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

Abstract

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

Keywords: Celiac axis stenosis; Median arcuate ligament syndrome; Pancreaticoduodenal artery aneurysms.

Fig 1

Preoperative computed tomography (CT) and intraoperative superior mesenteric artery (SMA) angiography. A, Enhanced CT showed significant stenosis of the celiac axis root origin and post-stenotic dilation, most likely because of median arcuate ligament syndrome (MALS) compression (arrow). B, CT showed a large retroperitoneal hematoma (peripancreatic and periduodenal; arrow) induced by rupture of multiple visceral artery aneurysms (asterisks). C, Angiography showed two 6-mm ruptured aneurysms (black arrows) and multiple pancreaticoduodenal artery arcade aneurysms (PDAAs; white arrows).

Fig 2

Comparison of the follow-up three-dimensional computed tomography (CT) image after the initial embolization. A, CT image immediately after the initial embolization showing two ruptured aneurysms (open arrows). B, Follow-up CT image at 1 month showing rapidly expanding aneurysm formation of the residual pancreaticoduodenal artery arcade aneurysms (PDAAs; arrow) and a new left gastric artery dissection (asterisk).

Fig 3

Selective superior mesenteric artery (SMA) angiogram shows retrograde blood flow through the peripancreatic arcade from the SMA to the common hepatic artery (arrow) and splenic artery (asterisk) before ligament resection.

Fig 4

Superior mesenteric artery (SMA) and aorta angiography after the bypass. A, After aorta-common hepatic artery bypass, retrograde flow from the SMA is decreased. B, The aortogram shows antegrade blood flow from infrarenal aorta to the common hepatic artery by bypass.

Fig 5

Postoperative follow-up three-dimensional computed tomography (CT) 7 days later shows regression of the pancreaticoduodenal artery (PDA) arcade (arrow).