Pancreaticoduodenal Arcade Aneurysms Research Articles

Aneurysms of pancreaticoduodenal arcade: Clinical profile and endovascular strategies.

Background and AimPancreaticoduodenal arcade aneurysms (PDAAs) are uncommon lesions associated with a significant risk of rupture and mortality. This study describes the etiology, clinical presentation, and endovascular management strategies of PDAAs across a spectrum of indications.MethodsThe clinical records of patients with PDAAs referred for endovascular management from January 2018 till November 2019 were retrospectively reviewed. Data on presenting symptoms, associated etiologies, and outcomes after endovascular treatment were collected and studied.ResultsWe found 15 patients with false and 1 patient with true aneurysm of pancreatoduodenal arcade (PDA). The associated conditions were coeliac artery stenosis, severe necrotizing pancreatitis, and chronic pancreatitis or iatrogenic (postendoscopic papillotomy and percutaneous metallic biliary stenting). The main presenting feature was gastrointestinal bleed, while 2 patients had abdominal pain and 1 had gastric outlet obstruction. A multiphase computed tomography scan demonstrated the ruptured aneurysm in all patients. Site of origin of PDAA influenced the choice of transarterial endovascular strategy (coiling for aneurysms of main trunk of arteries and glue injection for those arising from small arterial branches). This was carried out in an emergency setting for 12 patients and as an elective procedure in 4 patients. Technical success was demonstrated in all patients and clinical success in 14. The two patients who had rebleed were salvaged by repeat endovascular procedure. Postembolization syndrome was seen in three patients.ConclusionsWith advancing technology, endovascular strategies continue to evolve. Careful attention to ensure hemodynamic resuscitation and stability, correction of pre‐existing coagulopathy and attention to technique can lead to the possibility of endovascular approaches as a dependable option in the management of ruptured PDAAs.

The benefits of extrinsic ligament release for potentially hemodynamically unstable pancreaticoduodenal arcade aneurysm with median arcuate ligament syndrome: a case report

BackgroundA pancreaticoduodenal artery aneurysm (PDAA) occurring in close association with median arcuate ligament syndrome (MALS) is rare. A surgical procedure, such as median arcuate ligament (MAL) release, should be considered in such cases, but the operative criteria remain unknown. In this study, we reported an extremely rare case of PDAA with periarteritis nodosa (PAN) and MALS.Case presentationA 60-year-old man was transferred to our department with sudden onset of abdominal pain. We initially diagnosed his condition as a PDAA rupture with MALS based on enhanced computed tomography (CT). We promptly performed transcatheter arterial embolization (TAE) of PDAA, and the angiogram showed stagnant contrast agent in the celiac trunk, indicating total celiac artery occlusion. Follow-up enhanced CT three weeks after the first TAE clearly demonstrated newly formed, multiple aneurysms in the pancreaticoduodenal arcade and the hepatic artery. These findings indicated a systemic disorder, such as PAN or segmental arterial mediolysis, as the underlying cause. Therefore, we started corticosteroid therapy and performed diagnostic angiography to clarify the celiac artery’s patency. Contrary to the initial angiography, the second angiography showed sustained blood flow in the celiac artery. Nevertheless, we performed both extrinsic MAL release and consecutive TAE because of the risk of multiple aneurysms rupturing due to an uncontrolled systemic disorder and consequent hepatic ischemia. The patient had no episode of recurrence until one year of follow-up.ConclusionsIt is important to evaluate risk for hemodynamically unstable events to decide the best treatment strategy for MALS.

Clinical impact of collateral circulation in patients with median arcuate ligament syndrome.

We aimed to analyze computed tomography (CT) findings and medical records of patients diagnosed with median arcuate ligament syndrome (MALS) and evaluate possible risk factors associated with vascular complications that develop in patients with MALS. This retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. A total of 37 consecutive patients were diagnosed with MALS using both axial and sagittal CT reconstruction imaging at a single institution over a 7-year period. Dynamic contrast-enhanced CT data, medical records, and angiography results were reviewed. Thirty-two (86.5%) patients were asymptomatic and incidentally diagnosed with MALS using CT. Seventeen (45.9%) patients exhibited significant arterial collateral circulations and nine (24.3%) were found to have splanchnic artery aneurysms, including one (2.7%) with acute bleeding secondary to aneurysm rupture. Peripancreatic vascular network including pancreaticoduodenal arcades and dorsal pancreatic artery was the most common site for development of both collateral circulations (16/22, 72.7%) and aneurysms (9/16, 56.3%). Splanchnic artery aneurysms were significantly more common in patients with collateral circulations (8/17, 47.1%) compared with those without collateral circulations (1/20, 5%) (P < 0.01). At least one peripancreatic vascular aneurysm was found in five of nine patients with splanchnic artery aneurysms (55.6%). Splanchnic artery aneurysms are not uncommon in asymptomatic patients with collateral circulations caused by significant celiac trunk stenosis or obstruction due to median arcuate ligament. Therefore, careful imaging evaluation is necessary in patients with peripancreatic collateral circulations associated with MALS and regular follow-up is recommended for possibility of aneurysm development and rupture. Prophylactic endovascular treatment should be specifically performed in patients with pancreaticoduodenal arcade aneurysms to prevent life-threatening aneurysm rupture regardless of size.

3:54 PM Abstract No. 308 Treatment of inferior pancreaticoduodenal arcade aneurysms in the setting of MALS: a 5-year experience

Median arcuate ligament syndrome (MALS) is a rare but often underdiagnosed cause of chronic celiac occlusion. Flow-related inferior pancreaticoduodenal arcade (IPDA) aneurysms can often be challenging to manage. A retrospective review of a single-institution EMR from 1/1/2011 to 1/1/2016 was performed. The database included cases of pancreaticoduodenal arcade aneurysm, MALS, or idiopathic celiac stenosis. Eighty-seven cases met primary criteria. MALS was present in 21 cases. Of twenty-one (n = 21) patients with aortography-confirmed MALS, IPDA aneurysm was present in 6 (29%; mean age 58.7 years). Median aneurysm size was 2.1 cm (1.6–3.2 cm). All cases presented symptomatically (6/6): 4 with retroperitoneal hemorrhage and 2 with acute abdominal pain. Additional visceral aneurysms other than IPDA (splenic, right phrenic, and gastroepiploic) were identified in 3/6 cases in addition to IPDA aneurysm. Overall, 9/9 (100%) aneurysms were treated successfully (6 coil embolization, 2 coil/plug embolization, and 1 coil/stentgraft) and without procedure-related complications. All cases terminated with preserved collateral flow to the celiac axis. MALS with chronic abdominal pain was successfully managed in 7/21 [33%, mean age 58 (36–84) years] cases via surgical ligament release. Overall, 5/21 (24%) cases of MALS were incidentally identified post-hepatic transplant on routine surveillance imaging (sonography or MR angiography) [24%; mean age 57 (43–69) years] and confirmed with subsequent aortography. Overall, 0/5 cases demonstrated incidental visceral aneurysms. IPDA aneurysms seen in the setting of MALS can be treated using endovascular techniques with a high success rate. MALS is likely underdiagnosed and asymptomatic relative to true prevalence, as demonstrated by high relative incidence in orthotopic hepatic transplant surveillance imaging.

Perioperative Hemodynamic Monitoring of Common Hepatic Artery for Endovascular Embolization of a Pancreaticoduodenal Arcade Aneurysm with Celiac Stenosis.

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.

Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis

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. 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. 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. 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. 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.

Celiac artery dissection seen with ruptured pancreaticoduodenal arcade aneurysms in two cases of celiac artery stenosis from compression by median arcuate ligament

We report two cases of ruptured pancreaticoduodenal arcade aneurysms that were successfully treated by embolotherapy. In these cases, contrast-enhanced computed tomography, sagittal reformed images, and angiography revealed celiac artery stenoses due to compression by the median arcuate ligament. Computed tomography also showed acute localized dissection in the distal celiac axis, suggesting that aneurysmal rupture had occurred immediately after development of the dissection. When unruptured pancreaticoduodenal arcade aneurysms are identified in the context of celiac artery dissection, the possibility of rupture may be high and requires strict observation and consideration of embolotherapy.

Coil Embolization of an Inferior Pancreaticoduodenal Artery Aneurysm Associated with Celiac Artery Occlusion

Pancreaticoduodenal arcade aneurysms are rare. Untreated, these lesions enlarge progressively and have the potential for spontaneous rupture. Aneurysmal degeneration of pancreaticoduodenal arcade vessels is known to be associated with celiac artery occlusion, vasculitis, and certain connective tissue disorders. Given their precarious location, surgical expiration is a challenging endeavor. Innovations in endovascular techniques offer a possible alternative. We report a case of a 55-year-old gentleman with a 2.2 × 2.1 - cm aneurysm of one of the inferior pancreaticoduodenal arteries and a concomitant finding of occlusion of the celiac artery trunk. Percutaneous coil embolization of the aneurysm was employed as the treatment in this case with the successful exclusion of the aneurysm sac, while maintaining continuity of the native circulation. This case report demonstrates that, due to the success rate of aneurysm exclusion and the relatively low morbidity and mortality rates seen with endovascular repair as compared to surgical intervention, endovascular treatment has become the treatment of choice for pancreaticoduodenal artery aneurysms.

Coil embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac artery occlusion

Pancreaticoduodenal arcade aneurysms are rare. Untreated, these lesions enlarge progressively and have the potential for spontaneous rupture. Aneurysmal degeneration of pancreaticoduodenal arcade vessels is known to be associated with celiac artery occlusion, vasculitis, and certain connective tissue disorders. Given their precarious location, surgical expiration is a challenging endeavor. Innovations in endovascular techniques offer a possible alternative. We report a case of a 55-year-old gentleman with a 2.2×2.1-cm aneurysm of one of the inferior pancreaticoduodenal arteries and a concomitant finding of occlusion of the celiac artery trunk. Percutaneous coil embolization of the aneurysm was employed as the treatment in this case with the successful exclusion of the aneurysm sac, while maintaining continuity of the native circulation. This case report demonstrates that, due to the success rate of aneurysm exclusion and the relatively low morbidity and mortality rates seen with endovascular repair as compared to surgical intervention, endovascular treatment has become the treatment of choice for pancreaticoduodenal artery aneurysms.