Arteriovenous malformation of the pancreas: report of a case

Mimics of pancreatic neoplasms at cross-sectional imaging: Pearls for characterization and diagnostic work-up

Interpreting imaging examinations of the pancreas can be a challenge. Several different entities can mimic or mask pancreatic neoplasms, including normal anatomic variants, non-pancreatic lesions, and both acute and chronic pancreatitis. It is important to distinguish these entities from pancreatic neoplasms, as the management and prognosis of a pancreatic neoplasm, particularly adenocarcinoma, have considerable impact on patients. Normal pancreatic variants that mimic a focal lesion include focal fatty atrophy, annular pancreas, and ectopic pancreas. Extra-pancreatic lesions that can mimic a primary pancreatic neoplasm include vascular lesions, such as arteriovenous malformations and pseudoaneurysms, duodenal diverticula, and intra-pancreatic accessory spleen. Both acute and chronic pancreatitis can mimic or mask a pancreatic neoplasm and are also associated with pancreatic ductal adenocarcinoma. Awareness of these entities and their imaging features will enable the radiologist to narrow the differential diagnosis, provide recommendations that expedite diagnosis and avoid unnecessary work-up or delays in patient care.

Successful Surgical Resection of Pancreatic Arteriovenous Malformation Complicated by Acute Pancreatitis

A 73-year-old man presented with left hypochondral pain. Dynamic computed tomography (CT) revealed abnormal vessels surrounding the pancreas, leading to a suspected diagnosis of pancreatic arteriovenous malformation (PAVM). At the time of the initial examination, dynamic CT revealed mild acute pancreatitis, and PAVM was diagnosed based on the findings of dynamic CT. Although repeated abdominal pain was observed after the improvement of pancreatitis, distal pancreatectomy was performed. At >1 year after surgery, no recurrence of PAVM was observed. Surgical resection should be considered in patients with symptomatic PAVM.

An Update of Treatment of Pancreatic Arteriovenous Malformations

Pancreatic arteriovenous malformation is a rare entity (0.9%). There are about 200 articles available in PubMed. This review article includes 86 published articles, with 117 cases published after 2000. The median age at diagnosis was 51, and most of the patients were male (87.0%). The symptoms included pain, bleeding, pancreatitis, ulcers in the duodenum or stomach, varix formation, jaundice, and ascites. The diagnostic modalities were angiography, contrast-enhanced CT, MRI, and/or Ultra Sound. The most common treatments were surgery and embolization. The clinical success rate of embolization reported was 57.7%. The tailored embolization based on each agio-architecture had a clinical success rate of 80%. If embolic therapy is ineffective, surgical intervention should be considered.

Surgical resection of arteriovenous malformation of the pancreatic head with acute pancreatitis: a case report

Arteriovenous malformations (AVMs) are uncommon in the gastrointestinal tract, particularly in the pancreas. AVMs cause complications, including gastrointestinal bleeding, portal hypertension and pancreatitis. Therefore, a treatment strategy is not yet established. Surgical treatment or transcatheter arterial embolization is performed in patients with AVM, considering their conditions. A 54-year-old man presented with acute abdominal pain was diagnosed with acute pancreatitis due to AVM of the pancreatic head using dynamic computed tomography. Endoscopic ultrasonography further revealed meandering blood vessels in the pancreatic head. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histological examination revealed AVM of the pancreatic head with chronic pancreatitis. The patient had a good postoperative clinical course and was discharged on postoperative day 22. He remained asymptomatic. Pancreaticoduodenectomy can be considered an effective treatment method for selected cases of symptomatic AVM of the pancreatic head.

A case of pancreatic AV malformation in an elderly man

A 60-year-old man presented with recurrent abdominal pain and weight loss for 6 months. Abdominal imaging showed a large vascular lesion in the head and neck of pancreas suggestive of arteriovenous malformation (AV malformation). Endoscopic ultrasound was done which showed features of AV malformation with no evidence of pancreatic malignancy. Surgery was planned for definitive treatment of malformation. Digital subtraction angiography with angioembolization was done prior to surgery to reduce vascularity of the lesion. He recovered after a pylorus preserving pancreaticoduodenectomy. Histopathology of the resected specimen confirmed the pancreatic AV malformation. There has been no recurrence at 2 years of follow-up.

Pancreatic arteriovenous malformation mimicking pancreatic neoplasm: a systematic multimodality diagnostic approach and treatment

Pancreatic arteriovenous malformation (pAVM) is a very rare entity, as less than 100 cases are reported in the international literature. Patients with pAVM may be asymptomatic or may present a wide range of symptoms, such as vague pain, feeling of fullness, gastrointestinal bleeding, or even portal hypertension. We present the multimodality approach in the diagnosis of a patient with pAVM and treatment via transcatheter arterial embolization of the lesion using steel coils. The patient was free of symptoms 12 months later.

Acquired Pancreatic Arteriovenous Malformation

Pancreatic arteriovenous malformation is a rare vascular anomaly which may cause abdominal pain, acute pancreatitis, gastrointestinal bleeding and portal hypertension. Pancreatic arteriovenous malformation is mostly congenital; however secondary pancreatic arteriovenous malformation due to pancreatitis has been suggested by some authors. We encountered a case which can confirm this presumption. Several imaging modalities are useful for the diagnosis of pancreatic arteriovenous malformation, especially dynamic contrast-enhanced studies. Angiography is the most important diagnostic tool because of the dynamic features of this vascular lesion. Treatment is advised and consists of surgical resection and/or transarterial embolization.

Pancreatic arteriovenous malformation

BACKGROUND

Pancreatic arteriovenous malformation is very rare, but may cause significant clinical symptoms such as catastrophic bleeding. Herein, we discuss the clinical presentation and management of patients pancreatic arteriovenous malformations.

METHODS

The data pool for the analysis was collected from pancreatic arteriovenous malformation cases encountered by our institution and sporadic case reports in the English literature.

RESULTS

A total of 89 cases of pancreatic arteriovenous malformation were collected for this study, including 59 cases of arteriovenous malformation in the pancreatic head (62.3 %) and 30 in the pancreatic body-tail (33.7 %). The most commonly associated complications for overall cases of pancreatic arteriovenous malformation were bleeding (50.6 %), pancreatitis (16.9 %), portal hypertension (6.7 %), and pseudocyst (3.4 %). The most common presenting symptom of pancreatic arteriovenous malformation was gastrointestinal bleeding (47.2 %), followed by epigastric pain (46.1 %). Surgery (43.8 %) was the most common treatment for pancreatic arteriovenous malformation cases, followed by transarterial embolization (11.2 %), a combination of surgery and transarterial embolization (10.1 %), and radiotherapy (2.2 %). No intervention was done for 29.2 % of the cases of pancreatic arteriovenous malformation.

CONCLUSIONS

Pancreatic arteriovenous malformation occurs most commonly in the pancreatic head; gastrointestinal bleeding is the main symptom. Surgical resection or transarterial embolization appears to be indicated in patients with symptomatic pancreatic arteriovenous malformation.

Arteriovenous malformation of the pancreas: A case report and review of literature

Extrahepatic arteriovenous malformations (AVMs) of the gastrointestinal (GI) tract are rare and mostly asymptomatic congenital anomalies. The present case describes a 45-year-old woman with an AVM in the head of the pancreas, which caused massive GI bleeding that recurred after embolization, and which was subsequently treated with a pylorus-preserving Whipple pancreaticoduodenectomy. The authors then review the available literature pertaining to AVMs of the GI tract, the diagnostic modalities that have been used to identify them and the treatment approaches that have been described to date, which range from coil embolization of the feeding artery to radical resection of the affected organ. It is important to remember that these lesions shunt blood between the high-pressure arterial system and the low-pressure portal system, which leads to the much-dreaded consequence of portal hypertension.

Surgical outcomes of pancreatic arteriovenous malformation in a single center and review of literature

OBJECTIVE

Pancreatic arteriovenous malformation (P-AVM) is an extremely rare condition that can be accompanied by fatal complications. We have attempted to identify the possible management guidelines based on our and others' clinical experience.

METHODS

We retrospectively analyzed our findings including clinical characteristics, imaging modalities, and treatment in 12 patients. Sporadic reports of 69 patients with P-AVM were surveyed for representative characteristics and treatment strategy.

RESULTS

The mean age at diagnosis was 49.8 years (range, 44-64 years), and all 12 were male. The mean body mass index was 21.5 kg/m (range, 18.3-24.3 kg/m) and 6 (50%) were heavy smokers (mean, 30.9 pack-years; range, 7.5-120 pack-years). The most common clinical symptom is gastrointestinal bleeding, followed by abdominal pain. All patients were diagnosed with abdominal disease using computed tomography. Of the 12 patients, 11 underwent pancreatic resection and 1 patient was managed conservatively. No patient experienced any major postoperative complications during the median follow-up of 37 months.

CONCLUSIONS

In patients with symptomatic P-AVM, surgical resection of the affected pancreas showed a successful result. When a patient is at a high risk for surgical treatment, transjugular intrahepatic portosystemic shunt, transarterial embolization, and radiation therapy might be other treatment options.

Arteriovenous malformation of the pancreatic head--difficulties in diagnosis and treatment

A patient with pancreatic arteriovenous malformation who presented diagnostic and therapeutic difficulties is presented. The initial tests appeared to suggest inflammatory bowel disease, but the diagnosis was clinched by the finding of blood issuing from the ampulla of Vater. Repeated angiographic embolization did not obliterate the vascular malformation, and the symptoms eventually resolved after Whipple's pancreaticoduodenectomy.

A Case of Recurrent Acute Pancreatitis due to Pancreatic Arteriovenous Malformation

Pancreatic arteriovenous malformation (AVM) is an extremely rare condition with various clinical manifestations. We report herein a case of recurrent acute pancreatitis due to pancreatic AVM in a 49-year-old man. This patient presented with epigastric pain that had developed after consuming alcohol 2 days prior to admission. Serum amylase and lipase levels were elevated and computed tomography revealed focal low-attenuation lesions with peripancreatic infiltrations in the pancreatic tail and multiple collateral vessels around the low-attenuation lesions. He was diagnosed with acute pancreatitis and pancreatic AVM. Although he had stopped drinking after the first attack of acute pancreatitis, his pancreatitis recurred twice within 3 months. He underwent a distal pancreatectomy after the third attack of acute pancreatitis. He was free of symptoms for 2 years after the pancreatectomy.

The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy

PURPOSE

An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein.

METHODS

All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival.

RESULTS

A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups.

CONCLUSIONS

The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas.