Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: current management

Metachronous Rupture of Pancreatoduodenal Artery Aneurysm with Median Arcuate Ligament Syndrome: A Case Report and Review of 11 Cases

Median arcuate ligament syndrome (MALS) involves narrowing of the celiac artery root from MAL compression, leading to pancreatoduodenal artery aneurysm (PDAA) due to increased retrograde blood flow from the superior mesenteric artery into the PDA. We encountered a case in which coil embolization was performed for PDAA rupture due to MALS. Four years later, a second PDAA occurred and ruptured, necessitating coil reembolization. There have been no reports of recurrence during long-term follow-up after PDAA treatment in patients with MALS. We herein report a rare case of metachronous PDAA rupture in the context of MALS. The relevant literature and 11 PDAA/MALS cases are discussed.

Non-aneurysmal Gastroepiploic Arterial Hemorrhage With Median Arcuate Ligament Syndrome

Spontaneous non-aneurysmal gastroepiploic arterial hemorrhage is a rare occurrence, and its association with celiac axis compression syndrome (CACS), also referred to as median arcuate ligament syndrome (MALS), is even more uncommon. Furthermore, nontraumatic intraperitoneal hemorrhage due to defecation strain is also rare. This study reports an extremely rare case of non-aneurysmal gastroepiploic arterial hemorrhage with CACS/MALS after defecation strain. A 24-year-old man presented with a sudden upper abdominal pain on the left side after defecation. The patient was diagnosed with bleeding from the gastroepiploic artery and CACS/MALS using contrast-enhanced computed tomography. The patient underwent urgent laparotomy, and subsequent pathogenic examination revealed no aneurysm. This was an atypical case of intraperitoneal hemorrhage with CACS/MALS, and hemorrhage may have occurred due to a combination of vascular fragility, elevated arterial blood pressure, and hemostatic disorder.

Presentation and management of true aneurysms of the pancreaticoduodenal arcade with concomitant celiac artery stenosis using the endovascular approach

True aneurysms of the pancreaticoduodenal artery (PDA) arcade are rare but require intervention due to the high risk of rupture. Historically, these aneurysms have been managed with open surgical methods. In this study, we describe a contemporary series of aneurysms treated using a modern approach that includes endovascular and hybrid techniques. All the patients with aneurysms of the PDA arcade in an institutional database were identified between 2008 and 2022. Patients with history of pancreatic resection were excluded. Data on demographics, presenting symptoms, imaging findings, operative approach, and outcomes were collected and reviewed. There were nine patients diagnosed with a PDA aneurysm, and all nine underwent endovascular intervention. Most were men (n = 5; 55.6%) and White (n = 7; 77.8%) and had American Society of Anesthesiologists class II or III. The median aneurysm size was 21 mm (range, 6-42 mm), and five (55.5%) were symptomatic. Of the five symptomatic cases, two presented with rupture and were treated urgently. The median time to intervention for the nonurgent cases was 30 days. All but one patient had concomitant celiac artery stenosis and two of the eight cases (25%) were due to extrinsic compression from median arcuate ligament syndrome. Both patients underwent median arcuate ligament syndrome release before endovascular intervention. Another patient required open surgical bypass before endovascular repair from the supraceliac aorta to hepatic artery using a Dacron graft to maintain hepatic perfusion. Among the eight patients with celiac axis stenosis, five (62.5%) required celiac stent placement within the same operation. Coil embolization of the aneurysm was used for all except for two patients (n = 7 of 9; 77.8%), with one patient receiving embolic plugs and another receiving an 8 × 38-mm balloon-expandable covered stent for aneurysm exclusion. The median operating room time was 134 minutes. All repairs were technically successful without any intraoperative or postoperative complications. The mean follow-up was 30 months. There was no morbidity, mortality, or unplanned secondary reinterventions within 6 months after aneurysm repair. Stent patency and aneurysm size remained stable at 2 years of follow-up. True pancreaticoduodenal artery arcade aneurysms can be safely and effectively treated using endovascular and hybrid techniques. Because many of these aneurysms have concomitant celiac artery stenosis, the use of endovascular technology allows for simultaneous treatment of both the aneurysm and the stenosis with exceptional results.

Visceral Artery Aneurysms in the Presence of Upstream Stenoses

Background: Sutton-Kadir syndrome describes a rare pathology that commonly includes an aneurysm of the inferior pancreaticoduodenal artery in combination with a celiac trunk stenosis or occlusion, often caused by median arcuate ligament compression. Several therapeutic approaches exist including open surgical, endovascular, and hybrid treatments. Other combinations of visceral artery aneurysms and upstream stenoses exist but the cumulative body of evidence on these combinations is weak due to their rarity. Methods: A retrospective analysis of patient data from a single center was carried out. Electronic patient records were filtered for keywords including "visceral aneurysm", "Sutton-Kadir", and "median arcuate ligament". Imaging studies were re-examined by two blinded vascular surgeons with a third vascular surgeon as a referee in case of diverging results. Results: Sixteen patients had a visceral artery aneurysm with an upstream stenosis. All cases had a celiac trunk obstruction while one patient also had a concomitant superior mesenteric artery stenosis. Both median arcuate ligament compression and atherosclerotic lesions were identified. The location of the aneurysms varied even though the inferior pancreaticoduodenal artery was most frequently affected. A classification system based on the different combinations of stenoses and aneurysms is presented and introduced as a new pathologic entity: visceral artery aneurysm in the presence of upstream stenosis (VAPUS). Conclusions: The concomitant presence of visceral artery aneurysms, especially in the pancreaticoduodenal arteries, and blood flow impairment of the celiac axis or superior mesenteric artery is a rare pathology. The proposed VAPUS classification system offers an accessible and transparent route to the precise localization of the affected vessels.

Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone

INTRODUCTION

Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings.

METHODS

A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review.

RESULTS

Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients.

CONCLUSION

Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report

BACKGROUND

Median arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region. Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically.

CASE PRESENTATION

A 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved.

CONCLUSIONS

Reports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review

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.

Transarterial embolization for ruptured pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis combined with median arcuate ligament syndrome: a case report

A 75-year-old female with a history of Parkinson's disease treatment and hypertension presented at the emergency section with sudden onset of right abdominal pain. Contrast-enhanced computed tomography revealed beaded irregular stenosis and dilation of the superior mesenteric artery (SMA) and an aneurysm in the branch of the pancreaticoduodenal artery (PDA) that communicates with the common hepatic artery and SMA. Additionally, a hematoma had formed in the retroperitoneal space, and extravasation of contrast medium from the pancreaticoduodenal artery aneurysm (PDAA) into the hematoma was observed. The celiac artery (CA) was compressed by the median arcuate ligament; stenosis of the CA at its origin and dilation on the distal side were observed. Based on the imaging findings, it was diagnosed that PDAA was ruptured, SMA developed segmental arterial mediolysis (SAM), and CA developed median arcuate ligament syndrome (MALS). The ruptured PDAA was thought to be caused by SAM combined with MALS. Transcatheter arterial embolization (TAE) was performed for the ruptured PDAA. To the best of our knowledge, there have been no reports of TAE for a ruptured PDAA caused by SAM and MALS. After TAE, the PDAA did not re-rupture.

Interventional Radiology for High-Flow Aneurysm of the Pancreaticoduodenal Arcades with Median Arcuate Ligament Syndrome: Review of 14 Patients

Transarterial embolization (TAE) for high-flow pancreaticoduodenal artery (PDA) aneurysms in patients with celiac-trunk stenosis by the median arcuate ligament (MAL) has been found effective both after rupturing and to prevent rupture. The objective was to describe the TAE techniques used and their effectiveness in excluding PDA aneurysms due to MAL syndrome. This single-center retrospective study done at the Dijon-Bourgogne University Hospital included all patients treated by TAE in 2010-2022 for ruptured or unruptured high-flow PDA aneurysms caused by MAL syndrome. We identified 14 patients (7 women and 7 men; mean age, 64 years). Packing and trapping techniques were used alone or together. Occlusion was with microcoils, co-polymer, or cyanoacrylate glue, used separately or combined. Technical success was achieved in 13 (93%) patients. Clinical success was achieved in 12 (86%) patients. One major and two minor complications were recorded within the first 30 days. No complications occurred after 30 days. Follow-up ranged from 1 to 84 months. No cases of aneurysm recanalization have been recorded to date. TAE had high technical and clinical success rates in our patients with unruptured or ruptured PDA aneurysms due to MAL syndrome.

Spontaneous retroperitoneal hematoma with duodenal obstruction with diagnostic use of endoscopic ultrasound: A case series and literature review

Spontaneous retroperitoneal hematoma is rare and can cause duodenal obstruction. We report four cases of spontaneous retroperitoneal hematoma with duodenal obstruction, wherein endoscopic ultrasound was useful for diagnosis. The patients complained of vomiting with stable vital signs. Computed tomography, esophagogastroduodenoscopy, and endoscopic ultrasound findings were similar in all cases. Contrast-enhanced computed tomography revealed a low-density mass around the 2nd to 3rd part of the duodenum. Esophagogastroduodenoscopy showed an edematous, reddish, but non-neoplastic duodenal mucosa with stenosis of the lumen. Endoscopic ultrasound revealed a low-echoic mass around the duodenum and high-echoic floating matter suggesting debris and anechoic areas that indicated a liquid component. These findings suggested hematomas or abscesses. Although pseudoaneurysm of the pancreaticoduodenal artery was suspected in Case 3, we chose conservative treatment because the aneurysm was small. In Case 4, median arcuate ligament syndrome was suspected on angiography. No aneurysms or arteriovenous malformations were found; thus, endovascular embolization was not performed. The patients were treated conservatively and discharged within 3-5 weeks. English literature queries on spontaneous retroperitoneal hematoma with duodenal obstruction in MEDLINE revealed 21 cases in 18 studies. The clinical features of these patients and the present four cases have been discussed.

Ruptured small pancreaticoduodenal artery aneurysm-clinical features similar to pancreatitis: A case report

BACKGROUND

Pancreaticoduodenal artery aneurysm (PDAA) is rare and has high rupture risks. PDAA rupture has a wide range of clinical symptoms, including abdominal pain, nausea, syncope, and hemorrhagic shock, which is difficult to differentiate from other diseases.

PATIENT CONCERNS

A 55-year-old female patient was admitted to our hospital due to abdominal pain for 11 days.

DIAGNOSIS

Acute pancreatitis was initially diagnosed. The patient's hemoglobin decreased compared to before admission, suggesting that active bleeding may occur. CT volume diagram and maximum intensity projection diagram show that a small aneurysm with a diameter of about 6 mm can be seen at the pancreaticoduodenal artery arch. The patient was diagnosed with a rupture and hemorrhage of the small pancreaticoduodenal aneurysm.

INTERVENTIONS

Interventional treatment was performed. After the microcatheter was selected for the branch of the diseased artery for angiography, the pseudoaneurysm was displayed and embolized.

OUTCOMES

The angiography showed that the pseudoaneurysm was occluded, and the distal cavity was not redeveloped.

CONCLUSION

The clinical manifestations of PDAA rupture were significantly correlated with the aneurysm diameter. Because of small aneurysms, the bleeding is limited around the peripancreatic and duodenal horizontal segments, accompanied by abdominal pain, vomiting, and elevated serum amylase, similar to the clinical manifestations of acute pancreatitis but accompanied by the decrease of hemoglobin. This will help us to improve our understanding of the disease, avoid misdiagnosis, and provide the basis for clinical treatment.

Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report

INTRODUCTION AND IMPORTANCE

Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection.

CASE PRESENTATION

A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms.

CLINICAL DISCUSSION

MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS.

CONCLUSION

It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.

A Ruptured Inferior Pancreaticoduodenal Artery Aneurysm Detected With Ultrasonography: A Case Report

Pancreaticoduodenal artery aneurysm (PDAA) is a rare disease that is recognized as an intra-abdominal hemorrhage differential diagnosis. This case study reports on a ruptured PDAA case in which ultrasonography (US) proved useful for the initial diagnosis. A 60-year-old man presented to the emergency department with pain in the epigastrium and back. An abdominal US performed at presentation suggested a PDAA and intraperitoneal hemorrhage/retroperitoneal hematoma. In addition, a contrast-enhanced computed tomogram (CT) revealed a hematoma extending from the upper abdomen to the pelvic floor and an aneurysmal pancreaticoduodenal artery arcade dilatation. Furthermore, emergency abdominal angiography findings revealed bleeding from a posterior-inferior PDAA, and coil embolization was performed. Postoperative progress was good, and the postoperative CT at 7 days showed no rebleeding signs and/or enlargement or new PDAA development. Therefore, the patient was discharged from the hospital 14 days after embolization.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Transcatheter arterial embolization for bleeding from the pancreaticoduodenal artery in patients with celiac artery stenosis: A technical report

Background

Transcatheter arterial embolization (TAE) is widely accepted as a treatment for bleeding from the pancreaticodoudenal artery (PDA) in patients with celiac artery stenosis. However, the technical aspect of TAE has not received much attention.

Purpose

To report the technical details and success rate of TAE for bleeding from the PDA in patients with CA stenosis.

Material and Methods

Between 2015 and 2021, nine TAE procedures were performed in eight patients (five women, three men; one woman underwent TAE twice). The cause of CA stenosis was compression by the median arcuate ligament in eight cases and CA dissection in one case. The cause of bleeding was flow-related aneurysm rupture in six cases. Pre-TAE CT showed a pseudoaneurysm in all cases. The technical details of TAE were recorded, and the success rate was evaluated.

Results

The technical and clinical success rates were 100%. In six cases, both the CA and superior mesenteric artery (SMA) were cannulated using two parent catheters: a microcatheter advancing to the pseudoaneurysm from the CA (the CA approach) to achieve embolization and another catheter for angiography advancing from the SMA to map the vascular anatomy. In five cases, the CA approach was successfully performed after failed attempts of advancing a microcatheter from the SMA.

Conclusion

TAE is an effective treatment for bleeding from the PDA in patients with CA stenosis. Using two parent catheters, one for CA cannulation and microcatheter advancement and another for SMA cannulation and vascular mapping, may be a useful technique.

Ruptured Pancreaticoduodenal Artery Aneurysm with Median Arcuate Ligament Compression: A Two Staged Approach to Management

Introduction

Pancreaticoduodenal artery (PDA) aneurysms represent a small portion of rare visceral artery aneurysms. Rupture of these aneurysms results in fatal haemorrhage in up to 50% of cases, necessitating prompt endovascular or open intervention. As highlighted by a recent retrospective review, median arcuate ligament (MAL) release is an important part of management when these aneurysms are diagnosed in conjunction with median arcuate ligament compression (MALC). Two cases of successful urgent management of a ruptured inferior pancreatoduodenal artery aneurysm with staged MAL release are reported.

Report

A 65 year old male presented with a ruptured PDA aneurysm in the context of MALC. The patient was treated by emergency transcatheter arterial embolisation (TAE). Staged laparoscopic MAL release required open conversion and stenting one month after rupture. A 73 year old male presented to the same institution with a ruptured PDA aneurysm, again in the context of MALC. This patient was similarly managed by emergency TAE and later had an uncomplicated laparoscopic MAL release. On table mesenteric angiography confirmed successful release. Both patients have since recovered without any recurrence of bleeding or new aneurysm formation.

Discussion

Ruptured true PDA aneurysms, while uncommon, may be managed successfully using urgent endovascular techniques. Concomitant coeliac axis stenosis due to MALC requires secondary treatment and can be managed effectively using a staged approach following the urgent presentation.

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True PDA aneurysms may be associated with coeliac axis stenosis or occlusion.

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Ruptured true PDA aneurysms may result in fatal haemorrhage.

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Concomitant median arcuate ligament compression is a reversible cause of coeliac axis stenosis.

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Ligament release can be performed as a staged elective procedure following emergency treatment.

A Large Series of True Pancreaticoduodenal Artery Aneurysms

INTRODUCTION

True pancreaticoduodenal artery aneurysms (PDAA) are rare and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health-system from 2004-2019 with true PDAA, with a focus on risk factors, interventions, and patient outcomes.

METHODS

Patients were identified by querying a single health-system PACS database for radiographic reports noting a PDAA. Retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests.

RESULTS

A total of 59 true PDAA were identified. Forty aneurysms (68%) were intact (iPDAA) and 19 (32%) were ruptured (rPDAA) at presentation. Mean size of ruptured PDAA was 16.4 mm (median size 14.0 mm; range 10 - 42 mm) and mean size of intact PDAA was 19.4 mm (median size 17.5mm; range 8 - 88 mm), this difference was not statistically significant (P = 0.95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%, P=0.017), and less likely to have aneurysmal wall calcifications (6% vs 53%, P=0.002). Thirty-seven patients underwent intervention (63%); with eight (22%) undergoing concomitant hepatic revascularization (2 stents and 6 bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAA experienced an aneurysm related mortality of 10.5% while those with iPDAA experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. Ruptured PDAA showed a trend towards increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%, P=0.13).

CONCLUSIONS

These findings support previous reports that the rupture risk of PDAA is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both intact and ruptured PDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Ilio-Hepatic Artery Bypass for Hypoplasia of the Celiac Axis and Its Branches with an Inferior Pancreaticoduodenal Artery Aneurysm

Hemorrhage due to a ruptured pancreaticoduodenal artery aneurysm is potentially fatal. We describe a case of a 51-year-old man, incidentally diagnosed with an inferior pancreaticoduodenal artery aneurysm associated with probable congenital hypoplasia of the celiac axis and its branches. Considering the rupture risk, we performed an ilio-hepatic artery bypass with an autologous vein graft and aneurysmorrhaphy. The postoperative course was uneventful. At the 24-month follow-up, the bypass was patent, with no aneurysm recurrence. The ilio-hepatic artery bypass is effective and preserves visceral blood flow. However, the iliac artery is susceptible to occlusive disease, and long-term follow-up is required.

Small saccular aneurysms in the coronary and right epigastric arteries: A case report

Small saccular aneurysm in the right gastroepiploic artery is a sporadic disease accounting for approximately 0.4% of abdominal visceral aneurysms rarely observed during routine examination of other illnesses; however, it has been reported following rupture. The right gastroepiploic artery is a common alternative to the internal thoracic artery in coronary artery bypass grafting. We report a case of small aneurysms in the left anterior descending artery, diagonal branch artery, and right gastroepiploic artery and a pseudoaneurysm in right gastroepiploic artery. Coronary artery bypass grafting was performed using the left internal thoracic artery and right gastroepiploic artery, and a 5-mm aneurysm was observed in the right gastroepiploic artery. The resected 5-mm right gastroepiploic artery aneurysm was saccular. Pathological investigation revealed media loss and adventitial thinning, indicating the possibility of an aneurysm rupture. Thus, preoperative three-dimensional computed tomography is beneficial for patients with coronary arterial aneurysms and preoperative evaluation of right gastroepiploic artery to help achieve good clinical outcomes in patients undergoing coronary artery bypass grafting with another arterial aneurysm.

[Surgical treatment of pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion]

We report successful surgical treatment of inferior pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion. Considering angioarchitectonics of the afferent and efferent arteries (significant tortuosity), possible liver ischemia during endovascular occlusion of pancreaticoduodenal artery and expected low efficiency of embolization, the patient underwent open surgery (celiac trunk replacement and resection of pancreaticoduodenal artery aneurysm). Postoperative period was uneventful. The first and subsequent postoperative controls showed an adequate function of the prosthesis and no contrast enhancement of the aneurysm. We concluded that rational surgical approach ensured optimal solution of the problem, i.e. surgical treatment of pancreaticoduodenal artery aneurysm was the most radical and functional.

Pancreatoduodenal Artery Aneurism rupture post colonoscopy - Case report

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A case of Pancreatoduodenal Artery Aneurism rupture post colonoscopy.

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A rare entity that can be adequately treated with endovascular intervention.

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First report of rupture related to colonoscopy.

Introduction

Complications related to colonoscopy is considered low and in most cases involves intestinal perforation. Vascular complications involving aneurysm rupture are rare in the literature and may occur after colonoscopy.

Presentation of the case

We report a case of a 58-year-old male patient that ruptured pancreatoduodenal artery aneurysm after colonoscopy, successfully submitted to endovascular treatment.

Discussion

Colonoscopy is frequently used as a diagnostic procedure. The risk of complication inherent to the procedure is considered low, and intestinal perforation is one of the most frequent.

Other complications may present similar clinical symptoms, and it is necessary to complement the diagnostic investigation to offer the most appropriate treatment for the patient.

Among the complications, there is one report of aneurysm rupture after performing colonoscopies and no case involving aneurysm rupture of pancreatoduodenal artery has been reported to date.

Conclusion

A patient with ruptured pancreatoduodenal artery aneurysm is a rare entity that can be adequately treated with endovascular intervention. This is the first report of rupture related to colonoscopy.

A case of ruptured right gastroepiploic aneurysm treated by transcatheter arterial embolization avoiding emergency surgery

Gastroepiploic aneurysms are rare. We report the case of a 74-year-old man who presented with temporary loss of consciousness and abdominal pain. Computed tomography revealed a ruptured right gastroepiploic artery aneurysm. His vital signs improved after extracellular fluid infusion; hence, we performed transcatheter arterial embolization. There were no postoperative complications, and the patient was discharged on the 15th day of hospitalization. Ruptured abdominal aneurysms are often fatal and should be considered in patients with symptoms of anemia and abdominal pain. Currently, minimally invasive transcatheter arterial embolization had been designated as the preferred treatment option because of effectiveness in both diagnosis and treatment. Thus, we report a case of ruptured right gastroepiploic artery aneurysm treated by transcatheter arterial embolization, thereby preventing an emergency surgery.

Resuscitative endovascular balloon occlusion of the aorta for ruptured pancreaticoduodenal artery aneurysm

Resuscitative endovascular balloon occlusion of the aorta is useful as a troubleshooting response to hemorrhage and a temporary method for maintaining patient hemodynamics.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Combined Treatment of Multiple Splanchnic Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome: A Case Study and Review of the Literature

Patient: Female, 45-year-old

Final Diagnosis: Multiple splanchnic artery aneurysms secondary to median arcuate ligament syndrome • occlusion of the coeliac trunk • significant stenosis of the superior mesenteric artery

Symptoms: Abdominal pain • postprandial abdominal pain • weight loss

Medication:—

Clinical Procedure: Aorto-hepatic bypass • endovascular aneurysm embolization

Specialty: Surgery

Blood flow modification might prevent secondary rupture of multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis stenosis

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.

Hemodynamic Simulation of Pancreaticoduodenal Artery Aneurysm Formation Using an Electronic Circuit Model and a Case Series Analysis

Objective: To assess mechanisms underlying aneurysm formation using a simple electronic circuit model.

Materials and Methods: We created a simple circuit model connecting the celiac artery (CA) to the superior mesenteric artery via the pancreaticoduodenal arcade. We retrospectively reviewed 12 patients with true pancreaticoduodenal artery aneurysms (PDAAs) who received open or endovascular treatment between 2004 and 2017. We set the resistance of each artery and organ voltage and calculated flow volume and rate in response to degrees of simulated CA stenosis from 0% to 99.9%.

Results: Flow volume rates of the anterior pancreaticoduodenal artery and posterior pancreaticoduodenal artery decreased to zero when CA stenosis increased from 0% to 50% and then increased drastically, at which point flow direction reverted and the flow was up to three times the initial rate. The gastroduodenal artery (GDA) also showed reversed flow with severe CA stenosis. In 12 patients with PDAA, eight presented with a CA lesion, and the other patients presented with comorbidities causing the arteries to be pathologically fragile, such as Marfan syndrome, Behçet’s disease, and segmental arterial mediolysis. All four GDA aneurysms were not accompanied by CA lesions.

Conclusion: The mechanism underlying CA-lesion-associated PDAA formation may be partially explained using our model.

Hyper-dense fluid on plain computed tomography may reveal a ruptured aneurysm in patients with median arcuate ligament syndrome

Rupture of abdominal aneurysms associated with median arcuate ligament syndrome (MALS) is a serious condition and requires accurate diagnosis in a clinical setting. We examined three patients with this condition: two women aged 45 and 71 years, and a 61-year-old man. They complained of abdominal pain and had fluid collection around the duodenum. Plain computed tomography (CT) of the fluid collection revealed hyper density, which suggests the presence of blood. Moreover, contrast-enhanced CT revealed aneurysms in the pancreatic head area. Angiography revealed aneurysms of the branches of the gastroepiploic artery, which were treated by endovascular embolization in all patients. Thus, patients with abdominal pain and high-density fluid collection around the duodenum on plain CT may suffer from hemorrhage following rupture of MALS-associated aneurysms.

Ruptured pancreaticoduodenal artery aneurysm presenting with duodenal obstruction

Visceral aneurysms of the pancreaticoduodenal arcades are rare. Although these aneurysms are often asymptomatic and identified incidentally on cross-sectional imaging, aneurysm rupture presents significant morbidity. Ruptured pancreaticoduodenal arcade aneurysms typically present with abdominal pain, hemorrhagic shock, or gastrointestinal bleeding. A 72-year-old male presented with nausea and vomiting and was found to have imaging evidence of duodenal obstruction. This was due to a duodenal intramural hematoma caused by a ruptured submucosal aneurysm supplied by a branch of the inferior pancreaticoduodenal artery in the presence of median arcuate ligament compression of the celiac artery. This was subsequently treated with endovascular embolization with clinical improvement in duodenal obstruction. This case illustrates an unusual presentation of a ruptured pancreaticoduodenal arcade aneurysm.

Endovascular Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm with Celiac Axis Stenosis

BACKGROUND

Splanchnic artery aneurysms are relatively rare diseases. Pancreaticoduodenal arterial (PDA) aneurysms are especially uncommon and account for approximately 2% of all visceral aneurysms. However, rupture of a PDA aneurysm often results in fatal consequences. Intervention therapy has evolved as a mainstream method because of its low risk and rapid recovery. Previous studies have demonstrated that PDA aneurysms are often associated with occlusion or stenosis of the celiac artery, but management of the celiac artery lesion remains controversial. Here, we report a case of PDA aneurysm concurrent with celiac axis stenosis (CAS) that has been successfully treated by embolization of the PDA aneurysm and subsequent stenting of the celiac artery.

CASE PRESENTATION

A 50-year-old man complaining of epigastric pain for 15 hours was admitted to our emergency department. Blood tests revealed low hemoglobin, and an abdominal computed tomography (CT) showed a retroperitoneal hematoma. To determine the source of bleeding, celiac arteriography was performed immediately. Celiac truck stenosis was observed, and a PDA ruptured aneurysm was diagnosed. The outflow, aneurysm sac, and inflow of the aneurysm were embolized. The patient was discharged on the sixth day postoperatively. Unfortunately, the patient returned to our department 2 weeks later complaining of nausea and vomiting for 2 days. The abdominal CT scan showed no recurrent bleeding. Celiac artery stenting was performed, and the symptoms were significantly relieved. The postoperative course was uneventful, and the CT scan follow-up at 24 months showed patency of the celiac artery stent and total occlusion of the PDA.

CONCLUSIONS

PDA aneurysms associated with celiac stenosis are relatively rare. Once the PDA aneurysm ruptures, endovascular treatment is the first choice. The necessity for revascularization of the celiac axis remains controversial. If the patient develops gastric ischemia symptoms after initial treatment, proceeding to CAS treatment is necessary.

Median arcuate ligament syndrome and aneurysm in the pancreaticoduodenal artery detected by retroperitoneal hemorrhage: A case report

Here, we report a case with successful treatment of inferior pancreaticoduodenal artery aneurysm rupture due to celiac artery trunk compression caused by the median arcuate ligament. When clinicians see visceral aneurysms, the possibility of arcuate midline ligament compression syndrome (MALS) and ligamentectomy for MALS should be considered.

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.

The presentation and management of aneurysms of the pancreaticoduodenal arcade

OBJECTIVE

Gastroduodenal artery aneurysms (GDAAs) and pancreaticoduodenal artery aneurysms (PDAAs) are uncommon lesions associated, however, with a significant risk of rupture. This study describes the clinical presentation, associated imaging findings, and operative strategies for these aneurysms.

METHODS

The records of all patients with GDAAs or PDAAs identified through an institutional database by axial imaging between 1994 and 2014 were retrospectively reviewed. Data on presenting symptoms, comorbid conditions, imaging findings, and outcomes after operative intervention were collected and examined.

RESULTS

We identified 11 GDAAs and 25 PDAAs in 35 patients. Mean size of the GDAAs was 31.1 mm (range, 10-60 mm) and mean size of the PDAAs was 19.1 mm (range, 10-48 mm). At presentation, 13 aneurysms (36%) were symptomatic and seven aneurysms (19.4%) were ruptured. Median size of ruptured aneurysms was 20 mm (range, 10-60 mm). On axial imaging, 24 aneurysms (67%) were associated with a severe stenosis or occlusion of the celiac axis origin, and 11 aneurysms (31%) were thought to be associated with compression of the celiac axis in the setting of median arcuate ligament syndrome. Twenty-four aneurysms (67%) underwent repair. Of these aneurysms, 18 (75%) were successfully managed with primary endovascular repair (coil embolization with or without celiac stent), whereas endovascular therapy failed in two (8%) and required open repair. Four aneurysms (17%) were treated with primary open repair. Overall 30-day morbidity and mortality after aneurysm repair were 29% and 4%, respectively.

CONCLUSIONS

GDAAs and PDAAs are uncommon lesions that are often associated with a celiac axis stenosis/occlusion leading to altered hemodynamics in the pancreaticoduodenal arcade. These aneurysms are prone to rupture regardless of size, and intervention is accordingly recommended for all aneurysms upon recognition. Despite the concordant celiac axis obstruction and concern for maintenance of hepatic circulation, endovascular repair of these aneurysms is generally successful and should be considered as the initial operative approach.

Aneurysms of Peripancreatic Arterial Arcades Coexisting with Celiac Trunk Stenosis or Occlusion: Single Institution Experience

Introduction. True aneurysms of peripancreatic arterial arcades (PAAAs) are rare. Most of them coexist with celiac axis stenosis/occlusion due to median arcuate ligament (MAL) compression or atherosclerosis. The aim of this study was to evaluate the cause of celiac axis lesion and characterize the anatomy of the aneurysms. These findings may have important management implications. Material and Methods. A retrospective analysis of 15 patients with true PAAAs was performed. The diagnosis was established by contrast-enhanced CT, using a 64-MDCT scanner. We evaluated the most probable cause of celiac axis lesion. Aneurysms were characterized by their number, location, size, and morphology. Location of the aneurysms was classified either as pancreaticoduodenal arteries (PDA) or as dorsal pancreatic arteries (DPA) as they may represent different collateral pathways between superior mesenteric artery and celiac trunk. Results. A total of 32 true PAAAs were identified. Celiac trunk was occluded in 12 patients and critically narrowed in 3 patients. Celiac axis lesion was categorized as secondary to MAL compression in 14 cases and due to atherosclerosis in 1 case. The most common location of the aneurysms was inferior pancreaticoduodenal arteries. Only in 1 case aneurysms involved both PDA and DPA. Conclusions. Coexistence of PAAAs with celiac axis compression as well as involvement of either PDAs or DPAs has important therapeutic implications. The uninvolved collateral pathway may be sufficient to preserve effective circulation in celiac trunk branches in case of resection or embolization of the aneurysms. However, further studies are crucial to confirm our findings.

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.

Perioperative Hemodynamic Monitoring of Common Hepatic Artery for Endovascular Embolization of a Pancreaticoduodenal Arcade Aneurysm with Celiac Stenosis

This report describes perioperative hemodynamic monitoring of the common hepatic artery (CHA) during endovascular treatment of a pancreaticoduodenal arcade aneurysm, in a patient with celiac artery stenosis caused by the median arcuate ligament. Pressure monitoring was performed as a safety measure against critical complications such as liver ischemia. As the aneurysm was located in the anterior pancreaticoduodenal artery (APDA) and the posterior pancreaticoduodenal artery (PPDA) was small in caliber, the patient was considered to be at a high risk of liver ischemia. No significant change in pressure was observed in the CHA on balloon occlusion test in the APDA. Immediately after embolization, the PPDA enlarged and the pressure in the CHA was well maintained. Pressure monitoring appears to improve patient safety during endovascular treatment of visceral aneurysms.

Pancreaticoduodenal artery aneurysm associated with coeliac artery occlusion from an aortic intramural hematoma

Pancreaticoduodenal artery aneurysms are a rare type of visceral artery aneurysm, whose rupture is associated with high mortality. These aneurysms are of particular interest because local haemodynamic change caused by coeliac artery obstruction plays an important role in their development. However, the pathophysiological mechanism of coeliac artery obstruction is not completely understood. Pressure from the median arcuate ligament is most frequently reported cause. Although it is well-known that stenosis or occlusion of the visceral vessels may be caused by aortic syndrome, reports of pancreaticoduodenal artery aneurysm associated with coeliac artery occlusion due to aortic syndrome are extremely rare. Our case indicates a new aetiology for a pancreaticoduodenal artery aneurysm and demonstrates the rapid deterioration of the patient affected.

Multiple Pancreatoduodenal Artery Arcade Aneurysms Associated with Celiac Axis Root Segmental Stenosis Presenting as Aneurysm Rupture

A 57-year-old woman was admitted to our unit suffering from hemorrhagic shock and upper abdominal pain. An enhanced computerized tomography (CT) scan evidenced a large retroperitoneal hematoma due to visceral arteries aneurysm rupture and a significant celiac axis root segmental stenosis due to median arcuate ligament compression. A selective splanchnic arteries angiography showed 3 saccular pancreaticoduodenal artery arcade aneurysm (PDAAs), 2 in the inferior posterior pancreaticoduodenal artery, and 1 smaller in the superior anterior pancreaticoduodenal artery. The largest aneurysm showed evident rupture signs. Both inferior PDAAs were successfully treated via endovascular coil embolization. The celiac trunk stenosis and small inferior PDAA did not require treatment. A CT scan control at 1-year follow-up did not reveal any new PDAAs. In cases of celiac artery trunk (CAT) steno-occlusive lesions, multiple aneurysms can develop in the pancreaticoduodenal arcade. PDAAs should be treated because of high rupture risk, regardless of diameter. Although endovascular treatment via coil embolization represents the treatment of choice nowadays, a simultaneous treatment of the associated CAT lesions is still debated. However, in cases of aneurysm embolization alone, one cannot exclude that other PDAAs might develop in these patients in the future. Close monitoring and accurate long-term follow-up is highly recommended in these cases.

A pancreaticoduodenal artery aneurysm

A 70-year-old man was investigated with CT imaging for haematuria. An incidental finding was made of a large inferior pancreaticoduodenal artery aneurysm. Following a period of monitoring, the patient underwent open repair of the aneurysm. This case report highlights an unusual pathology and discusses the clinical complexities related to its management.

Polyarteritis nodosa-induced pancreaticoduodenal artery aneurysmal rupture

Polyarteritis nodosa (PAN) is a systemic, necrotizing vasculitis of small- and medium-sized arteries typically with multiorgan involvement. Most cases of PAN are idiopathic, although hepatitis B or C virus infections and hairy cell leukemia are important in the pathogenesis of some cases. PAN is characterized as segmental transmural inflammation of muscular arteries. Diagnosis is based on clinical suspicion, a negative immunofluorescence test for antineutrophil cytoplasmic antibodies, and whenever possible, biopsy conformation. Angiographic images may reveal microaneurysms affecting the renal, hepatic, or mesenteric vasculature. Aneurysmal formation and rupture are important complications that can be fatal. Treatment may warrant immunosuppression with steroids and cyclophosphamide. If left untreated, PAN can be fatal. To our knowledge, we report the second documented case of PAN-induced ruptured inferior pancreaticoduodenal artery aneurysm.

Pancreatoduodenal artery aneurysm resulting from median arcuate ligament compression successfully treated with laparoscopic ligament section

True aneurysms of the pancreatoduodenal arteries are frequently associated with stenosis or occlusion of the celiac trunk caused by median arcuate ligament compression. Celiac stenosis cannot be cured, even by transarterial embolization, which has recently become a good alternative to open surgical repair. To prevent recurrence, management of median arcuate ligament compression to correct hemodynamics in vascular networks should also be performed. Herein we report a case of pancreatoduodenal arterial aneurysm with median arcuate ligament compression that was successfully treated with minimally invasive laparoscopic median arcuate ligament section. The patient was discharged 4 days after surgery with no complications. Enhanced CT 1 month after surgery revealed no residual celiac trunk stenosis or aneurysm. Normalization of blood flow by laparoscopic median arcuate ligament section is a good option for some patients with a pancreatoduodenal arterial aneurysm.

Treatment Strategies for a Pancreaticoduodenal Artery Aneurysm with or without a Celiac Trunk Occlusive Lesion

OBJECTIVES

A true pancreaticoduodenal artery aneurysm (PDAA) is a rare disease, and has some unique characteristics: a high rupture risk and a strong correlation with celiac trunk stenotic lesions (CTSL). We showed here that our treatment strategy for PDAA.

MATERIALS AND METHODS

Seven consecutive patients with PDAA at our institution from 1998 to 2011 were retrospectively reviewed. Of the 7 patients, five were male and two were female, with a mean age of 55 ± 9.7 years. Three aneurysms were diagnosed incidentally, and the remaining four ruptured. The locations of the aneurysm were the anterior superior pancreaticoduodenal artery (ASPDA) in 3 patients and the inferior pancreaticoduodenal artery (IPDA) in four. CTSL found 3 patients in the IPDA.

RESULTS

Of four ruptured patients, emergency catheter coil embolization was performed in three, and a simple ligation was performed in one. Three patients with non-ruptured aneurysms in the IPDA with a CTSL underwent direct aneurysm resection with arterial reconstruction. Six patients were successfully treated without complications or the appearance of new aneurysms during the follow-up period.

CONCLUSION

The treatment strategy for PDAA should be selected by the site of the aneurysm, the patients' condition, and the anatomical situation. A hybrid treatment could be considered a beneficial option for a CTSL.