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Fujiwara S, Kawamura K, Nakano Y, Watanabe T, Yamashita H. Spontaneous complete regression of pancreaticoduodenal artery aneurysms with celiac artery occlusion after aorto-splenic bypass without additional treatment: a case report. Surg Case Rep 2024; 10:80. [PMID: 38584215 PMCID: PMC10999396 DOI: 10.1186/s40792-024-01880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/26/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Pancreaticoduodenal artery aneurysm (PDAA) is a rare, but fatal disease. However, the association between aneurysm size and the risk of rupture remains unclear. There are many options for therapeutic strategies that should be discussed well because the treatment options are often complicated and highly invasive. However, it remains unclear whether additional endovascular therapy is essential for all patients undergoing bypass surgery. Here, we present a case of triple PDAAs with celiac axis occlusion and spontaneous complete regression of inferior PDAAs (IPDAA) after aneurysmectomy of superior PDAA (SPDAA) and aorto-splenic bypass. CASE PRESENTATION A 68-year-old woman presented with one SPDAA and two IPDAAs caused by celiac axis occlusion. Aneurysmectomy for IPDAAs was difficult because of their anatomical location and shape. Therefore, we planned a two-stage hybrid therapy. The patient underwent aorto-splenic bypass and resection of the SPDAA. Follow-up CT was performed to evaluate the IPDAAs before planned endovascular embolization. Spontaneous regression of the IPDAAs and normalized PDA arcade decreased the blood flow in the PDA arcade. The patient is doing well without graft occlusion, and the IPDAAs have completely regressed 7 years after surgery. CONCLUSION Normalization of hyperinflow to the PDA arcade can lead to the regression of PDAA. Potentially, additional endovascular therapy may not be required in all cases when dilation of the PDA improves. However, more cases must be accumulated to establish criteria for predicting the risks of short- and long-term PDAA ruptures.
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Affiliation(s)
- Sho Fujiwara
- Department of Surgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate, 024-8507, Japan.
- Department of Surgery, Columbia University Irving Medical Center, 622 West 168th St, New York, NY, 10032, USA.
| | - Keiichiro Kawamura
- Department of Surgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate, 024-8507, Japan
- Department of Vascular Surgery, Iwate Prefectural Isawa Hospital, 61 Ryugababa, Mizusawa, Oshu, Iwate, 023-0864, Japan
| | - Yoshiyuki Nakano
- Department of Vascular Surgery, Japan Community Health Care Organization Sendai Hospital, 2-1-1 Murasakiyama, Sendai, Miyagi, 981-3205, Japan
| | - Tetsuo Watanabe
- Department of Cardiovascular Surgery, Sendai City Hospital, 1-1-1 Asutonagamachi, Sendai, Miyagi, 982-8502, Japan
| | - Hiroshi Yamashita
- Department of Surgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate, 024-8507, Japan
- Department of Vascular Surgery, Kitakami Saiseikai Hospital, 15-33 Kunenbashi, Kitakami, Iwate, 024-0063, Japan
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Fujioka M, Yabunaka K, Miyazaki M, Saga T. A Ruptured Inferior Pancreaticoduodenal Artery Aneurysm Detected With Ultrasonography: A Case Report. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2023. [DOI: 10.1177/87564793231153848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Pancreaticoduodenal artery aneurysm (PDAA) is a rare disease that is recognized as an intra-abdominal hemorrhage differential diagnosis. This case study reports on a ruptured PDAA case in which ultrasonography (US) proved useful for the initial diagnosis. A 60-year-old man presented to the emergency department with pain in the epigastrium and back. An abdominal US performed at presentation suggested a PDAA and intraperitoneal hemorrhage/retroperitoneal hematoma. In addition, a contrast-enhanced computed tomogram (CT) revealed a hematoma extending from the upper abdomen to the pelvic floor and an aneurysmal pancreaticoduodenal artery arcade dilatation. Furthermore, emergency abdominal angiography findings revealed bleeding from a posterior-inferior PDAA, and coil embolization was performed. Postoperative progress was good, and the postoperative CT at 7 days showed no rebleeding signs and/or enlargement or new PDAA development. Therefore, the patient was discharged from the hospital 14 days after embolization.
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Affiliation(s)
| | - Koichi Yabunaka
- Department of Ultrasound, Ono Memorial Hospital, Osaka, Japan
| | - Minoru Miyazaki
- Department of Cardiovascular Surgery, Katsuragi Hospital, Osaka, Japan
| | - Toshihiko Saga
- Department of Cardiovascular Surgery, Katsuragi Hospital, Osaka, Japan
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Takematsu T, Kosumi K, Tajiri T, Kanemitsu K, Mima K, Inoue M, Mizumoto T, Kubota T, Miyanari N, Baba H. Surgical resection of a ruptured transverse pancreatic artery aneurysm. Surg Case Rep 2021; 7:53. [PMID: 33616793 PMCID: PMC7900318 DOI: 10.1186/s40792-021-01128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/31/2021] [Indexed: 11/28/2022] Open
Abstract
Background Visceral artery aneurysms are rare, but they may cause heavy bleeding and high mortality. In addition, aneurysms originating from the superior mesenteric artery (SMA) account for only 1% of visceral artery aneurysms. We report the rare case of a ruptured transverse pancreatic artery aneurysm originating from the SMA that required urgent surgical treatment. Case presentation A 66-year-old woman presented with acute back pain after lunch, and she was transported by ambulance. She had upper quadrant spontaneous pain and moderate tenderness, but no guarding or rebound pain. She had rheumatoid arthritis, and was taking 10 mg of steroids per day. Contrast-enhanced computed tomography demonstrated a retroperitoneal hematoma spreading to the ventral side of the left kidney and extravasation of contrast agent from a branch of the SMA. We diagnosed rupture of aneurysm. We conferred with our IVR team on treatment strategy for the ruptured aneurysm. In addition, we finally selected operation, since the branch of the SMA to the aneurysm was too thin and complex to conduct IVR. For this reason, we performed emergency simple aneurysmectomy of the transverse pancreatic artery. The postoperative course was relatively smooth. Conclusion Rupture of a transverse pancreatic artery aneurysm originating from the SMA is rare. However, when diagnosing patients with acute abdomen or back pain, we should consider rupture of a visceral artery aneurysm. Endovascular treatment may currently be common for ruptured visceral artery aneurysms, but we should flexibly treat them according to the patient’s condition and facility considerations.
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Affiliation(s)
- Toru Takematsu
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Keisuke Kosumi
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Takuya Tajiri
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Kosuke Kanemitsu
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Kosuke Mima
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Mitsuhiro Inoue
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Takao Mizumoto
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Tatsuo Kubota
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Nobutomo Miyanari
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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Imagami T, Takayama S, Hattori T, Matsui R, Kani H, Tanaka A, Ando M, Kodani N. Transarterial Embolization With Complementary Surgical Ligation of Gastroduodenal Artery for Ruptured Pancreaticoduodenal Artery Aneurysm. Vasc Endovascular Surg 2019; 53:593-598. [PMID: 31248357 DOI: 10.1177/1538574419859693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The association between pancreaticoduodenal artery aneurysm (PDAA) and local hemodynamic changes in pancreaticoduodenal arcades is well established. However, there are few case reports of PDAA associated with acute aortic dissection. In this article, we outline and discuss the case of a 61-year-old man diagnosed with a type A acute aortic dissection who underwent emergency surgery and developed sudden-onset severe abdominal pain and shock 10 days later. Contrast-enhanced computed tomography showed a ruptured PDAA with feeding vessels from the gastroduodenal and superior mesenteric arteries, with evidence that the celiac artery was diverged from a false lumen. Transarterial embolization via the superior mesenteric artery alone was not expected to achieve hemostasis, so we performed a hybrid procedure involving transarterial embolization cannulated from superior mesenteric artery with complementary surgical ligation of the gastroduodenal artery. The postoperative course was uneventful, and follow-up contrast-enhanced computed tomography showed no persistence of the aneurysm 8 days after the second operation. This case proposed that visceral arterial malperfusion due to acute aortic dissection can cause PDAA in the early postoperative period. Although previous reports suggest that endovascular treatment is preferable, it may not always be feasible. Since ruptured PDAAs are often not detected during surgery, surgical treatment can be overly invasive. Whereas, transarterial embolization with complementary clamping or ligation of the gastroduodenal artery for ruptured PDAA is less invasive and can control hemorrhage, especially when cannulation to the celiac artery is impossible. Notably, the technique did not cause organ ischemia, presumably because the small collateral vessels of the pancreaticoduodenal arcades permitted sufficient blood flow. If endovascular treatment is unable to achieve rapid hemostasis, this technique may be a useful option for ruptured PDAA.
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Affiliation(s)
- Toru Imagami
- 1 Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Satoru Takayama
- 1 Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Taku Hattori
- 1 Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Ryohei Matsui
- 1 Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Hisanori Kani
- 1 Department of Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Akimitsu Tanaka
- 2 Department of Cardiology of Heart Center, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Miyuki Ando
- 2 Department of Cardiology of Heart Center, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Noriko Kodani
- 3 Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
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Unusual case of digestive bleeding nine months after a cephalic pancreaticoduodenectomy (CPD). Int J Surg Case Rep 2016; 21:133-5. [PMID: 26992037 PMCID: PMC4802324 DOI: 10.1016/j.ijscr.2016.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 02/18/2016] [Accepted: 02/23/2016] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Post-pancreaticoduodenectomy hemorrhage is mostly due to the gastroduodenal artery stump erosion. The diagnosis of arterial bleeding is done by digestive endoscopy, selective angiography or video capsule endoscopy. On failure of etiological research, surgery is the last resort despite its technical difficulties. CASE PRESENTATION A 63 years-old woman was admitted in surgery, nine months after cephalic pancreaticoduodenectomy for a pain of the right hypochondria combined with a pneumoperitoneum, after a 3rd episode of hemorrhage. Exploratory laparotomy is performed after a third hemorrhagic episode and failure of etiological research. Bleeding from the gastroduodenal artery stump was discovered and successfully treated. DISCUSSION Post-pancreaticoduodenectomy hemorrhage can occur very late. In these cases, a secondary arterial erosion obstructed by left hemi-liver should not be excluded. In these cases, despite the technical risks, surgery is required. CONCLUSION The failure of the means used for diagnostic must lead to the surgery right away, despite operating risk.
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