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Voigt MB, Kupczyk PA, Kania A, Meyer C, Wagenpfeil J, Dell T, Pieper CC, Luetkens JA, Kuetting D. Interventional treatment of peripancreatic aneurysms: can one strategy fit all? CVIR Endovasc 2025; 8:23. [PMID: 40106113 PMCID: PMC11923352 DOI: 10.1186/s42155-025-00533-2] [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: 01/15/2025] [Accepted: 02/27/2025] [Indexed: 03/22/2025] Open
Abstract
PURPOSE To identify the frequency and association of visceral arterial (VA) stenosis in peripancreatic aneurysms (PPAs) and to develop a uniform, more detailed treatment strategy for PPAs in case of accompanying VA stenosis, as current guidelines do not adequately address this constellation. MATERIALS AND METHODS Patients with PPAs diagnosed at a tertiary care hospital were retrospectively analyzed. In case of multiple PPAs, the aneurysm with the highest aneurysm-to-vessel ratio (AVR) within the celiac-mesenteric collateral circulation was classified as the primary aneurysm and categorized as "critical" or "non-critical" based on the risk of organ ischemia. Celiac artery and superior mesenteric artery stenoses were graded as low (< 50%), high (> 50%), or total occlusion. Treatment strategies were based on VA stenosis severity, aneurysm classification, and morphology. Treatment strategies included endovascular, surgical and watch-and-wait management. RESULTS Thirty-one patients with PPAs were included with a total of 53 aneurysms; mean aneurysm size: 12.5 ± 7.9 mm (range 5-38 mm), AVR: 3.5 ± 2.1 (range 1-11.3). The superior and inferior pancreaticoduodenal arteries as well as the pancreaticoduodenal arcade were affected in most cases (67.9%). AVR was significantly higher in cases of aneurysm rupture (6.2 ± 2.8; p = 0.031). Celiac artery stenosis was present in 87.1%. Aneurysm size and occurrence of active bleeding did not correlate (p = 0.925). 11 patients presented with critical aneurysms, with 10 patients requiring individually tailored treatment. Non-critical aneurysms were treated with coil embolization in most cases. CONCLUSION CA stenosis, aneurysm position, and AVR significantly influence treatment decisions. Individualized approaches based on anatomical and hemodynamic factors are needed in PPA treatment.
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Affiliation(s)
- Marilia B Voigt
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany.
| | - Patrick A Kupczyk
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Alexander Kania
- Department of Visceral and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Julia Wagenpfeil
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Tatjana Dell
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Claus-Christian Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Julian A Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Daniel Kuetting
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
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Almadwahi NY, Alshuja’a MA, Al-Hodiafy HZ, Jowah HM. A Rare Case of Gastroduodenal Artery Aneurysm Rupture with Perforated Duodenal Ulcer. Int Med Case Rep J 2024; 17:609-614. [PMID: 38911607 PMCID: PMC11192190 DOI: 10.2147/imcrj.s468278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024] Open
Abstract
Purpose In this case we report a rare presentation of a ruptured gastroduodenal artery aneurysm (GDA) accompanied by a duodenal perforation. It contributes to the scientific literature by discussing the management approach and results in a patient with dual complications and emphasizes the importance of early diagnosis and appropriate treatment. Case presentation A 50-year-old male presented with severe abdominal pain, anemia, and signs of hemodynamic instability. Diagnostic imaging including CTA revealed a large, thrombosed gastroduodenal artery aneurysm with evidence of rupture. The patient underwent open surgical exploration and repair to address both the aneurysm and the duodenal perforation. The patient's recovery was satisfactory and was discharged home in stable condition. Conclusion Early diagnosis and appropriate management in gastroduodenal artery aneurysms is crucial. There is a need for individualized surgical interventions based on the patient's hemodynamic status and associated complications. Dual complications required open surgical exploration and repair, resulting in favorable outcomes.
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Affiliation(s)
| | | | - Hamza Zaid Al-Hodiafy
- Department of Vascular Surgery, 48 Model Hospital, Sana’a University, Sana’a City, Yemen
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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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Ishihara T, Matsui T, Katoh T, Kobayashi K, Sekigawa K, Suzuki T, Mitsui H. Pancreaticoduodenal Artery Aneurysm Rupture Presenting as Duodenal Obstruction Successfully Treated with Early Transcatheter Arterial Embolization: A Case Report of Suspected Segmental Arterial Mediolysis. Intern Med 2023; 62:3479-3482. [PMID: 37062731 PMCID: PMC10749823 DOI: 10.2169/internalmedicine.1278-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/05/2023] [Indexed: 04/18/2023] Open
Abstract
Visceral aneurysms are a rare but important form of abdominal vascular disease. Rupture of the aneurysms leads to serious symptoms, such as acute abdomen or abdominal bleeding. However, duodenal obstruction due to arterial rupture of an aneurysm is very rare. We herein report a 50-year-old woman with suspected segmental arterial mediolysis (SAM) who was first diagnosed with acute abdomen and duodenal obstruction. Rupture of a pancreaticoduodenal artery aneurysm was confirmed, and she was treated with transcatheter arterial embolization. In cases of acute abdomen, SAM is a rare but important possibility to consider as a differential diagnosis.
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Affiliation(s)
| | - Toru Matsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | - Tomoji Katoh
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | | | | | - Takeo Suzuki
- Department of Intervention Radiology, Tokyo Teishin Hospital, Japan
| | - Hiroshi Mitsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
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Jalili J, Javadrashid R, Alvandfar D, Falahatian M, Jafarizadeh A, Alihosseini S, Hashemizadeh SE. 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. J Med Case Rep 2023; 17:385. [PMID: 37689729 PMCID: PMC10493028 DOI: 10.1186/s13256-023-04114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 08/03/2023] [Indexed: 09/11/2023] Open
Abstract
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.
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Affiliation(s)
- Javad Jalili
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Radiology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Javadrashid
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Radiology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Dara Alvandfar
- Department of General Surgery, Emam Reza Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masih Falahatian
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Ali Jafarizadeh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samin Alihosseini
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyedeh Elnaz Hashemizadeh
- Department of Surgical and Clinical Pathology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Zhang C, Wang K, Ma W, Sun MW. Inferior pancreaticoduodenal artery aneurysm rupture hemorrhage: A case report and literature review. Asian J Surg 2022; 46:2104-2106. [PMID: 36435628 DOI: 10.1016/j.asjsur.2022.11.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022] Open
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Ashraf MF, Vipani A, Batool A. An Unusual Case of Gastric Outlet Obstruction After Embolization of Gastroduodenal Artery Pseudoaneurysm. J Med Cases 2021; 12:464-467. [PMID: 34804308 PMCID: PMC8577608 DOI: 10.14740/jmc3786] [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: 09/07/2021] [Accepted: 09/28/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Asra Batool
- Division of Gastroenterology, Albany Medical Center, Albany, New York, USA
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Zerti HM, Saleem MS, Khan YI, Iqbal Z, Ninalowo H. Small Bowel Obstruction: A Rare Presentation of the Inferior Pancreaticoduodenal Artery Pseudoaneurysm Bleed. Cureus 2021; 13:e16943. [PMID: 34513511 PMCID: PMC8418819 DOI: 10.7759/cureus.16943] [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] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Abstract
Intra-abdominal and intramural hematomas are well-known complications of pseudoaneurysms. We present a case of small bowel obstruction as a result of external mechanical compression from hematoma. Bleeding was localized to the pseudoaneurysm of the gastroduodenal artery and inferior pancreaticoduodenal artery. Angiography was used to control the bleeding with coil embolization. This rare clinical manifestation represents just one of the symptoms associated with pseudoaneurysms of the gastrointestinal tract. Therapeutic options are discussed along with a review of the literature.
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Affiliation(s)
- Hasan M Zerti
- Internal Medicine, Geisinger Wyoming Valley Medical Center, Wilkes Barre, USA
| | | | | | - Zaid Iqbal
- Internal Medicine, Wright Cen, Scranton, USA
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9
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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. Surg Case Rep 2021; 7:174. [PMID: 34347194 PMCID: PMC8339153 DOI: 10.1186/s40792-021-01260-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Nagasaki K, Ariga H, Irie T, Kashimura J, Kobayashi H. Spontaneous retroperitoneal bleeding secondary to celiac artery compression syndrome. Clin Case Rep 2021; 9:e04158. [PMID: 34194757 PMCID: PMC8222652 DOI: 10.1002/ccr3.4158] [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: 02/18/2021] [Revised: 03/19/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022] Open
Abstract
Clinicians should consider celiac artery compression syndrome as the cause of ruptured visceral aneurysm and dissection and ask patients for unexplained chronic abdominal symptoms. Endovascular embolization with metallic coil placement is the first-line treatment, and surgery can be avoided in some cases.
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Affiliation(s)
- Kazuya Nagasaki
- Department of Internal MedicineMito Kyodo General HospitalUniversity of TsukubaMitoJapan
| | - Hiroyuki Ariga
- Department of GastroenterologyMito Kyodo General HospitalUniversity of TsukubaMitoJapan
| | - Toshiyuki Irie
- Department of RadiologyMito Kyodo General HospitalUniversity of TsukubaMitoJapan
| | - Junya Kashimura
- Department of GastroenterologyMito Kyodo General HospitalUniversity of TsukubaMitoJapan
| | - Hiroyuki Kobayashi
- Department of Internal MedicineMito Kyodo General HospitalUniversity of TsukubaMitoJapan
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Park C, Park DE. Ruptured Pancreaticoduodenal Artery Aneurysm with Pancreatitis Treated Using Endovascular and Endoscopic Methods. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:194-198. [PMID: 33896906 DOI: 10.4166/kjg.2021.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/03/2022]
Abstract
Pancreaticoduodenal artery aneurysm (PDAA) is a rare form of abdominal visceral aneurysm that accounts for approximately 2% of all cases. Most cases of PDAA are associated with celiac artery stenosis (CAS). Regardless of the size, there is a risk of rupture. Therefore, treatment should be performed immediately after discovery, even though the need to treat the accompanying CAS, if present, is controversial. The authors report a case of ruptured PDAA and accompanying pancreatitis treated using endovascular and endoscopic methods without treatment of CAS. A 50-year-old man was admitted to the emergency department of Wonkwang University Hospital with epigastric pain and hypovolemic shock. CT revealed a ruptured PDAA and a large volume hemoperitoneum. Emergency angiography was performed, and angioembolization of the PDAA was performed successfully. Follow-up CT revealed infection and pancreatitis, which were treated by surgical drainage and pancreatic duct stenting with ERCP. Because the degree of stenosis was not severe, it was decided to follow-up the accompanying CAS. After discharge, the patient was followed up without complications.
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Affiliation(s)
- Chan Park
- Department of Surgery, Wonkwang University School of Medicine, Iksan, Korea
| | - Dong Eun Park
- Department of Surgery, Wonkwang University School of Medicine, Iksan, Korea
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Outcomes After Open and Endovascular Repair of Non-Ruptured True Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Coeliac Artery Compression: A Multicentre Retrospective Study. Eur J Vasc Endovasc Surg 2021; 61:945-953. [PMID: 33762153 DOI: 10.1016/j.ejvs.2021.02.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 11/21/2022]
Abstract
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.
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Case report of a successful non-operative management of postoperative bleeding from pseudoaneurysm of the gastroduodenal artery, following gastric surgery. Int J Surg Case Rep 2020; 78:54-57. [PMID: 33310471 PMCID: PMC7736902 DOI: 10.1016/j.ijscr.2020.11.157] [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: 11/22/2020] [Revised: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 11/22/2022] Open
Abstract
Postoperative pseudoaneurysms occur after upper gastrointestinal operations. Almost half (52%) of the pseudoaneurysms are diagnosed when a rupture occurs. Rupture of the pseudoaneurysm can be treated by embolism of the artery. The formation of the pseudoaneurysm, occured in less than 48h as in earlier CTA the gastroduodenal artery appeared normal. Introduction Post operative pseudoaneurysm of the gastroduodenal artery is a very rare entity. Rupture of the pseudoaneurysm can be treated by embolism of the artery. Presentation of case A 71 years old male with a perforated pyloric ulcer was treated with controlled external duodenal fistula. Due to postoperative bleeding a subtotal gastrectomy was performed. A second episode of bleeding occurred and rupture of a pseudoaneurysm of the gastroduodenal artery was diagnosed by computed angiography and treated by embolism of the artery. Three days later the duodenal stump was ruptured and a new controlled external duodenal fistula was surgically created. The patient died 6 weeks later due to multiple organ failure. Discussion Pseudoaneurysm is the result of self-contained ruptures of one or more layers of the vascular wall. Computed angiography is the golden standard to identify pseudoaneurysms (100% sensitivity). Early suspicion for the presence of a pseudoaneurysm is crucial, as when the rupture actually occurs, the mortality rate is remarkably high. Endovascular approach is a minimally invasive procedure with high success rates (70–100%) and significantly lower morbidity and mortality rates. Surgical is reserved in case of bleeding recurrence. The fact that is particularly interesting in this patient is the timing of the formation of the pseudoaneurysm, considering the fact that 48 h earlier the gastroduodenal artery appeared normal. Conclusion There are no guidelines regarding the treatment of the pseudoaneurysm of the gastroduodenal artery. It seems reasonable to treat them immediately after diagnosis because a possible rupture of the aneurysm has an extremely high mortality.
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14
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Modestino F, Cappelli A, Mosconi C, Peta G, Bruno A, Vara G, De Benedictis C, Golfieri R. Balloon-assisted coil embolization (BACE) of a wide-necked aneurysm of the inferior pancreaticoduodenal artery. CVIR Endovasc 2020; 3:62. [PMID: 32889684 PMCID: PMC7474725 DOI: 10.1186/s42155-020-00155-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background Aneurysms of the pancreaticoduodenal arcades are an uncommon pathology, with a prevalence of 2%, and could be congenital or acquired. Treatment of visceral aneurysms is therefore generally recommended when the aneurysmal sac equals or exceeds 2 cm. Wide-necked (> 4 mm) and main artery branch aneurysms represent a challenge for conventional endovascular coil embolization due to the risk of coil migration. Main body This case describes the technical feasibility of balloon-assisted coil embolization (BACE) in the treatment a wide neck aneurysm of inferior pancreatic duodenal artery due to celiac axis occlusion. Short conclusion In case of celiac trunk occlusion, BACE is a safe procedure associated with optimal technical success rates, in order to treat the aneurysms and to preserve splanchnic vascularization.
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Affiliation(s)
- Francesco Modestino
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alberta Cappelli
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cristina Mosconi
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Bruno
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giulio Vara
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Caterina De Benedictis
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Diagnostic Medicine and Prevention, Radiology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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15
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Bonardelli S, Spampinato B, Ravanelli M, Cuomo R, Zanotti C, Paro B, Nodari F, Barbetta I, Portolani N. The role of emergency presentation and revascularization in aneurysms of the peripancreatic arteries secondary to celiac trunk or superior mesenteric artery occlusion. J Vasc Surg 2020; 72:46S-55S. [PMID: 32093911 DOI: 10.1016/j.jvs.2019.11.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
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16
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Sousa J, Costa D, Mansilha A. Visceral artery aneurysms: review on indications and current treatment strategies. INT ANGIOL 2019; 38:381-394. [PMID: 31284707 DOI: 10.23736/s0392-9590.19.04194-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.
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Affiliation(s)
- Joel Sousa
- Faculty of Medicine, University of Porto, Porto, Portugal -
- Department of Angiology and Vascular Surgery, Hospital of S. João, Porto, Portugal -
| | - Diogo Costa
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Hospital of S. João, Porto, Portugal
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Kuruma S, Kikuyama M, Kamisawa T, Chiba K. Hyper-dense fluid on plain computed tomography may reveal a ruptured aneurysm in patients with median arcuate ligament syndrome. Clin J Gastroenterol 2019; 12:473-478. [PMID: 30997671 DOI: 10.1007/s12328-019-00968-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/16/2019] [Indexed: 11/26/2022]
Abstract
Rupture of abdominal aneurysms associated with median arcuate ligament syndrome (MALS) is a serious condition and requires accurate diagnosis in a clinical setting. We examined three patients with this condition: two women aged 45 and 71 years, and a 61-year-old man. They complained of abdominal pain and had fluid collection around the duodenum. Plain computed tomography (CT) of the fluid collection revealed hyper density, which suggests the presence of blood. Moreover, contrast-enhanced CT revealed aneurysms in the pancreatic head area. Angiography revealed aneurysms of the branches of the gastroepiploic artery, which were treated by endovascular embolization in all patients. Thus, patients with abdominal pain and high-density fluid collection around the duodenum on plain CT may suffer from hemorrhage following rupture of MALS-associated aneurysms.
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Affiliation(s)
- Sawako Kuruma
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan.
| | - Masataka Kikuyama
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Terumi Kamisawa
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Kazuro Chiba
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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18
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Kamarajah SK, Kharkhanis S, Duddy M, Isaac J, Sutcliffe RP, Mehrzad H, Dasari B. Management of pancreaticoduodenal artery aneurysm associated with coeliac artery stenosis. Ann R Coll Surg Engl 2019; 101:e105-e107. [PMID: 30855165 DOI: 10.1308/rcsann.2019.0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- S K Kamarajah
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital , Birmingham , UK
| | - S Kharkhanis
- Department of Interventional Radiology, Queen Elizabeth Hospital , Birmingham , UK
| | - M Duddy
- Department of Interventional Radiology, Queen Elizabeth Hospital , Birmingham , UK
| | - J Isaac
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital , Birmingham , UK
| | - R P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital , Birmingham , UK
| | - H Mehrzad
- Department of Interventional Radiology, Queen Elizabeth Hospital , Birmingham , UK
| | - Bvm Dasari
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital , Birmingham , UK
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Abe K, Iijima M, Tominaga K, Masuyama S, Izawa N, Majima Y, Irisawa A. Retroperitoneal Hematoma: Rupture of Aneurysm in the Arc of Bühler Caused by Median Arcuate Ligament Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2019; 12:1179547619828716. [PMID: 30792583 PMCID: PMC6376540 DOI: 10.1177/1179547619828716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/13/2019] [Indexed: 12/20/2022]
Abstract
We herein report a case with aneurysm rupture in the arc of Bühler (AOB) caused by median arcuate ligament syndrome (MALS). The patient experienced a sudden onset of upper abdominal pain. Contrast-enhanced abdominal computed tomography (CT) showed an iso- to hyper-enhancing area mainly ranging from the dorsal aspect of the pancreatic head to the retroperitoneum around the right kidney. Abdominal angiography revealed marked stenosis in the origin of the celiac artery caused by MALS and a 7-mm saccular aneurysm in the AOB. Thus, we diagnosed the pain as having been caused by aneurysm rupture in the AOB due to MALS. The patient's symptoms and anemia also improved to normal range without surgery. Careful follow-up, considering possible recurrence of aneurysm at other sites in the future, is essential.
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Affiliation(s)
- Keiichiro Abe
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Makoto Iijima
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Satoshi Masuyama
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Naoya Izawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Yuichi Majima
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
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Zhang X, Zhang W, Zhou W, Zhou W. Endovascular Treatment of Ruptured Pancreaticoduodenal Artery Aneurysm with Celiac Axis Stenosis. Ann Vasc Surg 2019; 57:273.e1-273.e5. [PMID: 30684620 DOI: 10.1016/j.avsg.2018.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/06/2018] [Accepted: 09/28/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Xiaoyu Zhang
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenwen Zhang
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weimin Zhou
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
| | - Wei Zhou
- Department of Vascular Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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21
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Hanaki T, Fukuta S, Okamoto M, Tsuda A, Yagyu T, Urushibara S, Endo K, Suzuki K, Nakamura S, Ikeguchi M. Median arcuate ligament syndrome and aneurysm in the pancreaticoduodenal artery detected by retroperitoneal hemorrhage: A case report. Clin Case Rep 2018; 6:1496-1500. [PMID: 30147890 PMCID: PMC6099015 DOI: 10.1002/ccr3.1643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/20/2018] [Accepted: 05/23/2018] [Indexed: 12/20/2022] Open
Abstract
Here, we report a case with successful treatment of inferior pancreaticoduodenal artery aneurysm rupture due to celiac artery trunk compression caused by the median arcuate ligament. When clinicians see visceral aneurysms, the possibility of arcuate midline ligament compression syndrome (MALS) and ligamentectomy for MALS should be considered.
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Affiliation(s)
- Takehiko Hanaki
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | - Shiori Fukuta
- Department of General Internal MedicineTottori Prefectural Central HospitalTottoriJapan
| | - Masaru Okamoto
- Department of General Internal MedicineTottori Prefectural Central HospitalTottoriJapan
| | - Ayumi Tsuda
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | - Takuki Yagyu
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | | | - Kanenori Endo
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | - Kazunori Suzuki
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | - Seiichi Nakamura
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
| | - Masahide Ikeguchi
- Department of SurgeryTottori Prefectural Central HospitalTottoriJapan
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22
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Treatment Algorithm of Peripancreatic Arteries Aneurysm Coexisting with Coeliac Artery Lesion: Single Institution Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5745271. [PMID: 30112402 PMCID: PMC6077597 DOI: 10.1155/2018/5745271] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/05/2018] [Indexed: 11/21/2022]
Abstract
Introduction True aneurysms of peripancreatic arterial arcades (PAAAs) coexisting with celiac axis lesion are often asymptomatic. However, they may rupture regardless of their size and cause life-threatening hypovolemia. No treatment guidelines exist to date. We present a series of 21 patients and our management algorithm. Material and Methods For ruptured aneurysms we preformed endovascular embolization. Further treatment was dependent on patient's condition and control studies. In case of unruptured aneurysms, we assessed collateral circulation between superior mesenteric artery and celiac axis in angio-CT. If there was a pathway free from aneurysms, endovascular approach was chosen. Otherwise, surgical or combined treatment was favored. Results Endovascular treatment was performed in 14 patients with no complications. Follow-up studies revealed incomplete occlusion of the aneurysms in two cases. Surgical or combined treatment was performed in 7 patients with three serious perioperative complications. They were managed conservatively in two cases and surgically in one. Follow-up studies showed aneurismal dilatation and stenosis of a renohepatic by-pass in one case. Conclusion We present our management algorithm of PAAAs. Our results support the leading role of endovascular treatment. We present its limitations favoring surgical or combined treatment. All patients should be carefully followed.
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Pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: what we need to know. Surg Radiol Anat 2017; 40:401-405. [DOI: 10.1007/s00276-017-1950-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/24/2017] [Indexed: 10/18/2022]
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Ricci G, Riu P, Attinà GM, Trombetta S, Ialongo P, Di Cosimo C, Mancuso R, Marini P. Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report. Int J Surg Case Rep 2017; 41:205-208. [PMID: 29096344 PMCID: PMC5686227 DOI: 10.1016/j.ijscr.2017.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/18/2017] [Accepted: 10/22/2017] [Indexed: 11/26/2022] Open
Abstract
Ruptured pancreaticoduodenal artery aneursym is a very rare but potentially catastrophic occurence in an emergency department and its treatment is challenging. Very few cases of emergency endovascular treatment of ruptured visceral aneursyms are reported in the literature. This case report has the intention to elucidate in pancreaticodudoenal artery aneursym the importance of collateral vessels that could feed the aneurysm sac even after embolization of the inflow and outflow of the aneurysm. Introduction True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. Presentation of case A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5 cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. Discussion The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. Conclusion The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.
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Affiliation(s)
- Gabriele Ricci
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Pascale Riu
- Division of Interventional Radiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Grazia Maria Attinà
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Silvia Trombetta
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pasquale Ialongo
- Division of Radiology 2, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Carla Di Cosimo
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Rosaria Mancuso
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pierluigi Marini
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
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Vandy FC, Sell KA, Eliason JL, Coleman DM, Rectenwald JE, Stanley JC. Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Celiac Artery Occlusive Disease. Ann Vasc Surg 2017; 41:32-40. [DOI: 10.1016/j.avsg.2016.09.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/18/2016] [Accepted: 09/06/2016] [Indexed: 12/30/2022]
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Shibata E, Takao H, Amemiya S, Ohtomo K. Perioperative Hemodynamic Monitoring of Common Hepatic Artery for Endovascular Embolization of a Pancreaticoduodenal Arcade Aneurysm with Celiac Stenosis. Cardiovasc Intervent Radiol 2016; 40:465-469. [PMID: 27864611 DOI: 10.1007/s00270-016-1517-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/15/2016] [Indexed: 11/29/2022]
Abstract
This report describes perioperative hemodynamic monitoring of the common hepatic artery (CHA) during endovascular treatment of a pancreaticoduodenal arcade aneurysm, in a patient with celiac artery stenosis caused by the median arcuate ligament. Pressure monitoring was performed as a safety measure against critical complications such as liver ischemia. As the aneurysm was located in the anterior pancreaticoduodenal artery (APDA) and the posterior pancreaticoduodenal artery (PPDA) was small in caliber, the patient was considered to be at a high risk of liver ischemia. No significant change in pressure was observed in the CHA on balloon occlusion test in the APDA. Immediately after embolization, the PPDA enlarged and the pressure in the CHA was well maintained. Pressure monitoring appears to improve patient safety during endovascular treatment of visceral aneurysms.
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Affiliation(s)
- Eisuke Shibata
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hidemasa Takao
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shiori Amemiya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kuni Ohtomo
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis? J Am Coll Surg 2016; 224:199-203. [PMID: 27773774 DOI: 10.1016/j.jamcollsurg.2016.10.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 11/21/2022]
Abstract
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.
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Kickuth R, Hoppe H, Saar B, Inderbitzin D, Triller J, Raessler S, Gschossmann J. Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases. Abdom Radiol (NY) 2016; 41:1782-92. [PMID: 27188888 DOI: 10.1007/s00261-016-0772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications. METHODS During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications. RESULTS Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient. CONCLUSIONS Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.
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29
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Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular Management of Visceral Artery Aneurysm. J Endovasc Ther 2016; 8:150-5. [PMID: 11357975 DOI: 10.1177/152660280100800209] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. Methods: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 ± 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. Results: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 ± 29.6 months. Conclusions: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.
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Affiliation(s)
- K Kasirajan
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA
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Sakatani A, Doi Y, Kitayama T, Matsuda T, Sasai Y, Nishida N, Sakamoto M, Uenoyama N, Kinoshita K. Pancreaticoduodenal artery aneurysm associated with coeliac artery occlusion from an aortic intramural hematoma. World J Gastroenterol 2016; 22:4259-4263. [PMID: 27122676 PMCID: PMC4837443 DOI: 10.3748/wjg.v22.i16.4259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/27/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenal artery aneurysms are a rare type of visceral artery aneurysm, whose rupture is associated with high mortality. These aneurysms are of particular interest because local haemodynamic change caused by coeliac artery obstruction plays an important role in their development. However, the pathophysiological mechanism of coeliac artery obstruction is not completely understood. Pressure from the median arcuate ligament is most frequently reported cause. Although it is well-known that stenosis or occlusion of the visceral vessels may be caused by aortic syndrome, reports of pancreaticoduodenal artery aneurysm associated with coeliac artery occlusion due to aortic syndrome are extremely rare. Our case indicates a new aetiology for a pancreaticoduodenal artery aneurysm and demonstrates the rapid deterioration of the patient affected.
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Chivot C, Rebibo L, Robert B, Regimbeau JM, Yzet T. Ruptured Pancreaticoduodenal Artery Aneurysms Associated with Celiac Stenosis Caused by the Median Arcuate Ligament: A Poorly Known Etiology of Acute Abdominal Pain. Eur J Vasc Endovasc Surg 2016; 51:295-301. [DOI: 10.1016/j.ejvs.2015.10.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Takei T, Sakai M, Suzuki T, Yamamoto Y, Ogasawara Y, Shimizu T, Imaizumi J, Furuya R, Sekido H, Koizumi Y. Surgical Resection of a Ruptured Pancreaticoduodenal Artery Aneurysm. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:39-42. [PMID: 26794823 PMCID: PMC4729323 DOI: 10.12659/ajcr.895782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patient: Female, 71 Final Diagnosis: Rupture of a pancreaticoduodenal artery aneurysm Symptoms: — Medication: — Clinical Procedure: Surgical operation Specialty: Surgery
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Affiliation(s)
- Tomohide Takei
- Department of Emergency, Fujisawa Shounandai Hospital, Fujisawa, Japan
| | - Michihiro Sakai
- Department of Emergency, Fujisawa Shounandai Hospital, Fujisawa, Japan
| | - Takuya Suzuki
- Department of Radiology, Fujisawa Shounandai Hospital, Fujisawa, Japan
| | - Yuji Yamamoto
- Department of Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Yasuo Ogasawara
- Department of Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Tetsuya Shimizu
- Department of Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Jun Imaizumi
- Department of Emergency, Fujisawa Shounandai Hospital, Fujisawa, Japan
| | - Ryosuke Furuya
- Department of Critical care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Hitoshi Sekido
- Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan
| | - Yasuhiro Koizumi
- Department of Emergency, Fujisawa Shounandai Hospital, Fujisawa, Japan
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Kohama K, Ito Y, Kai T, Kotani J, Nakao A. Successfully treated life-threatening upper gastrointestinal bleeding from fistula between gastroduodenal artery pseudoaneurysm and duodenum. Acute Med Surg 2015; 3:192-194. [PMID: 29123781 DOI: 10.1002/ams2.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/20/2015] [Indexed: 11/11/2022] Open
Abstract
Case An 85-year-old man was admitted to the hospital, underwent laparotomy, and was diagnosed with diffuse peritonitis due to perforation of gastric ulcer. Omental patch repair was carried out. After surgery, he suddenly vomited blood and manifested hypovolemic shock. An emergency upper gastrointestinal endoscopy was carried out immediately. However, the bleeding source was not visible. Dynamic-enhanced abdominal computed tomography showed a pseudoaneurysm of the gastroduodenal artery-communicating duodenal lumen with extravasation. Next, the patient underwent angiography for embolization. However, selective arterial embolization was not successful. Outcome Finally, duodenotomy was carried out. The fistula between the pseudoaneurysm and duodenal lumen was directly ligated. An aneurysm could be clearly identified by previous findings. Conclusions Gastroduodenal artery aneurysms are very uncommon but possibly lethal if they rupture. This life-threatening condition requires rapid diagnosis and treatment. Minimally invasive treatment is the preferred therapy for gastroduodenal artery aneurysm; however, acute care surgery should be considered without hesitation when conditions are critical.
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Affiliation(s)
- Keisuke Kohama
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Osaka Japan.,Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Yusuke Ito
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Osaka Japan
| | - Tatsuro Kai
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Osaka Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Atsunori Nakao
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Nishinomiya Japan
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Vallverdú Scorza M, Valiñas R, Di Trápani N, Del Campo J, Estapé G. Rotura de aneurisma de la arteria pancreaticoduodenal inferior. Manejo endovascular. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Shuaib W, Tiwana MH, Vijayasarathi A, Sadiq MF, Anderson S, Amin N, Khosa F. Imaging of vascular pseudoaneurysms in the thorax and abdomen. Clin Imaging 2015; 39:352-62. [PMID: 25682302 DOI: 10.1016/j.clinimag.2015.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 12/27/2014] [Accepted: 01/14/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options. OBJECTIVE The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population. CONCLUSION In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.
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Affiliation(s)
- Waqas Shuaib
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA.
| | | | - Arvind Vijayasarathi
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | | | - Stephen Anderson
- Department of Radiology, Boston University School of Medicine, Boston, MA
| | - Neil Amin
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | - Faisal Khosa
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
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Miyayama S, Yamashiro M, Ogi T, Kayahashi M, Kawamura K, Yoshida M, Terada T, Kosugi I. Usefulness of automated feeder-detection software for identification of access routes to small pancreaticoduodenal artery aneurysms during embolotherapy. Vascular 2015; 23:663-7. [DOI: 10.1177/1708538114567186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Shiro Miyayama
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Masashi Yamashiro
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Takahiro Ogi
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Masanori Kayahashi
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Kenji Kawamura
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Miki Yoshida
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Takuro Terada
- Department of Surgery, Fukuiken Saiseikai Hospital, Fukui, Japan
| | - Ikuko Kosugi
- Department of Surgery, Fukuiken Saiseikai Hospital, Fukui, Japan
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Sgroi MD, Kabutey NK, Krishnam M, Fujitani RM. Pancreaticoduodenal artery aneurysms secondary to median arcuate ligament syndrome may not need celiac artery revascularization or ligament release. Ann Vasc Surg 2014; 29:122.e1-7. [PMID: 24930977 DOI: 10.1016/j.avsg.2014.05.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 05/18/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed. METHODS Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up. RESULTS PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment. CONCLUSION Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.
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Affiliation(s)
- Michael D Sgroi
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA.
| | - Nii-Kabu Kabutey
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
| | - Mayil Krishnam
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
| | - Roy M Fujitani
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA
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Ikeda O, Nakasone Y, Yokoyama K, Inoue S, Tamura Y, Yamashita Y. Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis. Acta Radiol 2013; 54:949-53. [PMID: 23761555 DOI: 10.1177/0284185113488577] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The degeneration of pancreaticoduodenal arcade vessels due to pancreaticoduodenal artery aneurysms is associated with celiac artery stenosis or occlusion. While technical advances have made it possible to treat pancreaticoduodenal arcade aneurysms (PDAA) and celiac artery stenosis by endovascular techniques, there is no consensus regarding their optimal treatment. PURPOSE To treat pancreaticoduodenal arcade aneurysms (PDAA) by simultaneous coil embolization and celiac artery stenting, and propose indications for treating PDAA with celiac artery stenosis by this method. MATERIAL AND METHODS We reviewed 11 patients who underwent transcatheter coil embolization (TCE) to treat PDAA. When the aneurysmal neck size was less than half of the short axis of the aneurysm we used packing only, when it was more than half of the short axis we undertook isolation. In the latter situation, when there was evidence of celiac artery stenosis, we performed celiac artery stenting using self-expandable stents. RESULTS Ten of the 11 patients (91%) presented with celiac axis stenosis due to median arcuate ligament compression. Coil-packing of the aneurysmal sac only, thus preserving the native arterial circulation, was done in five patients, another five underwent isolation by embolization of vessels distal and proximal to the PDAA with simultaneous stenting of the stenotic celiac axis, and one patient was treated by isolation only. One patient developed acute pancreatitis. There were no other complications and all aneurysms were successfully excluded. In one patient the celiac stent thrombosed after stopping the antiplatelet regimen. CONCLUSION TCE can be effective in patients with PDAA. In the presence of celiac artery stenosis, we recommend isolation of the aneurysms with simultaneous stenting of the stenotic celiac trunk using self-expandable stents.
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Affiliation(s)
- Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Honjo Kumamoto, Japan
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Ohira S, Kimura T, Takeuchi K, Matsushita T, Masuda S, Shimizu Y. Pancreaticoduodenal artery aneurysm involving papilla of vater successfully treated with endovascular approach despite intraoperative rupture. Ann Vasc Surg 2013; 27:802.e9-802.e12. [PMID: 23711966 DOI: 10.1016/j.avsg.2012.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 06/05/2012] [Accepted: 06/21/2012] [Indexed: 11/30/2022]
Abstract
An 81-year-old woman presented with dizziness and nasal bleeding. Gastrointestinal fiberscopy (GIF) showed a pulsatile aneurysm in the duodenum, and that the orifice of the papilla of Vater was involved. Three-dimensional computed tomography imaging showed an unruptured aneurysm in the pancreatic duodenal arcade. The patient underwent an emergent endovascular embolization of the donor arteries using coils and gelatin sponge particles. She was discharged without any complications. This case was extremely rare because of the anatomic location of the unruptured pancreaticoduodenal artery aneurysm and the fact that it involved the papilla of Vater, was detected with GIF, and was successfully treated endovascularly.
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Affiliation(s)
- Suguru Ohira
- Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Kyoto, Japan.
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40
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Jesinger RA, Thoreson AA, Lamba R. Abdominal and Pelvic Aneurysms and Pseudoaneurysms: Imaging Review with Clinical, Radiologic, and Treatment Correlation. Radiographics 2013; 33:E71-96. [DOI: 10.1148/rg.333115036] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2013. [PMID: 23587203 DOI: org/10.1186/1750-1164-7-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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42
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Habib N, Hassan S, Abdou R, Torbey E, Alkaied H, Maniatis T, Azab B, Chalhoub M, Harris K. Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2013; 7:4. [PMID: 23587203 PMCID: PMC3637616 DOI: 10.1186/1750-1164-7-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 03/25/2013] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Nicholas Habib
- Staten Island University Hospital, 475 Seaview ave, Staten Island, NY, 10305, USA.
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43
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Multiple aneurysms of the inferior pancreaticoduodenal artery: a rare complication of acute pancreatitis. Case Rep Vasc Med 2013; 2013:621350. [PMID: 23509663 PMCID: PMC3595677 DOI: 10.1155/2013/621350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/19/2013] [Indexed: 12/02/2022] Open
Abstract
Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon, representing nearly 2% of all visceral aneurysms, and sporadically associated with celiac artery stenosis. Multiple IPDA aneurysms have been rarely reported. We report a case of a 53-year-old female patient with a history of prior pancreatitis, who presented with two IPDA aneurysms combined with median arcuate ligament-syndrome-like stenosis of the celiac trunk. The patient was treated successfully with coil embolization under local anesthesia. The procedure is described and illustrated in detail and the advantages and technical considerations of such an approach are also being discussed.
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Flood K, Nicholson AA. Inferior pancreaticoduodenal artery aneurysms associated with occlusive lesions of the celiac axis: diagnosis, treatment options, outcomes, and review of the literature. Cardiovasc Intervent Radiol 2012; 36:578-87. [PMID: 23152034 DOI: 10.1007/s00270-012-0473-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 08/15/2012] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Karen Flood
- Department of Radiology, Leeds Teaching Hospitals, 1 Great George Street, Leeds, LS1 3EX, United Kingdom.
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45
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Brocker JA, Maher JL, Smith RW. True pancreaticoduodenal aneurysms with celiac stenosis or occlusion. Am J Surg 2012; 204:762-8. [PMID: 22578409 DOI: 10.1016/j.amjsurg.2012.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 03/02/2012] [Accepted: 03/02/2012] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Jason A Brocker
- Department of General Surgery, Scott and White Healthcare/Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
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46
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Lykoudis PM, Stafyla VK, Koutoulidis V, Xatziioannou A, Arkadopoulos N, Mourikis I, Smyrniotis V. Stenting of a gastroduodenal artery aneurysm: report of a case. Surg Today 2011; 42:72-4. [PMID: 22075656 DOI: 10.1007/s00595-011-0002-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 11/01/2010] [Indexed: 11/28/2022]
Abstract
We present a case of gastroduodenal artery stenting in a patient with recurrent episodes of pancreatitis due to gastroduodenal artery aneurysm. Stenting was performed under local anesthesia using a 6 × 38-mm primary covered Advanta V12 vascular stent graft. The procedure was successful and the patient is asymptomatic 21 months later. Endovascular treatment of gastroduodenal artery aneurysm should be considered a promising alternative to open surgery, due to lower mortality and morbidity.
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Affiliation(s)
- Panagis M Lykoudis
- Fifth Department of Surgery, School of Medicine, University of Athens, Aretaieion University Hospital, 76 Vassilisis Sofias Avenue, 11528 Athens, Greece
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Abstract
The Arc of Buhler (AOB) represents a persistence of the ventral anastomosis between the superior mesenteric artery (SMA) and the celiac arterial systems. The exact incidence of the AOB is not known, but it is believed to be ≤ 4%. Aneurysms of this rare anomaly are even more uncommon. We report a case of an aneurysm of the AOB with an intact pancreaticoduodenal artery arcade (PDAA) and near occlusive celiac origin stenosis. Stenoses or occlusions of the celiac origin have been reported in association with AOB aneurysms, as well as in patients with PDAA aneurysms. Transcatheter embolization (TCE) was successfully performed, thereby excluding the AOB aneurysm while preserving flow through the PDAA. To our knowledge, this is the first report of successful percutaneous treatment of an AOB aneurysm. The pathophysiology and management AOB and PDAA aneurysms are reviewed. Review of the literature suggests that TCE, when feasible, is at least as effective as conventional surgery in patients with PDAA aneurysms, but with lower morbidity and mortality. Based on this data and our experience, we believe that TCE should be the initial treatment of choice in patients with PDAA or AOB aneurysms.
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Affiliation(s)
- Gregory J Dubel
- Department of Diagnostic Imaging, Brown University Medical School, Providence, Rhode Island
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Golarz SR, Hohmann S. Obstruction of the celiac axis resulting in a pancreaticoduodenal artery aneurysm. Proc (Bayl Univ Med Cent) 2011; 22:330-1. [PMID: 19865503 DOI: 10.1080/08998280.2009.11928548] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A 47-year-old woman complained of abdominal pain, and a computed tomography scan indicated compressive obstruction of the celiac axis and a 4-cm retropancreatic aneurysm. An angiogram identified the aneurysmal vessel as the posterior pancreaticoduodenal artery. All foregut structures were supplied by this aneurysmal vessel. Via an open approach, the inflow and outflow of the aneurysm were ligated, and blood flow to the celiac axis was reconstructed via a bypass from the supraceliac aorta. A follow-up scan indicated complete thrombosis of the aneurysm. The patient is now symptom free. Open reconstruction of the celiac axis is mandatory when ligation of a pancreaticoduodenal aneurysm results in foregut ischemia. Ligation and reconstruction can be done safely and effectively in the elective setting.
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Affiliation(s)
- Scott R Golarz
- Department of Vascular Surgery, Baylor University Medical Center, Dallas, Texas. Dr. Golarz is now in private practice in Hawaii
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Bowens NM, Woo EY, Fairman RM. Reno-hepatic artery bypass for an inferior pancreaticoduodenal artery aneurysm with associated celiac occlusion. J Vasc Surg 2011; 53:1696-8. [DOI: 10.1016/j.jvs.2011.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 02/11/2011] [Accepted: 02/11/2011] [Indexed: 11/29/2022]
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Cano-Valderrama O, Gallego-Béuter JJ, Giner M. Endovascular therapy as a treatment for ruptured pancreaticoduodenal artery aneurysms. MINIM INVASIV THER 2011; 20:296-300. [PMID: 21247252 DOI: 10.3109/13645706.2010.545233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pancreaticoduodenal artery aneurysms (PDAAs) are uncommon. The treatment and prognosis for ruptured PDAAs have changed in recent years. A demonstrative case is reported. A review of the literature has been made and the case of a healthy man operated on an emergency basis because of a massive hemoperitoneum secondary to a ruptured PDAA is reported and analyzed with regard to the clinical presentation, radiologic findings, management, and outcome. A bleeding point was not detected at operation. An intraoperative arteriogram did not show active bleeding. The pancreas appeared infiltrated and oozing blood. The abdomen was gauze packed and the patient transferred for endovascular therapy (ET). Then, an arteriogram showed a bleeding PDAA. After embolization, bleeding ceased and the patient recovered. According to our literature survey, less than 200 cases of true and false PDAAs have been reported. For ruptured PDAAs, surgery is associated with high mortality since the bleeding point is usually not identified at operation. Similarly, intraoperative arteriograms are often fruitless due to the patient's poor hemodynamics plus suboptimal quality of the portable equipment. As shown in the present case and according to the specialized medical literature, ET has often been successful in the management of these patients and may be chosen as a first option for the treatment of ruptured PDAAs.
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