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Surgical Management of Pancreaticoduodenal Artery Aneurysms in Association with Celiac Trunk Occlusion or Stenosis
Surgical Management of Pancreaticoduodenal Artery Aneurysms in Association with Celiac Trunk Occlusion or Stenosis Philipp Hildebrand, MD, Hamed Esnaashari, MD, Christian Franke, MD, Conny B€ urk, MD, and Hans Peter Bruch, MD, L€ ubeck, Germany
Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. They show a wide clinical spectrum, ranging from asymptomatic incidental findings to rupture-inducing catastrophic bleedings. Since growth progression and the risk of rupture cannot be foreseen and there is no relation between the size of the aneurysm and propensity to rupture, rupture unfortunately carries a high mortality, >50%. Thus, all aneurysms of the pancreaticoduodenal artery should be treated. The therapy of choice, either operative intervention or catheter embolization, is determined by many factors. Among these are localization, size, relation to other vessels and neighboring organs, the urgency of intervention, and the experience of the therapist. Surgical therapy should be favored in patients with pancreaticoduodenal artery aneurysm due to celiac trunk occlusion. We report here our experience in the surgical treatment of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis over the last 5 years.
Representing 0.1-0.2% of all vessel aneurysms, aneurysms of the visceral arteries are rare.1 With only 2% of all aneurysms of the visceral arteries, aneurysm of the pancreaticoduodenal artery is a rarity.2 In 1895, Ferguson3 was the first to describe a case of an aneurysm of the pancreaticoduodenal artery. Since then, approximately 75 cases have been reported in the literature. Even though about 35% of all cases reported presented without rupture and were found incidentally or associated with abdominal pain, most accounts took place after rupture.4 Rupture of a pancreaticoduodenal artery aneurysm is associated with a high mortality of about 50% based on fatal bleeding in the retroperitoneum, intraperitoneally, or into the
gastrointestinal tract.4 Since the clinical appearance is rather unspecific, extensive diagnostics can be necessary. Computed tomographic (CT) scan, angiographic visualization, or CT angiography with vascular reconstruction is essential to obtain the correct diagnosis. Elimination of the aneurysm by ligature of the supplying arteries is the standard surgical procedure.5 Especially as an emergency intervention in rupture, endovascular catheter embolization is used as an alternative therapeutic option.6-8 Nevertheless, in patients with pancreaticoduodenal artery aneurysm in association with celiac trunk occlusion, surgical therapy should be favored because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to minor blood perfusion of the organs.
Department of Surgery, University of Schleswig-Holstein, Campus L€ ubeck, L€ ubeck, Germany.
PATIENTS AND METHODS
INTRODUCTION
Correspondence to: Philipp Hildebrand, MD, Department of Surgery, University of Schleswig-Holstein, Campus L€ ubeck, Ratzeburger Allee 160, D - 23538 L€ ubeck, Germany, E-mail: philipphildebrand@ yahoo.com Ann Vasc Surg 2007; 21: 10-15 DOI: 10.1016/j.avsg.2006.05.001 Ó Annals of Vascular Surgery Inc. Published online: January 12, 2007
10
The data on all patients who underwent surgery for pancreaticoduodenal artery aneurysms in association with occlusion or stenosis of the celiac trunk within a 5-year time period (2000-2005) were recorded prospectively and analyzed retrospectively with regard to age, sex, localization of aneurysm,
Vol. 21, No. 1, 2007
Pancreaticoduodenal artery aneurysm 11
diagnoses, clinical symptoms, type of procedure, intra- and postoperative complications, as well as postoperative course.
RESULTS During 2000e2005, three patients with pancreaticoduodenal artery aneurysms underwent surgical treatment. All showed simultaneous occlusion or stenosis of the celiac trunk on preoperative imaging. None had spontaneous rupture prior to operation. In all patients, duplex sonography for intraoperative assessment of blood perfusion was performed. In case of minor perfusion after ligation of the aneurysm, vascular reconstruction of the aneurysmal artery was preferred, to avoid ischemic complications. Case 1 A 66-year-old female patient was referred to our clinic within a surveillance program after mamma ablation for breast cancer, in which in an abdominal ultrasound of an echofree lesion with connection to the head of the pancreas was detected. On admission, the patient showed a good general condition with stable circulation as well as normal physical findings and laboratory parameters. CT scan revealed an aneurysmatic vessel close to the uncinate process and ventral to the vena cava. The process had a diameter of approximately 2.8 cm, suspected of being an aneurysm of a visceral artery originating from the celiac trunk. For precise assignment to one vessel, digital substraction angiography was performed. Aortography and mesenteric arteriography showed an uncleared occlusion of the celiac trunk and an ectatic mesenteric-celiac anastomosis with retrograde opacification of the hepatic, splenic, and left gastric arteries via the gastric duodenal artery. Filling of the aneurysm occurred in the early phase, most likely through the pancreaticoduodenal artery (Fig. 1). Based on the aneurysm size, location, and association with a celiac trunk occlusion, an elective surgical procedure was planned. Ligation of the supplying vessels and opening of the aneurysm was performed (Fig. 2). To avoid development of a pancreatic fistula, the aneurysm, which had direct contact with the capsule of the pancreas, remained untouched and was left in situ. Case 2 The second patient was a 53-year-old female patient known to have gallstone disease. Routine
Fig. 1. Mesenteric arteriography: filling of the aneurysm in the early phase (/), most likely through the inferior pancreaticoduodenal artery.
Fig. 2. Ligation of the supplying vessels and opening of the aneurysm (/).
abdominal ultrasound revealed an oval echo-free mass, suspected of being an aneurysm close to the superior mesenteric artery. The patient was referred to our hospital for extended diagnosis. On admission clinical examination, the patient presented a good general condition with stable circulation and a history of arterial hypertension. CT angiography showed an aneurysm of the pancreaticoduodenal artery 2.9 cm in diameter in close approximation to the outlet of the superior mesenteric artery (Fig. 3). Besides that, vascular reconstruction
12 Hildebrand et al.
Annals of Vascular Surgery
Fig. 3. CT scan: aneurysm of the pancreaticoduodenal artery (*) in close approximation to the superior mesenteric artery (/).
revealed a filiform stenosis of the celiac trunk with retrograde blood perfusion of the hepatic artery through the mesenteric-celiac arcade via the gastric duodenal artery (Fig. 4). Because of the close anatomic relation to the superior mesenteric artery as well as the additional retrograde blood supply of the liver based on a celiac trunk stenosis with high risk of minor perfusion, surgical treatment was mandatory. Resection of the aneurysm with vascular reconstruction of the pancreaticoduodenal artery by end-to-end anastomosis and additional cholecystectomy because of gallstone disease was performed. Case 3 The third patient was a 48-year-old female patient. She was admitted to our hospital with epigastric pain for several days. She had undergone appendectomy 20 years previously. Physical examination showed epigastric pain on palpation without abdominal guarding or peritonism. Blood analysis was normal except for a slight elevation of lactate dehydrogenase. Abdominal ultrasound showed an echo-free lesion close to the pancreas, which was suspected of being a visceral artery aneurysm. CT scan revealed an aneurysmatic vessel near the head of the pancreas with a diameter of 2.7 cm, suspected of being an aneurysm of the pancreaticoduodenal artery (Fig. 5). Celiac and mesenteric arteriography showed an aneurysm of the inferior pancreaticoduodenal artery and additional occlusion of the celiac trunk with enlarged gastroduodenal artery and retrograde opacification of the hepatic and splenic arteries. Because of the celiac
Fig. 4. Vascular reconstruction of CT angiography: stenosis of the celiac trunk with retrograde blood perfusion of the hepatic artery through the gastric duodenal artery (/).
trunk occlusion with retrograde opacification of the hepatic and splenic arteries, surgical management was preferred. Resection of the pancreaticoduodenal artery aneurysm with consecutive revascularization of the artery by end-to-end anastomosis was performed. In all patients, intraoperative vascular ultrasound showed good circulation of all visceral arteries, making revascularization of the celiac trunk unnecessary. No intra- or postoperative complications were observed. All patients could be discharged 4-6 days after operation.
Vol. 21, No. 1, 2007
Pancreaticoduodenal artery aneurysm 13
Fig. 5. CT scan: aneurysmatic vessel near the head of the pancreas with a diameter of approximately 2.7 cm (*), suspected of being an aneurysm of the pancreaticoduodenal artery.
DISCUSSION The first report of an aneurysm of the pancreaticoduodenal artery came from Ferguson in 1895.3 However, it took more than 50 years until the first description of a successfully treated patient with an aneurysm of the pancreaticoduodenal artery was made by Van Ouwerkerk in 1951.9 Since then, gradual improvements in CT and angiography have increased the possibility of localization and early treatment prior to rupture. Nevertheless, even today, most of these aneurysms rupture before they are detected, thus carrying a high mortality rate. The etiology of aneurysms in this anatomic region is variable. However, false (pseudoaneurysms) and true aneurysms of the pancreaticoduodenal artery have to be distinguished. False aneurysms are usually caused by infection (mycotic lesions, vasculitis), pancreatitis-related necrosis, or arterial wall erosion due to expansion of a pancreatic pseudocyst.6,7 Approximately 30% of aneurysms of the pancreaticoduodenal artery are pseudoaneurysms and can also develop after traumatic or iatrogenic vascular lesion and after biliary or gastroduodenal surgery.8 The development of true aneurysms of the pancreaticoduodenal artery is mostly explained by a hemodynamic theory first proposed by Sutton and Lawton in 1973.10 In contrast to aneurysms of the large vessels, arteriosclerosis is not likely to be the primary causative factor. The development of aneurysms in this region is rather caused by
increased blood flow through the pancreatic arcades due to stenosis or occlusion of the celiac trunk, like in our patients, leading to enlargement and dilatation of the pancreaticoduodenal artery and eventual development of an aneurysm.10-12 The same pathologic mechanism is postulated for aneurysm of the inferior mesenteric artery resulting from a syndromic occlusion of the celiac trunk and the superior mesenteric artery.13 In a few cases, other etiologic findings concerning true pancreaticoduodenal artery aneurysms in association with congenital aberration of the vessel or medial fibrodysplasia have been described.14,15 Upper abdominal pain is the most common symptom of aneurysms of the pancreaticoduodenal arteries, but in 50% of cases these aneurysms remain asymptomatic.4 The reported frequency of rupture is about 65% and mortality is up to 50%.4 The clinical picture is determined by the activity of the bleeding and the direction of rupture. Pancreaticoduodenal artery aneurysms rupture into the retroperitoneum or the peritoneal cavity with almost equal frequency.16,17 For diagnosis, ultrasound and CT are often helpful as they can provide important information concerning the location of the aneurysm and its relation to neighboring organs. Furthermore, other differential diagnoses of abdominal diseases can be excluded. To gain the right diagnosis and characterization of aneurysms of the visceral arteries, angiography is still an essential tool within the diagnostic armamentarium.16,18,19 In cases
14 Hildebrand et al.
with bleeding into the gastrointestinal tract (stomach, duodenum, and rarely biliary duct or pancreatic duct), endoscopy should be performed, even though the origin of the bleeding is often hard to detect.20 Because of the poor prognosis after rupture, treatment of pancreaticoduodenal artery aneurysms is mandatory even for asymptomatic patients.4,6,7 If possible, percutaneous transcatheter embolization of these aneurysms as a less invasive method should be attempted first.7,8 In these cases, this procedure can be used as a temporary measure7 as well as a definitive therapy in the majority of patients.8 Although coils are generally favored during catheter embolization, a variety of other materials have been used. Until now, no study comparing the safety and efficacy of these materials has been performed. Serious complications of this method, such as recurrence of bleeding due to incomplete arterial blockade or rupture of neighboring anatomic structures, have been reported only occasionally.21 Surgical therapy is always favored when catheter embolization is not possible, e.g., due to celiac trunk occlusion or other associated mesenteric vessel diseases, when hemodynamic instability of the patient precludes its accomplishment, or when diagnosis is unclear and the patient is actively bleeding.1,4,7 Especially in patients with additional celiac trunk occlusion or stenosis, surgical treatment should be performed because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to decreased blood perfusion. As seen in our cases, simple ligation of the entering and exiting vessels of the aneurysm can be sufficient. If good collateral circulation after elimination of the aneurysm is provided, vascular reconstruction is not required.1,22 Some surgeons have advocated treatment of the celiac trunk stenosis or occlusion which is the major cause of the development of pancreaticoduodenal artery aneurysms.12 In this case, one can perform direct revascularization of the celiac trunk (thromboendarterectomy with patch graft, continuity resection with an interposition graft, or reanastomosis and reimplantation of the artery) or bypass operations. However, no recurrence of pancreaticoduodenal artery aneurysms even in association with stenosis or occlusion of the celiac trunk is described after simple ligation or embolization; therefore, in our opinion, an additional vascular repair with increased operative risk is not necessary in principle. However, if there is an additional stenosis or occlusion of the celiac trunk, a critical intraoperative screening of the blood perfusion should be performed.12,18
Annals of Vascular Surgery
CONCLUSION Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. Because of the poor prognosis after rupture, treatment of pancreaticoduodenal artery aneurysms is mandatory even for asymptomatic patients. Surgical therapy is always favored in patients with additional celiac trunk occlusion or stenosis because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to decreased blood perfusion. REFERENCES 1. Van Berge Henegouwen DP, van Dongen RJAM. Aneurysmen der viszeralen Arterien. In: Heberer G, van Dongen RJAM, eds. Gefa¨ßchirurgie. Berlin: Springer, 1987, p 294. 2. Stanley JC, Wakefield TW, Graham LM, Whitehouse WM, Jr, Zelenock GB, Lindenauer SM. Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg 1986;3: 836-840. 3. Ferguson F. Aneurysm of the superior pancreaticoduodenalis, with perforation into the common bile duct. Proc N.Y. Pathol Soc 1895;24-36. 4. Iyomasa S, Matsuzaki Y, Hiei K, Sakaguchi H, Matsunaga H, Yamaguchi Y. Pancreaticoduodenal artery aneurysm: a case report and review of the literature. J Vasc Surg 1995;22: 161-166. 5. Stanley JC, Frey CF, Miller TA. Major arterial hemorrhage complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg 1976;111:45-51. 6. Granke K, Hollier LH, Bowen JC. Pancreaticoduodenal artery aneurysm: changing patterns. South Med J 1990;83: 918-921. 7. Stanley JC, Zelenoch GB. Splanchnic artery aneurysms. In: Rutherford RB, ed. Vascular Surgery. 4th ed. Philadelphia: Saunders, 1995, pp. 1124-1139. 8. Mandel SR, Jaques PF, Mauro MA, Sanofsky S. Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg 1987;205:126-128. 9. Van Ouwerkerk LW. Aneurysm of the arteria pancreaticoduodenalis. Arch Chir Neerl 1951;3:11-17. 10. Sutton D, Lawton G. Coeliac stenosis or occlusion with aneurysm of the collateral supply. Clin Radiol 1973;24: 49-53. 11. Kadir S, Athanasoulis CA, Yune HY, Wilkov H. Aneurysm of the pancreatico-duodenal arteries in association with celiac axis occlusion. Cardiovasc Intervent Radiol 1978;1:173-177. 12. Quandalle P, Chambon JP, Marache P, Saudemont A, Maes B. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Vasc Surg 1990;4:540-545. 13. Sugrue ME, Mehigan D, Hederman WP. Inferior mesenteric artery aneurysm. J Cardiovasc Surg 1990;3:380-381. 14. Woodward A, Purbey B, Williams H, Lewis MH. Two cases of aneurysm of the inferior pancreaticoduodenal artery: a review of treatment. J.R. Coll Edinb 1987;32:324-325. 15. Uher P, Nyman U, Ivancev K, Lindh M. Aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery. Abdom Imaging 1995;20:470-473. 16. Gangahar DM, Carveth SW, Reese HE, Buchman RJ, Breiner MA. True aneurysm of the pancreaticoduodenal
Vol. 21, No. 1, 2007
artery: a case report and review of the literature. J Vasc Surg 1985;2:741-742. 17. Neschis DG, Safford SD, Golden MA. Management of pancreaticoduodenal artery aneurysms presenting as catastrophic intraabdominal bleeding. Surgery 1998;128: 8-12. 18. Huttner S, Mrozek B. False ruptured aneurysm of the pancreaticoduodenal artery. A rare cause of duodenal stenosis. Chirurg 1991;62:217-220. 19. Leister I, Schlemminger P, Markus PM, Becker H. The bleeding pancreaticoduodenal artery aneurysm as a rare cause for
Pancreaticoduodenal artery aneurysm 15
upper gastrointestinal bleeding. Viszeralchirurgie 1999;34: 46-49. 20. Eckhauser FE, Stanley JC, Zelenock GB, Borlaza DT. Gastroduodenal and pancreaticoduodenal artery aneurysms: a complication of pancreatitis causing spontaneous gastrointestinal hemorrhage. Surgery 1980;88:335-342. 21. Khan KN, Nakata K, Shima M. Pancreatic tissue damage by transcatheter arterial embolization for hepatoma. Dig Dis Sci 1993;38:65-70. 22. Jonas J, Wraidlo W, Wittek M. Aneurysm of the pancreaticoduodenal artery. Chirurg 1988;59:50-53.
Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. They show a wide clinical spectrum, ranging from asymptomatic incidental findings to rupture-inducing catastrophic bleedings. Since growth progression and the risk of rupture cannot be foreseen and there is no relation between the size of the aneurysm and propensity to rupture, rupture unfortunately carries a high mortality, >50%. Thus, all aneurysms of the pancreaticoduodenal artery should be treated. The therapy of choice, either operative intervention or catheter embolization, is determined by many factors. Among these are localization, size, relation to other vessels and neighboring organs, the urgency of intervention, and the experience of the therapist. Surgical therapy should be favored in patients with pancreaticoduodenal artery aneurysm due to celiac trunk occlusion. We report here our experience in the surgical treatment of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis over the last 5 years.
Representing 0.1-0.2% of all vessel aneurysms, aneurysms of the visceral arteries are rare.1 With only 2% of all aneurysms of the visceral arteries, aneurysm of the pancreaticoduodenal artery is a rarity.2 In 1895, Ferguson3 was the first to describe a case of an aneurysm of the pancreaticoduodenal artery. Since then, approximately 75 cases have been reported in the literature. Even though about 35% of all cases reported presented without rupture and were found incidentally or associated with abdominal pain, most accounts took place after rupture.4 Rupture of a pancreaticoduodenal artery aneurysm is associated with a high mortality of about 50% based on fatal bleeding in the retroperitoneum, intraperitoneally, or into the
gastrointestinal tract.4 Since the clinical appearance is rather unspecific, extensive diagnostics can be necessary. Computed tomographic (CT) scan, angiographic visualization, or CT angiography with vascular reconstruction is essential to obtain the correct diagnosis. Elimination of the aneurysm by ligature of the supplying arteries is the standard surgical procedure.5 Especially as an emergency intervention in rupture, endovascular catheter embolization is used as an alternative therapeutic option.6-8 Nevertheless, in patients with pancreaticoduodenal artery aneurysm in association with celiac trunk occlusion, surgical therapy should be favored because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to minor blood perfusion of the organs.
Department of Surgery, University of Schleswig-Holstein, Campus L€ ubeck, L€ ubeck, Germany.
PATIENTS AND METHODS
INTRODUCTION
Correspondence to: Philipp Hildebrand, MD, Department of Surgery, University of Schleswig-Holstein, Campus L€ ubeck, Ratzeburger Allee 160, D - 23538 L€ ubeck, Germany, E-mail: philipphildebrand@ yahoo.com Ann Vasc Surg 2007; 21: 10-15 DOI: 10.1016/j.avsg.2006.05.001 Ó Annals of Vascular Surgery Inc. Published online: January 12, 2007
10
The data on all patients who underwent surgery for pancreaticoduodenal artery aneurysms in association with occlusion or stenosis of the celiac trunk within a 5-year time period (2000-2005) were recorded prospectively and analyzed retrospectively with regard to age, sex, localization of aneurysm,
Vol. 21, No. 1, 2007
Pancreaticoduodenal artery aneurysm 11
diagnoses, clinical symptoms, type of procedure, intra- and postoperative complications, as well as postoperative course.
RESULTS During 2000e2005, three patients with pancreaticoduodenal artery aneurysms underwent surgical treatment. All showed simultaneous occlusion or stenosis of the celiac trunk on preoperative imaging. None had spontaneous rupture prior to operation. In all patients, duplex sonography for intraoperative assessment of blood perfusion was performed. In case of minor perfusion after ligation of the aneurysm, vascular reconstruction of the aneurysmal artery was preferred, to avoid ischemic complications. Case 1 A 66-year-old female patient was referred to our clinic within a surveillance program after mamma ablation for breast cancer, in which in an abdominal ultrasound of an echofree lesion with connection to the head of the pancreas was detected. On admission, the patient showed a good general condition with stable circulation as well as normal physical findings and laboratory parameters. CT scan revealed an aneurysmatic vessel close to the uncinate process and ventral to the vena cava. The process had a diameter of approximately 2.8 cm, suspected of being an aneurysm of a visceral artery originating from the celiac trunk. For precise assignment to one vessel, digital substraction angiography was performed. Aortography and mesenteric arteriography showed an uncleared occlusion of the celiac trunk and an ectatic mesenteric-celiac anastomosis with retrograde opacification of the hepatic, splenic, and left gastric arteries via the gastric duodenal artery. Filling of the aneurysm occurred in the early phase, most likely through the pancreaticoduodenal artery (Fig. 1). Based on the aneurysm size, location, and association with a celiac trunk occlusion, an elective surgical procedure was planned. Ligation of the supplying vessels and opening of the aneurysm was performed (Fig. 2). To avoid development of a pancreatic fistula, the aneurysm, which had direct contact with the capsule of the pancreas, remained untouched and was left in situ. Case 2 The second patient was a 53-year-old female patient known to have gallstone disease. Routine
Fig. 1. Mesenteric arteriography: filling of the aneurysm in the early phase (/), most likely through the inferior pancreaticoduodenal artery.
Fig. 2. Ligation of the supplying vessels and opening of the aneurysm (/).
abdominal ultrasound revealed an oval echo-free mass, suspected of being an aneurysm close to the superior mesenteric artery. The patient was referred to our hospital for extended diagnosis. On admission clinical examination, the patient presented a good general condition with stable circulation and a history of arterial hypertension. CT angiography showed an aneurysm of the pancreaticoduodenal artery 2.9 cm in diameter in close approximation to the outlet of the superior mesenteric artery (Fig. 3). Besides that, vascular reconstruction
12 Hildebrand et al.
Annals of Vascular Surgery
Fig. 3. CT scan: aneurysm of the pancreaticoduodenal artery (*) in close approximation to the superior mesenteric artery (/).
revealed a filiform stenosis of the celiac trunk with retrograde blood perfusion of the hepatic artery through the mesenteric-celiac arcade via the gastric duodenal artery (Fig. 4). Because of the close anatomic relation to the superior mesenteric artery as well as the additional retrograde blood supply of the liver based on a celiac trunk stenosis with high risk of minor perfusion, surgical treatment was mandatory. Resection of the aneurysm with vascular reconstruction of the pancreaticoduodenal artery by end-to-end anastomosis and additional cholecystectomy because of gallstone disease was performed. Case 3 The third patient was a 48-year-old female patient. She was admitted to our hospital with epigastric pain for several days. She had undergone appendectomy 20 years previously. Physical examination showed epigastric pain on palpation without abdominal guarding or peritonism. Blood analysis was normal except for a slight elevation of lactate dehydrogenase. Abdominal ultrasound showed an echo-free lesion close to the pancreas, which was suspected of being a visceral artery aneurysm. CT scan revealed an aneurysmatic vessel near the head of the pancreas with a diameter of 2.7 cm, suspected of being an aneurysm of the pancreaticoduodenal artery (Fig. 5). Celiac and mesenteric arteriography showed an aneurysm of the inferior pancreaticoduodenal artery and additional occlusion of the celiac trunk with enlarged gastroduodenal artery and retrograde opacification of the hepatic and splenic arteries. Because of the celiac
Fig. 4. Vascular reconstruction of CT angiography: stenosis of the celiac trunk with retrograde blood perfusion of the hepatic artery through the gastric duodenal artery (/).
trunk occlusion with retrograde opacification of the hepatic and splenic arteries, surgical management was preferred. Resection of the pancreaticoduodenal artery aneurysm with consecutive revascularization of the artery by end-to-end anastomosis was performed. In all patients, intraoperative vascular ultrasound showed good circulation of all visceral arteries, making revascularization of the celiac trunk unnecessary. No intra- or postoperative complications were observed. All patients could be discharged 4-6 days after operation.
Vol. 21, No. 1, 2007
Pancreaticoduodenal artery aneurysm 13
Fig. 5. CT scan: aneurysmatic vessel near the head of the pancreas with a diameter of approximately 2.7 cm (*), suspected of being an aneurysm of the pancreaticoduodenal artery.
DISCUSSION The first report of an aneurysm of the pancreaticoduodenal artery came from Ferguson in 1895.3 However, it took more than 50 years until the first description of a successfully treated patient with an aneurysm of the pancreaticoduodenal artery was made by Van Ouwerkerk in 1951.9 Since then, gradual improvements in CT and angiography have increased the possibility of localization and early treatment prior to rupture. Nevertheless, even today, most of these aneurysms rupture before they are detected, thus carrying a high mortality rate. The etiology of aneurysms in this anatomic region is variable. However, false (pseudoaneurysms) and true aneurysms of the pancreaticoduodenal artery have to be distinguished. False aneurysms are usually caused by infection (mycotic lesions, vasculitis), pancreatitis-related necrosis, or arterial wall erosion due to expansion of a pancreatic pseudocyst.6,7 Approximately 30% of aneurysms of the pancreaticoduodenal artery are pseudoaneurysms and can also develop after traumatic or iatrogenic vascular lesion and after biliary or gastroduodenal surgery.8 The development of true aneurysms of the pancreaticoduodenal artery is mostly explained by a hemodynamic theory first proposed by Sutton and Lawton in 1973.10 In contrast to aneurysms of the large vessels, arteriosclerosis is not likely to be the primary causative factor. The development of aneurysms in this region is rather caused by
increased blood flow through the pancreatic arcades due to stenosis or occlusion of the celiac trunk, like in our patients, leading to enlargement and dilatation of the pancreaticoduodenal artery and eventual development of an aneurysm.10-12 The same pathologic mechanism is postulated for aneurysm of the inferior mesenteric artery resulting from a syndromic occlusion of the celiac trunk and the superior mesenteric artery.13 In a few cases, other etiologic findings concerning true pancreaticoduodenal artery aneurysms in association with congenital aberration of the vessel or medial fibrodysplasia have been described.14,15 Upper abdominal pain is the most common symptom of aneurysms of the pancreaticoduodenal arteries, but in 50% of cases these aneurysms remain asymptomatic.4 The reported frequency of rupture is about 65% and mortality is up to 50%.4 The clinical picture is determined by the activity of the bleeding and the direction of rupture. Pancreaticoduodenal artery aneurysms rupture into the retroperitoneum or the peritoneal cavity with almost equal frequency.16,17 For diagnosis, ultrasound and CT are often helpful as they can provide important information concerning the location of the aneurysm and its relation to neighboring organs. Furthermore, other differential diagnoses of abdominal diseases can be excluded. To gain the right diagnosis and characterization of aneurysms of the visceral arteries, angiography is still an essential tool within the diagnostic armamentarium.16,18,19 In cases
14 Hildebrand et al.
with bleeding into the gastrointestinal tract (stomach, duodenum, and rarely biliary duct or pancreatic duct), endoscopy should be performed, even though the origin of the bleeding is often hard to detect.20 Because of the poor prognosis after rupture, treatment of pancreaticoduodenal artery aneurysms is mandatory even for asymptomatic patients.4,6,7 If possible, percutaneous transcatheter embolization of these aneurysms as a less invasive method should be attempted first.7,8 In these cases, this procedure can be used as a temporary measure7 as well as a definitive therapy in the majority of patients.8 Although coils are generally favored during catheter embolization, a variety of other materials have been used. Until now, no study comparing the safety and efficacy of these materials has been performed. Serious complications of this method, such as recurrence of bleeding due to incomplete arterial blockade or rupture of neighboring anatomic structures, have been reported only occasionally.21 Surgical therapy is always favored when catheter embolization is not possible, e.g., due to celiac trunk occlusion or other associated mesenteric vessel diseases, when hemodynamic instability of the patient precludes its accomplishment, or when diagnosis is unclear and the patient is actively bleeding.1,4,7 Especially in patients with additional celiac trunk occlusion or stenosis, surgical treatment should be performed because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to decreased blood perfusion. As seen in our cases, simple ligation of the entering and exiting vessels of the aneurysm can be sufficient. If good collateral circulation after elimination of the aneurysm is provided, vascular reconstruction is not required.1,22 Some surgeons have advocated treatment of the celiac trunk stenosis or occlusion which is the major cause of the development of pancreaticoduodenal artery aneurysms.12 In this case, one can perform direct revascularization of the celiac trunk (thromboendarterectomy with patch graft, continuity resection with an interposition graft, or reanastomosis and reimplantation of the artery) or bypass operations. However, no recurrence of pancreaticoduodenal artery aneurysms even in association with stenosis or occlusion of the celiac trunk is described after simple ligation or embolization; therefore, in our opinion, an additional vascular repair with increased operative risk is not necessary in principle. However, if there is an additional stenosis or occlusion of the celiac trunk, a critical intraoperative screening of the blood perfusion should be performed.12,18
Annals of Vascular Surgery
CONCLUSION Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. Because of the poor prognosis after rupture, treatment of pancreaticoduodenal artery aneurysms is mandatory even for asymptomatic patients. Surgical therapy is always favored in patients with additional celiac trunk occlusion or stenosis because of the possible necessity of intraoperative vascular reconstruction due to poor collateral circulation leading to decreased blood perfusion. REFERENCES 1. Van Berge Henegouwen DP, van Dongen RJAM. Aneurysmen der viszeralen Arterien. In: Heberer G, van Dongen RJAM, eds. Gefa¨ßchirurgie. Berlin: Springer, 1987, p 294. 2. Stanley JC, Wakefield TW, Graham LM, Whitehouse WM, Jr, Zelenock GB, Lindenauer SM. Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg 1986;3: 836-840. 3. Ferguson F. Aneurysm of the superior pancreaticoduodenalis, with perforation into the common bile duct. Proc N.Y. Pathol Soc 1895;24-36. 4. Iyomasa S, Matsuzaki Y, Hiei K, Sakaguchi H, Matsunaga H, Yamaguchi Y. Pancreaticoduodenal artery aneurysm: a case report and review of the literature. J Vasc Surg 1995;22: 161-166. 5. Stanley JC, Frey CF, Miller TA. Major arterial hemorrhage complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg 1976;111:45-51. 6. Granke K, Hollier LH, Bowen JC. Pancreaticoduodenal artery aneurysm: changing patterns. South Med J 1990;83: 918-921. 7. Stanley JC, Zelenoch GB. Splanchnic artery aneurysms. In: Rutherford RB, ed. Vascular Surgery. 4th ed. Philadelphia: Saunders, 1995, pp. 1124-1139. 8. Mandel SR, Jaques PF, Mauro MA, Sanofsky S. Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg 1987;205:126-128. 9. Van Ouwerkerk LW. Aneurysm of the arteria pancreaticoduodenalis. Arch Chir Neerl 1951;3:11-17. 10. Sutton D, Lawton G. Coeliac stenosis or occlusion with aneurysm of the collateral supply. Clin Radiol 1973;24: 49-53. 11. Kadir S, Athanasoulis CA, Yune HY, Wilkov H. Aneurysm of the pancreatico-duodenal arteries in association with celiac axis occlusion. Cardiovasc Intervent Radiol 1978;1:173-177. 12. Quandalle P, Chambon JP, Marache P, Saudemont A, Maes B. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Vasc Surg 1990;4:540-545. 13. Sugrue ME, Mehigan D, Hederman WP. Inferior mesenteric artery aneurysm. J Cardiovasc Surg 1990;3:380-381. 14. Woodward A, Purbey B, Williams H, Lewis MH. Two cases of aneurysm of the inferior pancreaticoduodenal artery: a review of treatment. J.R. Coll Edinb 1987;32:324-325. 15. Uher P, Nyman U, Ivancev K, Lindh M. Aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery. Abdom Imaging 1995;20:470-473. 16. Gangahar DM, Carveth SW, Reese HE, Buchman RJ, Breiner MA. True aneurysm of the pancreaticoduodenal
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