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Case Reports
. 2022 Mar 30:55:42-46.
doi: 10.1016/j.ejvsvf.2022.03.005. eCollection 2022.

Ruptured Pancreaticoduodenal Artery Aneurysm with Median Arcuate Ligament Compression: A Two Staged Approach to Management

Laura Casey  1 , Sivakumar Gananadha  1   2 , Alister Jones  3   2
Affiliations
Case Reports

Ruptured Pancreaticoduodenal Artery Aneurysm with Median Arcuate Ligament Compression: A Two Staged Approach to Management

Laura Casey et al. EJVES Vasc Forum. .

Abstract

Introduction: Pancreaticoduodenal artery (PDA) aneurysms represent a small portion of rare visceral artery aneurysms. Rupture of these aneurysms results in fatal haemorrhage in up to 50% of cases, necessitating prompt endovascular or open intervention. As highlighted by a recent retrospective review, median arcuate ligament (MAL) release is an important part of management when these aneurysms are diagnosed in conjunction with median arcuate ligament compression (MALC). Two cases of successful urgent management of a ruptured inferior pancreatoduodenal artery aneurysm with staged MAL release are reported.

Report: A 65 year old male presented with a ruptured PDA aneurysm in the context of MALC. The patient was treated by emergency transcatheter arterial embolisation (TAE). Staged laparoscopic MAL release required open conversion and stenting one month after rupture. A 73 year old male presented to the same institution with a ruptured PDA aneurysm, again in the context of MALC. This patient was similarly managed by emergency TAE and later had an uncomplicated laparoscopic MAL release. On table mesenteric angiography confirmed successful release. Both patients have since recovered without any recurrence of bleeding or new aneurysm formation.

Discussion: Ruptured true PDA aneurysms, while uncommon, may be managed successfully using urgent endovascular techniques. Concomitant coeliac axis stenosis due to MALC requires secondary treatment and can be managed effectively using a staged approach following the urgent presentation.

Keywords: Median arcuate ligament syndrome; Transcatheter arterial embolisation; True inferior pancreaticoduodenal aneurysm.

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Figures

Figure 1
Figure 1
(A) Patient 1. Anterior inferior pancreaticoduodenal artery (AIPDA) aneurysm with hypertrophy of gastroduodenal artery (GDA) and reversal of flow through the pancreaticoduodenal arcade via the superior mesenteric artery (SMA) suggesting proximal coeliac trunk stenosis marked CA (coeliac axis). Common hepatic artery (CHA), posterior inferior pancreaticoduodenal artery (PIPDA), and anterior superior pancreaticoduodenal artery (ASPDA) marked for reference. (B) Patient 1. Post successful coil embolisation of the inferior pancreaticoduodenal artery (IPDA) aneurysm. (C) Patient 1. Computed tomography angiography sagittal section showing proximal coeliac stenosis with retroperitoneal haemorrhage associated with IPDA aneurysm rupture, prior to median arcuate ligament compression release. (D) Patient 1. Final sagittal plane image of patient 1 CA post-release and stenting of the residual coeliac stenosis.
Figure 2
Figure 2
(A) Patient 2. Digital subtraction angiography showing the bleeding inferior pancreaticoduodenal artery (IPDA) aneurysm. (B) Patient 2. Post-endovascular coiling with retrograde filling of the pancreaticoduodenal arcade and proximal coeliac axis (CA). Common hepatic artery (CHA) and gastroduodenal artery (GDA) have been marked for reference. (C) Patient 2. Computed tomography angiography sagittal scan prior to treatment showing proximal coeliac stenosis with large retroperitoneal haemorrhage associated with IPDA aneurysm rupture. (D) Patient 2. Post-intervention duplex ultrasound showing antegrade flow in CA and superior mesenteric artery (SMA). AIPDA = anterior inferior pancreaticoduodenal artery; ASPDA = anterior superior pancreaticoduodenal artery; PIPDA = posterior inferior pancreaticoduodenal artery; PSPDA = posterior superior pancreaticoduodenal artery.
See this image and copyright information in PMC

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