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Abdominal Aortic Pseudoaneurysm Associated with Chronic Pancreatitis
EJVES Extra 9, 46–48 (2005) doi:10.1016/j.ejvsextra.2005.02.007, available online at http://www.sciencedirect.com on
SHORT REPORT
Abdominal Aortic Pseudoaneurysm Associated with Chronic Pancreatitis H. Takagi,* H. Manabe, S. Sekino, T. Kato, Y. Matsuno and T. Umemoto Department of Cardiovascular Surgery, Sizuoka Medical Center, Shizuoka, Japan Chronic pancreatitis is a common cause of splenic artery pseudoaneurysm. An abdominal aortic pseudoaneurysm associated with pancreatitis is extremely rare and thus far only seen in an acute exacerbation of chronic pancreatitis with multiple fluid collections in the retroperitoneum. We describe an abdominal aortic pseudoaneurysm associated with chronic pancreatitis without acute inflammation. This was successfully treated with a prosthetic tube graft. Keywords: Abdominal aortic pseudoaneurysm; Chronic pancreatitis.
Introduction Although pancreatitis or pancreatic pseudocyst is a common cause of splenic artery pseudoaneurysm,1 abdominal aortic pseudoaneurysm associated with pancreatitis is extremely rare. Only three cases2–4 have been found in the literature, and they presented with multiple fluid collections in the retroperitoneum,2 multiple pancreatic pseudocysts, 3 and an acute exacerbation of chronic pancreatitis.4 We describe abdominal aortic pseudoaneurysm associated with chronic pancreatitis without acute inflammation.
Case Report A 63-year-old man on medication for diabetes mellitus presented with a chronic and dull back pain for more than 10 years. He had a history of significant alcohol intake. There was no history of abdominal trauma. Computed tomography scanning showed calcification of the pancreatic head (Fig. 1A) and a saccular aneurysm of the infrarenal abdominal aorta (Fig. 1B). Aortography revealed a loculated infrarenal abdominal aortic aneurysm (Fig. 2). White blood cell count, C* Corresponding author. H. Takagi, MD, PhD, Department of Cardiovascular Surgery, Sizuoka Medical Center, 762-1 Nagasawa, Shimizu-cho, Sunto-gun, Shizuoka 411-8611, Japan. E-mail address: [email protected]
reactive protein, total bilirubin, glutamine–oxaloacetic transaminase, glutamic–pyruvic transaminase, lactate dehydrogenase, alkaline phosphatase, serum amylase, elastase 1, and lipase were all within normal limits. Treponema pallidum hemagglutination test was negative. Only gamma-glutamyl transpeptidase was increased to 100 (%40) mU/mL. The patient was diagnosed as abdominal aortic pseudoaneurysm associated with chronic pancreatitis, and replacement of the aneurysm with a prosthetic tube graft was successfully performed. Although there was adhesion between the aneurysm and the retroperitoneum probably due to chronic inflammation, neither ongoing inflammation nor abscess was confirmed. Although microbiological studies were not performed, histopathological examination of the aneurysmal wall showed a false aneurysm without infection. The postoperative course was uneventful without graft infection.
Discussion Arterial lesions related to pancreatitis are predominantly localized in the splenic artery (in 42%) and the gastroduodenal artery (in 22%,) but are also found on small pancreatic vessels (in 25%).5 Rarer lesions affected the hepatic artery, superior mesenteric artery, and more distant vessels such as the gastric arteries,
1533–3167/000046 + 03 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.
AAA with Pancreatitis
47
Fig. 1. Computed tomography scanning disclosed calcification of the pancreatic head (panel A) and a saccular aneurysm of the infrarenal abdominal aorta (panel B).
jejunal arteries, ileo-caeco-appendicular arteries, and left renal artery. The abdominal aorta is seldom involved, and very few cases of pseudoaneurysm2,4 or mycotic aneurysm 3 have been found in the literature. The present case had had no acute exacerbation of chronic pancreatitis during the history, and neither fluid collection in the retroperitoneum,
pancreatic pseudocysts, nor retroperitoneal abscess was found when the psuedoaneurysm was diagnosed. The proposed mechanism of formation of abdominal aortic psuedoaneurysms involves the release of proteolytic pancreatic enzymes, particularly trypsin and elastase, into the periaortic space with subsequent enzymatic digestion of the aortic wall, and this autodigestion may then weaken the aortic wall sufficiently to allow aneurysmal changes to occur.2 The optimal management of abdominal aortic psuedoaneurysm associated with pancreatitis remains controversial because of its rarity. In the reported cases, the pseudoaneurysm was resected and bypassed with an axillofemoral–femorofemoral graft,2 the mycotic aneurysm was resected and replaced in situ with a cryopreserved aortic allograft,3 and the pseudoaneurysm was excluded using a Zenith aortomonoiliac endovascular graft with a Dacron femorofemoral crossover graft.4 In the present case, though the psuedoaneurysm was replaced in situ with a prosthetic graft because of neither infection nor acute inflammation in the periaorta, long-term follow-up is mandatory to ensure no evidence of graft sepsis.
References
Fig. 2. Aortography revealed a loculated infrarenal abdominal aortic aneurysm.
1 Tessier DJ, Stone WM, Fowl RJ, Abbas MA, Andrews JC, Bower TC et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg 2003;38:69–74. EJVES Extra Vol 9, March 2005
48
H. Takagi et al.
2 Giles RA, Pevec WC. Aortic pseudoaneurysm secondary to pancreatitis. J Vasc Surg 2000;31:1056–1059. 3 Knosalla C, Bauer M, Weng Y, Weidemann H, Hetzer R et al. Complicated chronic pancreatitis causing mycotic aortic aneurysm: in situ replacement with a cryopreserved aortic allograft. J Vasc Surg 2000;32:1034–1037. 4 Hinchliffe RJ, Yung M, Hopkinson BR. Endovascular exclusion of a ruptured pseudoaneurysm of the infrarenal abdominal aorta secondary to pancreatitis. J Endovasc Ther 2002;9:590–592.
EJVES Extra Vol 9, March 2005
5 Boudghe`ne F, L’Hermine´ C, Bigot J-M. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 1993;4:551–558. Accepted 10 February 2005
SHORT REPORT
Abdominal Aortic Pseudoaneurysm Associated with Chronic Pancreatitis H. Takagi,* H. Manabe, S. Sekino, T. Kato, Y. Matsuno and T. Umemoto Department of Cardiovascular Surgery, Sizuoka Medical Center, Shizuoka, Japan Chronic pancreatitis is a common cause of splenic artery pseudoaneurysm. An abdominal aortic pseudoaneurysm associated with pancreatitis is extremely rare and thus far only seen in an acute exacerbation of chronic pancreatitis with multiple fluid collections in the retroperitoneum. We describe an abdominal aortic pseudoaneurysm associated with chronic pancreatitis without acute inflammation. This was successfully treated with a prosthetic tube graft. Keywords: Abdominal aortic pseudoaneurysm; Chronic pancreatitis.
Introduction Although pancreatitis or pancreatic pseudocyst is a common cause of splenic artery pseudoaneurysm,1 abdominal aortic pseudoaneurysm associated with pancreatitis is extremely rare. Only three cases2–4 have been found in the literature, and they presented with multiple fluid collections in the retroperitoneum,2 multiple pancreatic pseudocysts, 3 and an acute exacerbation of chronic pancreatitis.4 We describe abdominal aortic pseudoaneurysm associated with chronic pancreatitis without acute inflammation.
Case Report A 63-year-old man on medication for diabetes mellitus presented with a chronic and dull back pain for more than 10 years. He had a history of significant alcohol intake. There was no history of abdominal trauma. Computed tomography scanning showed calcification of the pancreatic head (Fig. 1A) and a saccular aneurysm of the infrarenal abdominal aorta (Fig. 1B). Aortography revealed a loculated infrarenal abdominal aortic aneurysm (Fig. 2). White blood cell count, C* Corresponding author. H. Takagi, MD, PhD, Department of Cardiovascular Surgery, Sizuoka Medical Center, 762-1 Nagasawa, Shimizu-cho, Sunto-gun, Shizuoka 411-8611, Japan. E-mail address: [email protected]
reactive protein, total bilirubin, glutamine–oxaloacetic transaminase, glutamic–pyruvic transaminase, lactate dehydrogenase, alkaline phosphatase, serum amylase, elastase 1, and lipase were all within normal limits. Treponema pallidum hemagglutination test was negative. Only gamma-glutamyl transpeptidase was increased to 100 (%40) mU/mL. The patient was diagnosed as abdominal aortic pseudoaneurysm associated with chronic pancreatitis, and replacement of the aneurysm with a prosthetic tube graft was successfully performed. Although there was adhesion between the aneurysm and the retroperitoneum probably due to chronic inflammation, neither ongoing inflammation nor abscess was confirmed. Although microbiological studies were not performed, histopathological examination of the aneurysmal wall showed a false aneurysm without infection. The postoperative course was uneventful without graft infection.
Discussion Arterial lesions related to pancreatitis are predominantly localized in the splenic artery (in 42%) and the gastroduodenal artery (in 22%,) but are also found on small pancreatic vessels (in 25%).5 Rarer lesions affected the hepatic artery, superior mesenteric artery, and more distant vessels such as the gastric arteries,
1533–3167/000046 + 03 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.
AAA with Pancreatitis
47
Fig. 1. Computed tomography scanning disclosed calcification of the pancreatic head (panel A) and a saccular aneurysm of the infrarenal abdominal aorta (panel B).
jejunal arteries, ileo-caeco-appendicular arteries, and left renal artery. The abdominal aorta is seldom involved, and very few cases of pseudoaneurysm2,4 or mycotic aneurysm 3 have been found in the literature. The present case had had no acute exacerbation of chronic pancreatitis during the history, and neither fluid collection in the retroperitoneum,
pancreatic pseudocysts, nor retroperitoneal abscess was found when the psuedoaneurysm was diagnosed. The proposed mechanism of formation of abdominal aortic psuedoaneurysms involves the release of proteolytic pancreatic enzymes, particularly trypsin and elastase, into the periaortic space with subsequent enzymatic digestion of the aortic wall, and this autodigestion may then weaken the aortic wall sufficiently to allow aneurysmal changes to occur.2 The optimal management of abdominal aortic psuedoaneurysm associated with pancreatitis remains controversial because of its rarity. In the reported cases, the pseudoaneurysm was resected and bypassed with an axillofemoral–femorofemoral graft,2 the mycotic aneurysm was resected and replaced in situ with a cryopreserved aortic allograft,3 and the pseudoaneurysm was excluded using a Zenith aortomonoiliac endovascular graft with a Dacron femorofemoral crossover graft.4 In the present case, though the psuedoaneurysm was replaced in situ with a prosthetic graft because of neither infection nor acute inflammation in the periaorta, long-term follow-up is mandatory to ensure no evidence of graft sepsis.
References
Fig. 2. Aortography revealed a loculated infrarenal abdominal aortic aneurysm.
1 Tessier DJ, Stone WM, Fowl RJ, Abbas MA, Andrews JC, Bower TC et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg 2003;38:69–74. EJVES Extra Vol 9, March 2005
48
H. Takagi et al.
2 Giles RA, Pevec WC. Aortic pseudoaneurysm secondary to pancreatitis. J Vasc Surg 2000;31:1056–1059. 3 Knosalla C, Bauer M, Weng Y, Weidemann H, Hetzer R et al. Complicated chronic pancreatitis causing mycotic aortic aneurysm: in situ replacement with a cryopreserved aortic allograft. J Vasc Surg 2000;32:1034–1037. 4 Hinchliffe RJ, Yung M, Hopkinson BR. Endovascular exclusion of a ruptured pseudoaneurysm of the infrarenal abdominal aorta secondary to pancreatitis. J Endovasc Ther 2002;9:590–592.
EJVES Extra Vol 9, March 2005
5 Boudghe`ne F, L’Hermine´ C, Bigot J-M. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 1993;4:551–558. Accepted 10 February 2005