Case Report Multiple Aneurysms of the Inferior ...downloads.hindawi.com/journals/crivam/2013/621350.pdf · A Rare Complication of Acute Pancreatitis ... Subsequently, the proximal

Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2013 Article ID 621350 5 pageshttpdxdoiorg1011552013621350

Case ReportMultiple Aneurysms of the Inferior Pancreaticoduodenal ArteryA Rare Complication of Acute Pancreatitis

Chris Klonaris1 Emmanouil Psathas1 Athanasios Katsargyris1 Stella Lioudaki1

Achilleas Chatziioannou2 and Theodore Karatzas1

1 Second Department of Propaedeutic Surgery University of Athens Medical School ldquoLaikonrdquo Hospital 17 Ag Thoma Street11527 Athens Greece

2 Department of Radiology University of Athens Medical School ldquoAreteionrdquo University Hospital 76 Vassilissis Sofias Str11528 Athens Greece

Correspondence should be addressed to Emmanouil Psathas epsathgmailcom

Received 16 November 2012 Accepted 19 January 2013

Academic Editors G Pasterkamp M Sindel and Y-J Wu

Copyright copy 2013 Chris Klonaris et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon representing nearly 2 of all visceral aneurysms andsporadically associated with celiac artery stenosis Multiple IPDA aneurysms have been rarely reported We report a case of a53-year-old female patient with a history of prior pancreatitis who presented with two IPDA aneurysms combined with medianarcuate ligament-syndrome-like stenosis of the celiac trunkThe patient was treated successfully with coil embolization under localanesthesiaThe procedure is described and illustrated in detail and the advantages and technical considerations of such an approachare also being discussed

1 Introduction

Aneurysms of the inferior pancreaticoduodenal artery(IPDAA) represent about 2 of all visceral artery aneurysmsand are typically associated with pancreatic or biliary tractdisease [1] Although rare IPDA aneurysms tend to rupturequite often and unlike other splanchnic artery aneurysmsthere is no clear correlation between the size of PDAAs andrupture which occurs in up to 75 of cases [2] Thus inci-dental diagnosis of asymptomatic IPDAAs warrants promptevaluation and treatment Due to their anatomical locationin surgically inaccessible regions and the often coexistingpancreatic infection open surgical repair is challenging evenin cases without rupture [3] Endovascular techniques pro-vide an attractive alternative treatment option with minimalmorbidity for patients presenting with IPDAAs We reporton the management of a female patient that was presentedto our department with two IPDA aneurysms (26mm and20mm in diameter) two years after an episode of gallstonepancreatitis

2 Case ReportA 53-years-old female patient was being evaluated by herphysician for atypical dyspeptic symptoms over the past eightweeks Her medical history included gallstone pancreatitisand open cholecystectomy two years previously At presen-tation she was asymptomatic with unremarkable laboratoryprofile Duplex ultrasonography of the abdomen revealedtwo intrapancreatic formations that represented arterialaneurysms A CTA of the abdominal aorta and splanchnicarteries revealed two saccular aneurysms of the inferiorpancreaticoduodenal artery (IPDA) 26mm and 20mm indiameter respectively (Figures 1(a) and 1(b)) These findingswere combinedwithmedian arcuate ligament-syndrome-likestenosis of the celiac trunk (Figure 1(c))

Due to the location of the IPDA aneurysms as well aspatientrsquos refusal to primarily undergoing open surgical repairshe was referred to our department for endovascular treat-ment Further image processing with 3D volume renderingdemonstrated the exact anatomy of the pancreatic arterialarcade and allowed for interventional planning since both

2 Case Reports in Vascular Medicine

(a) (b)

(c) (d)

Figure 1 (a b) Intrapancreatic aneurysms of the IPDAonCTA (c)Median arcuate ligament-syndrome-like stenosis of the celiac trunk origin(d) 3D volume rendering image processing provides closeup of the superior mesenteric artery both IPDA aneurysms and their connectingbranch

aneurysms looked morphologically suitable for coil embol-izationmdashsaccular with narrow neckmdashand were also con-nected with a small collateral branch (Figure 1(d)mdashdashedline) Informed consent was obtained and we proceeded withcoil embolization of both aneurysms

The procedure was performed in the operating roomwith a C-Arm (Philips BV 300) under local anesthesiavia right brachial access After intravenous administrationof 5000 IU of heparin a 6 Fr guiding sheath (ArrowInternational Inc PA USA) was advanced to the level ofthe superior mesenteric artery (SMA) The ostium of theSMA was initially catheterized using a 003510158401015840 hydrophilicstiff Terumo guidewire and a 5F long selective multipur-pose catheter using standard coaxial technique (Figure 2(1))Subsequently the proximal aneurysm sac was catheteri-zed and the guiding sheath was advanced into it inorder to provide additional support for further maneuvers(Figure 2(2) and (3)) Thereafter we attempted to catheterize

the communicating collateral branch leading to the distalaneurysm To do so the wire and the selective multi-purpose catheter had to follow a circular route aroundthe sac since the ostium of the collateral communicatingbranch was in close proximity and in a steep angle tothe aneurysm neck (Figure 2(4)) With the multipurposecatheter placed at the upper proximal part of the com-municating branch the 003510158401015840 hydrophilic guidewire wasexchanged for a BMW 001410158401015840 wire (Guidant Corpora-tion Temecula CA) and the distal IPDA aneurysm wascatheterized (Figure 2(5)) A 3F microferret microcatheter(COOK Inc Bloomington IN USA) was then advanced intothe distal aneurysm (Figure 2(6)) through which we pro-ceeded to coil embolization with Hilal Embolization Micro-coils (COOK Inc Bloomington IN USA) (Figure 2(7))A total of 30 microcoils were ultimately used There-after the microcatheter was withdrawn and the multipur-pose selective catheter was pulled back into the proximal

Case Reports in Vascular Medicine 3

(1) Catheterization of the SMA from the

right brachial access

(2) Selective catheterization of the

proximal aneurysm sac(3) Advancement of the guiding sheath into the sac

(4) Selective catheterization of thedistal portion of the IPDA(communication collateral) +advancement of the selective catheter

catheterization of the distalaneurysm sac

(5) Exchange for 0014998400 998400 wire +(6) Selective microcatheter overthe wire into the distal aneurysm

(7) Coiling of the distal aneurysmwith microcoils

(8) Coiling of the proximalaneurysm with larger coils through

the selective catheter(9) Retrieval of devices and final result

Figure 2 Diagram demonstrating the steps of the procedure SMA superiormesenteric artery colorsmdashblue guiding sheath yellow selectivecatheter green 003510158401015840 hydrophilic guidewire red microcatheter Cyan 001410158401015840 guidewire olive gray coils

aneurysm sac The latter was successfully embolized withlarger 15mm MReye Embolization Coils (COOK IncBloomington IN USA) (Figure 2(8)) After successful coil-ing of both aneurysms the whole system was retrievedand hemostasis was achieved with manual compression(Figure 2(9)) The whole procedure lasted for 94 minuteswith total fluoroscopy time of 38 minutes and minimal bloodloss (lt50mL) The patient was sent back to the ward and

was discharged the following day Follow-up imaging withCTA at 1 and 3 months postoperatively revealed patent SMAwith preservation of collaterals and successful thrombosisof both IPDA aneurysms without any signs of sac reper-fusion or enlargement (Figure 3mdashblue arrows) The patientremained well 18-month after intervention and is beingfollowed up with duplex ultrasound studies on a 6-monthbasis


Figure 3 Follow-up imaging with volume-rendering lateral CTAviews showing patent SMA and branches with thrombosis of bothIPDA aneurysms and no sac reperfusion

3 Discussion

Aneurysms of the pancreaticoduodenal artery (PDA) are rareand most of the time present with rupture intra-abdominalhemorrhage or pancreaticus [4] Mortality in rupturedPDAAs is high approximating 29 of cases [5] makingthus their early detection and prompt treatment mandatoryAsymptomatic PDA aneurysms are diagnosed incidentallyduring abdominal ultrasound or CTMRI for other indica-tions Apart from atherosclerosis PDA aneurysms may bealso due to other etiologies including pancreatitis biliarydisease fibrodysplasia trauma and congenital anomaliesThe coexistence of a IPDAA with celiac trunk stenosis orocclusion has been well described [6] although the presenceof multiple aneurysmsmdashas in our casemdashis extremely rare [7]

Open surgical repair includes a variety of major opera-tions ranging from simple ligation with or without revascu-larization to partial pancreaticoduodenectomy [3] Mortalityrates are high and reported to be up to 19 [8] On theother hand endovascular methods including cyanoacrylateglue thrombosis aneurysm exclusion using a stent graft andembolization with intravascular coils or detachable balloons[9] provide an attractive alternative with minimal morbidityand mortality compared to open surgery [10]

The use of coils in particular offers many advantagesover other endovascular techniques mostly because of theprecision in their deployment and preservation of collateralbranches Nevertheless selective catheterization of the sacand coiling can be challenging and has also anatomicallimitations In cases of saccular aneurysms the diameter ofthe neck and the neck-sac diameter ratio is a crucial pointand should not exceed 3mm and 15 respectively in order toavoid embolization of the coil outside the sac to distal arterialbranches [11]

Careful examination of the 3D-CTA images in multipleviews can help planning a safe endovascular approach and

provides adequate information for the exact anatomic local-ization of these lesions and especially their correlation to thepancreas that is very important in case of open conversion[12] With the advent of modern CT and MR angiographyvisceral artery aneurysms less than 1 cm in diameter areroutinely detected Multislice computed tomography angiog-raphy is also a convenient imaging modality for followingup after embolization although it frequently presents withartifacts in cases of coiling and angiography is occasionallymandatory to exclude aneurysm reperfusion Duplex ultra-sonography performed by a vascular specialist is also anaccurate method to follow up these patients and provideshemodynamic information for the whole visceral circulation[13]

Regarding the coexistence of celiac trunk stenosis andPDAAs Sutton and Lawton [14] have proposed that hemo-dynamic changes due to celiac artery stenosis could causeaneurysm formation in the PDA Nevertheless during our18-month followup no new aneurysm or dilatation in thepancreatic arcade was noticed Stenosis of the celiac trunk inour case was considered to be due to the compression fromthe median arcuate ligament rather than atherosclerotic andtherefore endovascular intervention either with PTA or stent-ing of the celiac trunk origin was precluded Furthermoredue to the asymptomatic nature of the stenosis we decidedto follow up this patient rather than offering open repair

4 Conclusion

Although inferior pancreaticoduodenal artery aneurysms(IPDAAs) represent a rare entity they tend to rupture quiteoften and unlike other splanchnic artery aneurysms there isno clear correlation between size and rupture [2] thus theirdetection mandates prompt treatment Selective emboliza-tion of these lesions is a less invasive procedure with minimalmortality and good results [9] although long-term followupis recommended Multislice computed tomography angiog-raphy offers an accurate diagnosis and valuable informationfor preoperative planning [12]

Conflict of Interests

The authors have no conflict of interests to declare

References

[1] A Formentini D Birk R Kunz K H Orend and H GBeger ldquoInferior pancreaticoduodenal artery aneurysm as aconsequence of traumatic acute pancreatitis a case report andreview of the literaturerdquo International Journal of Pancreatologyvol 21 no 3 pp 263ndash267 1997

[2] S Iyomasa Y Matsuzaki K Hiei H Sakaguchi H Matsunagaand Y Yamaguchi ldquoPancreaticoduodenal artery aneurysm acase report and review of the literaturerdquo Journal of VascularSurgery vol 22 no 2 pp 161ndash166 1995

[3] E Ducasse F Roy J Chevalier et al ldquoAneurysm of the pan-creaticoduodenal arteries with a celiac trunk lesion currentmanagementrdquo Journal of Vascular Surgery vol 39 no 4 pp906ndash911 2004


[4] S Santiagu S Gananadha T J Harrington and J S SamraldquoDirect percutaneous puncture embolization of a peripancre-atic pseudoaneurysm presenting with haemosuccus pancreati-cusrdquo Journal of Medical Imaging and Radiation Oncology vol52 no 4 pp 370ndash373 2008

[5] E Moore M R Matthews D J Minion et al ldquoSurgical man-agement of peripancreatic arterial aneurysmsrdquo Journal of Vas-cular Surgery vol 40 no 2 pp 247ndash253 2004

[6] P G Tarazov A M Ignashov A V Pavlovskij and A S Nov-ikova ldquoPancreaticoduodenal artery aneurysm associated withceliac axis stenosis combined angiographic and surgical treat-mentrdquo Digestive Diseases and Sciences vol 46 no 6 pp 1232ndash1235 2001

[7] S V Sakpal M Addis and R S Chamberlain ldquoRapid progres-sion of multiple splanchnic artery aneurysmsrdquo Surgery vol 145no 5 pp 573ndash574 2009

[8] D P Coll R Ierardi M D Kerstein S Yost A Wilson and TMatsumoto ldquoAneurysms of the pancreaticoduodenal arteries achange in managementrdquo Annals of Vascular Surgery vol 12 no3 pp 286ndash291 1998

[9] G T Fankhauser W M Stone S G Naidu et al ldquoThe min-imally invasive management of visceral artery aneurysms andpseudoaneurysmsrdquo Journal of Vascular Surgery vol 53 no 4pp 966ndash970 2011

[10] S Murata H Tajima T Fukunaga et al ldquoManagement ofpancreaticoduodenal artery aneurysms results of superse-lective transcatheter embolizationrdquo The American Journal ofRoentgenology vol 187 no 3 pp W290ndashW298 2006

[11] B Richling G Bavinzski C Gross A Gruber and M KillerldquoEarly clinical outcome of patients with ruptured cerebralaneurysms treated by endovascular (GDC) or microsurgicaltechniques A single center experiencerdquo Interventional Neuro-radiology vol 30 no 1 pp 19ndash27 1995

[12] K M Horton C Smith and E K Fishman ldquoMDCT and 3DCT angiography of splanchnic artery aneurysmsrdquoTheAmericanJournal of Roentgenology vol 189 no 3 pp 641ndash647 2007

[13] L Y Zhou X Y Xie D Chen and M D Lu ldquoContrast-enhanced ultrasound in detection and follow-up of pancre-aticoduodenal artery pseudoaneurysm a case reportrdquo ChineseMedical Journal vol 124 no 17 pp 2792ndash2794 2011

[14] D Sutton and G Lawton ldquoCoeliac stenosis or occlusion withaneurysm of the collateral supplyrdquo Clinical Radiology vol 24no 1 pp 49ndash53 1973

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


(a) (b)

(c) (d)

Figure 1 (a b) Intrapancreatic aneurysms of the IPDAonCTA (c)Median arcuate ligament-syndrome-like stenosis of the celiac trunk origin(d) 3D volume rendering image processing provides closeup of the superior mesenteric artery both IPDA aneurysms and their connectingbranch

aneurysms looked morphologically suitable for coil embol-izationmdashsaccular with narrow neckmdashand were also con-nected with a small collateral branch (Figure 1(d)mdashdashedline) Informed consent was obtained and we proceeded withcoil embolization of both aneurysms

The procedure was performed in the operating roomwith a C-Arm (Philips BV 300) under local anesthesiavia right brachial access After intravenous administrationof 5000 IU of heparin a 6 Fr guiding sheath (ArrowInternational Inc PA USA) was advanced to the level ofthe superior mesenteric artery (SMA) The ostium of theSMA was initially catheterized using a 003510158401015840 hydrophilicstiff Terumo guidewire and a 5F long selective multipur-pose catheter using standard coaxial technique (Figure 2(1))Subsequently the proximal aneurysm sac was catheteri-zed and the guiding sheath was advanced into it inorder to provide additional support for further maneuvers(Figure 2(2) and (3)) Thereafter we attempted to catheterize

the communicating collateral branch leading to the distalaneurysm To do so the wire and the selective multi-purpose catheter had to follow a circular route aroundthe sac since the ostium of the collateral communicatingbranch was in close proximity and in a steep angle tothe aneurysm neck (Figure 2(4)) With the multipurposecatheter placed at the upper proximal part of the com-municating branch the 003510158401015840 hydrophilic guidewire wasexchanged for a BMW 001410158401015840 wire (Guidant Corpora-tion Temecula CA) and the distal IPDA aneurysm wascatheterized (Figure 2(5)) A 3F microferret microcatheter(COOK Inc Bloomington IN USA) was then advanced intothe distal aneurysm (Figure 2(6)) through which we pro-ceeded to coil embolization with Hilal Embolization Micro-coils (COOK Inc Bloomington IN USA) (Figure 2(7))A total of 30 microcoils were ultimately used There-after the microcatheter was withdrawn and the multipur-pose selective catheter was pulled back into the proximal

















3 Discussion







4 Conclusion




References





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
































3 Discussion







4 Conclusion




References





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















3 Discussion







4 Conclusion




References





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Documents

Case Report Multiple Aneurysms of the Inferior ...downloads.hindawi.com/journals/crivam/2013/621350.pdf · A Rare Complication of Acute Pancreatitis ... Subsequently, the proximal