Reno-hepatic artery bypass for an inferior pancreaticoduodenal artery aneurysm with associated celiac occlusion

Abstract

Pancreaticoduodenal artery (PDA) aneurysms are rare and often found in association with lesions of the celiac axis. We report the case of a 72-year-old morbidly obese male who presented with chronic abdominal pain and a 4.5 cm inferior PDA aneurysm with associated occlusion of the celiac axis. The patient was treated successfully with right renal to common hepatic artery bypass followed by aneurysm ligation and excision. When encountered, PDA aneurysms require expeditious treatment. Precise definition of vascular anatomy and collateral flow is mandatory. While endovascular techniques may aid in management, surgery remains the most effective treatment for complex aneurysms of the pancreaticoduodenal arteries.

Current management strategies for visceral artery aneurysms: an overview

“…The arteries that can be used for proximal anastomosis for bypassing the extrahepatic artery include the aorta, iliac artery, splenic artery, and renal artery. The surgical technique of reno-hepatic artery bypass, when bypassing from the right renal artery, is simple and effective, and the bypass distance is short [51]. Once the anatomical conditions, such as a relatively large arterial diameter and sufficient proximal and distal sealing zones, are confirmed, stent graft placement is indicated.…”

The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms

“…4,212 In cases of median arcuate ligament syndrome, celiac revascularization can be achieved with division of the median arcuate ligament and celiac plexus, aortoceliac bypass, or renohepatic bypass. 230 In cases not associated with median arcuate ligament compression, primary stenting of a celiac stenosis is an option. 216,231 Few data exist regarding screening for GDAA and PDAA.…”

Management of pancreaticoduodenal artery aneurysm associated with coeliac artery stenosis

“…To avoid this, revascularisation of the coeliac artery before or shortly after treating the pancreaticoduodenal artery aneurysm is an option. 7,13 Late complications, including aneurysmal rupture, may occur from endovascular therapies, so long-term follow-up of patients is recommended. 14 Open surgical treatment of gastroduodenal and pancreaticoduodenal artery aneurysms is performed when endovascular therapy fails, is technically inappropriate or in haemodynamically unstable patients.…”

“…15,16 Such revascularisation entails reanastomosis of the affected arteries, release of median arcuate ligament entrapment of the coeliac artery, aortocoeliac or aortohepatic artery bypass. 11,13 If no foregut ischemia is present, simple ligation of the aneurysm's entering and exiting arteries can be done while preserving the collateral vessels. Open surgical treatment of gastroduodenal artery aneurysms is technically less challenging than pancreaticoduodenal artery aneurysms, since the former are usually more anterior to the pancreas and distant from the superior mesenteric artery.…”