Analysis of five cases of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament

Characteristics and Trends in Median Arcuate Ligament Syndrome (MALS) Associated Visceral Artery Aneurysms: A Systematic Descriptive Review of the Literature

Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P = .84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P = .02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management.

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?

Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review

BACKGROUND

Despite being rare, pancreaticoduodenal artery aneurysms (PDAAs) carry a risk of rupture of up to 50% and are frequently associated with coeliac artery occlusion.

METHODS

PubMed and Embase databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines.

RESULTS

We present the case of a 2 cm pancreaticoduodenal artery aneurysm pre-operative angiography demonstrated that the coeliac artery was occluded and the pancreaticoduodenal artery was providing collateral blood supply to the liver. Treatment was a staged hybrid intervention inclusive of an aorto-hepatic bypass using a 6 mm graft, followed by coil embolisation of the aneurysm. We also present a systematic review of the management of PDAAs. Two hundred and ninety-two publications were identified initially with 81 publications included in the final review. Of the 258 peripancreatic aneurysms included, 175 (61%) were associated with coeliac artery disease either occlusion or stenosis. Abdominal pain was the main presentation in 158 cases. Rupture occurred in 111 (40%) of patients with only ten (3.8%) cases being unstable on presentation. Fifty (18%) cases were detected incidentally while investigating another pathology. Over half the cases (n=141/54.6%) were treated by trans arterial embolisation (TAE) alone, while 37 cases had open surgery only. Twenty-one cases needed TAE and a coeliac stent. Seventeen cases underwent hybrid treatment (open and endovascular). Sixteen cases were treated conservatively and in 26 cases, treatment was not specified.

CONCLUSION

PDAAs are commonly associated with coeliac artery disease. The most common presentation is pain followed by rupture. The scarcity of literature about true peripancreatic artery aneurysms associated with CA occlusive disease makes it difficult to assess the natural history or the appropriate treatment. Revascularisation of hepatic artery is better done with bypass in setting of median arcuate ligament compression and occluded celiac trunk.

Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk

Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.

Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization

PURPOSE

To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization.

METHODS

Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis.

RESULTS

MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases.

CONCLUSIONS

In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.

A Hybrid Approach in the Management of a Large Pancreaticoduodenal Artery Aneurysm

Pancreaticoduodenal artery aneurysms (PDAA) are rare and represent a small fraction of known visceral aneurysms. We describe a case of a 79-year-old male with an 82 mm PDAA in the setting of chronic celiac artery occlusion. The patient was treated with an open repair. Due to the large size of the aneurysm and the dense adhesions to the surrounding tissues, vascular control of the superior mesenteric artery (SMA) was achieved by endovascular balloon occlusion and the aneurysm repaired with resection and primary aneurysmorrhaphy. The patient had an uneventful postoperative course.

[Surgical treatment of pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion]

We report successful surgical treatment of inferior pancreaticoduodenal artery aneurysm combined with celiac trunk occlusion. Considering angioarchitectonics of the afferent and efferent arteries (significant tortuosity), possible liver ischemia during endovascular occlusion of pancreaticoduodenal artery and expected low efficiency of embolization, the patient underwent open surgery (celiac trunk replacement and resection of pancreaticoduodenal artery aneurysm). Postoperative period was uneventful. The first and subsequent postoperative controls showed an adequate function of the prosthesis and no contrast enhancement of the aneurysm. We concluded that rational surgical approach ensured optimal solution of the problem, i.e. surgical treatment of pancreaticoduodenal artery aneurysm was the most radical and functional.

Blood flow modification might prevent secondary rupture of multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis stenosis

A pancreaticoduodenal artery arcade aneurysm (PDAA) is rare and often associated with celiac axis stenosis by the median arcuate ligament. Although rupture risk of the PDAA is not related to its size, treatment guidelines are absent. Here we describe a 59-year-old woman with multiple ruptured PDAAs associated with celiac axis stenosis who was successfully treated with coil embolization. As follow-up computed tomography revealed rapid expansion of residual PDAAs and new gastric artery dissection, median arcuate ligament resection was followed by aorta-common hepatic artery bypass, which resulted in aneurysmal regression. Blood flow modification might prevent secondary rupture of PDAA associated with celiac axis stenosis.

Laparoscopic treatment of median arcuate ligament syndrome: a systematic review

INTRODUCTION

Median arcuate ligament syndrome (MALS) is an uncommon condition caused by the extrinsic compression of the celiac trunk (CT) and celiac ganglion, secondary to an anatomical abnormality of the median arcuate ligament fibers. It is characterized by postprandial epigastric pain, chronic abdominal pain, weight loss, nausea and vomiting. MALS is typically diagnosed after the exclusion of other, more common conditions; however, a variety of imaging and diagnostic modalities, including Duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry and angiography can suggest findings consistent with MALS.

EVIDENCE ACQUISITION

Laparoscopic approach has been proposed as the option of choice for the treatment of these patients. A systematic review of the international literature regarding this modality of treatment is presented here.

EVIDENCE SYNTHESIS

The review included 504 cases, and several principles are suggested to improve the management. The advantages of this minimally invasive technique include short operative time (136.0 minutes, range 70-242), shorter hospital stay (3.8 days, range 0.5-7) and low rate of conversion to open surgery (4.2%).

CONCLUSIONS

Various treatment modalities are available to decompress the celiac trunk. Although open surgery has been traditionally accepted as the gold standard, laparoscopic division of the MALS has proven equal results. Others have described different treatment modalities, including bypass surgery and endovascular procedures (angioplasty or stent placement). Laparoscopic approaches to correct MALS are feasible and safe. It may be the preferred modality of treatment in view of its lack of morbidity, shorter hospital stay and good results.

Severe duodenal stenosis due to rupture of pancreaticoduodenal artery aneurysm

When a patient complains of nausea, gastrointestinal endoscopy tends to be the first-choice diagnostic method. However, physicians must rule out the possibility of aneurysm rupture by careful physical assessment before performing gastrointestinal endoscopy, which can be extremely dangerous.

Aneurysms of Peripancreatic Arterial Arcades Coexisting with Celiac Trunk Stenosis or Occlusion: Single Institution Experience

Introduction. True aneurysms of peripancreatic arterial arcades (PAAAs) are rare. Most of them coexist with celiac axis stenosis/occlusion due to median arcuate ligament (MAL) compression or atherosclerosis. The aim of this study was to evaluate the cause of celiac axis lesion and characterize the anatomy of the aneurysms. These findings may have important management implications. Material and Methods. A retrospective analysis of 15 patients with true PAAAs was performed. The diagnosis was established by contrast-enhanced CT, using a 64-MDCT scanner. We evaluated the most probable cause of celiac axis lesion. Aneurysms were characterized by their number, location, size, and morphology. Location of the aneurysms was classified either as pancreaticoduodenal arteries (PDA) or as dorsal pancreatic arteries (DPA) as they may represent different collateral pathways between superior mesenteric artery and celiac trunk. Results. A total of 32 true PAAAs were identified. Celiac trunk was occluded in 12 patients and critically narrowed in 3 patients. Celiac axis lesion was categorized as secondary to MAL compression in 14 cases and due to atherosclerosis in 1 case. The most common location of the aneurysms was inferior pancreaticoduodenal arteries. Only in 1 case aneurysms involved both PDA and DPA. Conclusions. Coexistence of PAAAs with celiac axis compression as well as involvement of either PDAs or DPAs has important therapeutic implications. The uninvolved collateral pathway may be sufficient to preserve effective circulation in celiac trunk branches in case of resection or embolization of the aneurysms. However, further studies are crucial to confirm our findings.

Multidetector Computed Tomographic Angiography for Optimal Cartography of the Visceral Abdominal Arterial Network: An Extensive Pictorial Review with Emphasis on Common and Uncommon Collateral Pathways, Complications and some Specific Syndromes

Multidetector computed tomographic angiography (MDCTA) is the new gold standard for diagnostic evaluation of the abdominal and/or mesenteric arteries. It is not invasive and provides a 2D and 3D global cartography of all abdominal arteries and that with only a limited amount of contrast media.

MDCTA allows the optimal diagnosis of single or multiple arterial stenosis and easily analyses sometimes very complex collateral pathways. It constitutes a major advance to plan the arterial visceral safety of major commonly performed abdominal surgical procedures such as aorto-iliac surgery, endovascular aneurysm repair (EVAR), but also complex pancreatic and gastrointestinal or colonic surgery. It also allows to plan the most optimal strategy for revascularization of the mesenteric system through percutaneous angioplasty, stent placement or surgical bypass.

This extensive pictorial review illustrates a large variety of situations which may be found during clinical practise. Single compression or stenosis of each digestive artery, combined and/or complex associations of stenosis and/or compressions of several arteries, secondary complications like aneurysms and classical but also sometimes unusual patterns of collateralization are richly illustrated. Specific syndromes comprising the median arcuate ligament syndrome (MALS) and the Leriche’s syndrome are also discussed.

Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients

PURPOSE

The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm.

METHODS

Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms.

RESULTS

False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P<0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible.

CONCLUSIONS

Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.

Multiple Pancreatoduodenal Artery Arcade Aneurysms Associated with Celiac Axis Root Segmental Stenosis Presenting as Aneurysm Rupture

A 57-year-old woman was admitted to our unit suffering from hemorrhagic shock and upper abdominal pain. An enhanced computerized tomography (CT) scan evidenced a large retroperitoneal hematoma due to visceral arteries aneurysm rupture and a significant celiac axis root segmental stenosis due to median arcuate ligament compression. A selective splanchnic arteries angiography showed 3 saccular pancreaticoduodenal artery arcade aneurysm (PDAAs), 2 in the inferior posterior pancreaticoduodenal artery, and 1 smaller in the superior anterior pancreaticoduodenal artery. The largest aneurysm showed evident rupture signs. Both inferior PDAAs were successfully treated via endovascular coil embolization. The celiac trunk stenosis and small inferior PDAA did not require treatment. A CT scan control at 1-year follow-up did not reveal any new PDAAs. In cases of celiac artery trunk (CAT) steno-occlusive lesions, multiple aneurysms can develop in the pancreaticoduodenal arcade. PDAAs should be treated because of high rupture risk, regardless of diameter. Although endovascular treatment via coil embolization represents the treatment of choice nowadays, a simultaneous treatment of the associated CAT lesions is still debated. However, in cases of aneurysm embolization alone, one cannot exclude that other PDAAs might develop in these patients in the future. Close monitoring and accurate long-term follow-up is highly recommended in these cases.

Uncommon CT imaging of the hepatic falciform artery in patients presenting with very unusual variants of gastrointestinal arteries: report of two cases

The hepatic falciform artery (HFA) may be found in 68% of subjects in post-mortem dissections. It is well known by interventional radiologists who perform selective hepatic angiography. The reason essentially results from the potential supraumbilical skin complications which may produce by the distribution of chemotherapeutic agents through the HFA after transcatheter chemoinfusion or chemoembolization for liver tumors. Nevertheless, the spontaneous visualization of the HFA remains very unusual in current abdominal CT practice. We hereby report the demonstration of a patent HFA during conventional abdominal CT in two patients presenting without liver disease but in which very unusual variants of the gastrointestinal arteries were simultaneously found. The first patient had a common celiomesenteric trunk and the second had a severe compression of both the celiac trunk and superior mesenteric artery by the median arcuate ligament of the diaphragm. We shortly review the literature about these rare variants. We hypothesize that the HFA was spontaneously visible in our patients because of hypertrophy due supplying collateralization.

Polyarteritis nodosa-induced pancreaticoduodenal artery aneurysmal rupture

Polyarteritis nodosa (PAN) is a systemic, necrotizing vasculitis of small- and medium-sized arteries typically with multiorgan involvement. Most cases of PAN are idiopathic, although hepatitis B or C virus infections and hairy cell leukemia are important in the pathogenesis of some cases. PAN is characterized as segmental transmural inflammation of muscular arteries. Diagnosis is based on clinical suspicion, a negative immunofluorescence test for antineutrophil cytoplasmic antibodies, and whenever possible, biopsy conformation. Angiographic images may reveal microaneurysms affecting the renal, hepatic, or mesenteric vasculature. Aneurysmal formation and rupture are important complications that can be fatal. Treatment may warrant immunosuppression with steroids and cyclophosphamide. If left untreated, PAN can be fatal. To our knowledge, we report the second documented case of PAN-induced ruptured inferior pancreaticoduodenal artery aneurysm.

Two patients with ruptured posterior inferior pancreaticoduodenal artery aneurysms associated with compression of the celiac axis by the median arcuate ligament

Patients with compression of the celiac axis by the median arcuate ligament may develop aneurysms in the pancreaticoduodenal arcades. We experienced two cases of ruptured pancreaticoduodenal artery aneurysm associated with this condition. Both patients presented with abdominal pain and shock, and abdominal contrast-enhanced computed tomography showed retroperitoneal hematoma and compression of the celiac axis by the median arcuate ligament. Both patients were successfully treated by coil embolization. Patients with celiac axis compression or stenosis may develop recurrent aneurysms unless revascularization of the celiac axis is performed. Long-term follow-up is required because aneurysms may develop after 10 years or longer.

Pancreatoduodenal artery aneurysm resulting from median arcuate ligament compression successfully treated with laparoscopic ligament section

True aneurysms of the pancreatoduodenal arteries are frequently associated with stenosis or occlusion of the celiac trunk caused by median arcuate ligament compression. Celiac stenosis cannot be cured, even by transarterial embolization, which has recently become a good alternative to open surgical repair. To prevent recurrence, management of median arcuate ligament compression to correct hemodynamics in vascular networks should also be performed. Herein we report a case of pancreatoduodenal arterial aneurysm with median arcuate ligament compression that was successfully treated with minimally invasive laparoscopic median arcuate ligament section. The patient was discharged 4 days after surgery with no complications. Enhanced CT 1 month after surgery revealed no residual celiac trunk stenosis or aneurysm. Normalization of blood flow by laparoscopic median arcuate ligament section is a good option for some patients with a pancreatoduodenal arterial aneurysm.

Treatment Strategies for a Pancreaticoduodenal Artery Aneurysm with or without a Celiac Trunk Occlusive Lesion

OBJECTIVES

A true pancreaticoduodenal artery aneurysm (PDAA) is a rare disease, and has some unique characteristics: a high rupture risk and a strong correlation with celiac trunk stenotic lesions (CTSL). We showed here that our treatment strategy for PDAA.

MATERIALS AND METHODS

Seven consecutive patients with PDAA at our institution from 1998 to 2011 were retrospectively reviewed. Of the 7 patients, five were male and two were female, with a mean age of 55 ± 9.7 years. Three aneurysms were diagnosed incidentally, and the remaining four ruptured. The locations of the aneurysm were the anterior superior pancreaticoduodenal artery (ASPDA) in 3 patients and the inferior pancreaticoduodenal artery (IPDA) in four. CTSL found 3 patients in the IPDA.

RESULTS

Of four ruptured patients, emergency catheter coil embolization was performed in three, and a simple ligation was performed in one. Three patients with non-ruptured aneurysms in the IPDA with a CTSL underwent direct aneurysm resection with arterial reconstruction. Six patients were successfully treated without complications or the appearance of new aneurysms during the follow-up period.

CONCLUSION

The treatment strategy for PDAA should be selected by the site of the aneurysm, the patients' condition, and the anatomical situation. A hybrid treatment could be considered a beneficial option for a CTSL.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion

BACKGROUND

Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence.

DATA SOURCES

Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized.

CONCLUSIONS

Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

A rare cause of abdominal angina

The authors report a case of a young male with median arcuate ligament syndrome (MALS). An abnormally low insertion of the median arcuate ligament fibres caused extrinsic compression and stenosis of the coeliac trunk. However, partial dissection of ligament fibres by laparoscopic surgery did not relieve abdominal angina. Multidetector CT confirmed that MALS did not differ from the preoperative scan. The arcuate ligament compressed the coeliac trunk on expiration, thereby eliciting occlusion of the coeliac trunk. Inspiration induced decompression of the ligament with partial release of occlusion of the coeliac trunk. This leads to hypo-perfusion of intestinal organs and abdominal angina. Considering the severe impairment of quality of life, open surgery for decompression of the coeliac trunk with vascular reconstruction is a reasonable option.

Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion

Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis or occlusion are well described in the literature. These aneurysms are true aneurysms and develop as a result of increased flow through the pancreaticoduodenal arcades in the presence of hemodynamically significant stenosis of the celiac axis or common hepatic artery. Aneurysms may be multiple and rarely associated with aneurysms in other collateral pathways-such as the dorsal pancreatic artery or the arc of Buhler. These aneurysms may be incidentally detected or patients may present with abdominal pain or shock secondary to rupture of the aneurysms. Treatment options include surgical resection and transcatheter embolization; current literature favors the latter option. Treatment of celiac axis stenosis may be recommended in addition to treating the aneurysms; however, no formal guidelines exist on this recommendation.

Natural history of true pancreaticoduodenal artery aneurysms

Advances in non-invasive diagnostic techniques, such as CT and ultrasonography, have improved our ability to detect unruptured pancreaticoduodenal artery aneurysms. No definitive study evaluating the natural history of these lesions or their preferred method of treatment has been published. In this report, we describe five patients with eight unruptured true pancreaticoduodenal artery aneurysms followed without treatment. Of these patients, four had coeliac axis stenosis (n = 1) or occlusion (n = 3) and one had occlusion of the superior mesenteric artery. The mean diameter of the aneurysms was 12.0 mm (range 7-17 mm). The mean duration of follow-up was 29.4 months (range 6-57 months). There was no aneurysm rupture during a total of 147 patient-months (243 aneurysm-months) of follow-up. Of the eight aneurysms, three increased in size over the follow-up period. We conclude that the risk of rupture of true pancreaticoduodenal artery aneurysms might be lower than expected from the data on ruptured aneurysms; however, careful follow-up of untreated aneurysms is necessary.

Percutaneous transcatheter arterial embolization of inferior pancreatico-duodenal artery aneurysms associated with celiac artery stenosis or occlusion

OBJECTIVES

To report our experience with percutaneous TAE of true IPDA aneurysms.

BACKGROUND

Most IPDA aneurysms are ruptured at presentation causing a high mortality risk. Minimally invasive treatment approaches may improve overall outcomes in such patients.

METHODS

Between 1996 and 2007, seven patients (5 Males; mean age 55 y) with symptomatic IPDA aneurysms and severe degree (>75%) celiac artery stenosis were treated with percutaneous TAE. The medical and imaging records were reviewed for demographics, clinical presentation, treatment, complications and follow-up. Patients presented with epigastric pain (7/7), hemodynamic shock (2/7) and rectal bleeding (2/7). Selective catheter angiography was performed in all patients with the intent to embolize the aneurysms.

RESULTS

A total of nine aneurysms were seen in seven patients. Two patients had two aneurysms each. The aneurysms ranged in size from 0.5 to 4.0 cm (mean 1.9 cm). Trans-catheter coil embolization was successful in 8/9 (89%) aneurysms in 6 patients. Following unsuccessful TAE of one aneurysm in one of the patient, the aneurysm was treated successfully with direct CT-guided percutaneous transabdominal injection of N-butyl-2-cyanoacrylate. There were no complications on follow up. Angioplasty and stenting of the celiac artery were performed in one patient for complete occlusion. None of the patients developed clinical or imaging evidence of visceral ischemia following embolization. None had recurrent symptoms during clinical follow-up (median 3 years, range 0.5-13.5 years). Follow-up CT (Median 6.6 months, range 4 days-11.5 years) in all patients showed no recurrence of the aneurysm.

CONCLUSION

IPDA aneurysms associated with celiac axis stenosis can be successfully treated with percutaneous embolization with minimal recurrence.