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

Abstract

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.

Spontaneous complete regression of pancreaticoduodenal artery aneurysms with celiac artery occlusion after aorto-splenic bypass without additional treatment: a case report

“…To the best of our knowledge, we have reviewed CT and angiography images in case reports published within a few decades. In most cases that can be assessed both before and after treatment, the dilated PDA arcade seemed to be normalized after successful treatment for celiac root stenosis or occlusion by revascularization or bypass [ 6 , 8 , 13 , 14 , 17 , 18 ].…”

Treatment strategies for unruptured pancreaticoduodenal artery aneurysms associated with celiac artery occlusion

“…10 However, it has been suggested that all PDAAs should be treated regardless of size because there are reports of rupture of PDAAs smaller than 2 cm. 11,15 However, these reported to ensure blood flow in the CA region and treat the aneurysm on a different day. 5 In Case 4, as in Case 2, with a weak LGA (Figure 3B), the PDAA was treated on a different date.…”

“…The indication for treatment of some VAAs is an aneurysmal diameter of ≥2 cm 10 . However, it has been suggested that all PDAAs should be treated regardless of size because there are reports of rupture of PDAAs smaller than 2 cm 11,15 . However, these reported cases were diagnosed after rupture; therefore, blood flow in the PDA remained high, and intravascular pressure also remained high.…”

“…This procedure is performed when LRA‐SA bypass is impossible. AA‐SA bypass requires a graft, and the great saphenous vein (GSV) (Figure 1B) or an artificial vessel (Figure 1C,D) are options 11 . In patients receiving artificial vessels, antiplatelet medications should be administered.…”

“…AA‐SA bypass requires a graft, and the great saphenous vein (GSV) (Figure 1B ) or an artificial vessel (Figure 1C,D ) are options. 11 In patients receiving artificial vessels, antiplatelet medications should be administered. The graft should pass dorsal to the mesentery.…”