Pancreatic pseudoaneurysm and its conundrum

Rupture of visceral artery pseudoaneurysm can lead to hypovolemic shock in a patient with pancreatitis. With the advent of minimally invasive treatment techniques most of these can be managed by minimally invasive route and have excellent prognosis when timely intervention is initiated. Herewith, we reported a case of ruptured pseudoaneurysm of superior pancreaticoduodenal artery in a patient with pancreatitis who presented with haematemesis. The patient was successfully managed with coil embolization. A brief case report with review of literature is presented here.

Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding

The pancreaticoduodenal arteries are rare sites for true aneurysm formation, but these may develop in association with occlusion of the coeliac circulation, degenerative conditions or inflammatory vascular disorders. These have a high risk of rupture regardless of size or other factors. One identified cause is polyarteritis nodosa (PAN), which is an autoimmune necrotising vascular condition that affects small-sized and medium-sized arteries. We report a case of a 40-year-old man with massive gastrointestinal tract bleeding from a ruptured pancreaticoduodenal artery aneurysm secondary to PAN. This was managed with emergent open aneurysm ligation followed by high-dose corticosteroids and cyclophosphamide pulse therapy. Only three other cases of PAN-associated pancreaticoduodenal artery aneurysms have been reported in the literature.

639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation

Background Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE. Case Summary A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely. Conclusions RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.

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

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.

Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience

Objectives: Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years. Methods: We retrospectively reviewed our prospectively maintained registry between January 1, 1992 – March 30, 2020. Results: We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity. Conclusion: Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.