Aneurysms of pancreaticoduodenal arcade: Clinical profile and endovascular strategies

Abstract

Background and Aim: Pancreaticoduodenal 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. Methods: The 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. Results: We 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. Conclusions: With advancing technology, endovascular strategies continue to evolve. Careful attention to ensure hemodynamic resuscitation and stability, correction of preexisting coagulopathy and attention to technique can lead to the possibility of endovascular approaches as a dependable option in the management of ruptured PDAAs.

A Rare Case of a Sickle Cell Patient With Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis and Pseudoaneurysm Formation: An Association Worth Exploring

“…Pseudoaneurysms are missed 58% of the time so it should be considered when patients develop abrupt worsening of abdominal pain, acute decrease in hemoglobin, hemodynamic instability, and when there is clinical suspicion of gastrointestinal bleeding without obvious cause [4,9,10]. Several mechanisms have been proposed for this in pancreatitis, such as pancreatic enzyme digestion of the vessel wall, direct trauma to the vessel, mechanical irritation from post-operative drains, enlarging pseudocysts or abscesses causing ischemia with the release of pancreatic enzymes, and vessel wall stress [3,8,11]. These can result in localized bleeding, vessel erosion, and hemorrhage [3,11].…”

“…Several mechanisms have been proposed for this in pancreatitis, such as pancreatic enzyme digestion of the vessel wall, direct trauma to the vessel, mechanical irritation from post-operative drains, enlarging pseudocysts or abscesses causing ischemia with the release of pancreatic enzymes, and vessel wall stress [3,8,11]. These can result in localized bleeding, vessel erosion, and hemorrhage [3,11]. Our patient developed pancreatitis after ERCP from trauma secondary to instrumentation insertion, stent placement, or the contrast medium [8].…”

“…Conventionally, pseudoaneurysms have been treated using surgical and endoscopic approaches [3,10,18]. An endovascular approach is now the first line for hemodynamically stable patients with as high as 100% success rate and 37% chance of recurrent bleeding [5,11]. This has led to a lower length of stay in the hospital and a decrease in the need for subsequent blood transfusions [5,11].…”

“…An endovascular approach is now the first line for hemodynamically stable patients with as high as 100% success rate and 37% chance of recurrent bleeding [5,11]. This has led to a lower length of stay in the hospital and a decrease in the need for subsequent blood transfusions [5,11]. Options for management include gel foam slurries which can be injected; however, vessels can recanalize in several months so these may require further procedures or surgeries [19].…”

An Unusual Case of Gastric Outlet Obstruction After Embolization of Gastroduodenal Artery Pseudoaneurysm

“…Other causes of gastric outlet obstruction are relatively uncommon and include gastric tuberculosis, annular pancreas, corrosive ingestion, gastric polyps, Crohn’s disease, Bouverete syndrome and gastric volvulus. Gastric outlet obstruction from visceral artery aneurysms is rare and a subject of a few case reports [ 3 , 4 ]. To the best of our knowledge, no cases are found in the literature of gastric outlet obstruction after embolization of visceral artery aneurysms and pseudoaneurysms.…”