Original post, lightly edited for flow: bit.ly/3DKhM1O
The patient is a 56-year-old woman whose only past medical history is migraines—for which she uses nonsteroidals—and a duodenal ulcer diagnosed without EGD 20 years ago. She presented with acute onset of severe RUQ pain that bores into her back. CT showed a cluster of aneurysms in the GDA distribution with “some regional fluid and stranding that could reflect mild leakage, bleeding, and impending rupture, inflammation/infection.” The patient underwent angiogram that showed a markedly dilated pancreaticoduodenal/GDA arcade artery with four aneurysms in series along the artery, measuring between 2 and 4 cm. The celiac origin was occluded and celiac flow was reconstituted by the aneurysmal artery and a collateral that was acting like an arc of Buehler. The feeders were embolized, which successfully occluded the aneurysms.
I’ve seen this pattern many times in the splenic artery, but never here, so I’m not sure how to explain it. There are no other aneurysms and no findings of FMD or vasculitis. The patient is too old and has the wrong phenotype for the usual collagen vascular disorders like Marfan and Ehlers-Danlos syndromes. She has no history of sepsis or bacteremia episodes that may have caused mycotic aneurysms. EGD during the current event did show an active duodenal ulcer in the third portion.
Has anyone seen this pattern in this location? Should I just assume these are related to ulcers? Any other thoughts?
Author name and contact information
R. Torrance Andrews, MD, FSIR
Swedish Medical Center, First Hill
Author background and current practice preferences for treatment of mesenteric aneurysms?
I have spent 26 years in full-time IR practice, with the first 12 years academic and more recently private practice. I usually treat mesenteric aneurysms > 2 cm with either coil embolization or endograft exclusion, depending on the anatomy. I use endografts to preserve flow if the lesion in question is either fusiform along the main channel or eccentric but with a large enough neck that I can’t pack it with coils and be confident they won’t prolapse into the main artery. I embolize the feeding artery with coils if I don’t mind sacrificing it. The challenge with endografts is that they are unwieldy and difficult to maneuver around a lot of turns.
How often have you encountered unusual patterns of mesenteric aneurysms such as this case?
This was the first time I had seen aneurysms in the pancreaticoduodenal arcade, and they were also unusual because of their large size and multiplicity.
What is your preferred IR approach in treating patients with mesenteric aneurysms in a pancreaticoduodenal or GDA distribution?
Given the relatively small size of the normal pancreaticoduodenal arteries and the vigorous collateral supply in the area, I would normally just coil the feeding arteries. However, this case was unusual because the pancreaticoduodenal arcade was also supplying flow to branches of the occluded celiac trunk, and careless embolization might have infarcted the spleen and reduced hepatic perfusion as well. The trunk vessels were too tortuous for endograft exclusion. Fortunately, we were able to identify and isolate a large collateral channel that was not involved in the cluster of aneurysms and that vessel was felt to be an adequate alternative collateral.
What was the outcome for this patient on follow-up?
The aneurysmal segment was embolized successfully and without complication. At follow-up approximately 5 years later, the large cluster of aneurysms in the pancreaticoduodenal arcade remain occluded and no new aneurysms in that distribution or other adjacent distributions have been identified. In other words, this does not appear to have been a collagen vascular disorder, vasculitis, or other chronic or relapsing condition. The parallel channel—perhaps an uninvolved pancreaticoduodenal branch or an arc of Bueuhler—continues to supply the celiac distribution, so the patient has not had any ischemic complications of the liver, stomach, or spleen.
Which specific methods or techniques do you find useful in treating these aneurysms?
The patient needed some mechanism for maintaining perfusion to the celiac trunk after embolization or excision of the aneurysms. The question was whether to do this by endovascular means, surgically, or by some combination of both. I think any of these would have been viable options. Had there not been an adequate collateral vessel and had revascularization of the celiac been required, I would have attempted this by endovascular approach. Had that failed, it might have been necessary for surgical revascularization.
What specifically prompted you to reach out regarding this case/topic?
I was concerned that I might be missing something, and specifically that the patient might have some type of vasculitis or collagen vascular disease with which I was unfamiliar.
What post or posts were most valuable to you and why?
There were several pointing out that, while this was a new finding for me, it had been described in the past with celiac artery occlusion. Thomas Gregory Walker, MD, FSIR, from MGH, provided a list of published articles describing the scenario I was seeing.
Will you, or have you changed your practice patterns based upon responses you’ve seen on SIR Connect? Please describe any changes you are considering.
I do routinely adjust my practice on the basis of conversations on SIR Connect. The collective knowledge and experience of SIR Connect participants is a deep well from which can be drawn a great deal of expertise at no cost and with very little effort. And it’s great to know that the conversation is exactly that: a back-and-forth exchange that can be accessed in near-real-time as needed.
Additional commentary:
Visceral arterial aneurysms occur in 2% of the population, often in asymptomatic patients or those with non-specific abdominal pain during cross-sectional imaging.1 Approximately 22% of patients with visceral aneurysms present with emergent rupture.1–4 Mesenteric aneurysms account for approximately 6% of visceral arterial aneurysms1 and may involve the gastroduodenal or PDA as true or false aneurysms, commonly due to trauma or erosion from pancreatitis or a duodenal ulcer.1,5 Multiple aneurysms within medium-sized vessel branches of the large abdominal aortic vessels can be seen in collagen vascular disease, vasculitis and conditions such as segmental arterial mediolysis (SAM).6 As in the index case, mesenteric arterial aneurysms have also been associated with concomitant celiac artery occlusion in rare cases.3,5,7,8,9 The pathophysiology of this pattern of aneurysms is still uncertain, thought in part to be attributed to redistribution and elevations in blood flow to collaterals causing endothelial shear stress and vessel dilation.5 In patients with celiac artery occlusion, PDA aneurysms tend to occur more frequently than their gastroduodenal counterparts.5 The inferior PDA artery is most commonly affected, typically within 5 mm of its origin from the SMA.5,7 This is clinically important, as pancreaticoduodenal arcade aneurysms have an increased risk of rupture and mortality irrespective of size, thus often warranting early treatment,8,9
Pre-procedural imaging workup with contrast-enhanced CT or MR angiography is essential and allows for better depiction of visceral arterial anatomy, identification of congenital or anatomic variants, branching, collateral flow and detecting the presence of bleeding into the peritoneal cavity from a ruptured aneurysm.1,3 Treatment includes surgery, embolization therapy and celiac trunk lesion treatment.3 The technical success of transcatheter arterial embolization of visceral arterial aneurysms overall ranges from 67–92%.1,4,10 Endovascular therapy has typically been favored as the initial intervention of choice.5,7 Embolic agents for visceral aneurysms have traditionally included coil packing, liquid embolic agents or covered stents; however, stent graft approach can occasionally prove difficult due to complex branching vessel anatomy in the foregut.1,5 Important peri-procedural concerns include special care to prevent embolic agent migration and parent artery occlusion.3 Additional considerations include revascularizing the celiac artery or collaterals before or after embolization, especially if the risk of jeopardizing foregut perfusion is high.5,11 A multidisciplinary approach between vascular surgery and IR can play a valuable role.
Disclaimer:This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.
References:
- Hovsepian DM and Kos S. Visceral aneurysms. Handbook of Interventional Radiologic Procedures, by Krishna Kandarpa et al., Lippincott Williams & Wilkins. 2016:240-245.
- Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: Risk factor analysis and therapeutic opinion. J. Vasc. Endovasc. Surg. 2007;33(3):293–301. doi.org/10.1016/j.ejvs.2006.09.016.
- Ducasse E, Roy F, Chevalier J, Massouille D, Smith M, Speciale F, Fiorani P, Puppinck P. Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: Current management. Vasc. Surg. Cases. 2004;39(4). doi.org/10.1016/j.jvs.2003.09.049.
- Chadha M, Chaitanya A. Visceral artery aneurysms: Diagnosis and percutaneous management. Vasc. Interv. September 2009;26(3):196–206. doi.org/10.1055/s-0029-1225670.
- Vandy FC. Sell AS, Eliason JL, Coleman DM, Rectenwald JE, Stanley JC. Pancreaticoduodenal and Gastroduodenal artery aneurysms associated with celiac artery occlusive disease. Vasc. Surg. May 2017;41:32–40. doi.org/10.1016/j.avsg.2016.09.018.
- Chao CP. Segmental arterial mediolysis. Interv. Radiol. September 2009;26(3):224–32. doi.org/10.1055/s-0029-1225666.
- Flood K, Nicholson AA. Inferior pancreaticoduodenal artery aneurysms associated with occlusive lesions of the celiac axis: Diagnosis, treatment options, outcomes, and review of the literature. Intervent. Radiol. June 2013;36(3):578–87. doi.org/10.1007/s00270-012-0473-2.
- Sanal B, Nas OF, Hacikurt K, Hakyemez KH, Erdogan C. Retrievable stent-assisted coiling technique using a solitaire stent: Treatment of pancreaticoduodenal artery aneurysm associated with celiac artery occlusion. Endovascular Surg. February 2016;50(2):84–87. doi.org/10.1177/1538574416631644.
- Kitaoka T, Deguchi J, Kamiya C, Suzuki J, Sato O. Pancreaticoduodenal artery aneurysm formation with superior mesenteric artery stenosis. Vasc. Dis. 2014;7(3):312–15. doi.org/10.3400/avd.cr.14-00040.
- Chiesa R, Astore D, Guzzo G, Frigerio S, Tshomba Y, Castellano R, Liberato de Moura MR, Melissano G. Visceral artery aneurysms. Vasc. Surg. January 2005;19(1):42–48. doi.org/10.1007/s10016-004-0150-2.
- Bageacu S, Cuilleron M, Kaczmarek D, Porcheron J. True aneurysms of the pancreaticoduodenal artery: Successful non-operative management. May 2006;135(5):608–16. doi.org/10.1016/j.surg.2005.10.015.
