Aneurysm of pancreaticoduodenal arcade caused by medial arcuate ligament syndrome – case report and review of literature

Introduction: Visceral artery aneurysms are rare vascular pathologies. They are usually incidental findings during the examination for other reasons. The most common clinical symptoms are nonspecific abdominal pain and bleeding caused by their rupture, with a severe clinical presentation. Aneurysms of pancreaticoduodenal arcade are more common in patients with well-developed collateral circulation due to the coeliac trunk stenosis or occlusion. Case report: In this case report the authors present a rare case of a patient with incidental finding of pancreaticoduodenal arcade aneurysm in the setting of severe stenosis of coeliac trunk origin caused by medial arcuate ligament compression. The diameter of the aneurysm was 40 mm and endovascular treatment was not possible because of unfavorable anatomical setting. The patient was successfully treated with resection of the aneurysm and the division of medial arcuate ligament during one surgery. Conclusion: There is no correlation between the diameter and the risk of rupture of the pancreaticoduodenal arcade aneurysm. Because of high morbidity and mortality of their rupture, most authors recommend active treatment of these aneurysms. The necessity to treat truncus coeliacus stenosis or occlusion remains a controversial issue.

Inferior pancreaticoduodenal artery aneurysm rupture as a cause of haemoperitoneum – case report and review of the literature

Introduction: Arterial aneurysms of the pancreaticoduodenal arcade (PDA) represent approximately 2% of all aneurysms of visceral arteries. Despite a low incidence, this group of aneurysms is clinically significant due to its high risk of rupture. Case report: A 45 years old patient presented with a pancreaticoduodenal arcade aneurysm rupture along with a tight stenosis at the origin of the coeliac trunk. Retrograde blood flow from the superior mesenteric artery (SMA) to the hepatic artery (HA) via PDA limited our therapeutic options due to the necessity to maintain liver perfusion. The patient was indicated for an interventional radiology procedure, which consisted of percutaneous transluminal angioplasty (PTA) with stent placement at the origin of the coeliac trunk and subsequent transarterial embolisation (TAE) – trapping of the aneurysm using coils. Due to clinical signs of the intra-abdominal compartment syndrome, within 24 hours of the radiological treatment, the patient was indicated for surgical revision (laparotomy). During the surgery, no signs of active bleeding were found; coagula were evacuated from the abdominal cavity (800 ml) and laparostomy was performed with a temporary closure using a grid. Final closure of the abdominal cavity was performed on postoperative day 20 from the initial procedure. Follow-up abdominal CT performed 22 months after TAE showed no recurrence of the aneurysm. Conclusion: Aneurysm rupture represents a serious case of acute abdomen which requires urgent treatment. The preferred method of treatment for ruptured PDA aneurysms is the endovascular intervention using TAE, which is associated with lower morbidity and mortality than the surgical intervention. Concurrent coeliac trunk stenosis requires consideration given the need to maintain sufficient liver perfusion after TAE of the PDA aneurysm, acting up to this point as a collateral circulation of the liver. The choice of the therapeutic approach should be individualised taking into account the above mentioned recommendations.

Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access

Purpose: The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. Methods: We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. Results: Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. Conclusions: The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.

Transcatheter Chemoembolization of a Hepatocellular Carcinoma Utilizing Lipiodol through the Pancreaticoduodenal Arcade: A Case Report

This case report describes the chemoembolization of a small hepatocellular carcinoma employing a lipiodol drug delivery system utilizing a novel arterial pathway. Because the target lesion was precariously located adjacent to the inferior heart border and the diaphragm, it was unsuitable for imaging-guided microwave ablation. To achieve chemoembolization, several intraprocedural adaptations were necessary, given the variant anatomy encountered and difficulty accessing the left gastric artery through a celiac artery approach. The left gastric artery was selected from a superior mesenteric artery approach through the pancreaticoduodenal arcade (Rio Branco’s arcade). This case illustrates the importance of a mastery of the vascular anatomy and variants of hepatic arterial flow.