The benefits of extrinsic ligament release for potentially hemodynamically unstable pancreaticoduodenal arcade aneurysm with median arcuate ligament syndrome: a case report

Abstract

Background A pancreaticoduodenal artery aneurysm (PDAA) occurring in close association with median arcuate ligament syndrome (MALS) is rare. A surgical procedure, such as median arcuate ligament (MAL) release, should be considered in such cases, but the operative criteria remain unknown. In this study, we reported an extremely rare case of PDAA with periarteritis nodosa (PAN) and MALS. Case presentation A 60-year-old man was transferred to our department with sudden onset of abdominal pain. We initially diagnosed his condition as a PDAA rupture with MALS based on enhanced computed tomography (CT). We promptly performed transcatheter arterial embolization (TAE) of PDAA, and the angiogram showed stagnant contrast agent in the celiac trunk, indicating total celiac artery occlusion. Follow-up enhanced CT three weeks after the first TAE clearly demonstrated newly formed, multiple aneurysms in the pancreaticoduodenal arcade and the hepatic artery. These findings indicated a systemic disorder, such as PAN or segmental arterial mediolysis, as the underlying cause. Therefore, we started corticosteroid therapy and performed diagnostic angiography to clarify the celiac artery’s patency. Contrary to the initial angiography, the second angiography showed sustained blood flow in the celiac artery. Nevertheless, we performed both extrinsic MAL release and consecutive TAE because of the risk of multiple aneurysms rupturing due to an uncontrolled systemic disorder and consequent hepatic ischemia. The patient had no episode of recurrence until one year of follow-up. Conclusions It is important to evaluate risk for hemodynamically unstable events to decide the best treatment strategy for MALS.

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

“… 3 , 8 Given that multiple reports demonstrate that PDA aneurysm size does not predict rupture, active management of both the aneurysm and the CA stenosis is required for definitive treatment. 1 , 3 , 4 , 5 , 8 , 9 …”

“…Treatment approaches for ruptured PDA aneurysms with MALC vary from transcatheter arterial embolisation (TAE) with or without coeliac artery stenting to open aneurysmorrhaphy with or without concomitant MAL release. 1 , 2 , 3 , 4 , 9 Percutaneous TAE is considered the preferred first line option for both ruptured and unruptured PDA aneurysms. 2 , 4 , 6 TAE also allows treatment of the concomitant CA stenosis using stents.…”

“… 3 , 4 , 6 Hepatic or foregut ischaemia may occur after TAE where foregut perfusion is reliant on the coiled collaterals. 2 , 8 , 9 If urgent open surgery is required, reported techniques include PDA ligation, resection with bypass, or pancreaticoduodenectomy. In addition, open MALC release can be performed simultaneously.…”

Resection and reconstruction of pancreatic artery aneurysms caused by the compression of the celiac trunk by the median arcuate ligament: a report of two cases

“…The probability of rupture is said to be higher for PAAs than for other visceral artery aneurysms [4]. Therefore, simple follow-up would be dangerous just because of its small size.…”

Median Arcuate Ligament Syndrome With Celiac Artery Aneurysm and Dissection

“…9 These aneurysms and associated complications are normally addressed by endovascular techniques, though the stenosis should be addressed by surgical release of ligament. 10 In the event that surgical release is insufficient and the celiac artery stenosis persists, other modalities have been described that can offer additional help. These include bypass surgery, angioplasty, or stent placement.…”