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Chidambaram R, Soares J, Hicks R, Samuelson S, Tibballs J, Ferguson J, Jansen S. Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone. J Med Imaging Radiat Oncol 2024; 68:289-296. [PMID: 38437188 DOI: 10.1111/1754-9485.13631] [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] [Received: 10/18/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024]
Abstract
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.
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Affiliation(s)
- Rama Chidambaram
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Julian Soares
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rhiannon Hicks
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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2
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Kang J, Kim S, Yang SS, Kim YW, Do YS, Park KB, Park YJ. Clinical Characteristics and Management of Peripancreatic Arterial Aneurysms: A 20-year Experience. Angiology 2023:33197231225281. [PMID: 38147027 DOI: 10.1177/00033197231225281] [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: 12/27/2023]
Abstract
Pancreaticoduodenal and gastroduodenal artery aneurysms (PDAAs and GDAAs) are rare visceral aneurysms. Considering the rupture risk regardless of size, treatment should be provided promptly. We reviewed the characteristics and management of peripancreatic aneurysms in a retrospective, single-center review of consecutive patients with PDAAs and GDAAs between 2000 and 2022. Demographics, clinical characteristics, radiologic features, treatment, and outcomes were recorded. Nineteen PDAAs and seven GDAAs were identified in 24 patients. The median sizes of the PDAAs and GDAAs were 21 mm (range: 8-50 mm) and 14 mm (range: 11-32 mm), respectively. There were 4 ruptured cases (15.4%). Ten aneurysms (38.5%) had concomitant visceral aneurysms, and 16 (61.6%) were associated with celiac pathology. Aneurysms were managed using endovascular in 12 (46.2%), surgical in 4 (15.4%), and combined methods in 3 (11.5%) cases; 7 patients (26.9%) were lost to follow-up or refused treatments. During a median 13.8-month follow-up (range: 1-147.6), two complications (7.7%) occurred including pancreatitis and coil migration into the superior mesenteric artery after embolization within 30 days. After 30 days, aorto-common hepatic artery bypass graft stenosis was identified in one PDAA. Depending on the characteristics of peripancreatic aneurysms, endovascular, surgical, and hybrid approaches might all be practical treatment options.
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Affiliation(s)
- Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Sejun Kim
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Department of Surgery, Incheon Sejong Hospital, Incheon, Korea
| | - Young-Soo Do
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kwang-Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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3
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Zeng R, Cao Z, Zheng Y. A gastroduodenal artery aneurysm with superior mesenteric artery occlusion repaired by incomplete aneurysmectomy for mesenteric collateral vasculature protection. J Vasc Surg 2023; 78:1333-1334. [PMID: 37865426 DOI: 10.1016/j.jvs.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 10/23/2023]
Affiliation(s)
- Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital (Dongdan campus), Beijing, China
| | - Zenghan Cao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital (Dongdan campus), Beijing, China.
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4
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Fei K, Zani S, Ronald JS, Shortell CK, Southerland KW. A minimally invasive approach for management of pancreaticoduodenal artery and gastroduodenal artery aneurysm with celiac artery occlusion. J Vasc Surg Cases Innov Tech 2023; 9:101180. [PMID: 37388670 PMCID: PMC10300390 DOI: 10.1016/j.jvscit.2023.101180] [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] [Received: 12/21/2022] [Accepted: 03/23/2023] [Indexed: 07/01/2023] Open
Abstract
Management of pancreaticoduodenal artery aneurysms (PDAAs) and gastroduodenal artery aneurysms (GDAAs) with concomitant celiac occlusion represents a challenging clinical scenario. Here, we describe a 62-year-old female with PDAA and GDAA complicated by celiac artery occlusion due to median arcuate ligament syndrome. We used a staged, minimally invasive approach consisting of: (1) a robotic median arcuate ligament release; (2) endovascular celiac artery stenting; and (3) visceral aneurysm coiling. The findings from this case report represent a novel treatment strategy for the management of PDAA/GDAA with celiac artery compression secondary to median arcuate ligament syndrome.
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Affiliation(s)
- Kaileen Fei
- Duke University School of Medicine, Durham, NC
| | - Sabino Zani
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC
| | - James S. Ronald
- Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, NC
| | - Cynthia K. Shortell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Kevin W. Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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5
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Siauve V, Chevallier O, Mazit A, Falvo N, Comby PO, Loffroy R. Interventional Radiology for High-Flow Aneurysm of the Pancreaticoduodenal Arcades with Median Arcuate Ligament Syndrome: Review of 14 Patients. J Clin Med 2023; 12:4692. [PMID: 37510806 PMCID: PMC10381139 DOI: 10.3390/jcm12144692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Valentin Siauve
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
- ICMUB Labboratory, UMR CNRS 6302, University of Burgundy, 9 Avenue Alain Savary, 21000 Dijon, France
| | - Amin Mazit
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
- ICMUB Labboratory, UMR CNRS 6302, University of Burgundy, 9 Avenue Alain Savary, 21000 Dijon, France
| | - Pierre-Olivier Comby
- ICMUB Labboratory, UMR CNRS 6302, University of Burgundy, 9 Avenue Alain Savary, 21000 Dijon, France
- Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France
- ICMUB Labboratory, UMR CNRS 6302, University of Burgundy, 9 Avenue Alain Savary, 21000 Dijon, France
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6
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Two cases of pancreaticoduodenal aneurysm with median arcuate ligament syndrome treated with coil embolization and median arcuate ligament incision. Radiol Case Rep 2022; 17:3663-3668. [PMID: 35936877 PMCID: PMC9352807 DOI: 10.1016/j.radcr.2022.07.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
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7
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Maeno R, Hoshina K, Miyahara K, Suhara M, Matsukura M, Isaji T, Takayama T. Volumetric computed tomography analysis for gastroduodenal and pancreaticoduodenal artery aneurysm formation: A retrospective single-center study. Medicine (Baltimore) 2022; 101:e29539. [PMID: 35713464 PMCID: PMC9276393 DOI: 10.1097/md.0000000000029539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/06/2022] [Indexed: 11/26/2022] Open
Abstract
Gastroduodenal artery aneurysms (GDAA) and pancreaticoduodenal artery aneurysms (PDAA) are rare, have high rupture risks, and are located in the arcade between the celiac artery and the superior mesenteric artery. Pancreaticoduodenal artery aneurysms are associated with celiac artery stenosis, and it is hypothesized that these celiac lesions might contribute to the formation of aneurysms. In contrast, a few studies have reported an association between a gastroduodenal artery aneurysm and celiac lesions. This study aimed to investigate the potential differences between patients with gastroduodenal and pancreaticoduodenal artery aneurysms and better understand their pathogenesis.We selected patients with GDAA and PDAA who were admitted to our department between January 2010 and December 2020. Aortic wall volume, aortic wall calcification, and pancreaticoduodenal arcade volume of computed tomography images were calculated semi-manually using Horos 3.3.5.Eight GDAAs and 11 PDAAs were analyzed. Celiac lesions were found in all PDAA patients, with none in GDAA cases. Volumetry demonstrated that aortic wall volume and calcification were more prominent in the GDAA group than in the PDAA group (P = .026 and P = .049, respectively). The pancreaticoduodenal arcade volume was larger in the PDAA group (P = .002).In our study, celiac artery lesions were strongly correlated with PDAA. The volume of the pancreaticoduodenal arcade was larger in the PDAA group, and aortic wall volume and calcification were larger in the GDAA group.
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8
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Davis AL, Shepherd T, Cadogan M, Foo J. Bryant's sign as a manifestation of a retroperitoneal paraduodenal bleed and subsequent small bowel obstruction. BMJ Case Rep 2022; 15:15/3/e247442. [PMID: 35346950 DOI: 10.1136/bcr-2021-247442] [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: 11/04/2022] Open
Abstract
Bryant's sign is defined as ecchymosis at the base of the penis and scrotum and is usually associated with a retroperitoneal bleed or ruptured aortic aneurysm. We report the case of a retroperitoneal paraduodenal bleed which presented with Bryant's sign. Imaging confirmed a pancreaticoduodenal arcade microaneurysm and associated low-grade coeliac artery stenosis (Sutton-Kadir syndrome). Retroperitoneal bleeding can be life threatening and requires prompt diagnosis and management. However, diagnosis can be challenging due to the clinical variation in presentation. The rarity of presentation in this case caused significant uncertainty necessitating a multidisciplinary approach for diagnostic clarity and safe patient care.
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Affiliation(s)
- Amelia Leigh Davis
- Surgical Acute Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Talia Shepherd
- Upper Gastrointestinal Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,The University of Western Australia, Perth, Western Australia, Australia
| | - Mike Cadogan
- Emergency Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Jonathan Foo
- Upper Gastrointestinal Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Discipline of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Crawley, Western Australia, Australia
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9
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Whitley A, Bafrnec J, Rokosny S, Lawrie K, Balaz P. Pancreaticoduodenal artery aneurysm associated with coeliac trunk occlusion treated with aorto-hepatic bypass and aneurysm resection. Vascular 2022; 31:598-602. [PMID: 35230917 DOI: 10.1177/17085381211070353] [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
Pancreaticoduodenal artery aneurysms are rare visceral artery aneurysms that may be associated with stenosis of the coeliac trunk. We present a case of a 48-year-old woman with a symptomatic aneurysm of the inferior pancreaticoduodenal artery caused by occlusion of the coeliac trunk due to median arcuate ligament syndrome. The patient was treated with an aorto-hepatic bypass and excision of the aneurysm. We discuss the case and the complexities and controversies in the treatment of this disease.
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Affiliation(s)
- Adam Whitley
- Department of Surgery, 385317University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Department of Anatomy, Second Faculty of Medicine, Charles University, Prague Czech Republic
| | - Jan Bafrnec
- Division of Vascular Surgery, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Slavomir Rokosny
- Division of Vascular Surgery, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katerina Lawrie
- Division of Vascular Surgery, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Peter Balaz
- Division of Vascular Surgery, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Vascular Surgery, National Institute for Cardiovascular Disease, Bratislava, Slovak Republic
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10
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A Large Series of True Pancreaticoduodenal Artery Aneurysms. J Vasc Surg 2022; 75:1634-1642.e1. [PMID: 35085750 DOI: 10.1016/j.jvs.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022]
Abstract
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.
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11
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Nemoto M, Watanabe T, Tadokoro Y, Takayama Y, Yamamoto J. Ilio-Hepatic Artery Bypass for Hypoplasia of the Celiac Axis and Its Branches with an Inferior Pancreaticoduodenal Artery Aneurysm. Ann Vasc Dis 2021; 14:270-272. [PMID: 34630773 PMCID: PMC8474088 DOI: 10.3400/avd.cr.21-00059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/15/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Masaru Nemoto
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama, Ibaraki, Japan
| | - Tatsuki Watanabe
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama, Ibaraki, Japan
| | - Yu Tadokoro
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama, Ibaraki, Japan
| | | | - Junji Yamamoto
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama, Ibaraki, Japan
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12
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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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13
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Metzger PB, Costa KR, Silva SLE, Gouveia AC, Berbert MQ, Mello MODA, de Oliveira FM, Melo RFF. Inferior pancreaticoduodenal artery aneurysm: endovascular approach. J Vasc Bras 2021; 20:e20200101. [PMID: 34093677 PMCID: PMC8147707 DOI: 10.1590/1677-5449.200101] [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: 11/22/2022] Open
Abstract
Aneurysms of the pancreaticoduodenal arteries are a rare condition. In the majority of cases, diagnosis is made in emergency situations due to complications such as rupture, which is associated with high mortality rates (21-26%). Embolization of the aneurysm sac is the treatment of choice, because of its high efficacy and lower mortality. This article presents and discusses a case of inferior pancreaticoduodenal artery aneurysm that was diagnosed during investigation of gastrointestinal symptoms. The treatment provided was microcoil embolization, with complete exclusion of the aneurysm and a good clinical course.
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14
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Parfenov IP, Shubin AA, Vardanyan AV, Dolidze DD, Kovantsev SD. [Surgical treatment of pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion]. Khirurgiia (Mosk) 2021:64-69. [PMID: 33759471 DOI: 10.17116/hirurgia202104164] [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: 11/17/2022]
Abstract
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.
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Affiliation(s)
- I P Parfenov
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - A A Shubin
- Botkin City Clinical Hospital, Moscow, Russia
| | - A V Vardanyan
- Botkin City Clinical Hospital, Moscow, Russia.,Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - D D Dolidze
- Botkin City Clinical Hospital, Moscow, Russia.,Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - S D Kovantsev
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
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15
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Pivetta LGA, de Carvalho JPV, Telles GJP, de Freitas Amaral PH, Roll S. Pancreatoduodenal Artery Aneurism rupture post colonoscopy - Case report. Int J Surg Case Rep 2021; 80:105682. [PMID: 33636405 PMCID: PMC7918268 DOI: 10.1016/j.ijscr.2021.105682] [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] [Received: 01/10/2021] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/18/2022] Open
Abstract
A case of Pancreatoduodenal Artery Aneurism rupture post colonoscopy. A rare entity that can be adequately treated with endovascular intervention. 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.
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Affiliation(s)
| | | | | | | | - Sergio Roll
- Hernia Center, Gastrointestinal Surgery Service, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
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16
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Taboada CR, Alonso JG, Cortés RP, Pelayo LV, Hernández PV, Sánchez FSL. Dual endovascular repair (coils and stent) of a true aneurysm of the gastroduodenal artery. J Vasc Bras 2020; 19:e20190123. [PMID: 34178066 PMCID: PMC8202159 DOI: 10.1590/1677-5449.190123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report a case of an asymptomatic gastroduodenal artery aneurysm diagnosed in a 39 year-old woman. An abdominal ultrasound study showed an aneurysmal dilatation of the gastroduodenal artery with 2 x 2 cm diameter. To confirm this finding, she then underwent a computed tomography scan of the abdomen and pelvis that showed a saccular aneurysm of the gastroduodenal artery. A dual endovascular approach was used to exclude the aneurysm by stent-assisted coil embolization. Complete exclusion of the aneurysm sac was confirmed on final angiography. She was discharged from the hospital on postoperative day 1.
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Affiliation(s)
| | | | - Rubén Peña Cortés
- Hospital Clínico de Salamanca, Angiología y Cirugía Vascular, Salamanca, España
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17
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Kaszczewski P, Leszczyński J, Elwertowski M, Maciąg R, Chudziński W, Gałązka Z. Combined Treatment of Multiple Splanchnic Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome: A Case Study and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926074. [PMID: 32778636 PMCID: PMC7440745 DOI: 10.12659/ajcr.926074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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
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Affiliation(s)
- Piotr Kaszczewski
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jerzy Leszczyński
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Elwertowski
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Rafał Maciąg
- II Division of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Witold Chudziński
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gałązka
- Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, Warsaw, Poland
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18
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Savlania A, Naik AL, Pandey A, Gorsi U, Singh A. Symptomatic pancreaticoduodenal artery aneurysm with coeliac artery occlusion repaired by ligation of aneurysm and creation of neocoeliac trunk. ANZ J Surg 2020; 91:E137-E139. [PMID: 32678495 DOI: 10.1111/ans.16175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ajay Savlania
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil L Naik
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Pandey
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhinav Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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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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20
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Bonardelli S, Spampinato B, Ravanelli M, Cuomo R, Zanotti C, Paro B, Nodari F, Barbetta I, Portolani N. The role of emergency presentation and revascularization in aneurysms of the peripancreatic arteries secondary to celiac trunk or superior mesenteric artery occlusion. J Vasc Surg 2020; 72:46S-55S. [DOI: 10.1016/j.jvs.2019.11.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
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21
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Imam R, Khalayleh H, Khoury D, Lin G, Imam A. Rupture of an Idiopathic Aneurysm of the Inferior Pancreaticoduodenal Artery Leading to an Intra-Abdominal Bleeding. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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22
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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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Asaumi Y, Sakatoku M, Okamoto J, Hayashi S, Ota N, Yoshida K, Sugahara H, Tabata S, Kaneki M, Ietsugu K, Kiyohara K. Laparoscopic decompression of a stricture of the celiac artery caused by the median arcuate ligament in a gastric cancer patient: A case of report. Asian J Endosc Surg 2019; 12:315-317. [PMID: 30259706 DOI: 10.1111/ases.12650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 05/28/2018] [Accepted: 08/19/2018] [Indexed: 12/01/2022]
Abstract
Stricture of the celiac artery caused by the median arcuate ligament induces abdominal ischemic symptoms and aneurysm near the pancreatic head. However, the need to treat asymptomatic patients is unclear. We safely performed surgical decompression of a stricture of the celiac artery by MAL in an asymptomatic patient at the same time as gastrectomy for gastric cancer. After surgery, the stricture of the celiac artery had disappeared as demonstrated by CT scan and 3-D CT angiography.
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Affiliation(s)
- Yoshihide Asaumi
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Mitsuaki Sakatoku
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Junpei Okamoto
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Saki Hayashi
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Naohiro Ota
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Kouichi Yoshida
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Hiroyuki Sugahara
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Satoshi Tabata
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Masahiro Kaneki
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Kenichi Ietsugu
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
| | - Kaoru Kiyohara
- Department of Surgery, Tonami General Municipal Hospital, Toyama, Japan
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Miyahara K, Hoshina K, Nitta J, Kimura M, Yamamoto S, Ohshima M. Hemodynamic Simulation of Pancreaticoduodenal Artery Aneurysm Formation Using an Electronic Circuit Model and a Case Series Analysis. Ann Vasc Dis 2019; 12:176-181. [PMID: 31275470 PMCID: PMC6600102 DOI: 10.3400/avd.oa.19-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Kazuhiro Miyahara
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Nitta
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaru Kimura
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sota Yamamoto
- Department of Mechanical Engineering, Graduate School, Shibaura Institute of Technology, Tokyo, Japan
| | - Marie Ohshima
- Interfaculty Initiative in Information Studies/Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
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25
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Zhang X, Zhang W, Zhou W, Zhou W. Endovascular Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm with Celiac Axis Stenosis. Ann Vasc Surg 2019; 57:273.e1-273.e5. [PMID: 30684620 DOI: 10.1016/j.avsg.2018.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/06/2018] [Accepted: 09/28/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Xiaoyu Zhang
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenwen Zhang
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weimin Zhou
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
| | - Wei Zhou
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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26
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Michalinos A, Schizas D, Ntourakis D, Filippou D, Troupis T. Arc of Bühler: the surgical significance of a rare anatomical variation. Surg Radiol Anat 2018; 41:575-581. [PMID: 30552487 DOI: 10.1007/s00276-018-2168-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/08/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The arc of Bühler, an anastomotic vessel between celiac artery and superior mesenteric artery, is a rare anatomic variation. Various radiologic and surgical procedures can be affected by its existence. We aim to review all available information and identify possible clinical implications. METHODS A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The following terms were utilized in various combinations: "Bühler", "arc of Bühler", "visceral aneurysm", "pancreaticoduodenal arcades". RESULTS Only 53 cases have been described until today in the literature. The arc of Bühler enhances collateral circulation between celiac artery and superior mesenteric artery alongside with pancreaticoduodenal arcades and dorsal pancreatic artery. Computerized tomography and angiography are the main studies used for its detection and evaluation. Aneurysms of Bühler's arc have been rarely described and seem to share common pathophysiological mechanisms with aneurysms of the pancreaticoduodenal arcades. CONCLUSIONS Various radiologic and surgical procedures such as embolization or pancreaticoduodenectomy are potentially affected by its existence.
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Affiliation(s)
- Adamantios Michalinos
- Department of Anatomy and Surgical Anatomy, School of Medicine, National and Kapodistrian University of Athens, Tetrapoleos 18, 75 Mikras Asias Str, 11527, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, Faculty of Medicine, National and Kapodistrian University of Athens, Tetrapoleos 18, 11527, Athens, Greece
| | - Dimitrios Ntourakis
- Department of Surgery, European University of Cyprus, Diogenis Str 6, 2404, Nicosia, Cyprus
| | - Dimitrios Filippou
- Department of Anatomy and Surgical Anatomy, School of Medicine, National and Kapodistrian University of Athens, Tetrapoleos 18, 75 Mikras Asias Str, 11527, Athens, Greece
| | - Theodore Troupis
- Department of Anatomy and Surgical Anatomy, School of Medicine, National and Kapodistrian University of Athens, Tetrapoleos 18, 75 Mikras Asias Str, 11527, Athens, Greece.
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Heo S, Kim HJ, Kim B, Lee JH, Kim J, Kim JK. Clinical impact of collateral circulation in patients with median arcuate ligament syndrome. ACTA ACUST UNITED AC 2018; 24:181-186. [PMID: 30091707 DOI: 10.5152/dir.2018.17514] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE We aimed to analyze computed tomography (CT) findings and medical records of patients diagnosed with median arcuate ligament syndrome (MALS) and evaluate possible risk factors associated with vascular complications that develop in patients with MALS. METHODS This retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. A total of 37 consecutive patients were diagnosed with MALS using both axial and sagittal CT reconstruction imaging at a single institution over a 7-year period. Dynamic contrast-enhanced CT data, medical records, and angiography results were reviewed. RESULTS Thirty-two (86.5%) patients were asymptomatic and incidentally diagnosed with MALS using CT. Seventeen (45.9%) patients exhibited significant arterial collateral circulations and nine (24.3%) were found to have splanchnic artery aneurysms, including one (2.7%) with acute bleeding secondary to aneurysm rupture. Peripancreatic vascular network including pancreaticoduodenal arcades and dorsal pancreatic artery was the most common site for development of both collateral circulations (16/22, 72.7%) and aneurysms (9/16, 56.3%). Splanchnic artery aneurysms were significantly more common in patients with collateral circulations (8/17, 47.1%) compared with those without collateral circulations (1/20, 5%) (P < 0.01). At least one peripancreatic vascular aneurysm was found in five of nine patients with splanchnic artery aneurysms (55.6%). CONCLUSION Splanchnic artery aneurysms are not uncommon in asymptomatic patients with collateral circulations caused by significant celiac trunk stenosis or obstruction due to median arcuate ligament. Therefore, careful imaging evaluation is necessary in patients with peripancreatic collateral circulations associated with MALS and regular follow-up is recommended for possibility of aneurysm development and rupture. Prophylactic endovascular treatment should be specifically performed in patients with pancreaticoduodenal arcade aneurysms to prevent life-threatening aneurysm rupture regardless of size.
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Affiliation(s)
- Subin Heo
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Hye Jin Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Bohyun Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jei Hee Lee
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jai Keun Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
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Miyamotto M, Kanegusuku CN, Okabe CM, Claus CMP, Ramos FZ, Rothert Á, Gubert APN, Moreira RCR. Laparoscopic treatment of celiac axis compression by the median arcuate ligament and endovascular repair of a pancreaticoduodenal artery aneurysm: case report. J Vasc Bras 2018; 17:252-256. [PMID: 30643513 PMCID: PMC6326135 DOI: 10.1590/1677-5449.000118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Compression of the celiac axis by the median arcuate ligament of the diaphragm can cause nonspecific symptoms such as abdominal pain, vomiting, and weight loss. There is a known association between stenosis or occlusion of the celiac trunk and aneurysms of the pancreaticoduodenal artery. Treatment strategies for patients who have this association should be selected on a case-by-case basis. We describe the case of a patient with pancreaticoduodenal artery aneurysm associated with compression of the celiac trunk by the arcuate ligament, which were managed with endovascular and laparoscopic techniques, respectively.
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Affiliation(s)
- Marcio Miyamotto
- Pontifícia Universidade Católica do Paraná - PUC-PR, Hospital Universitário Cajuru - HUC, Serviço de Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil.,Instituto VESSEL de Aperfeiçoamento Endovascular de Curitiba, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil
| | - Cecilia Naomi Kanegusuku
- Pontifícia Universidade Católica do Paraná - PUC-PR, Hospital Universitário Cajuru - HUC, Liga Acadêmica de Medicina Vascular - LAMEV, Curitiba, PR, Brasil
| | - Carla Mariko Okabe
- Pontifícia Universidade Católica do Paraná - PUC-PR, Hospital Universitário Cajuru - HUC, Liga Acadêmica de Medicina Vascular - LAMEV, Curitiba, PR, Brasil
| | | | - Fernanda Zandavalli Ramos
- Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil
| | - Ágata Rothert
- Pontifícia Universidade Católica do Paraná - PUC-PR, Hospital Universitário Cajuru - HUC, Liga Acadêmica de Medicina Vascular - LAMEV, Curitiba, PR, Brasil
| | | | - Ricardo César Rocha Moreira
- Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil
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29
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Kimura N, Tsuchiya A, Nakamura A, Ueda M, Yoshikawa S, Hoshi T, Takano A, Takagi S, Miura T, Yamada S, Yanagi M, Tani T, Hirahara H. A Case of Successful Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Dissection. Case Rep Gastroenterol 2018; 12:385-389. [PMID: 30186089 PMCID: PMC6120411 DOI: 10.1159/000491384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 12/12/2022] Open
Abstract
A 52-year-old man was admitted due to severe epigastric lesion pain. Esophagus gastroduodenal endoscopy showed impaired duodenal dilatation, and contrast-enhanced computed tomography revealed a pancreaticoduodenal artery (PDA) aneurysm 13 mm in diameter below the head of the pancreas, retroperitoneal hematoma, idiopathic celiac artery (CA) dissection, and common hepatic artery disruption. Angiographic embolization with a mixture of N-butyl-1,2-cyanoacrylate and lipiodol was performed, and follow-up study showed improvement of the dilatation of the duodenum and disappearance of the aneurysm. Here we report a quite rare case of PDA aneurysm by idiopathic dissection of CA treated successfully with angiographic embolization.
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Affiliation(s)
- Naruhiro Kimura
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan.,Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Atsunori Tsuchiya
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Akihiro Nakamura
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Muneatsu Ueda
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Seiichi Yoshikawa
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Takahiro Hoshi
- Division of Gastroenterology and Hepatology, Uonuma Institute of Community Medicine, Niigata Medical and Dental Hospital, Minami-Uonuma, Japan
| | - Akito Takano
- Division of Gastroenterology and Hepatology, Tachikawa General Hospital, Nagaoka, Japan
| | - Satoshi Takagi
- Division of Radiology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Tsutomu Miura
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Satoshi Yamada
- Division of Gastroenterology and Hepatology, Tachikawa General Hospital, Nagaoka, Japan
| | - Masahiko Yanagi
- Division of Gastroenterology and Hepatology, Ojiya General Hospital, Ojiya, Japan
| | - Tatsuo Tani
- Division of Surgery, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Hiroyuki Hirahara
- Division of Cardiovascular Surgery, Nagaoka Red Cross Hospital, Nagaoka, Japan
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30
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Giovanardi F, Lai Q, Garofalo M, Arroyo Murillo GA, Choppin de Janvry E, Hassan R, Larghi Laureiro Z, Consolo A, Melandro F, Berloco PB. Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature. Pancreatology 2018; 18:592-600. [PMID: 29776725 DOI: 10.1016/j.pan.2018.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Celiac axis stenosis (CAS) represents an uncommon and typically innocuous condition. However, when a pancreatic resection is required, a high risk for upper abdominal organs ischemia is observed. In presence of collaterals, such a risk is minimized if their preservation is realized. The aim of the present study is to systematically review the literature with the intent to address the routine management of collateral arteries in the case of CAS patients requiring pancreatoduodenectomy. METHODS A systematic search was done in accordance with the PRISMA guidelines, using "celiac axis stenosis" AND "pancreatoduodenectomy" as MeSH terms. Seventy-four articles were initially screened: eventually, 30 articles were identified (n = 87). RESULTS The main cause of CAS was median arcuate ligament (MAL) (n = 31; 35.6%), followed by atherosclerosis (n = 20; 23.0%). CAS was occasionally discovered during the Whipple procedure in 15 (17.2%) cases. Typically, MAL was divided during surgery (n = 24/31; 77.4%). In the great majority of cases (n = 83; 95.4%), vascular abnormalities involved the pancreatoduodenal arteries (i.e., dilatation, arcade, channels, aneurysms). Collateral arteries were typically preserved, being divided or reconstructed in only 14 (16.1%) cases, respectively. Severe ischemic complications were reported in six (6.9%) patients, 20.0% of whom were reported in patients with preoperatively unknown CAS (p-value 0.06). CONCLUSIONS A correct pre-operative evaluation of anatomical conditions as well as a correct surgical planning represent the paramount targets in CAS patients with arterial collaterals. Vascular flow must be always safeguarded preserving/reconstructing the collaterals or resolving the CAS, with the final intent to avoid dreadful intra- and post-operative complications.
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Affiliation(s)
- Francesco Giovanardi
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy.
| | - Quirino Lai
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Manuela Garofalo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Gabriela A Arroyo Murillo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Eleonore Choppin de Janvry
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Redan Hassan
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Zoe Larghi Laureiro
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Adriano Consolo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Fabio Melandro
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Pasquale B Berloco
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
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Murata A, Amaya K, Mochizuki K, Sotokawa M, Otaka S, Tani K, Nakagaki S, Ueda T. Superior Mesenteric Artery-Pancreaticoduodenal Arcade Bypass Grafting for Repair of Inferior Pancreaticoduodenal Artery Aneurysm with Celiac Axis Occlusion. Ann Vasc Dis 2018; 11:153-157. [PMID: 29682126 PMCID: PMC5882345 DOI: 10.3400/avd.cr.17-00113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Akira Murata
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kentaro Mochizuki
- Department of Radiology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Masami Sotokawa
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shingo Otaka
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kazuhiro Tani
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shota Nakagaki
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Tetsuyuki Ueda
- Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
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Ricci G, Riu P, Attinà GM, Trombetta S, Ialongo P, Di Cosimo C, Mancuso R, Marini P. Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report. Int J Surg Case Rep 2017; 41:205-208. [PMID: 29096344 PMCID: PMC5686227 DOI: 10.1016/j.ijscr.2017.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/18/2017] [Accepted: 10/22/2017] [Indexed: 11/26/2022] Open
Abstract
Ruptured pancreaticoduodenal artery aneursym is a very rare but potentially catastrophic occurence in an emergency department and its treatment is challenging. Very few cases of emergency endovascular treatment of ruptured visceral aneursyms are reported in the literature. This case report has the intention to elucidate in pancreaticodudoenal artery aneursym the importance of collateral vessels that could feed the aneurysm sac even after embolization of the inflow and outflow of the aneurysm.
Introduction True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. Presentation of case A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5 cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. Discussion The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. Conclusion The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.
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Affiliation(s)
- Gabriele Ricci
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Pascale Riu
- Division of Interventional Radiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Grazia Maria Attinà
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Silvia Trombetta
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pasquale Ialongo
- Division of Radiology 2, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Carla Di Cosimo
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Rosaria Mancuso
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pierluigi Marini
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
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33
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Ruptured Pancreaticoduodenal Artery Aneurysm due to a Median Arcuate Ligament Treated Solely by Revascularization of the Celiac Trunk. Ann Vasc Surg 2017; 43:310.e13-310.e16. [DOI: 10.1016/j.avsg.2017.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/24/2022]
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34
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Pancreaticoduodenal Artery Aneurysm Associated with Celiac Trunk Stenosis: Case Illustration and Literature Review. Case Rep Radiol 2017; 2017:6989673. [PMID: 28815097 PMCID: PMC5549485 DOI: 10.1155/2017/6989673] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/19/2017] [Indexed: 11/17/2022] Open
Abstract
Pancreaticoduodenal artery aneurysms (PDA) are rare visceral aneurysms. Celiac trunk stenosis represents a common attributable aetiology for those aneurysms. Therefore, an alternative treatment approach, which differs from those isolated aneurysms, is recommended. We hereby present a 77-year-old male patient who was admitted with sudden onset of severe abdominal pain and significant drop in haemoglobin, occurring within a 24-hour interval. Contrast-enhanced computed tomography revealed a ruptured visceral aneurysm arising from the anterior branch of the inferior pancreaticoduodenal artery. A severe stenosis was also noted at the take-off of the celiac trunk. Selective catheterization of the supplying branch of the superior mesenteric artery, followed by coil embolization of the aneurysm, was performed, resulting in cessation of flow within the aneurysm, with preservation of the posterior branch, supplying the celiac territory. PDAs are usually asymptomatic and discovered incidentally at rupture. The risk of rupture is independent of the aneurysmal size and is associated with a 50% mortality rate. The consensus on coping with aneurysms is to treat them whenever they are discovered. Selective angiography followed by coil embolization represents a less invasive, and frequently definitive, approach than surgery. The risk for ischemia mandates that the celiac territory must not be compromised after embolization.
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35
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Corey MR, Ergul EA, Cambria RP, Patel VI, Lancaster RT, Kwolek CJ, Conrad MF. The presentation and management of aneurysms of the pancreaticoduodenal arcade. J Vasc Surg 2017; 64:1734-1740. [PMID: 27871496 DOI: 10.1016/j.jvs.2016.05.067] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/18/2016] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Michael R Corey
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Emel A Ergul
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Richard P Cambria
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - R Todd Lancaster
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher J Kwolek
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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36
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Vandy FC, Sell KA, Eliason JL, Coleman DM, Rectenwald JE, Stanley JC. Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Celiac Artery Occlusive Disease. Ann Vasc Surg 2017; 41:32-40. [DOI: 10.1016/j.avsg.2016.09.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/18/2016] [Accepted: 09/06/2016] [Indexed: 12/30/2022]
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37
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Shibata E, Takao H, Amemiya S, Ohtomo K. Perioperative Hemodynamic Monitoring of Common Hepatic Artery for Endovascular Embolization of a Pancreaticoduodenal Arcade Aneurysm with Celiac Stenosis. Cardiovasc Intervent Radiol 2016; 40:465-469. [PMID: 27864611 DOI: 10.1007/s00270-016-1517-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/15/2016] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Eisuke Shibata
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hidemasa Takao
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shiori Amemiya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kuni Ohtomo
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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38
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Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis? J Am Coll Surg 2016; 224:199-203. [PMID: 27773774 DOI: 10.1016/j.jamcollsurg.2016.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND True aneurysms of the gastroduodenal (GDA) and pancreaticoduodenal (PDA) arteries have been attributed to increased collateral flow due to tandem celiac artery stenosis or occlusion. Although GDA and PDA aneurysm exclusion is recommended because of the high reported risk of rupture, it remains uncertain whether simultaneous celiac artery reconstruction is necessary to preserve end-organ flow. STUDY DESIGN We conducted a retrospective analysis of consecutive patients admitted from 1996 to 2015 with true aneurysms of the GDA or PDA. RESULTS Twenty patients with true aneurysms of the PDA (n = 16) or GDA (n = 4) were identified. Mean age was 61.5 years (range 35 to 85 years) and 11 (55%) were women. Nine (45%) presented with rupture, 8 (40%) presented with pain, and 3 (15%) were asymptomatic. All 9 patients who presented with rupture had contained retroperitoneal hematomas, and none experienced rebleeding. Fifteen (75%) patients had an associated celiac artery >60% stenosis or occlusion, and 2 (10%) had both celiac and superior mesenteric artery stenoses. Thirteen (65%) patients underwent successful endovascular coiling, only 1 of which had a prophylactic celiac artery bypass. Three (15%) patients underwent open aneurysm exclusion and celiac bypass, and 4 (20%) others were observed. There were no aneurysm-related deaths in this series, and none of the patients who underwent coiling without celiac revascularization had hepatic ischemia or other mesenteric morbidity develop during a median follow-up of 6 months (maximum 200 months). CONCLUSIONS Gastroduodenal artery and PDA aneurysms present most commonly with pain or bleeding, and all should be considered for repair, regardless of size. Aneurysm exclusion is safely and effectively achieved with endovascular coiling. Although associated celiac artery stenosis is found in the majority of cases, celiac revascularization might not be necessary.
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39
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Hughes T, Chatzizacharias NA, Richards J, Harper S. Aorto-hepatic bypass graft for repair of an inferior pancreatico-duodenal artery aneurysm associated with coeliac axis occlusion: A case report. Int J Surg Case Rep 2016; 28:131-134. [PMID: 27701003 PMCID: PMC5048667 DOI: 10.1016/j.ijscr.2016.09.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 12/01/2022] Open
Abstract
IPDA aneurysms associated with coeliac axis occlusion are rare. Management includes radiologically guided endovascular approach or surgical repair. Given mortalities of greater than 50% with rupture, intervention is indicated. We present a case of a surgical repair with a supra-coeliac aorto-hepatic bypass.
Introduction Inferior pancreatico-duodenal artery (IPDA) aneurysms are very rare and commonly associated with coeliac axis stenosis or occlusion due to atherosclerosis, thrombosis or median arcuate ligament syndrome. We present a case of a surgical repair of an IPDA aneurysm with the use of a supra-coeliac aorto-hepatic bypass with a polytetrafluoroethylene (PTFE) graft, following a failed initial attempt at an endovascular repair. Presentation A 75 year old female, who was under investigation for night sweats, was referred to our team with an incidental finding of a 19 mm fusiform IPDA aneurysm. Initial attempt at endovascular coiling of the aneurysm was unsuccessful. Elective surgical repair involved excision of the aneurysm and to restore arterial inflow to the hepatic artery, a PTFE bypass graft was used from the supra-coeliac aorta to the hepatic artery. The patient was well 2 months following the procedure with a patent graft shown on contrast enhanced computer tomography (ceCT). Discussion Management options for IPDA aneurysms include radiologically guided endovascular approach or surgical repair. Given the high mortality of greater than 50% with ruptured aneurysms intervention is indicated in all detected cases. Conclusion Surgical excision with bypass grafting from the supra-coeliac aorta, as reported by our team, represents a satisfactory management option in patients where interventional approaches have failed or are not appropriate.
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Affiliation(s)
- Tom Hughes
- Department of Hepatobilliary and Pancreatic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 2QQ, UK.
| | - Nikolaos A Chatzizacharias
- Department of Hepatobilliary and Pancreatic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 2QQ, UK.
| | - James Richards
- Department of Hepatobilliary and Pancreatic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 2QQ, UK.
| | - Simon Harper
- Department of Hepatobilliary and Pancreatic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 2QQ, UK.
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40
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Orion KC, Najafian A, Ehlert BA, Malas MB, Black JH, Abularrage CJ. Gender Predicts Rupture of Pancreaticoduodenal Artery Aneurysms. Ann Vasc Surg 2016; 36:1-6. [DOI: 10.1016/j.avsg.2016.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/19/2016] [Accepted: 03/03/2016] [Indexed: 11/28/2022]
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41
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Roberts AB, Roslyn JJ, Gahtan V, Kerstein MD, Bradford S, Weiss J. Changing Patterns in the Diagnosis and Treatment of Pancreaticoduodenal Artery Aneurysms. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449803200505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An aneurysm of the pancreaticoduodenal artery was identified in a 60-year-old woman with the primary complaint of epigastric pain that radiated through to her back. A computerized tomography (CT) scan with contrast established the initial diagnosis; an angiogram confirmed the diagnosis and vascular anatomy. The aneurysm was opened and a reverse saphenous vein reestablished circulation.
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Affiliation(s)
| | - Joel J. Roslyn
- Departments of Surgery, Allegheny University Hospitals, Allegheny University of the Health Sciences, Medical College of Pennsylvania/Hahnemann University, Philadelphia, PA
| | - Vivian Gahtan
- Yale University School of Medicine, Section of Vascular Surgery, New Haven, Connecticut
| | | | - Susan Bradford
- Departments of Surgery, Allegheny University Hospitals, Allegheny University of the Health Sciences, Medical College of Pennsylvania/Hahnemann University, Philadelphia, PA
| | - Jeffrey Weiss
- Departments of Radiology, Allegheny University Hospitals, Allegheny University of the Health Sciences, Medical College of Pennsylvania/Hahnemann University, Philadelphia, PA
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42
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de Virgilio C, Donayre C, Sadra M, White R. Inferior Pancreaticoduodenal Artery Aneurysm in Association with Celiac Axis Occlusion. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449703100623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
True aneurysms of the inferior pancreaticoduodenal artery (IPDA) are rare. Nearly half present with rupture. Stenosis or occlusion of the celiac axis is well recognized in association with IPDA aneurysm. The authors report a case of nonruptured IPDA aneurysm that presented with postprandial abdominal pain. Arteriography revealed celiac axis occlusion. The patient was successfully managed by aortohepatic bypass and aneurysm exclusion.
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Affiliation(s)
| | | | | | - Rodney White
- Department of Surgery, Division of Vascular Surgery, West Los Angeles Veterans Administration Medical Center, Los Angeles, California
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43
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Savastano S, Feltrin GP, Miotto D, Chiesura-Corona M, Sandri P. Embolization of Ruptured Aneurysm of the Pancreaticoduodenal Artery Secondary to Long-standing Stenosis of The Celiac Axis. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449502900409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Long-standing stenosis of the celiac axis is a rare cause of aneurysm of the inferior pancreaticoduodenal artery, which serves as a collateral pathway; the etiology is believed to be due to turbulence from increased blood flow. The authors describe 2 cases of such aneurysm, which ruptured in the retroperitoneum and were treated with transcatheter embolization.
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Affiliation(s)
| | | | | | | | - Paola Sandri
- Istituto di Radiologia—Universitá degli Studi, Padova, Italy
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44
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Eldar S, Fajer S, Kunin J, Naschitz J, Nash E, Karmeli R. Pancreaticoduodenal Artery Aneurysms. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449803200113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreaticoduodenal artery aneurysms are rare but challenging surgical problems. While physical examination, ultrasound, and computed tomography scans may suggest the diagnosis, more definitive information may be achieved noninvasively by scintiangiog raphy. Angiography is the diagnostic gold standard and remains crucial for rational planning of operative strategy. Surgical repair is usually achieved by exclusion or endoa neurysmorrhaphy. Through use of modern diagnostic and surgical approaches, mortality rates have been reduced from as high as 22% to 6%. The authors herein describe 2 patients with pancreaticoduodenal artery aneurysms and review the management strate gies of this challenging problem.
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Affiliation(s)
- Samuel Eldar
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
| | - Simone Fajer
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
| | - Joshua Kunin
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
| | - Johanan Naschitz
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
| | - Ernest Nash
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
| | - Ron Karmeli
- Department of Surgery Bnai Zion Medical Center P.O. Box 4940 Haifa 31048, Israel
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45
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Prosper A, Saremi F. Delayed Development of Multiple Pancreaticoduodenal Arcade Pseudoaneurysms after Abdominal Trauma. Ann Vasc Surg 2016; 36:297.e11-297.e15. [PMID: 27427348 DOI: 10.1016/j.avsg.2016.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/12/2016] [Accepted: 04/13/2016] [Indexed: 11/25/2022]
Abstract
This case report demonstrates development and progressive enlargement of multiple pancreaticoduodenal arcade pseudoaneurysms using computed tomography angiographies over a period of 5 weeks after abdominal trauma. The mechanism of pseudoaneurysm formation, as shown by serial imaging, attributed to preexisting celiac axis stenosis by the median arcuate ligament, posttraumatic celiac artery dissection, and secondary occlusion of proper hepatic artery resulting in elevation of pressure and flow in the pancreaticoduodenal arcade and rupture of small arterial branches. Successful pseudoaneurysm occlusion was achieved through arterial embolization.
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Affiliation(s)
- Ashley Prosper
- Department of Radiology, University of Southern California, Los Angeles, CA
| | - Farhood Saremi
- Department of Radiology, University of Southern California, Los Angeles, CA.
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Armstrong PJ, Franklin DP. Superior Mesenteric Artery Branch Aneurysm with Absence of the Celiac Trunk. Vascular 2016; 14:109-12. [PMID: 16956480 DOI: 10.2310/6670.2006.00015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Superior mesenteric artery and pancreaticoduodenal artery aneurysms are rare. Agenesis of the celiac axis has only been reported four times. The reported etiologies of superior mesenteric artery and branch artery aneurysms include infection, atherosclerosis, inflammatory processes such as pancreatitis, dissection, collagen vascular disorders, polyarteritis nodosa, and trauma. We report an aneurysm of the superior mesenteric artery (SMA) branch, the inferior pancreaticoduodenal artery, arising in a patient with congenital absence of the celiac trunk. The patient presented with intermittent left upper quadrant pain without weight loss or change in bowel habits. The aneurysm was identified on abdominal computed tomography scan with angiographic confirmation of the aberrant anatomy. The patient was treated by aneurysmectomy and pancreaticoduodenal artery reconstruction with an interposition vein graft from the SMA. The patient recovered without complications and is asymptomatic with a patent vein graft 2 years after operation.
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Affiliation(s)
- Peter J Armstrong
- Section of Vascular Surgery, Geisinger Medical Center, Danville, PA,
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Morishita H, Takeuchi Y, Ito T, Kanayama T, Koshino S, Sato O. Non-Traumatic Rupture of the Retroportal Artery. Cardiovasc Intervent Radiol 2016; 39:1085-7. [PMID: 27150805 DOI: 10.1007/s00270-016-1355-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 04/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Hiroyuki Morishita
- Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, Japan.
| | - Yoshito Takeuchi
- Department of Radiology, North Medical Center, Kyoto Prefectural University of Medicine, 481 Otokoyama, Yosanocho, Yosagun, Kyoto, 629-2261, Japan
| | - Takaaki Ito
- Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, Japan
| | - Taisei Kanayama
- Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, Japan
| | - Sachiko Koshino
- Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, Japan
| | - Osamu Sato
- Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, Japan
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Chivot C, Rebibo L, Robert B, Regimbeau JM, Yzet T. Ruptured Pancreaticoduodenal Artery Aneurysms Associated with Celiac Stenosis Caused by the Median Arcuate Ligament: A Poorly Known Etiology of Acute Abdominal Pain. Eur J Vasc Endovasc Surg 2016; 51:295-301. [DOI: 10.1016/j.ejvs.2015.10.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Hong IK, Choi JH, Chu YC, Jeon YS, Lee KY. Multiple visceral artery aneurysms managed by Yasargil aneurysm clips. Ann Surg Treat Res 2015; 89:162-5. [PMID: 26366387 PMCID: PMC4559620 DOI: 10.4174/astr.2015.89.3.162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/19/2015] [Accepted: 06/05/2015] [Indexed: 11/30/2022] Open
Abstract
Here, we present the case of a 37-year-old woman with multiple visceral artery aneurysms in the pancreaticoduodenal, inferior pancreatic and splenic arteries associated with celiac trunk stenosis. An aneurysmectomy and end-to-end anastomosis was performed for two adjacent aneurysms, while clipping with intracranial aneurysm clips were performed for the other three aneurysms. During 36-month follow-up, no recurrence or newly developed lesions were noted, and the celiac artery had been reconstituted spontaneously. We believe that using intracranial aneurysm clips in the treatment of visceral artery aneurysms is feasible and safe and can be considered when endovascular procedures are unlikely to be successful.
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Affiliation(s)
- In-Kee Hong
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Ji-Ho Choi
- Department of Family Medicine, Inha University School of Medicine, Incheon, Korea
| | - Young Chae Chu
- Department of Pathology, Inha University School of Medicine, Incheon, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University School of Medicine, Incheon, Korea
| | - Keon-Young Lee
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
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De Santis F, Bruni A, Da Ros V, Chaves Brait CM, Scevola G, Di Cintio V. Multiple Pancreatoduodenal Artery Arcade Aneurysms Associated with Celiac Axis Root Segmental Stenosis Presenting as Aneurysm Rupture. Ann Vasc Surg 2015; 29:1657.e1-7. [PMID: 26169466 DOI: 10.1016/j.avsg.2015.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/17/2015] [Accepted: 05/18/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Antonio Bruni
- Department of Interventional Radiology, "Sandro Pertini" Hospital, Rome, Italy
| | - Valerio Da Ros
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy, University Hospital "Tor Vergata", Rome, Italy
| | | | - Germano Scevola
- Department of Interventional Radiology, "Sandro Pertini" Hospital, Rome, Italy
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