not obviously indicated in an emergency as well as in case of a compression syndrome of the celi- ac artery by the median arcuate ligament of the diaphragm.
Vascular Surgery
VOLUME 29
JULY/AUGUST 1995
NUMBER 4
Embolization of Ruptured Aneurysm of the Pancreaticoduodenal Artery Secondary to Long-standing Stenosis of The Celiac Axis Case Reports Sergio Savastano, M.D. Gian Piero Feltrin, M.D. Diego Miotto, M.D. Matteo Chiesura-Corona, M.D. and Paola Sandri, M.D. PADOVA, ITALY
Long-standing stenosis of the celiac axis is a rare cause of aneurysm of the inferior pancreaticoduodenal artery, which serves as a collateral pathway; the etiology is believed to be due to turbulence from increased blood flow. The authors describe 2 cases of such aneurysm, which ruptured in the retroperitoneum and were treated with transcatheter embolization.
From Istituto di Radiologia-Universit'a degli Studi, Padova, Italy. C1995 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.
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Introduction Pancreatic duodenal artery aneurysms account for approximately 2% of splanchnic aneurysms1l2; they are usually secondary to atherosclerosis or pancreatitis; infection, dysplasia, trauma, and surgery are other possible etiologies.2'3-8 Long-standing celiac axis stenosis or occlusion has been recognized as a further cause of pancreaticoduodenal aneurysm.3'9-12 We here report 2 cases of such ruptured aneurysm, which we treated with transcatheter embolization. Case Reports
Case 1. A forty-nine-year-old man was referred to us because of large retroperitoneal hematoma and posthemorrhagic anemia. He had no history of pancreatitis, peptic ulcer, hypertension, or atherosclerosis. The patient had an acute pain in the right upper abdominal quadrant one week before; he was not bleeding at the admission. Abdominal computed tomography (CT) showed a high-density paraduodenal fluid collection consisting of recent hematoma (Figure 1A). Visceral angiography identified a reversed flow from the superior mesenteric artery to the hepatic artery via the pancreaticoduodenal and gastroduodenal arteries because of a stenosis of the celiac trunk (Figure 1B); a small fusiform aneurysm of the anterior pancreaticoduodenal artery was also identified. I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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Figure 1-Case 1. A. Abdominal computed tomography (CT) showed a large, high-density paraduodenal fluid collection consisting of recent hematoma. B. Angiography of the superior mesenteric artery identified a reversed flow through the pancreaticoduodenal arteries and the gastroduodenal artery to the hepatic artery because of the tight stenosis of the celiac axis (not shown). A small fusiform aneurysm of the anterior pancreaticoduodenal arcade is also recognized. C. Superselective catheterization of the anterior pancreaticoduodenal artery. D. Attempts to obtain a more distal catheterization for coil embolization resulted in the perforation of the artery; the superior mesenteric arteriography showed an extravasation of the contrast medium. E. The extravasation spontaneously stopped after ten minutes. F. Angiography repeated two weeks later because of a new episode of retroperitoneal bleeding recognized leakage of the anterior pancreaticoduodenal artery; a tiny aneurysm of the posterior pancreaticoduodenal artery due to guide wire negotiation during the previous investigation is also visible. The inferior pancreaticoduodenal artery was embolized with gelatin sponge particles via the mesenteric artery. G,H. Both the celiac and the superior mesenteric arteriography performed one month later demonstrated the persistent occlusion of the pancreaticoduodenal arteries; blood flow in the gastroduodenal artery is restored.
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In order to position a steel coil within the aneurysmal vessel, the anterior pancreaticoduodenal artery was superselectively catheterized with a 5F hook catheter (Figure 1C), but perforation from the guide wire occurred. The patient immediately experienced a pain in the right upper abdominal quadrant and developed signs of hemorrhagic shock. Repeated angiography of the superior mesenteric artery demonstrated extravasation of contrast medium from the pancreaticoduodenal arcades (Figure 1D); the catheter was left inserted, and a repeated angiography ten minutes later showed the cessation of bleeding (Figure 1E). The patient was conservatively managed and recovered within a few days. Two weeks later the patient complained of a new episode of abdominal pain and collapse. Extravasation of the contrast medium from the pancreaticoduodenal arteries was identified at angiography (Figure 1F); gelatin sponge embolization achieved an immediate vascular occlusion, persistent at angiography repeated one month later (Figure 1G,H). Serum amylases and transaminases were slightly elevated after the procedure but returned to normal values within a few days. The paraduodenal hematoma was not evident after a period of nine months at CT; at present the patient is in good health after a four-year follow-up.
Figure 2- Case 2. A. Abdominal aortography diagnosed a tight extrinsic compression of the celiac axis caused by median arcuate ligament of the diaphragm. B. Tiny aneurysm of the inferior pancreaticoduodenal artery (arrow) was recognized by the superselective angiography; the common hepatic artery and the splenic artery were retrogradely opacified. C. Steel coil embolization was subsequently performed. D. Follow-up arteriography one month later showed the persistent occlusion of the inferior pancreaticoduodenal artery; collateral supply through the transverse pancreatic artery and the middle colic artery were also demonstrated.
No retroperitoneal fluid collection was appreciable at CT after ten months; the patient remained well during the next three years.
Discussion Pancreaticoduodenal arteries serve as collateral pathways when the celiac trunk or the superior mesenteric arteries are stenotic or occluded; in such instances an aneurysm of the inferior pancreaticoduodenal artery can exceptionally
Case 2. A sixty-nine-year-old man was hospitalized because of an acute pain in the right flank along with symptoms of shock (tachycardia, sweating, fainting); the patient spontaneously recovered within thirty minutes. His medical history was otherwise consistently unremarkable. Red blood cell count indicated a moderate normochromic anemia; a retroperitoneal paraduodenal hematoma was diagnosed at CT. The patient was referred to our University hospital for angiography one week later. Angiography identified a compression syndrome of the celiac trunk by the median arcuate ligament of the diaphragm (Figure 2A); the hepatic and splenic arteries were filled via enlarged tortuous aneurysmal pancreaticoduodenal arteries and the transverse pancreatic artery (Figure 2B); the inferior pancreaticoduodenal artery showed some small aneurysmal dilatation and was occluded with a 0.038" 1.5-5 steel coil (Figure 2C,D).
develop.3,9-12 Aneurysms of the pancreaticoduodenal arteries secondary to celiac trunk stenosis or occlusion" can be incidentally discovered,9'10 but they usually present as abdominal pain, obstructive jaundice, or acute hemorrhage from aneurysm,4'10 which can rupture in the peritoneal cavity, in the gastrointestinal tract (including choledochus or Wirsung duct), or in the
retroperitoneum.2-4'7'8'11'12 Rupture of a pancreaticoduodenal aneurysm in the retroperitoneum can cause a self-limiting hematoma, which can seal the leaked artery as it enlarges. What is the proper therapeutic approach in such instances? The answer is difficult to give because the fate of such aneurysms complicated by retroperitoneal bleeding is unknown when untreated. 312
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The interventional treatment should be first preferred at present. Angioplasty of the celiac artery may be the theoretical treatment of choice in the case of atherosclerotic stenosis; however, although the recanalization of the celiac artery recovers the physiological blood flow through the pancreaticoduodenal arcades, there is no certainty that the aneurysm can spontaneously disappear; restenosis after angioplasty should also be considered. Furthermore, angioplasty is not obviously indicated in an emergency as well as in case of a compression syndrome of the celiac artery by the median arcuate ligament of the diaphragm.
The potential risk of rebleeding is considered a sufficient criterion to undertake aggressive therapy. Surgery should be considered when the aneurysm causes compression symptoms, mimicking a pancreatic head carcinoma. Besides these circumstances, surgery may be questionable since artery ligation (with or without aneurysm resection) cannot be always feasible, and a partial pancreatectomy can be necessary.1'10 Proud and Chamberlain reported the disappearance of an aneurysm of the pancreaticoduodenal artery after resection of the medial arcuate ligament of the diaphragm in a patient with extrinsic compression of the celiac axis.13 313
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Conclusion Because of all the previous statements we feel that embolization of the aneurysmal vessel is the best therapeutic approach, also considering that symptoms of bowel ischemia do not occur after the arterial occlusion. Since embolization remains a symptomatic treatment, radiologic follow-up (including angiography when necessary) should always be undertaken to detect promptly other possible aneurysms of the collateral circulation.
Sergio Savastano, M.D. Istituto di Radiologia Universit'a degli Studi via Giustiniani 2 1-35128 Padova, Italy
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969-983. 2. West JE, Bernhardt H, Bowers RF: Aneurysms of the pancreaticoduodenal artery. Am J Surg 115:835839, 1968. 3. Batthika JG, Schneider PA, Garcia J, et al: Ruptured arterial aneurysms in the area of the celiac trunk. Eur J Radiol 7:94-97, 1987. 4. Eyskens E: L'aneurisme des arteres pancreaticoduodenales. Presentation d'un cas personnel. Revue et analyse de la litterature. Chirurgie 108:734-743, 1982. 5. Harris RD, Anderson JE, Coel MN: Aneurysms of the small pancreatic arteries: A cause of upper abdominal pain and intestinal bleeding. Radiology 115:1720, 1975. 6. Mandel SR, Jaques PF, Mauro MA, et al: Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg 205:126-128, 1987. 7. Teich S, Tsangaris N, Giordano J, et al: Mycotic aneurysm of the inferior pancreaticoduodenal artery:
9. Grech B, Rowlands P, Crofton M: Aneurysm of the inferior pancreaticoduodenal artery diagnosed by real-time ultrasound and pulsed Doppler. Br J Radiol 62:753-755, 1989. 10. Kadir S, Athanasoulis CA, Yune HY, et al: Aneurysms of the pancreaticoduodenal arteries in association with celiac axis occlusion. Cardiovasc Radiol 1:173177, 1978.
11. Lindberg C-G, Stridberg H: Aneurysms of the superior mesenteric artery and its branches. Gastrointest
Radiol 17:132-134, 1992. 12. Sutton D, Lawton G: Coeliac stenosis or occlusion with aneurysm of the collateral supply. Clin Radiol 24:49-53, 1973.
13. Proud G, Chamberlain J: Aneurysm formation on the small pancreatic arteries in association with coeliac axis compression. Ann R Coll Surg England 60:294297, 1978.
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