Management of pancreaticoduodenal artery aneurysm associated with coeliac artery stenosis

Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review

BACKGROUND

Despite being rare, pancreaticoduodenal artery aneurysms (PDAAs) carry a risk of rupture of up to 50% and are frequently associated with coeliac artery occlusion.

METHODS

PubMed and Embase databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines.

RESULTS

We present the case of a 2 cm pancreaticoduodenal artery aneurysm pre-operative angiography demonstrated that the coeliac artery was occluded and the pancreaticoduodenal artery was providing collateral blood supply to the liver. Treatment was a staged hybrid intervention inclusive of an aorto-hepatic bypass using a 6 mm graft, followed by coil embolisation of the aneurysm. We also present a systematic review of the management of PDAAs. Two hundred and ninety-two publications were identified initially with 81 publications included in the final review. Of the 258 peripancreatic aneurysms included, 175 (61%) were associated with coeliac artery disease either occlusion or stenosis. Abdominal pain was the main presentation in 158 cases. Rupture occurred in 111 (40%) of patients with only ten (3.8%) cases being unstable on presentation. Fifty (18%) cases were detected incidentally while investigating another pathology. Over half the cases (n=141/54.6%) were treated by trans arterial embolisation (TAE) alone, while 37 cases had open surgery only. Twenty-one cases needed TAE and a coeliac stent. Seventeen cases underwent hybrid treatment (open and endovascular). Sixteen cases were treated conservatively and in 26 cases, treatment was not specified.

CONCLUSION

PDAAs are commonly associated with coeliac artery disease. The most common presentation is pain followed by rupture. The scarcity of literature about true peripancreatic artery aneurysms associated with CA occlusive disease makes it difficult to assess the natural history or the appropriate treatment. Revascularisation of hepatic artery is better done with bypass in setting of median arcuate ligament compression and occluded celiac trunk.

Treatment strategies for unruptured pancreaticoduodenal artery aneurysms associated with celiac artery occlusion

Celiac artery (CA) occlusion or stenosis is identified in up to almost half of all patients undergoing abdominal angiography, and the resulting increased collateral blood flow from the superior mesenteric artery to the pancreaticoduodenal artery (PDA) may cause PDA aneurysms (PDAAs). PDAAs are rare but could be fatal if they rupture. However, treatment of the PDAA could block this important collateral blood flow pathway, leading to ischemic organ damage. Treatment of such aneurysms is therefore difficult, especially in patients with multiple PDAAs. Successful treatment of PDAAs requires establishing blood flow in the CA region and selecting which aneurysm(s) to treat. We present four patients who underwent surgery for unruptured PDAAs caused by CA obstruction. Blood flow in the CA region was established by bypassing the splenic artery and by anastomosing it either directly to the left renal artery (n = 1) or to the abdominal aorta using a graft (saphenous vein: n = 1; artificial vessel: n = 2). Three patients had multiple PDAAs: all PDAAs were treated in one patient with PDAAs of similar size and shape, but only the largest PDAA with the highest risk of rupture was treated in the other two patients to simplify the procedure. The median observation period was 19.5 months (range: 11-28 months), and all patients were alive without recurrence at the time of writing. Surgical treatment including splenic artery bypass may thus be a viable option for treating patients with unruptured PDAAs.