Ruptured pancreaticoduodenal pseudoaneurysm causing arterioportal fistula: combined transarterial and transportal embolization

Abstract

Background Arterioportal fistulas are rare vascular disorders of the abdominal viscera. They are arteriovenous communications between the splanchnic arteries and the portal vein or its tributaries. We herein report a case of an extrahepatic arterioportal fistula that was caused by rupture of a pseudoaneurysm of the pancreaticoduodenal artery and successfully treated with embolization using a combination of the arterial and percutaneous transhepatic portal venous approaches. Case presentation A 79-year-old man was transferred to our hospital because of the sudden appearance of a hematoma containing a large pseudoaneurysm in the mesentery of the duodenum. Emergency abdominal angiography revealed that a pseudoaneurysm of the anterior inferior pancreaticoduodenal arterial branch had perforated into the portal system (arterioportal fistula). We performed coil embolization via the inflow artery and portal vein using a percutaneous transhepatic approach. The patient recovered without complications and was discharged. Conclusion This rare vascular disorder was successfully treated with an unplanned combination therapy. We believe that flexible strategy changes led to the successful treatment in this case.

Large gastroduodenal artery pseudoaneurysm, arterioportal fistula and portal vein stenosis in chronic pancreatitis treated using combined transarterial embolization and transportal stenting: A case report

“…As a result of the search, there were cases of obstructive jaundice due to compression of the common bile duct by GDA pseudoaneurysm, [2] celiac axis stenosis due to true pancreatoduodenal arcade aneurysm, [9] portal vein stenosis due to pseudoaneurysm of the hepatic and gastroduodenal arteries, [10] hepatic artery pseudoaneurysm, and portal vein stenosis due to inflammatory changes that occurred after a leak at the hepaticojejunostomy, [11] portal vein thrombosis and stenosis with cavernous transformation due to chronic pancreatitis, [12,13] and APF due to a ruptured pancreaticoduodenal pseudoaneurysm. [4] There was a case similar to ours, in which GDA pseudoaneurysm and APF coexisted in chronic pancreatitis [14] ; however, portal vein stenosis did not exist as in our case.…”

“…The most common etiology of APF is trauma (e.g., blunt, stab gunshot wounds) followed by iatrogenic causes such as surgical and non-surgical interventions, congenital abnormalities, neoplasms, and rupture of pseudoaneuryms. [ 4 , 5 ] Pseudoaneurysm and APFs are associated with conditions ranging from asymptomatic to life-threatening, such as peritoneal or retroperitoneal hemorrhage. [ 6 ] Besides, APFs have large shunt flow, and are therefore likely to cause symptoms of portal hypertension.…”

“…[ 6 ] Besides, APFs have large shunt flow, and are therefore likely to cause symptoms of portal hypertension. [ 4 ]…”

“…APFs are more commonly intrahepatic than extrahepatic. [ 4 ] Approximately 15% of APFs are caused by ruptured splanchnic artery aneurysms. [ 5 ] Visceral artery pseudoaneurysm and APF occur together in rare cases.…”

Transarterial Embolization of Ruptured Pancreaticoduodenal Artery Pseudoaneurysm Related to Chronic Pancreatitis

“…Although it is a rare pathology, it is lethal in the absence of intervention. Endovascular treatment is currently the primary approach in the event of these pathologies, with a high success rate and excellent patient progression [ 4 , 9 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. A 67-year-old woman presented with lightheadedness, diaphoresis, and acute epigastric and right hypochondrium pain.…”