Aneurysms of the pancreaticoduodenal artery

Endovascular Treatment of Unruptured Pancreatic Arcade Aneurysms

PURPOSE

This study aimed to assess the safety and efficacy of endovascular treatment of unruptured pancreatic arcade aneurysms in a single-center series.

MATERIALS AND METHODS

The electronic medical records of patients who underwent endovascular treatment for unruptured pancreatic arcade aneurysms between 2011 and 2022 at our tertiary center were retrospectively reviewed. The presence of celiac artery stenosis/occlusion; aneurysm number, location, and size; endovascular technique; procedure-related complication incidence; and clinical outcomes were assessed.

RESULTS

Twenty-three patients (12 men and 11 women; mean [range] age, 63.8 [45-84] years) with 33 unruptured pancreatic arcade aneurysms were identified. Celiac artery stenosis/occlusion coexisted in 17 (74%) patients. Five (21%) patients had multiple aneurysms. The median aneurysm size was 9.3 mm (range, 4-18 mm). Seven, 6, 6, 5, 4, 3, and 2 aneurysms were located in the gastroduodenal, dorsal pancreatic, anterior superior pancreaticoduodenal, inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal, posterior superior pancreaticoduodenal, and anterior inferior pancreaticoduodenal arteries, respectively. Four (15%) and 22 (85%) aneurysms were treated with endosaccular packing alone and coil embolization with endosaccular packing and parent artery occlusion, respectively, with resulting exclusion from arterial circulation. The remaining 7 aneurysms coexisting with larger aneurysms in other peripancreatic arteries were observed without embolization because they were small and for preserving collateral blood flow to the celiac artery. The treated aneurysms did not rupture or recur during the follow-up period (median, 40 months).

CONCLUSION

Endovascular treatment is a safe and effective treatment for unruptured pancreatic arcade aneurysms.

LEVEL OF EVIDENCE

3, non-controlled retrospective cohort study.

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

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

Clinical Characteristics and Management of Peripancreatic Arterial Aneurysms: A 20-year Experience

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.

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

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

Obstructive jaundice as a rare complication of multiple pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: a case report and review of the literature

BACKGROUND

Obstructive jaundice has various causes, and one of the rarest is pancreaticoduodenal artery aneurysm (PDAA), which is often associated with celiac axis stenosis caused by median arcuate ligament syndrome (MALS).

CASE PRESENTATION

The patient was a 77-year-old Azeri woman who presented with progressive jaundice, vague abdominal pain, and abdominal distension from 6 months ago. The intra- and extrahepatic bile ducts were dilated, the liver's margin was slightly irregular, and the echogenicity of the liver was mildly heterogeneous in the initial ultrasound exam. A huge cystic mass with peripheral calcification and compressive effect on the common bile duct (CBD) was also seen near the pancreatic head, which was connected to the superior mesenteric artery (SMA) and had internal turbulent blood flow on color Doppler ultrasound. According to the computed tomography angiography (CTA) findings, the huge mass of the pancreatic head was diagnosed as a true aneurysm of the pancreaticoduodenal artery caused by MALS. Two similar smaller aneurysms were also present at the huge aneurysm's superior margin. Due to impending rupture signs in the huge aneurysm, the severe compression effect of this aneurysm on CBD, and the patient's family will surgery was chosen for the patient to resect the aneurysms, but unfortunately, the patient died on the first day after the operation due to hemorrhagic shock.

CONCLUSION

In unexpected obstructive jaundice due to a mass with vascular origin in the head of the pancreas, PDAA should be considered, and celiac trunk should be evaluated because the main reason for PDAA is celiac trunk stenosis or occlusion by atherosclerosis or MALS. The treatment method chosen (including transarterial embolization, open surgery, or combined method) depends on the patient's clinical status and radiological findings, but transarterial embolization would be safer and should be used as a first-line method.

A Large Series of True Pancreaticoduodenal Artery Aneurysms

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Pancreatoduodenal Artery Aneurism rupture post colonoscopy - Case report

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A case of Pancreatoduodenal Artery Aneurism rupture post colonoscopy.

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

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First report of rupture related to colonoscopy.

Introduction

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

Presentation of the case

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

Discussion

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

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

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

Conclusion

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

Multiple large pancreaticoduodenal artery aneurysms due to celiac artery occlusion: Combination of the aorto-hepatic bypass and coil embolization with a dual approach through both the superior mesenteric artery and bypass

Pancreaticoduodenal artery aneurysm can occur from occlusion or stenosis of the celiac artery due to arteriosclerosis or median arcuate ligament compression. The risk of rupture of the aneurysm is independent of the aneurysmal diameter. A 78-year-old woman presented with multiple large aneurysms of the anterior superior pancreaticoduodenal artery. To preserve arterial flow to the liver, bypass grafting from the supra-celiac aorta to the common hepatic artery was performed at first. Coil embolization was successfully performed 10 days later with a dual approach through both the superior mesenteric artery and bypass. It was considered that the combination of the aorto-hepatic bypass and coil embolization was effective for the pancreaticoduodenal artery aneurysms due to celiac artery occlusion.

Aneurysms of pancreaticoduodenal arcade: Clinical profile and endovascular strategies

Background and Aim

Pancreaticoduodenal arcade aneurysms (PDAAs) are uncommon lesions associated with a significant risk of rupture and mortality. This study describes the etiology, clinical presentation, and endovascular management strategies of PDAAs across a spectrum of indications.

Methods

The clinical records of patients with PDAAs referred for endovascular management from January 2018 till November 2019 were retrospectively reviewed. Data on presenting symptoms, associated etiologies, and outcomes after endovascular treatment were collected and studied.

Results

We found 15 patients with false and 1 patient with true aneurysm of pancreatoduodenal arcade (PDA). The associated conditions were coeliac artery stenosis, severe necrotizing pancreatitis, and chronic pancreatitis or iatrogenic (postendoscopic papillotomy and percutaneous metallic biliary stenting). The main presenting feature was gastrointestinal bleed, while 2 patients had abdominal pain and 1 had gastric outlet obstruction. A multiphase computed tomography scan demonstrated the ruptured aneurysm in all patients. Site of origin of PDAA influenced the choice of transarterial endovascular strategy (coiling for aneurysms of main trunk of arteries and glue injection for those arising from small arterial branches). This was carried out in an emergency setting for 12 patients and as an elective procedure in 4 patients. Technical success was demonstrated in all patients and clinical success in 14. The two patients who had rebleed were salvaged by repeat endovascular procedure. Postembolization syndrome was seen in three patients.

Conclusions

With advancing technology, endovascular strategies continue to evolve. Careful attention to ensure hemodynamic resuscitation and stability, correction of pre‐existing coagulopathy and attention to technique can lead to the possibility of endovascular approaches as a dependable option in the management of ruptured PDAAs.

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

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

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

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

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

Optimal Treatment for Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Obstruction Due to Celiac Artery Dissection

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.

The presentation and management of aneurysms of the pancreaticoduodenal arcade

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis?

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.

Aorto-hepatic bypass graft for repair of an inferior pancreatico-duodenal artery aneurysm associated with coeliac axis occlusion: A case report

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IPDA aneurysms associated with coeliac axis occlusion are rare.

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Management includes radiologically guided endovascular approach or surgical repair.

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Given mortalities of greater than 50% with rupture, intervention is indicated.

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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.

Changing Patterns in the Diagnosis and Treatment of Pancreaticoduodenal Artery Aneurysms

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.

Superior Mesenteric Artery Branch Aneurysm with Absence of the Celiac Trunk

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.

Obstructive jaundice caused by pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: case report and review of the literature

Pancreaticoduodenal artery aneurysm (PDA) is quite rare, which accounts for only approximate 2% of all visceral aneurysms. Besides, PDA is usually related to celiac axis stenosis (CAS) and prone to rupture. Advanced imaging examination can facilitate the disclosure of such peripancreatic masses, but most of them were seldom diagnosed until they rupture because of the nonspecific symptoms. Secondary to PDA, obstructive jaundice is however an extremely rare manifestation. A case of an 84-year-old man is reported here, who suffered from severe jaundice caused by a ruptured PDA associated with CAS. In addition, this review collects and organizes PDAs with jaundice by applying a MEDLINE search and discusses the pathogenesis and therapeutic options of these aneurysms leading to external compression over the bile duct. Consequently, the formation of PDA with obstructive jaundice is based on the specific anatomy of pancreaticoduodenal arcades. When there is a retroperitoneal mass around the head of the pancreas associated with unexpected jaundice, PDA should be considered, for which early aggressive therapy is required. The case report and literature review suggest that PDA associated with obstructive jaundice may be treated successfully by single transcatheter arterial embolization (TAE) without auxiliary biliary drainage, whether it ruptures or not.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Inferior pancreaticoduodenal artery aneurysms associated with occlusive lesions of the celiac axis: diagnosis, treatment options, outcomes, and review of the literature

PURPOSE

To describe the presentation, treatment, and outcomes for 14 patients with aneurysms of the inferior pancreaticoduodenal arteries associated with occlusive lesions of the celiac axis, and to review the literature for similar cases.

METHODS

Over a period of 12 years, 14 patients (10 women and 4 men) ranging in age from 26 to 50 (mean 46) years were demonstrated to have aneurysms of the inferior pancreaticoduodenal artery origin associated with stenosis or occlusion of the celiac axis. All patients were treated by a combination of surgery and interventional radiology.

RESULTS

Outcome data collected between 3 months and 4 years (mean 2 years) demonstrated that all aneurysms remained excluded, and all 14 patients were well. The 49 case reports in the literature confirm the findings of this cohort.

CONCLUSION

In inferior pancreaticoduodenal artery aneurysm resulting from celiac occlusive disease, endovascular treatment is best achieved by stenting the celiac axis and/or embolizing the aneurysm when necessary.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion

BACKGROUND

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

DATA SOURCES

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

CONCLUSIONS

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

Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion

Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis or occlusion are well described in the literature. These aneurysms are true aneurysms and develop as a result of increased flow through the pancreaticoduodenal arcades in the presence of hemodynamically significant stenosis of the celiac axis or common hepatic artery. Aneurysms may be multiple and rarely associated with aneurysms in other collateral pathways-such as the dorsal pancreatic artery or the arc of Buhler. These aneurysms may be incidentally detected or patients may present with abdominal pain or shock secondary to rupture of the aneurysms. Treatment options include surgical resection and transcatheter embolization; current literature favors the latter option. Treatment of celiac axis stenosis may be recommended in addition to treating the aneurysms; however, no formal guidelines exist on this recommendation.

Percutaneous transcatheter arterial embolization of inferior pancreatico-duodenal artery aneurysms associated with celiac artery stenosis or occlusion

OBJECTIVES

To report our experience with percutaneous TAE of true IPDA aneurysms.

BACKGROUND

Most IPDA aneurysms are ruptured at presentation causing a high mortality risk. Minimally invasive treatment approaches may improve overall outcomes in such patients.

METHODS

Between 1996 and 2007, seven patients (5 Males; mean age 55 y) with symptomatic IPDA aneurysms and severe degree (>75%) celiac artery stenosis were treated with percutaneous TAE. The medical and imaging records were reviewed for demographics, clinical presentation, treatment, complications and follow-up. Patients presented with epigastric pain (7/7), hemodynamic shock (2/7) and rectal bleeding (2/7). Selective catheter angiography was performed in all patients with the intent to embolize the aneurysms.

RESULTS

A total of nine aneurysms were seen in seven patients. Two patients had two aneurysms each. The aneurysms ranged in size from 0.5 to 4.0 cm (mean 1.9 cm). Trans-catheter coil embolization was successful in 8/9 (89%) aneurysms in 6 patients. Following unsuccessful TAE of one aneurysm in one of the patient, the aneurysm was treated successfully with direct CT-guided percutaneous transabdominal injection of N-butyl-2-cyanoacrylate. There were no complications on follow up. Angioplasty and stenting of the celiac artery were performed in one patient for complete occlusion. None of the patients developed clinical or imaging evidence of visceral ischemia following embolization. None had recurrent symptoms during clinical follow-up (median 3 years, range 0.5-13.5 years). Follow-up CT (Median 6.6 months, range 4 days-11.5 years) in all patients showed no recurrence of the aneurysm.

CONCLUSION

IPDA aneurysms associated with celiac axis stenosis can be successfully treated with percutaneous embolization with minimal recurrence.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of Pancreaticoduodenal Artery Aneurysms: Results of Superselective Transcatheter Embolization

OBJECTIVE

The purpose of our study was to assess the efficacy of transcatheter arterial embolization for pancreaticoduodenal artery aneurysms.

CONCLUSION

We concluded that transcatheter arterial embolization is the initial and definitive therapeutic choice for pancreaticoduodenal artery aneurysms, with a possible option to perform surgery after embolization.

True aneurysms of the pancreaticoduodenal artery: successful non-operative management

BACKGROUND

True aneurysms of the pancreaticoduodenal arteries (PDA) are rare, often ruptured, and treated by operation with a high level of mortality. We review our experience since 1994 and that of the literature in the past 20 years to provide management guidelines for this uncommon clinical entity. About 100 cases of PDA aneurysms are described in the literature, most of them as case report.

METHODS

Nine patients were admitted to our institution between 1994 and 2004 for true aneurysm of the PDA. They were analyzed with regard to the clinical presentation, radiologic findings, management, and outcome.

RESULTS

Seven patients presented for sudden abdominal pain from retroperitoneal hemorrhage. In 2 patients PDA aneurysm was an incidental finding. Abdominal ultrasonography, computed tomographic scan, and visceral angiography was carried out in all cases. Aneurysms ranged from 4 to 30 mm (median, 16.5) in size. Celiac axis stenosis or occlusion was identified in 3 patients. One patient required emergent laparotomy for intra-abdominal rupture of a retro peritoneal hematoma. Therapeutic embolization was successful in all 9 patients. All except 1 are alive with no evidence of recurrence of the true PDA aneurysm with a mean follow-up of 59 months.

CONCLUSIONS

The authors recommend definitive treatment of all true aneurysms PDA because of their high risk of rupture. Ruptured PDA aneurysms suspected on CT-scan requires emergent visceral angiography and selective embolization as definitive treatment.

Pancreaticoduodenal Artery Aneurysms Associated with Celiac Axis Occlusion

True aneurysms of the pancreaticoduodenal artery associated with celiac axis occlusion are very rare; only 38 cases have been reported, according to our literature review. We present three consecutive cases with different options of surgical treatment.

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

A case of three pancreaticoduodenal artery (PDA) aneurysms associated with coeliac artery occlusion and a concomitant splenic arterial aneurysm is described. Surgical treatment was used because it was anticipated that the hepatic blood supply would be obstructed completely if percutaneous transluminal embolization for three PDA aneurysms were performed. Splenectomy in continuity with the splenic artery aneurysm and PDA aneurysmectomies were performed, and infrarenal abdominal aorto-splenic artery bypass was accomplished using a 6mm ringed expanded polytetrafluoroethylene graft. The postoperative course was uneventful. Graft patency and successful aneurysm ablation were confirmed using MRA and intravenous DSA. Arterial histology revealed segmental arterial mediolysis. At 2-year follow-up, the patient was well and asymptomatic. A literature review of PDA aneurysms is presented.

Surgical management of peripancreatic arterial aneurysms

Peripancreatic artery aneurysms--gastroduodenal (GDA) and pancreaticoduodenal (PDA)--are highly unusual. We report 4 such aneurysms and have collated reports of true peripancreatic artery aneurysms based on an extensive review of the English literature. From this review, patient characteristics, clinical behavior, outcome and management strategies are assessed.

Visceral artery aneurysm rupture

PURPOSE

Aneurysms of the visceral arteries are infrequently encountered. Many are found incidentally and are thought to have a benign outcome. To better characterize these lesions and their clinical course, we reviewed our experience with visceral artery aneurysms (VAAs) at a single institution.

METHODS

A retrospective analysis of all VAAs diagnosed at our institution over the past 10 years was performed. The presentation, management, and outcome of therapy was examined for each patient.

RESULTS

Thirty-four VAAs in 26 patients were diagnosed over the past 10 years. Four patients had multiple VAAs: splenic (17), hepatic (7), celiac (3), superior mesenteric (2), gastroduodenal (2), pancreaticoduodenal (1), right gastric (1), ileal (1) artery aneurysms. Associated aneurysms were found in 31% of patients and involved the thoracic aorta (3 patients), abdominal aorta (4 patients), renal arteries (2 patients), iliac artery (3 patients), lower extremity (1 patient), and intracranium (1 patient). In 15 patients (58%), VAAs were detected before rupture by chance or because abdominal symptoms resulted in diagnostic evaluation. Eight of these underwent elective surgery, and there were no deaths. Of those 15 patients with known VAAs, one patient died of rupture and hemorrhage from an untreated splenic artery aneurysm. Eleven patients (42%) presented unexpectedly with rupture, and two died despite prompt surgical treatment. The mortality rate in patients who had ruptured VAAs was 25%, including those who presented with ruptured aneurysms and those observed whose aneurysms eventually ruptured.

CONCLUSIONS

Aneurysms of the visceral arteries are rare but important vascular lesions. Associated aneurysms are common. Because of the risk of rupture, often with a fatal outcome, an aggressive approach to the treatment of VAA is essential.