Korean J Gastroenterol.  2021 Apr;77(4):194-198. 10.4166/kjg.2021.032.

Ruptured Pancreaticoduodenal Artery Aneurysm with Pancreatitis Treated Using Endovascular and Endoscopic Methods

• Park C
• Park DE

• KMID: 2515141
• DOI: http://doi.org/10.4166/kjg.2021.032

Abstract

Pancreaticoduodenal artery aneurysm (PDAA) is a rare form of abdominal visceral aneurysm that accounts for approximately 2% of all cases. Most cases of PDAA are associated with celiac artery stenosis (CAS). Regardless of the size, there is a risk of rupture. Therefore, treatment should be performed immediately after discovery, even though the need to treat the accompanying CAS, if present, is controversial. The authors report a case of ruptured PDAA and accompanying pancreatitis treated using endovascular and endoscopic methods without treatment of CAS. A 50-year-old man was admitted to the emergency department of Wonkwang University Hospital with epigastric pain and hypovolemic shock. CT revealed a ruptured PDAA and a large volume hemoperitoneum. Emergency angiography was performed, and angioembolization of the PDAA was performed successfully. Follow-up CT revealed infection and pancreatitis, which were treated by surgical drainage and pancreatic duct stenting with ERCP. Because the degree of stenosis was not severe, it was decided to follow-up the accompanying CAS. After discharge, the patient was followed up without complications.

Keyword

Median arcuate ligament syndrome; Hemoperitoneum; Aneurysm; ruptured

Figure

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  Fig. 1 Initial computed tomography (CT) performed in the emergency department. (A) Axial CT demonstrating contrast extravasation of the inferior pancreaticoduodenal artery (PDA) (arrow), which appears to be due to an aneurysmal sac, and large acute hematoma in the right anterior pararenal space and perihepatic space are shown. (B) CT revealing a mild hypodense lesion at the pancreas head, suggesting acute pancreatitis (arrow). (C) Maximum intensity projection image revealing aneurysmal dilatation of the inferior PDA (arrow).

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  Fig. 2 Arteriography after initial resuscitation. (A) Celiac artery stenosis (CAS) (arrowhead) and hepatic arterial blood flow from the pancreaticoduodenal artery (PDA) are shown (arrow). (B) Large pseudoaneurysm and extravasation in the superior anterior PDA were detected (arrow).

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  Fig. 3 Vascular-aorta computed tomography angiography after 2 days of transarterial embolization. (A) Coronal image revealing slightly decreased size of hematoma in the anterior pararenal space. (B) Celiac artery stenosis is also apparent (arrow).

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  Fig. 4 Magnetic resonance imaging and endoscopic retrograde cholangiopancreatography (ERCP) performed to determine the etiology of the elevated serum amylase and lipase and treat pancreatitis (A) increased signal intensity in the T1-weighted image at the head of the pancreas (arrow). (B) ERCP with plastic stenting in the pancreatic duct was performed.

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  Fig. 5 Computed tomography performed 6 months after discharge. Marked decreased size of the previously noted mass-like lesion with mild haziness in the retromesenteric space, suggesting an improving state of organizing hematoma with adjacent fibrotic changes (arrow).

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