Treatment of Three Pancreaticoduodenal Artery Aneurysms Associated with CœLiac Artery Occlusion and Splenic Artery Aneurysm: A Case Report and Review of the Literature

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?

Superior Mesenteric Artery-Pancreaticoduodenal Arcade Bypass Grafting for Repair of Inferior Pancreaticoduodenal Artery Aneurysm with Celiac Axis Occlusion

We report a case of an aneurysm of the inferior pancreaticoduodenal artery (IPDA), with chronic occlusion of the celiac axis. Both surgical aneurysmectomy and endovascular coil embolization were anticipated to sacrifice IPDA, which could lead to severe acute ischemia in the celiac region. The treatment involved surgical ligation of the aneurysm after bypass grafting from the superior mesenteric artery to the anterior IPDA. A postoperative computed tomography revealed no enhancement of the aneurysm and sufficient collateral blood supply by the patent bypass graft.

A 2-Stage Surgical and Endovascular Treatment of Rare Multiple Aneurysms of Pancreatic Arteries

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.

Longitudinal Evaluation of Segmental Arterial Mediolysis in Splanchnic Arteries: Case Series and Systematic Review

BACKGROUND

Segmental arterial mediolysis (SAM) is a rare non-atherosclerotic, non-inflammatory vascular disorder varying widely in clinical course. The purpose of this study is to analyze detailing clinical and imaging manifestations over time in patients with SAM through a literature review and to suggest an optimal management strategy.

METHODS

A retrospective review of eight consecutive patients diagnosed with SAM between January, 2000 and January, 2012 was conducted. All presented with acute-onset abdominal or flank pain. Clinical features, imaging studies, and laboratory findings served as grounds for diagnosis, having excluded more common conditions (ie, fibromuscular dysplasia, collagen vascular disorders, or arteritis). CT angiography was done initially and repeated periodically (Week 1, Month 3, then yearly). Treatment was conservative, utilizing endovascular intervention as warranted by CT diagnostics. In a related systematic review, all English literature from 1976 to 2015 was screened via the PubMed database, assessing patient demographics, affected arteries, clinical presentations, and treatment methods.

FINDINGS

Ultimately, 25 arterial lesions identified in eight patients (median age, 62.8 years; range, 40-84 years) were monitored for a median period of 26 months (range, 15-57 months). At baseline, celiac axis (3/8, 37.5%), superior mesenteric (4/8, 50%), and common hepatic (2/8, 25%) arteries were involved, in addition to isolated lesions of right renal, splenic, right colic, middle colic, gastroduodenal, left gastric, right gastroepiploic, proper hepatic, right hepatic, and left hepatic arteries. Compared with prior publications, celiac axis and superior mesenteric artery were more commonly affected in cohort. Arterial dissections (n = 8), aneurysms (n = 5), stenoses or occlusions (n = 4), and a single pseudoaneurysm were documented. Despite careful conservative management, new splanchnic arterial lesions (n = 4) arose during follow-up. Considering the few available reports of new arterial lesions in the literature, newly developing pathology is a distinctive feature of our patients, four of whom eventually required endovascular interventions.

CONCLUSIONS

Careful clinical observation via periodic CT angiography is required in patients with SAM, checking for newly developing lesions. The natural history of SAM should be clarified in a larger patient population.

Segmental arterial mediolysis: a systematic review of 85 cases

BACKGROUND

Segmental arterial mediolysis (SAM) is a nonatherosclerotic, noninflammatory arteriopathy of unknown etiology with life-threatening manifestations. With advances in endovascular techniques, SAM is increasingly being managed without the need for major surgery.

METHODS

A systematic review of the literature published on SAM between 1976 and 2012 was performed, focusing on arterial involvement, diagnostic imaging modalities, mortality and morbidity rates, and in particular treatment outcomes with open versus endovascular intervention.

RESULTS

Sixty-two studies reporting on 85 cases of SAM were reviewed. Sixty-nine percent of cases were diagnosed histologically (24% on autopsy). Angiography was the most common form of diagnostic imaging modality (56% of cases). Arterial involvement was largely abdominal or cranial, with splenic arterial involvement being the most prevalent (29% of cases). There was a total SAM-related mortality of 26%. Endovascular intervention, most commonly in the form of coil embolization of aneurysmal vessel(s), was successful in 88% of cases where attempted, with no reported mortality. There was a mortality rate of 9% where open surgery was attempted.

CONCLUSIONS

Catheter-based endovascular techniques can be a successful, minimally invasive treatment option in the management of this potentially life-threatening condition, and may also provide a temporary bailout measure in the acute phase before definitive surgical treatment at a later stage.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion

BACKGROUND

Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence.

DATA SOURCES

Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized.

CONCLUSIONS

Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

Infective aneurysm of the inferior pancreaticoduodenal artery

INTRODUCTION

Pancreaticoduodenal (PD) artery aneurysms account for less than 2% of all splanchnic aneurysms. A mycotic aetiology is extremely uncommon.

INTRODUCTION

Two weeks following an episode of sepsis related to a prostatic biopsy, a 59-year-old man presented with abdominal pain and anaemia. Ultrasonography and computed tomography revealed an inferior PD artery pseudoaneurysm with an associated mesenteric root haematoma. This was treated successfully by transcatheter embolisation.

INTRODUCTION

Infective pseudoaneurysms of the PD artery are rare but can be associated with rupture into the gastrointestinal tract or retroperitoneum. Transcatheter embolisation remains the most effective therapy as it is associated with low morbidity and mortality rates and recurrence is very unlikely provided the aneurysm is completely excluded from the circulation.

Spontaneous dissection with rupture of the superior mesenteric artery from segmental arterial mediolysis

Spontaneous dissection of the superior mesenteric artery (SMA) is rare. We report a case of rupture of the SMA after spontaneous dissection in a 51-year-old male who presented with acute onset of abdominal pain and hypotension. The patient was initially treated with intravenous fluid resuscitation and endovascular intervention followed by open surgery. No identifiable cause for dissection was found. The patient was diagnosed as having segmental arterial mediolysis (SAM). The patients' presentation, treatment, outcome, and all relevant imaging, pathologic, and laboratory studies were reviewed. The relevant features of the case and SAM are presented herein. In addition, a review of all available published literature on SAM to date is presented.

Analysis of five cases of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament

AIM

To elucidate the mechanism of occurrence of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament, and also to discuss the management for this relatively rare condition.

MATERIALS AND METHODS

Five consecutive cases of splanchnic artery aneurysm associated with coeliac axis stenosis due to compression by the median arcuate ligament, including four cases of pancreaticoduodenal artery aneurysm and one case of epiploic artery aneurysm, were investigated. These cases were collected over a 5-year period in our local and affiliated hospitals. Among these five cases, three were discovered because of rupture of the aneurysm, and two were found incidentally in annual medical check-ups.

RESULTS

In all cases, conspicuously developed collateral arteries, which were of the dilated pancreaticoduodenal arcade and its branches, were conspicuously found on digital subtraction angiography of the superior mesenteric artery. The findings suggested that haemodynamic changes in the splanchnic arterial networks (an increase in blood flow mainly through the pancreaticoduodenal arcade), were the possible cause of the corresponding aneurysms.

CONCLUSION

Compression by the median arcuate ligament might be a frequent cause of splanchnic aneurysm, which, on rupture of the aneurysm, could be life-threatening.