and released the MAL to normalize the blood flow of the CA region. However, the patient died on postoperative day 8 because of rupture of the untreated aneurysm of the AIPDA.
Conclusions
This is the first report of metachronous ruptures of multiple pancreaticoduodenal aneurysms due to MALS, even after a MAL release. Although rare, a residual aneurysm in the pancreatic head region may need to be embolized quickly.
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Aryal B, Komokata T, Ueno T, Yamamoto B, Senokuchi T, Yasuda H, Kaieda M, Imoto Y. A 2-Stage Surgical and Endovascular Treatment of Rare Multiple Aneurysms of Pancreatic Arteries. Ann Vasc Surg 2016; 40:295.e9-295.e13. [PMID: 27913123 DOI: 10.1016/j.avsg.2016.07.092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 06/19/2016] [Accepted: 07/17/2016] [Indexed: 11/16/2022]
Abstract
Aneurysms of pancreatic arteries (PAs) are often found incidentally during evaluation of other abdominal pathology. Aneurysms involving multiple PAs are rarely reported in the literature. In case reports of PA aneurysm, inferior pancreaticoduodenal artery is the usual site of aneurysm occurrence. PA aneurysms can be treated surgically by aneurysm exclusion, excision, and by endovascular techniques. However, no clear consensus exists regarding treatment modality, leaving the surgeon to determine the most appropriate approach bearing in mind their experience, anatomical location of the aneurysm, involved artery, and urgency of the procedure. We report a rare PA aneurysm involving dorsal pancreatic artery (DPA) and anterior inferior pancreaticoduodenal artery (AIPDA) associated with celiac stenosis that was incidentally diagnosed in a patient with hepatic hemangioma. In addition, we reviewed data from the literature on patients with diffuse or multiple PA aneurysms and discuss the treatment modality in these rare variants. Both surgical and endovascular procedures are equally advocated in treatment of multiple PA aneurysms. In our report, we demonstrate a 2-stage surgical and endovascular treatment modality; DPA aneurysm that was not suitable for endovascular treatment was surgically resected and an iliohepatic bypass was made between left common iliac artery and AIPDA to ensure good hepatic perfusion. One month after the first procedure, AIPDA aneurysm was treated with endovascular embolization. Two-stage surgical and endovascular procedure may represent a useful strategy to treat aneurysms involving multiple PAs.
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Affiliation(s)
- Bibek Aryal
- Cardiovascular and Gastroenterological Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Teruo Komokata
- Department of Surgery, Kagoshima Medical Center, National Hospital Organization, Kagoshima, Japan.
| | - Takayuki Ueno
- Department of Cardiovascular surgery, Kagoshima Medical Center, National Hospital Organization, Kagoshima, Japan
| | - Bunsei Yamamoto
- Cardiovascular and Gastroenterological Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Terutoshi Senokuchi
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroshi Yasuda
- Department of Surgery, Kagoshima Medical Center, National Hospital Organization, Kagoshima, Japan
| | - Mamoru Kaieda
- Department of Surgery, Kagoshima Medical Center, National Hospital Organization, Kagoshima, Japan
| | - Yutaka Imoto
- Cardiovascular and Gastroenterological Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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