Gender Predicts Rupture of Pancreaticoduodenal Artery Aneurysms

Abstract

There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAAs) because they are exceedingly rare. We sought to evaluate risk factors for rupture and to compare the outcomes of open and endovascular surgery. We performed a retrospective review of all PDAAs over a 15-year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo grade I. A total of 21 PDAAs were identified (mean size, 20 [interquartile range, 8-32] mm). Eight patients (38%) were male, with an average age at diagnosis of 54.3 ± 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, and five patients (24%) presented with rupture. Six patients (29%) had an open repair, including four aneurysm ligations and two emergency Whipple procedures. Eleven patients underwent an endovascular intervention, including 10 (48%) embolizations and one stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and in 0% of endovascular patients (P = .01). Death occurred in two ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P = .02); however, size of the aneurysm was not (P = .77). There was a trend toward an increased rupture rate in those with celiac stenosis (P = .10). In the largest series of PDAAs to date, only male gender was associated with rupture. Although technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice.