Inferior Pancreatico-Duodenal Artery Aneurysm with Superior Mesenteric Artery Stenosis

Abstract

Pancreatico-duodenal artery aneurysm (PDAA) associated with stenosis or occlusion of the celiac trunk is a rare condition. Furthermore, PDAAs associated with stenosis of the superior mesenteric artery (SMA) are even more uncommon, with only six cases reported in the literature. We report a case of a 61-year old male patient who presented with hematemesis, haematochezia and haemorrhagic shock. The upper gastrointestinal endoscopy revealed an ulcerous lesion at the third portion of the duodenum, without achieving the haemostasis. The emergency laparotomy (suture of the lesion and gastro-entero-anastomosis) permitted temporary haemostasis. Computed tomography angiography identified the PDAA ruptured into the third portion of the duodenum and the SMA stenosis at its origin; a dense network of collateral vessels was present. The patient was successfully managed with coil embolization. Short and mid-term follow-up were without incidents.

Aneurisma de artéria pancreatoduodenal inferior: tratamento endovascular

“…10 The patient in this case was diagnosed with a true IPDAA, since she did not meet the criteria for suspected mycotic infection or connective tissue diseases and also did not have ostial stenosis of the CT or SMA, ruling out the hyperdynamic collateral circulation hypothesis. 2,5,8,9 In view of this, the probable cause of this patient's aneurysm is atherosclerotic disease.…”

“…Inferior pancreaticoduodenal artery aneurysms are extremely rare, but are probably undernotified, since symptoms are nonspecific and the location makes diagnosis less likely. 5,6 They affect both sexes with equal incidence, 5,6 and mean age of greatest diagnostic frequency is 60 years. 6 The primary cause of true IPDAAs is occlusion or stenosis of one of the main arterial trunks, whether the SMA or the CT, the second of which is more often involved (80%); these aneurysms are related to occlusive arterial disease involving the ostia of the trunk arteries in 50-80% of cases.…”

“…3,7,8 After this event, the velocity of blood flow to the pancreatic arterial arches increases, causing progressive dilation of the arterial lumen (the hyperdynamic collateral circulation hypothesis). 2,5,8,9 Other reported causes are atherosclerosis, connective tissue diseases, and infections. 5,10 For many years the last of these were considered the primary cause of IPDAA (60%), but recent studies have shown that atherosclerotic disease is the most common cause and infectious etiology is responsible for 4.8% of cases diagnosed, rather than over half, as was previously thought.…”

“…2,5,8,9 Other reported causes are atherosclerosis, connective tissue diseases, and infections. 5,10 For many years the last of these were considered the primary cause of IPDAA (60%), but recent studies have shown that atherosclerotic disease is the most common cause and infectious etiology is responsible for 4.8% of cases diagnosed, rather than over half, as was previously thought. 10 The patient in this case was diagnosed with a true IPDAA, since she did not meet the criteria for suspected mycotic infection or connective tissue diseases and also did not have ostial stenosis of the CT or SMA, ruling out the hyperdynamic collateral circulation hypothesis.…”

“…[1][2][3] Nonetheless, the majority of PDAA are still discovered and treated in emergency situations, with increased risk of complications such as hemoperitoneum and hypovolemic shock, with rates of aneurysm rupture in the literature in the range of 45-53%. [3][4][5] These aneurysms are supplied by collateral vessels with hyperdynamic flow and are often associated with occlusive stenosis of the celiac trunk (CT) and superior mesenteric artery (SMA). 3,4 Endovascular treatment is the preferred method, except in cases of suspected visceral ischemia, in patients with hostile vascular anatomy, or if prior endovascular treatment has failed.…”