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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 274-276

Chronic versus acute aneurysmal disease of the pancreaticoduodenal arcade: A case-based discussion


1 Department of Radiology, St. Luke's University Health Network, Bethlehem, USA
2 Lewis Katz School of Medicine at Temple University, St. Luke's University Hospital Campus, Bethlehem, PA, USA

Date of Web Publication9-Jan-2018

Correspondence Address:
Dr. Jamie L Thomas
St. Luke's University Health Network, 801 Ostrum St., Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_38_17

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  Abstract 


We report a 67-year-old female with chronic aneurysmal disease of the pancreaticoduodenal arcade due to complete celiac occlusion. The chronic aneurysm had no associated bleeding and was nonemergently embolized. Aneurysms in this location may present acutely with bleeding. A companion case of a 62-year-old male with ruptured aneurysmal disease of the pancreaticoduodenal arcade is also included in this manuscript.
The following core competencies are addressed in this article: Medical knowledge, Patient care.

Keywords: Aneurysm repair, interventional radiology, median arcuate ligament syndrome, pancreaticoduodenal arcade


How to cite this article:
Thomas JL, Redstone EA, Warden BA. Chronic versus acute aneurysmal disease of the pancreaticoduodenal arcade: A case-based discussion. Int J Acad Med 2017;3:274-6

How to cite this URL:
Thomas JL, Redstone EA, Warden BA. Chronic versus acute aneurysmal disease of the pancreaticoduodenal arcade: A case-based discussion. Int J Acad Med [serial online] 2017 [cited 2019 Jun 27];3:274-6. Available from: http://www.ijam-web.org/text.asp?2017/3/2/274/222471




  Introduction Top


Aneurysmal disease of the pancreaticoduodenal arcade in the setting of celiac stenosis is a rare entity making up only 2% of visceral aneurysms.[1] Typically, the celiac occlusion is due to median arcuate ligament syndrome (MALS). The arcuate ligament is an anatomical band that traverses the aorta superior to the celiac artery. Currently, there is some debate whether the abdominal pain associated with MALS is due to the occlusion of the celiac artery or the compression of the celiac plexus or some combination of both. However, some reviews show patients receive relief with ligation of MAL.[2] In any case, there appears to be sufficient retrograde flow through the superior mesenteric artery (SMA) and inferior mesenteric artery to avoid bowel and solid organ ischemia in these patients.[3] These collaterals, including the pancreaticoduodenal arteries, may become aneurysmal due to the increased flow and wall stress.


  Case Reports Top


Case report 1

A 67-year-old morbidly obese female was hospitalized for cardiac disease. The patient had a history of bilateral leg swelling. She denied pain with walking, abdominal pain, or back pain. Surgical history included hysterectomy. She denied any accident, trauma, or history of aneurysmal disease. During cardiac workup, a computed tomography (CT) was performed and revealed an incidental finding of an asymptomatic occlusion of the celiac artery with massive aneurysmal disease involving the gastroduodenal arcade (pancreaticoduodenal arcade). Interventional radiology was consulted for diagnostic and possible therapeutic management of the aneurysm [Figure 1]a, [Figure 1]b and [Figure 2]a,[Figure 2]b,[Figure 2]c.
Figure 1: (a) Posteroanterior aortic arteriogram – aortic angiogram demonstrates occlusion of the celiac artery with a large hypertrophied branch of the superior mesenteric artery giving rise to aneurysm. The entire pancreaticoduodenal arcade is massively aneurysmal and has become the sole blood supply to the liver. The aneurysm wall is calcified suggesting chronicity. (b) Aortic angiogram left lateral

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Figure 2: (a) Arteriogram 1, (b) Arteriogram 2, (c) Arteriogram 3

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She was diagnosed with chronic celiac artery occlusions with asymptomatic pancreaticoduodenal aneurysm. Due to risk of rupture, these aneurysms should be embolized.[4] Coil embolization was performed successfully. The endovascular treatment excluded the aneurysm and preserved flow to the SMA and the celiac distributions. Before embolization, an angiogram with a balloon in the feeding artery was performed to prove that the treatment would not sacrifice flow to the SMA distribution [Figure 3].
Figure 3: Embolization

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Case report 2 - companion case

A 62-year-old male presented to the emergency department with abdominal pain and two episodes of nonbilious vomiting, reported heavy drinking 2 days before admission. The patient had no history of gallstones or medications. Complete blood count showed decreased hemoglobin. CT of the abdomen was obtained and showed large solid collection in pararenal space. Despite normal appearing pancreas on CT, the patient was admitted to the Intensive Care Unit with presumed diagnosis of hemorrhagic pancreatitis and prescribed a piperacillin/tazobactam combination drug. Further study of the CT and follow-up angiography showed ruptured aneurysmal disease of the pancreaticoduodenal arcade secondary to celiac occlusion [Figure 4].
Figure 4: Angiography showing ruptured aneurysmal disease of the pancreaticoduodenal arcade secondary to celiac occlusion (white arrow)

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The patient was taken emergently to the interventional suite for embolization. The ruptured aneurysm was successfully embolized, and the patient had an uncomplicated recovery.


  Discussion Top


This case is uncommon because of the chronic state of her aneurysmal disease and the massiveness of the aneurysms. This is the largest aneurysm of this type reported in the literature. Before the advent of highly sensitive CT scanning, this type of aneurysmal disease would present with hemorrhage and would be treated with open surgery. Some treatment teams still opt for surgery despite available endovascular treatment options.[5] Especially, in this case, comorbidities would have excluded many patients for treatment. Today, the aneurysms are an incidental finding, and the preferred initial treatment is endovascular.[6] The companion case displays a more acute presentation of celiac occlusion and aneurysmal disease of the pancreaticoduodenal arcade. Typically, this disease is silent until the patient presents with abdominal pain, bleeding, and requires embolization. Case studies of emergent treatment is more common in the literature.[7]


  Conclusion Top


Pancreaticoduodenal aneurysms are rare, and discovery of such a large unruptured aneurysm is extremely rare. The aneurysm we report is the largest unruptured and extensive pancreaticoduodenal arcade aneurysm found in the literature to date. Incidentally discovered aneurysms in this location should be treated.[4] Options for treatment include surgical and endovascular embolization. Endovascular treatment is preferred – certainly in patients with comorbidities if not all patients. If left untreated, patients with aneurysms may rupture and present acutely.[8]

Acknowledgments

The author would like to thank esteemed nurses and staff in Interventional Radiology Department at St. Luke's University Health Network.

Financial support and sponsorship

This study was financially supported by St. Luke's Health Network for equipment, etc.

Ethical conduct of research

The authors attest that this scholarly work was conducted in accordance with the recommendations of The International Committee of Medical Journal Editors. Patient consent was obtained prior to the submission of this manuscript for publication in the International Journal of Academic Medicine.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hildebrand P, Esnaashari H, Franke C, Bürk C, Bruch HP. Surgical management of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis. Ann Vasc Surg 2007;21:10-15.  Back to cited text no. 1
    
2.
Jimenez JC, Harlander-Locke M, Dutson EP. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg 2012;56:869-73.  Back to cited text no. 2
[PUBMED]    
3.
Bobadilla JL. Mesenteric ischemia. Surg Clin North Am 2013;93:925-40, ix.  Back to cited text no. 3
[PUBMED]    
4.
Jesinger RA, Thoreson AA, Lamba R. Abdominal and pelvic aneurysms and pseudoaneurysms: Imaging review with clinical, radiologic, and treatment correlation. Radiographics 2013;33:E71.  Back to cited text no. 4
[PUBMED]    
5.
Kitaoka T, Deguchi J, Kamiya C, Suzuki J, Sato O. Pancreaticoduodenal artery aneurysm formation with superior mesenteric artery stenosis. Ann Vasc Dis 2014;7:312-5.  Back to cited text no. 5
[PUBMED]    
6.
Murata S, Tajima H, Fukunaga T, Abe Y, Niggemann P, Onozawa S, et al. Management of pancreaticoduodenal artery aneurysms: Results of superselective transcatheter embolization. AJR Am J Roentgenol 2006;187:W290-8.  Back to cited text no. 6
[PUBMED]    
7.
Takase A, Akuzawa N, Hatori T, Imai K, Kitahara Y, Aoki J, et al. Two patients with ruptured posterior inferior pancreaticoduodenal artery aneurysms associated with compression of the celiac axis by the median arcuate ligament. Ann Vasc Dis 2014;7:87-92.  Back to cited text no. 7
[PUBMED]    
8.
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 2015;29:122.e1-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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