Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature

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.

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.

Volumetric computed tomography analysis for gastroduodenal and pancreaticoduodenal artery aneurysm formation: A retrospective single-center study

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.

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.

An Unusual Case of Gastric Outlet Obstruction After Embolization of Gastroduodenal Artery Pseudoaneurysm

Gastric outlet obstruction can occur secondary to intrinsic or extrinsic pathology. Historically peptic ulcer disease was the most common cause of gastric outlet obstruction but now malignancy-associated disease process is more common. Gastric outlet obstruction from mucosal ischemia caused by embolization of gastroduodenal artery is unheard of. This is due to the extensive blood supply of the stomach. We present an unusual presentation of gastric outlet obstruction in a patient with recent embolization of pancreatitis-induced pseudoaneurysm of the gastroduodenal artery. The diagnosis was confirmed with esophagogastroduodenoscopy, computed tomography, and upper gastrointestinal series. The case was managed conservatively with a clear liquid diet and proton pump inhibitors. Repeat upper endoscopies at 1 and 6 months after presentation confirmed disease resolution. No guidelines exist on the management of such cases due to the rarity of the disease.

Combined treatment of an aortosplenic bypass followed by coil embolization in the treatment of pancreaticoduodenal artery aneurysms caused by median arcuate ligament compression: a report of two cases

Background

Pancreaticoduodenal artery aneurysms (PDAAs) are rare visceral aneurysms, and prompt intervention/treatment of all PDAAs is recommended at the time of diagnosis to avoid rupture of aneurysms. Herein, we report two cases of PDAA caused by the median arcuate ligament syndrome, treated with surgical revascularization by aortosplenic bypass followed by coil embolization.

Case presentation

Case 1 A 54-year-old woman presented with a chief complaint of severe epigastralgia and was diagnosed with two large fusiform inferior PDAAs and celiac axis occlusion. To preserve the blood flow of the pancreatic head, duodenum, liver, and spleen, we performed elective surgery to release the MAL along with aortosplenic bypass. At 6 days postoperatively, transcatheter arterial embolization was performed. At the 8-year 6-month follow-up observation, no recurrent perfusion of the embolized PDAAs or rupture had occurred, including the non-embolized small PDAA, and the bypass graft had excellent patency.

Case 2 A 39-year-old man who had been in good health was found to have a PDAA with celiac stenosis during a medical checkup. Computed tomography and superior mesenteric arteriography showed severe celiac axis stenosis and a markedly dilated pancreatic arcade with a large saccular PDAA. To preserve the blood flow of the pancreatic arcade, we performed elective surgery to release the MAL along with aortosplenic bypass. At 9 days postoperatively, transcatheter arterial embolization was performed. At the 6-year 7-month follow-up observation, no recurrent perfusion or rupture of the PDAA had occurred, and the bypass graft had excellent patency.

Conclusion

Combined treatment with bypass surgery and coil embolization can be an effective option for the treatment of PDAAs associated with celiac axis occlusion or severe stenosis.

[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.

Outcomes After Open and Endovascular Repair of Non-Ruptured True Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Coeliac Artery Compression: A Multicentre Retrospective Study

OBJECTIVE

True aneurysms of the peri-pancreatic arcade (PDAA) have been attributed to increased collateral flow related to coeliac axis (CA) occlusion by a median arcuate ligament (MAL). Although PDAA exclusion is currently recommended, simultaneous CA release and the technique to be used are debated. The aim of this retrospective multicentre study was to compare the results of open surgical repair of true non-ruptured PDAA with release or CA bypass (group A) vs. coil embolisation of PDAA and CA stenting or laparoscopic release (group B).

METHODS

From January 1994 to February 2019, 57 consecutive patients (group A: 31 patients; group B: 26 patients), including 35 (61%) men (mean age 56 ± 11 years), were treated at three centres. Twenty-six patients (46%) presented with non-specific abdominal pain: 15 (48%) in group A and 11 (42%) in group B (p = .80).

RESULTS

No patient died during the post-operative period. At 30 days, all PDAAs following open repair and embolisation had been treated successfully. In group A, all CAs treated by MAL release or bypass were patent. In group B, 2/12 CA stentings failed at < 48 hours, and all MAL released by laparoscopy were successful. Median length of hospital stay was significantly greater in group A than in group B (5 vs. 3 days; p = .001). In group A, all PDAAs remained excluded. In group B, three PDAA recanalisations following embolisation were treated successfully (two redo embolisations and one open surgical resection). At six years, Kaplan-Meier estimates of freedom for PDAA recanalisation were 100% in group A, and 88% ± 6% in group B (p = .082). No PDAA ruptured during follow up. In group A, all 37 CAs treated by MAL release were patent, and one aortohepatic bypass occluded. In group B, five CAs occluded: four after stenting and the other after laparoscopic MAL release with two redo stenting and three aortohepatic bypasses. Estimates of freedom from CA restenosis/occlusion were 95% ± 3% for MAL release or visceral bypass, and 60% ± 9% for CA stenting (p = .001). Two late restenoses following CA stenting were associated with PDAA recanalisation.

CONCLUSION

Current data suggest that open and endovascular treatment of PDAA can be performed with excellent post-operative results in both groups. However, PDAA embolisation was associated with few midterm recanalisations and CA stenting with a significant number of early and midterm failures.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

Management of pancreaticoduodenal artery aneurysm associated with coeliac artery stenosis

Pancreaticoduodenal and gastroduodenal artery aneurysms are rare but require early radiological or surgical intervention due to a high risk (61%) of rupture. A 71-year-old woman presented with an incidental 30-mm aneurysm arising from the inferior pancreaticoduodenal artery associated with coeliac axis stenosis. She underwent embolisation of the pancreaticoduodenal aneurysm, but the coeliac axis stenosis was not amenable to radiological intervention. She remained well at six months of follow-up and a repeat computed tomography angiogram six months later reported stable appearances. The management of pancreaticoduodenal aneurysms is discussed.

Endovascular Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm with Celiac Axis Stenosis

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

A Case of Successful Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Dissection

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.

Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature

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.

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.

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report

A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.

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.

Inferior Pancreaticoduodenal Artery Aneurysm in Association with Celiac Axis Occlusion

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.

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.

Multiple visceral artery aneurysms managed by Yasargil aneurysm clips

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.

Ruptured pancreaticoduodenal artery aneurysm associated with median arcuate ligament compression and aortic dissection successfully treated with embolotherapy

A 51-year-old man with a ruptured pancreaticoduodenal artery (PDA) aneurysm caused by compression of the celiac artery by the median arcuate ligament and aortic dissection involving the celiac axis was transferred to our hospital for endovascular treatment. A 4-F catheter was advanced into the superior mesenteric artery through the narrow true lumen via the left brachial artery, and coil embolization of the aneurysm was successfully performed. In this case, rapid increase of blood flow in the superior mesenteric artery, which compensated for the decreased celiac blood flow by aortic dissection, increased hemodynamic stress on the PDA, leading to aneurysmal rupture.

Usefulness of automated feeder-detection software for identification of access routes to small pancreaticoduodenal artery aneurysms during embolotherapy

The mortality rate of patients with ruptured pancreaticoduodenal artery aneurysms is high; therefore, it is recommended to treat pancreaticoduodenal artery aneurysms regardless of their size. In small pancreaticoduodenal artery aneurysms, however, identification of the access route on two-dimensional arteriography is sometimes difficult because of the superimposition of many hypertrophied branches of pancreaticoduodenal arteries on the aneurysm. We report two cases of ruptured pancreaticoduodenal artery aneurysm embolized successfully with metallic coils, assisted by automated feeder-detection software using cone-beam computed tomography data. This new technology may reduce physicians’ workload during the procedure.

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.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

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.

Celiac artery dissection seen with ruptured pancreaticoduodenal arcade aneurysms in two cases of celiac artery stenosis from compression by median arcuate ligament

We report two cases of ruptured pancreaticoduodenal arcade aneurysms that were successfully treated by embolotherapy. In these cases, contrast-enhanced computed tomography, sagittal reformed images, and angiography revealed celiac artery stenoses due to compression by the median arcuate ligament. Computed tomography also showed acute localized dissection in the distal celiac axis, suggesting that aneurysmal rupture had occurred immediately after development of the dissection. When unruptured pancreaticoduodenal arcade aneurysms are identified in the context of celiac artery dissection, the possibility of rupture may be high and requires strict observation and consideration of embolotherapy.

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.

Coil embolization of a celiac artery aneurysm using the neck remodeling technique

Aneurysms of the celiac trunk are rare. Untreated lesions enlarge progressively and may rupture spontaneously. We report the case of a 56-year-old man whose wide neck celiac aneurysm was successfully packed with coils with preservation of the native arterial circulation by percutaneous transcatheter embolization using the neck remodeling technique.

True aneurysm of the pancreaticoduodenal arteries: a single institution experience

BACKGROUND

True pancreaticoduodenal artery (PDA) aneurysm is a rare but potentially fatal disease. The aim of this study was to make recommendations for management of true PDA aneurysm.

METHODS

True aneurysms of the PDA were diagnosed at our institution between 1996 and 2007 and analyzed retrospectively, for clinical presentation, management, and outcome.

RESULTS

Eight patients were admitted to our institution for true aneurysms of the PDA. Five patients had aneurysmal rupture, and three were asymptomatic. In the rupture group, computed tomography (CT) showed the retroperitoneal hematoma around the pancreas and aneurysm, ranging from 5 to 25 mm (median, 12 mm). In the non-rupture group, CT revealed saccular aneurysm, ranging from 10 to 20 mm (median, 16 mm). The celiac axis was occluded in two patients, stenotic in four, and normal in two. Two patients underwent laparotomy, and we finally performed transcatheter arterial embolization in seven. All patients are alive, and there is no evidence of recurrence after median follow-up of 6 years.

CONCLUSIONS

We recommend treatment of all true PDA aneurysms at the time of diagnosis. True PDA aneurysm with celiac artery stenosis or occlusion requires precise techniques for embolization to preserve blood flow in the celiac artery territory.

Stenosis of the third portion of the duodenum due to bleeding from the anterior pancreaticoduodenal artery: assessment by multiphase contrast-enhanced examination with multislice CT

BACKGROUND

This study was undertaken to analyze the CT findings for the rare pathological process that stenosis of the third portion of the duodenum was presumed to be caused by bleeding from the anterior pancreaticoduodenal artery.

METHODS

Four consecutive patients presenting with frequent vomiting, who did not have well-known underlying disorders causing duodenal stenosis, were retrospectively recruited. Multiphase contrast-enhanced CT examinations were performed with 0.5- or 1-mm collimation. Two radiologists evaluated 2-mm axial and multiplanar reformatted images.

RESULTS

In all patients, endoscopy demonstrated severe edematous stenosis of the third portion of the duodenum not associated with ulcer, bleeding, or neoplasm. The following CT findings were observed in all patients: homogenous swelling of the third portion of the duodenum associated with luminal stenosis in un-enhanced images, a band-like area of lower contrast-enhancement surrounding the walls of the third portion of the duodenum in pancreatic-phase images, and stenosis of the celiac axis. In three patients, aneurysms of the anterior pancreaticoduodenal artery in arterial-phase images were depicted. In the remaining patient, the diameter of the artery was irregular.

CONCLUSIONS

Multiphase contrast-enhanced CT examination using a multislice CT scanner helps to establish the diagnosis of this pathological process.

Aneurysm of the Superior Posterior Pancreatic-Duodenal Artery Presenting with Recurrent Syncopes

We present a 61-year-old woman with hypovolemic shock due to a ruptured aneurysm of the superior posterior pancreatic-duodenal artery in whom recurrent syncopes were the first presenting sign of pancreatic-duodenal artery aneurysm (PDAA). PDAA is a rare but life-threatening condition. The widely varying symptomatology may lead to a delay in diagnosis and treatment. Patients with atypical symptoms, such as vague abdominal pain, recurrent dizziness or syncope, may actually suffer from a sentinel bleeding of the vascular malformation. Radiological imaging, especially selective angiography, may provide a diagnostic as well as a therapeutic tool in these patients.

Pancreaticoduodenal Artery Pseudoaneurysm Embolization

We report a case of successful transcatheter arterial embolization of a pancreaticoduodenal artery pseudoaneurysm (PSA) caused by erosion of the pancreatic pseudocyst content near pancreaticoduodenal arteries. A 55-year-old man was admitted to a local hospital for investigation of severe, stabbing epigastric pain confined to the upper abdomen. He had a history of previous alcohol abuse, chronic pancreatitis, and a duodenal ulcer. Upper gastrointestinal endoscopy revealed narrowing in the pyloric channel along with an ulcer located at the first and second portions of the duodenum with oozing beneath an adherent cloth and duodenal distortion. Computed tomography additionally revealed an enlarged head of the pancreas with numerous spot calcifications and round cystic formation inside, with a diameter of 30 × 25 mm. Following two surgical procedures for duodenal ulcers, selective angiography revealed a PSA located inside the pancreas head and high-grade stenosis > 90% of the celiac trunk and hepatic artery that rose separately from the aorta. Fiber coil embolization was used to occlude the PSA sac successfully. There was no complication after completion of the last embolic procedure. The patient was doing well after 26 months.

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.

Surgical Management of Pancreaticoduodenal Artery Aneurysms in Association with Celiac Trunk Occlusion or Stenosis

Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. They show a wide clinical spectrum, ranging from asymptomatic incidental findings to rupture-inducing catastrophic bleedings. Since growth progression and the risk of rupture cannot be foreseen and there is no relation between the size of the aneurysm and propensity to rupture, rupture unfortunately carries a high mortality, >50%. Thus, all aneurysms of the pancreaticoduodenal artery should be treated. The therapy of choice, either operative intervention or catheter embolization, is determined by many factors. Among these are localization, size, relation to other vessels and neighboring organs, the urgency of intervention, and the experience of the therapist. Surgical therapy should be favored in patients with pancreaticoduodenal artery aneurysm due to celiac trunk occlusion. We report here our experience in the surgical treatment of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis over the last 5 years.

Significance of intraoperative monitoring of arterial blood flow velocity and hepatic venous oxygen saturation for performing minimally invasive surgery in a patient with multiple calcified pancreaticoduodenal aneurysms with celiac artery occlusion

Even for patients with multiple pancreaticoduodenal aneurysms, successful treatment with noninvasive operative procedures can be employed, if intraoperative devices are considered. A 73-year-old man, without any symptoms, was admitted to our hospital and had computed tomography (CT) scanning to examine his liver for hepatitis C virus (HCV). Selective superior mesenteric artery (SMA) angiography confirmed multiple aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), one aneurysm in the posterior inferior mesenteric artery (PIPDA), and another in the occluded celiac trunk, all with severe calcification. All of the aneurysms were thought to communicate with each other. With the celiac artery occlusion, the right hepatic artery (RHA) was revealed to be supplied by collateral arteries from the aneurysms in the AIPDA, and the left hepatic artery was shown to be supplied by collaterals from the left gastric artery. Intraoperative Doppler echography, at the time of the clamping of both IPDAs, demonstrated a marked decrease of blood velocity in all aneurysms (before clamping, >50 cm/s; after, <10 cm/s), although loss of pulsation and a marked decrease of flow in the RHA were inevitable. Therefore, each of these two IPDAs were ligated on the proximal side to the aneurysm, thus preserving the blood flow of the pancreas head fed by the PIPDA; bypass grafting from the AIPDA to the RHA, using the great saphenous vein, was done at the same time. After the creation of an anastomosis, the hepatic venous oxygen saturation (ShvO2) increased from 38% (at the time of ligation of the IPDAs) to 57% under ventilation. The patient's postoperative clinical course was uneventful. We describe and discuss our successful noninvasive operative management of multiple pancreaticoduodenal aneurysms, done while monitoring the blood flow and ShvO2, with some consideration of the literature.