Polyarteritis nodosa-induced pancreaticoduodenal artery aneurysmal rupture

Intraperitoneal hemorrhage secondary to ruptured omental artery aneurysm associated with polyarteritis nodosa: a case report

BACKGROUND

Polyarteritis nodsa (PAN) is a rare disease characterized by acute focal inflammatory damage to small and medium arteries. PAN complicated by ruptured aneurysm is an infrequent presentation with the most affected arteries being the renal and mesenteric arteries.

CASE PRESENTATION

A 76-year-old female presented with a low-grade fever, generalized body aches, and abdominal pain. Investigation revealed intraperitoneal bleeding secondary to a ruptured and actively bleeding right omental artery aneurysm. Clinical manifestation, angiography and histology were consistent with PAN. Laparotomy was performed for stabilization and resection of the bleeding aneurysm followed by post operative steroids and cyclophosphamide. Patient was discharged in a stable condition. We reviewed seven cases found in the literature of omental artery aneurysm and rupture. Four cases were proceeded with laparotomy and aneurysm resection while three cases were proceeded with a less invasive approach of arterial embolization.

CONCLUSIONS

Omental artery aneurysm is a rare occurrence with even fewer reported cases associated with PAN. Of the seven reported cases, all patients were treated with a surgical intervention. In addition, PAN patients should be treated post-operatively with a course of steroids and cyclophosphamide.

Spontaneous Retroperitoneal Hemorrhage - A Rare Presentation of Polyarteritis Nodosa: Role of Angiography in Diagnosis and Management

Spontaneous retroperitoneal hemorrhage (RPH) is a rare but serious complication of polyarteritis nodosa (PAN) and must be considered in patients presenting with RPH as their first presentation. Renal infarctions, liver infarctions, and ruptured microaneurysms are all complications of PAN. We present two cases presenting with abdominal and back pain. The first patient’s abdominal computed tomography (CT) scan revealed fractured right kidney with retroperitoneal pericapsular hematoma and multiple hepatic and splenic infarcts. The digital subtraction angiography (DSA) demonstrated large areas of devascularization of the right kidney and right renal arterial wall irregularity with multifocal areas of stenosis, dilatations, and microaneurysms without active extravasation of IV contrast. She was treated conservatively and started on a pulsed dose of steroids and cyclophosphamide. The second patient’s abdominal CT angiography revealed multiple visceral aneurysms and focal areas of stenosis in branches of celiac axis and superior mesentery artery without active contrast extravasation. The DSA demonstrated multifocal areas of irregularity and narrowing in celiac and intrahepatic arteries as well as a 9 mm pseudoaneurysm in the inferior pancreaticoduodenal artery which was embolized with metallic coils. PAN has a vague clinical presentation and is clinically occult. Patients may be diagnosed while getting investigated for some other causes of abdominal pain. The emergency physician and the radiologist should be aware of the findings and should be able to correlate with pathology to prevent life-threatening complications. Angiography plays a crucial role, not only in diagnosis but also in appropriate management.

Hybrid Surgery to Treat Multiple Visceral Aneurysms Secondary to Polyarteritis Nodosa

A 57-year-old woman presented to vascular surgery clinic with visceral artery aneurysms that were incidentally detected during regular check-up. Imaging studies revealed occlusion of the celiac axis and severe stenosis of the superior mesenteric artery and 3 aneurysms along the posterior and inferior pancreaticoduodenal arteries, as well as the right gastroepiploic artery. Endovascular embolization of all aneurysms was rejected because of the risk of hepatic ischemia. These complicated lesion caused by polyarteritis nodosa were successfully treated using a hybrid operation with coil embolization, aneurysm resection, and antegrade aorto-celiac-superior mesentery artery bypass.

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

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