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Hybrid Approach to Aneurysms of the Pancreaticoduodenal Artery Associated with Occlusion of the Celiac Axis
Case Report Hybrid Approach to Aneurysms of the Pancreaticoduodenal Artery Associated with Occlusion of the Celiac Axis Meryl A. Simon,1,2 Nasim Hedayati,1 and William C. Pevec,1 Sacramento, California
Pancreaticoduodenal artery aneurysms are uncommon but often associated with occlusion or absence of the celiac axis. This anatomic alteration makes management decisions challenging. Presented here are 2 cases of incidentally identified aneurysms, treated with a hybrid approach.
CASE REPORTS Case 1 A 39-year-old woman was found to have a 4-cm inferior pancreaticoduodenal artery aneurysm (PDAA) during work-up for abdominal pain. Her medical history included psoriatic arthritis and prior appendectomy. She was a Jehovah’s Witness and declined blood transfusion. Computed tomography (CT) and angiography showed absence of the celiac axis (Fig. 1A), with the pancreaticoduodenal artery (PDA) giving rise to the splenic and hepatic arteries via retrograde flow. A hybrid approach was undertaken to avoid hepatic and splenic ischemia after aneurysm exclusion. A guiding catheter was first placed into the superior mesenteric artery (SMA), and the inferior pancreaticoduodenal artery (IPDA) was selected with a 2.2 microcatheter over a 0.014-inch wire. Embolization was achieved with the use of 11 detachable platinum coils (Ruby Coil Embolization System, Penumbra, Alameda, CA) of various sizes (Fig. 1C). A 32 mm 60 cm coil was first placed to approximate a sphere with a diameter similar to that of the aneurysm, thus acting as a scaffold. This was followed by placement of both standard and soft coils ranging from 16 to
1 2
University of California Davis Medical Center, Sacramento, CA. David Grant USAF Medical Center, Travis Air Force Base, CA.
Correspondence to: William C. Pevec, 4860 Y Street, Suite 3400, Sacramento, CA 95817, USA; E-mail: [email protected] Ann Vasc Surg 2017; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2017.04.012 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: August 20, 2016; manuscript accepted: April 27, 2017; published online: - - -
28 mm by 50 to 60 cm to pack within the sac until the aneurysm was successfully occluded. A right subcostal incision was then made, and the infrarenal aorta and gastroduodenal artery (GDA) exposed. The GDA was divided and ligated. The right great saphenous vein was harvested. A retrograde bypass was constructed, anastomosing the proximal end of the reversed vein to the side to the infrarenal aorta and the distal end of the vein to the common hepatic artery at the orifice of the previously transected GDA. On postoperative CT and duplex imaging at 1 week, the aneurysm was fully excluded and the bypass was patent. She was most recently seen in follow-up 1 year postoperatively and was clinically doing well. Imaging confirmed bypass patency, and the plan will be yearly follow-up with duplex surveillance. Case 2 A 61-year-old woman was incidentally found to have multiple aneurysms of the pancreaticoduodenal arcade after undergoing CT imaging for minor trauma, the largest measuring 2 cm in diameter and appearing to arise from the IPDA. The patient’s medical history included coil embolization of a cerebral artery aneurysm, hypertension, hyperlipidemia, and asthma. On CT, the celiac axis was occluded, with the hepatic and splenic arteries filling via the pancreaticoduodenal arcade from the SMA (Fig. 2). A staged procedure was chosen. She underwent a descending thoracic aorta to celiac axis bypass with a 6-mm Dacron graft, via a left thoracoabdominal approach. The celiac axis was found to be heavily calcified and friable, and the distal anastomosis required multiple revisions with pledgets reinforcing all of the sutures. One month later, angiography was performed to assess bypass patency and to embolize the PDA aneurysms if the 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Images from case 1. Preoperative imaging of the aneurysm is seen in both the coronal view of the computed tomography (CT) scan (A) and the anteroposterior angiogram (B). The aneurysm was successfully coil embolized (C). Image (D) shows the proximal aspect of
the saphenous bypass (long white arrow) in relation to the duodenum (short white arrow), left renal vein (black arrow head ), aorta (white arrow head ), and inferior vena cava (black arrow).
aortoceliac bypass graft was patent. The bypass was patent, with a distal anastomotic stenosis. The splenic artery remained patent, but it was unclear if inflow came from the bypass or SMA collaterals. Via femoral artery puncture, the common hepatic artery was selectively catheterized, and the distal anastomosis of the aortoceliac graft dilated with a 3.5 40 mm balloon. Next, via the bypass graft, the superior PDA was selected with a 2.6F microcatheter over a 0.014-inch wire, and the second largest aneurysm was entered. Multiple detachable platinum coils (Ruby Coil Embolization System) of various sizes (14 mm 60 cm, 10 mm 35 cm, 5 mm 20 cm) were packed into the aneurysm sac. The SMA was selected next with a renal double-curved catheter. The largest aneurysm was accessed with a microcatheter over a 0.014-inch hydrophilic wire. Again, multiple coils of various sizes were packed into the sac. A total of 14 coils were used to fully embolize the 2 aneurysms (Fig. 3). On follow-up imaging 5 weeks later, both aneurysms
remained successfully embolized, but the aortoceliac bypass graft was occluded. The hepatic and splenic vessels filled via persistent posterior pancreaticoduodenal branches from the SMA. The patient was asymptomatic. On most recent follow-up 18 months’ postintervention, she continues to do well clinically. Her imaging shows the occluded bypass, with persistent collaterals giving rise to the hepatic and splenic arteries. The residual small aneurysms remain unchanged in size. The plan is for annual CT imaging surveillance.
DISCUSSION Visceral artery aneurysms are rare, occurring at a rate of 0.1e0.2% of all aneurysms. True aneurysms of the pancreaticoduodenal arcade are even less common, making up only 2% of all splanchnic artery aneurysms.1,2 Spontaneous PDAAs commonly
Volume
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2017
Fig. 2. The preoperative CT scan of the patient from case 2. The sagittal view shows the occluded celiac axis, patent SMA, and the large pancreaticoduodenal artery aneurysm.
Fig. 3. This angiographic image from the patient in case 2 shows the patent aortoceliac bypass graft along with one of the successfully coil-embolized aneurysms.
Case Report 3
occur in association with significant stenosis or occlusions of the mesenteric vessels, most frequently with the celiac axis. This may be due to atherosclerotic disease, median arcuate ligament syndrome, or congenital absence of the celiac axis, as seen in our first patient.3 Association with stenosis of the SMA has also been reported.2 These aneurysms are likely a result of altered hemodynamics. As the pancreaticoduodenal arcade is the major collateral source between the celiac axis and the SMA, when a stenosis or occlusion of either artery exists, there is persistently elevated blood flow through this arcade. With the increased flow, these collateral arteries dilate over time, likely causing the fragile arteries to weaken and leading to eventual aneurysmal degeneration.4 The risk of rupture of these aneurysms does not seem to correlate with arterial diameter. Case reports of rupture include pancreaticoduodenal aneurysms as small as 8 millimeters in diameter.5 Clinical presentation varies from an incidental imaging finding, such as presented here, vague abdominal pain, to rupture and potentially life-threatening hemorrhage. For these reasons, treatment should be expeditiously undertaken once the diagnosis is made. The choice of technique should address the coexisting problems: treatment of the aneurysm to prevent rupture and preservation of blood flow (most often to the celiac territory and occasionally the SMA distribution). Treatment will also theoretically alter the hemodynamic abnormality, potentially preventing future aneurysmal degeneration. No guidelines exist for management of this condition. Other case reports have described a variety of options, including no treatmentdchosen for a poor surgical candidate in a case report in 1990, resulting in death secondary to hemorrhage,6 surgical management (bypass and aneurysm ligation), and endovascular management (transcatheter embolization). The endovascular techniques described in most case reports discuss embolization of a branch vessel of the pancreaticoduodenal arcade, such as the anterior or posterior branch of the PDA. This strategy is appropriate for cases where the remainder of the arcade is still intact. Embolization of the inferior or superior PDA itself has also been described, but in cases with celiac stenosis not complete occlusion. Aneurysm ablation, if within the main PDA, without concurrent revascularization would risk hepatic and biliary ischemia. Endovascular only approaches also fail to address the altered hemodynamics that led to aneurysm formation in the first place.
4 Case Report
The surgical only approach does solve both problems but requires extensive exposure and dissection to identify and ligate the aneurysm. In instances of aneurysm rupture, several case reports described performing a pancreaticoduodenectomy for hemorrhage control.6 There have been multiple case reports of endovascular aneurysm management combined with laparotomy for open division of the median arcuate ligament in cases of median arcuate ligament compression syndrome. Review of the literature found only a single case report of a hybrid approach to this problem. Teng et al. described a patient who presented with a ruptured pancreaticoduodenal aneurysm. They began by performing aortohepatic and aorto-SMA bypasses, followed by aneurysm coiling the following day.7 Two patients are presented who were found incidentally to have celiac axis occlusion/absence and PDAAs on abdominal imaging. The first patient’s aneurysm came directly from the IPDA, yet the second patient’s anatomy was difficult to determine from imaging. We propose that it is safer to reconstruct first with cases of uncertainty to avoid foregut ischemia. Although the second patient’s bypass failure was disappointing, she fortunately had a remaining intact posterior arcade to provide collateral circulation. This hybrid approach allows for a minimally invasive technique for aneurysm
Annals of Vascular Surgery
management, while addressing revascularization needs when the aneurysm does involve the main arcade branch. Revascularization also, in theory, corrects the altered hemodynamics that lead to aneurysm formation.
REFERENCES 1. Kobayashi T, Uenoyama S, Isogai S. Successful transcatheter arterial embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac axis stenosis. J Gastroenterol Hepatol 2004;19:599e601. 2. Ikoma A, Nakai M, Sato M, et al. Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement. World J Radiol 2012;4:387e90. 3. Ogino H, Sato Y, Banno T, et al. Embolization in a patient with ruptured anterior inferior pancreaticoduodenal arterial aneurysm with median arcuate ligament syndrome. Cardiovasc Intervent Radiol 2002;25:318e9. 4. Turkvatan A, Turkoglu MA, Yener O. CT angiography diagnosis of inferior pancreaticoduodenal artery aneurysm in association with celiac artery occlusion. Pancreatology 2013;13:314e5. 5. Ducasse E, Roy F, Chevalier J, et al. Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: current management. J Vasc Surg 2004;39:906e11. 6. Quandalle P, Chambon JP, Marache P, et al. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Vasc Surg 1990;4:540e5. 7. Teng W, Sarfati MR, Mueller MT, et al. A ruptured pancreaticoduodenal artery aneurysm repaired by combined endovascular and open techniques. Ann Vasc Surg 2006;20:792e5.
Pancreaticoduodenal artery aneurysms are uncommon but often associated with occlusion or absence of the celiac axis. This anatomic alteration makes management decisions challenging. Presented here are 2 cases of incidentally identified aneurysms, treated with a hybrid approach.
CASE REPORTS Case 1 A 39-year-old woman was found to have a 4-cm inferior pancreaticoduodenal artery aneurysm (PDAA) during work-up for abdominal pain. Her medical history included psoriatic arthritis and prior appendectomy. She was a Jehovah’s Witness and declined blood transfusion. Computed tomography (CT) and angiography showed absence of the celiac axis (Fig. 1A), with the pancreaticoduodenal artery (PDA) giving rise to the splenic and hepatic arteries via retrograde flow. A hybrid approach was undertaken to avoid hepatic and splenic ischemia after aneurysm exclusion. A guiding catheter was first placed into the superior mesenteric artery (SMA), and the inferior pancreaticoduodenal artery (IPDA) was selected with a 2.2 microcatheter over a 0.014-inch wire. Embolization was achieved with the use of 11 detachable platinum coils (Ruby Coil Embolization System, Penumbra, Alameda, CA) of various sizes (Fig. 1C). A 32 mm 60 cm coil was first placed to approximate a sphere with a diameter similar to that of the aneurysm, thus acting as a scaffold. This was followed by placement of both standard and soft coils ranging from 16 to
1 2
University of California Davis Medical Center, Sacramento, CA. David Grant USAF Medical Center, Travis Air Force Base, CA.
Correspondence to: William C. Pevec, 4860 Y Street, Suite 3400, Sacramento, CA 95817, USA; E-mail: [email protected] Ann Vasc Surg 2017; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2017.04.012 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: August 20, 2016; manuscript accepted: April 27, 2017; published online: - - -
28 mm by 50 to 60 cm to pack within the sac until the aneurysm was successfully occluded. A right subcostal incision was then made, and the infrarenal aorta and gastroduodenal artery (GDA) exposed. The GDA was divided and ligated. The right great saphenous vein was harvested. A retrograde bypass was constructed, anastomosing the proximal end of the reversed vein to the side to the infrarenal aorta and the distal end of the vein to the common hepatic artery at the orifice of the previously transected GDA. On postoperative CT and duplex imaging at 1 week, the aneurysm was fully excluded and the bypass was patent. She was most recently seen in follow-up 1 year postoperatively and was clinically doing well. Imaging confirmed bypass patency, and the plan will be yearly follow-up with duplex surveillance. Case 2 A 61-year-old woman was incidentally found to have multiple aneurysms of the pancreaticoduodenal arcade after undergoing CT imaging for minor trauma, the largest measuring 2 cm in diameter and appearing to arise from the IPDA. The patient’s medical history included coil embolization of a cerebral artery aneurysm, hypertension, hyperlipidemia, and asthma. On CT, the celiac axis was occluded, with the hepatic and splenic arteries filling via the pancreaticoduodenal arcade from the SMA (Fig. 2). A staged procedure was chosen. She underwent a descending thoracic aorta to celiac axis bypass with a 6-mm Dacron graft, via a left thoracoabdominal approach. The celiac axis was found to be heavily calcified and friable, and the distal anastomosis required multiple revisions with pledgets reinforcing all of the sutures. One month later, angiography was performed to assess bypass patency and to embolize the PDA aneurysms if the 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Images from case 1. Preoperative imaging of the aneurysm is seen in both the coronal view of the computed tomography (CT) scan (A) and the anteroposterior angiogram (B). The aneurysm was successfully coil embolized (C). Image (D) shows the proximal aspect of
the saphenous bypass (long white arrow) in relation to the duodenum (short white arrow), left renal vein (black arrow head ), aorta (white arrow head ), and inferior vena cava (black arrow).
aortoceliac bypass graft was patent. The bypass was patent, with a distal anastomotic stenosis. The splenic artery remained patent, but it was unclear if inflow came from the bypass or SMA collaterals. Via femoral artery puncture, the common hepatic artery was selectively catheterized, and the distal anastomosis of the aortoceliac graft dilated with a 3.5 40 mm balloon. Next, via the bypass graft, the superior PDA was selected with a 2.6F microcatheter over a 0.014-inch wire, and the second largest aneurysm was entered. Multiple detachable platinum coils (Ruby Coil Embolization System) of various sizes (14 mm 60 cm, 10 mm 35 cm, 5 mm 20 cm) were packed into the aneurysm sac. The SMA was selected next with a renal double-curved catheter. The largest aneurysm was accessed with a microcatheter over a 0.014-inch hydrophilic wire. Again, multiple coils of various sizes were packed into the sac. A total of 14 coils were used to fully embolize the 2 aneurysms (Fig. 3). On follow-up imaging 5 weeks later, both aneurysms
remained successfully embolized, but the aortoceliac bypass graft was occluded. The hepatic and splenic vessels filled via persistent posterior pancreaticoduodenal branches from the SMA. The patient was asymptomatic. On most recent follow-up 18 months’ postintervention, she continues to do well clinically. Her imaging shows the occluded bypass, with persistent collaterals giving rise to the hepatic and splenic arteries. The residual small aneurysms remain unchanged in size. The plan is for annual CT imaging surveillance.
DISCUSSION Visceral artery aneurysms are rare, occurring at a rate of 0.1e0.2% of all aneurysms. True aneurysms of the pancreaticoduodenal arcade are even less common, making up only 2% of all splanchnic artery aneurysms.1,2 Spontaneous PDAAs commonly
Volume
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2017
Fig. 2. The preoperative CT scan of the patient from case 2. The sagittal view shows the occluded celiac axis, patent SMA, and the large pancreaticoduodenal artery aneurysm.
Fig. 3. This angiographic image from the patient in case 2 shows the patent aortoceliac bypass graft along with one of the successfully coil-embolized aneurysms.
Case Report 3
occur in association with significant stenosis or occlusions of the mesenteric vessels, most frequently with the celiac axis. This may be due to atherosclerotic disease, median arcuate ligament syndrome, or congenital absence of the celiac axis, as seen in our first patient.3 Association with stenosis of the SMA has also been reported.2 These aneurysms are likely a result of altered hemodynamics. As the pancreaticoduodenal arcade is the major collateral source between the celiac axis and the SMA, when a stenosis or occlusion of either artery exists, there is persistently elevated blood flow through this arcade. With the increased flow, these collateral arteries dilate over time, likely causing the fragile arteries to weaken and leading to eventual aneurysmal degeneration.4 The risk of rupture of these aneurysms does not seem to correlate with arterial diameter. Case reports of rupture include pancreaticoduodenal aneurysms as small as 8 millimeters in diameter.5 Clinical presentation varies from an incidental imaging finding, such as presented here, vague abdominal pain, to rupture and potentially life-threatening hemorrhage. For these reasons, treatment should be expeditiously undertaken once the diagnosis is made. The choice of technique should address the coexisting problems: treatment of the aneurysm to prevent rupture and preservation of blood flow (most often to the celiac territory and occasionally the SMA distribution). Treatment will also theoretically alter the hemodynamic abnormality, potentially preventing future aneurysmal degeneration. No guidelines exist for management of this condition. Other case reports have described a variety of options, including no treatmentdchosen for a poor surgical candidate in a case report in 1990, resulting in death secondary to hemorrhage,6 surgical management (bypass and aneurysm ligation), and endovascular management (transcatheter embolization). The endovascular techniques described in most case reports discuss embolization of a branch vessel of the pancreaticoduodenal arcade, such as the anterior or posterior branch of the PDA. This strategy is appropriate for cases where the remainder of the arcade is still intact. Embolization of the inferior or superior PDA itself has also been described, but in cases with celiac stenosis not complete occlusion. Aneurysm ablation, if within the main PDA, without concurrent revascularization would risk hepatic and biliary ischemia. Endovascular only approaches also fail to address the altered hemodynamics that led to aneurysm formation in the first place.
4 Case Report
The surgical only approach does solve both problems but requires extensive exposure and dissection to identify and ligate the aneurysm. In instances of aneurysm rupture, several case reports described performing a pancreaticoduodenectomy for hemorrhage control.6 There have been multiple case reports of endovascular aneurysm management combined with laparotomy for open division of the median arcuate ligament in cases of median arcuate ligament compression syndrome. Review of the literature found only a single case report of a hybrid approach to this problem. Teng et al. described a patient who presented with a ruptured pancreaticoduodenal aneurysm. They began by performing aortohepatic and aorto-SMA bypasses, followed by aneurysm coiling the following day.7 Two patients are presented who were found incidentally to have celiac axis occlusion/absence and PDAAs on abdominal imaging. The first patient’s aneurysm came directly from the IPDA, yet the second patient’s anatomy was difficult to determine from imaging. We propose that it is safer to reconstruct first with cases of uncertainty to avoid foregut ischemia. Although the second patient’s bypass failure was disappointing, she fortunately had a remaining intact posterior arcade to provide collateral circulation. This hybrid approach allows for a minimally invasive technique for aneurysm
Annals of Vascular Surgery
management, while addressing revascularization needs when the aneurysm does involve the main arcade branch. Revascularization also, in theory, corrects the altered hemodynamics that lead to aneurysm formation.
REFERENCES 1. Kobayashi T, Uenoyama S, Isogai S. Successful transcatheter arterial embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac axis stenosis. J Gastroenterol Hepatol 2004;19:599e601. 2. Ikoma A, Nakai M, Sato M, et al. Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement. World J Radiol 2012;4:387e90. 3. Ogino H, Sato Y, Banno T, et al. Embolization in a patient with ruptured anterior inferior pancreaticoduodenal arterial aneurysm with median arcuate ligament syndrome. Cardiovasc Intervent Radiol 2002;25:318e9. 4. Turkvatan A, Turkoglu MA, Yener O. CT angiography diagnosis of inferior pancreaticoduodenal artery aneurysm in association with celiac artery occlusion. Pancreatology 2013;13:314e5. 5. Ducasse E, Roy F, Chevalier J, et al. Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: current management. J Vasc Surg 2004;39:906e11. 6. Quandalle P, Chambon JP, Marache P, et al. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Vasc Surg 1990;4:540e5. 7. Teng W, Sarfati MR, Mueller MT, et al. A ruptured pancreaticoduodenal artery aneurysm repaired by combined endovascular and open techniques. Ann Vasc Surg 2006;20:792e5.