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Management of Pancreaticoduodenal Artery Aneurysms: Results of Superselective Transcatheter Embolization

¹ Department of Radiology, Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo, Japan 113-8602.
² Department of Radiology, RWTH Aachen University Hospital, Aachen, Germany.
³ Department of Radiology, Hitachi General Hospital, Hitachi, Ibaragi, Japan.
⁴ Department of Diagnostic Radiology, National Disaster Medical Center, Tokyo, Japan.

Received November 9, 2004; accepted after revision May 19, 2005.

 
Address correspondence to S. Murata.

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Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. The purpose of our study was to assess the efficacy of transcatheter arterial embolization for pancreaticoduodenal artery aneurysms.

CONCLUSION. We concluded that transcatheter arterial embolization is the initial and definitive therapeutic choice for pancreaticoduodenal artery aneurysms, with a possible option to perform surgery after embolization.

Keywords: aneurysm • embolization • interventional radiology • pancreas

Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Aneurysms of the pancreaticoduodenal arteries are rare and make up only 2% of all splanchnic aneurysms [1]. Pancreaticoduodenal artery aneurysms may have an increased propensity for rupture: 64% of patients seeking medical advice from symptoms related to the aneurysm have had a rupture [2]. Pancreaticoduodenal artery aneurysm ruptures can be life threatening because they result in bleeding into the retroperitoneal space, abdominal cavity, the gastrointestinal tract, or a combination of these. Before 1980, surgery was the only treatment for pancreaticoduodenal artery aneurysm, and its mortality rate was 26% [3]. However, the in-hospital mortality rate for patients who received no surgical treatment was 80% [3].

Recently, the rapid development of interventional radiology has made it possible to perform transcatheter arterial embolization of visceral aneurysms safely and effectively. In addition to surgery, transcatheter arterial embolization has been performed since 1980, and the mortality rate has significantly improved [3-4]. Despite these facts, the choice of initial therapy remains controversial.

During the last decade, the number of case reports of pancreaticoduodenal artery aneurysm has increased because of improved detection rates with advances in noninvasive diagnostic techniques, such as CT and sonography. Therefore, it is important to choose a therapy—transcatheter arterial embolization or surgery—for initial treatment. The purposes of this article are to evaluate the results of transcatheter arterial embolization therapy and to discuss which treatment should be chosen for pancreaticoduodenal artery aneurysms in various cases.

Subjects and Methods

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Patients
Between January 1992 and December 2002, 10 patients with pancreaticoduodenal artery aneurysms were admitted to Nippon Medical School Hospital. The clinical findings of these patients are summarized in Table 1. One woman and nine men, with a median age of 57 years (range, 45 to 72 years) were identified. All patients underwent transcatheter arterial embolization. Three patients had a history of hypertension and three were alcoholics. Two patients had a history of partial gastrectomy for gastric ulcer, and one of them showed signs of ileus. One patient had advanced common bile duct cancer. One patient had no history of any particular disease. Nine of the 10 patients had ruptured pancreaticoduodenal artery aneurysms. Five of these nine had gastrointestinal bleeding, and two also had hematemesis. Six patients were hemodynamically stable during and after volemic resuscitation, but three were hemodynamically unstable (shock index: heart rate/systolic blood pressure > 1) despite volemic resuscitation. One of those with shock received emergency laparotomy, and the other two underwent clipping by endoscopy with the intention of stopping the bleeding before embolization; however, in these three patients the bleeding could not be stopped. They therefore required immediate embolization. The patient whose aneurysm had not ruptured was symptom free. She was followed up by her family physician, and CT revealed that the aneurysm increased in diameter from 2 to 2.8 cm within 1 year. She rejected surgical resection after the surgeons explained the potential complications of surgery, and she decided to undergo transcatheter arterial embolization.

Embolization Technique
After diagnostic angiography with a 5-French catheter, a 3-French microcatheter was inserted as close as possible to the aneurysm. Arteriography was then performed.

The method of embolization of the pancreaticoduodenal artery aneurysm was as follows: The basic procedure involved isolation and exclusion of the afferent and efferent arteries close to the aneurysm, using microcoils with a coaxial system to exclude and occlude the aneurysm because of the presence of anastomotic branches around the pancreas. If a microcatheter could not be advanced into the efferent arteries, we first tried to pack the aneurysm and then embolized the afferent arteries with microcoils. If a microcatheter could not be advanced into the aneurysm (i.e., if we could not even pack the aneurysm), we embolized the afferent arteries and recommended surgical treatment.

Informed consent for embolization was obtained from conscious patients as far as the emergency permitted. Otherwise, the immediate family was informed.

Data Analysis
Technical success reflects immediate results and is typically evaluated by completion angiography [5]. The technical success of our series was defined as nonvisualization of aneurysms and nonvisualization of bleeding, as verified by postembolization angiography. Clinical success reflects the results in the 30 days immediately after the embolization procedure and is typically assessed by close patient follow-up [5]. Clinical success in our series was defined by the patients' condition (the 30-day outcome)—that is, whether patients were hemodynamically stable without blood transfusion. Cases in which additional surgery or endoscopic treatment for the aneurysm were performed after the embolization procedure were excluded from the clinical successes. For follow-up, contrast-enhanced CT or sonography was performed in each patient 1 week to 2 months after embolization to assess the stoppage of bleeding or thrombosis of the aneurysms or both. In particular, patients with celiac trunk stenosis (n = 2) were given an additional follow-up contrast-enhanced CT every 3 months for 1 year, and every 6 months after 1 year (range, 21 months to 34 months; mean, 27.5 months) to check for the presence of recurrent or new aneurysms.

Results

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The causes of these pancreaticoduodenal artery aneurysms were arteriosclerosis, in association with celiac axis stenosis or occlusion (n = 2); compression of the median arcuate ligament of the diaphragm (n = 1); pancreatitis (n = 3); postsurgery (n = 2); advanced common bile duct cancer (n = 1); and unknown (n = 1) (patient had no history of systemic vascular disease, abdominal trauma, or chronic pancreatitis).

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —72-year-old woman with embolization of nonruptured pancreaticoduodenal artery aneurysm caused by celiac axis stenosis. Contrast-enhanced CT scan reveals aneurysm (2.8 cm in diameter) located behind pancreas head.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —72-year-old woman with embolization of nonruptured pancreaticoduodenal artery aneurysm caused by celiac axis stenosis. Angiography of superior mesenteric artery shows pancreaticoduodenal artery aneurysm of inferior pancreaticoduodenal artery. Hepatic arteries and splenic artery are opacified through dilated dorsal pancreas artery as main feeder. Afferent artery of aneurysm is embolized through superior mesenteric artery route, and efferent artery is also embolized through celiac artery route.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —72-year-old woman with embolization of nonruptured pancreaticoduodenal artery aneurysm caused by celiac axis stenosis. Superior mesenteric arteriography after embolization of aneurysm shows no visualized aneurysm.

View larger version (77K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —72-year-old woman with embolization of nonruptured pancreaticoduodenal artery aneurysm caused by celiac axis stenosis. Contrast-enhanced CT scan 1 week after transcatheter arterial embolization shows complete thrombosis of the aneurysm.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —53-year-old man with embolization of multiple ruptured pancreaticoduodenal artery aneurysms. Superior mesenteric arteriogram shows four aneurysms.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —53-year-old man with embolization of multiple ruptured pancreaticoduodenal artery aneurysms. Selective inferior pancreaticoduodenal arteriogram clearly shows aneurysms, three on the pancreaticoduodenal artery (arrows) and one on first jejunum artery (arrowhead).

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —53-year-old man with embolization of multiple ruptured pancreaticoduodenal artery aneurysms. Gastroduodenal artery arteriogram after embolization with microcoils (arrows) and gelatin sponge particles shows no extravasation and no visualized aneurysms.

Technical Success
Nine of the 10 patients with pancreaticoduodenal artery aneurysms were successfully embolized by transcatheter arterial embolization alone using only microcoils (eight patients) or using microcoils combined with gelatin sponge (one patient). In five of the 10 patients, isolation was obtained with microcoils using the coaxial system to exclude both afferent and efferent arteries close to the aneurysm. Of these five patients, one had an unruptured aneurysm, seen with CT and Doppler sonography, 1 week after embolization. The patient was found to have complete thrombosis of the aneurysm (Figs. 1A, 1B, 1C, and 1D). In another patient, we had intended to perform the isolation using only microcoils, but we did not have enough microcoils on hand. Consequently, we first embolized the inferior pancreaticoduodenal artery and a small aneurysm of the first jejunal artery with microcoils, and then embolized the superior pancreaticoduodenal artery with particles of gelatin sponge. After these procedures, the superior pancreaticoduodenal artery was embolized with microcoils (Figs. 2A, 2B, and 2C). Four patients underwent packing of their aneurysms and embolization of the afferent arteries with microcoils (Figs. 3A, 3B, 3C, and 3D). In the remaining patient, who had rupture of the pancreaticoduodenal artery aneurysm caused by compression of the median arcuate ligament, although we managed to advance a microguidewire into the aneurysm, a microcatheter could not be advanced along with the microguidewire because of the tortuous nature of the afferent artery and the use of an initial coaxial catheter system. Therefore, we embolized only the afferent artery with microcoils (Figs. 4A, 4B, and 4C). Superior mesenteric arteriography immediately after embolization showed no visible aneurysm, and the patient became hemodynamically stable. We recommended surgery because we considered him to be at high risk for re-rupture, but he rejected surgery.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —54-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysms caused by celiac axis stenosis. Unenhanced CT scan shows retroperitoneal hematoma.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —54-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysms caused by celiac axis stenosis. Selective superior mesenteric arteriogram shows two aneurysms, 3.3 cm and 0.5 cm in diameter, arising from anterior inferior pancreaticoduodenal artery.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —54-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysms caused by celiac axis stenosis. Selective superior mesenteric arteriogram after embolization with microcoils (arrows) shows no visualized aneurysms.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —54-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysms caused by celiac axis stenosis. Contrast-enhanced CT scan 4 weeks after embolization shows no hematoma in abdominal cavity.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —58-year-old man with pancreaticoduodenal aneurysm rupture caused by median arcuate ligament syndrome. Contrast-enhanced CT scan shows hematoma surrounding duodenum in retroperitoneal space.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —58-year-old man with pancreaticoduodenal aneurysm rupture caused by median arcuate ligament syndrome. Selective superior mesenteric arteriogram shows saccular aneurysm (arrow), 3.2 cm in diameter, arising from anterior inferior pancreaticoduodenal artery. Celiac axis is completely occluded and blood flow to liver and spleen is supplied by way of enlarged pancreaticoduodenal artery.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —58-year-old man with pancreaticoduodenal aneurysm rupture caused by median arcuate ligament syndrome. Contrast-enhanced CT scan obtained 2 weeks after embolization of only afferent artery shows well-enhanced aneurysm with mural thrombus (arrows).

The technical success rate of embolization as an immediate result was 100% (10 of 10 patients).

Clinical Success
There were no complications directly resulting from the embolization procedures and no cases of re-rupture. We observed two instances in which we did not obtain clinical success between days 8 and 14. One patient was successfully treated by embolization of the ruptured pancreaticoduodenal artery aneurysm (Figs. 5A, 5B, and 5C) and became hemodynamically stable. He then received repeat surgery for suture failure 3 days after embolization but developed disseminated intervascular coagulation and died 5 days after the repeat surgery. The other patient was treated by embolization of only the afferent artery with microcoils (Figs. 4A, 4B, and 4C); he was hemodynamically stable after transcatheter arterial embolization and rejected surgery. A follow-up contrast-enhanced CT at 14 days after transcatheter arterial embolization, however, showed a well-enhanced pancreaticoduodenal artery aneurysm. Therefore, he agreed to undergo surgery, and surgical treatment was successfully performed.

View larger version (179K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —53-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysm caused after surgery. Arteriogram via gastroduodenal artery shows extravasation (arrows) from posterior superior pancreaticoduodenal artery. Metallic coils (arrowheads) were placed in patient at another hospital.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —53-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysm caused after surgery. Selective posterior superior pancreaticoduodenal arteriography reveals ruptured aneurysm (arrow) and contrast media flow into abdominal cavity.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —53-year-old man with embolization of ruptured pancreaticoduodenal artery aneurysm caused after surgery. Selective posterior superior pancreaticoduodenal arteriogram after embolization with coil (arrow) shows no visualized aneurysm or bleeding.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Pancreaticoduodenal artery aneurysms are uncommon but clinically important forms of vascular disease. Slightly more than 100 cases have been reported in the English-language literature. Most of these are isolated case reports. There have been only a few small series. Management of pancreaticoduodenal artery aneurysms in these reports has varied from surgery to transcatheter arterial embolization to no treatment. In our series, we performed transcatheter arterial embolization in all 10 patients. The purpose of this series was to determine which treatment for these aneurysms should be chosen in various cases.

Some researchers have reported that transcatheter arterial embolization is effective in the treatment of visceral aneurysms, has few complications, and results in low recurrence rates [3-4, 6-9]. Coll et al. [3] reported that, since 1980, the mortality rate associated with surgery has been 19%, whereas that associated with transcatheter arterial embolization has been 0%; they reported no significant difference in the risk of recurrent hemorrhage, with rates between 0% and 5%. Despite these results, surgery is still considered by many physicians to be the initial and only definitive treatment of aneurysms involving the pancreaticoduodenal artery.

There are three major reasons for this treatment path. One is that embolization is not always technically feasible because of the difficulty of selective catheterization of the vessel feeding the aneurysm [10-14]. The second is that embolization may be associated with aneurysmal rupture during the procedure [11-12, 15]. The third is that, in the case of celiac axis stenosis or occlusion in which pancreaticoduodenal artery aneurysms are observed, transcatheter arterial embolization without bypass may lead to recurrence of pancreaticoduodenal artery aneurysm or ischemic injury as a result of the absence of major collateral vessels—that is, embolization without bypassing may be ill advised [11-12, 14, 16-19].

Catheterization of the vessels requires a proficient interventional technique; however, the advent of newer coaxial catheterization techniques has greatly improved the embolization of small, tortuous vessels. Therefore, we obtained complete embolization of all pancreaticoduodenal artery aneurysms except one, and we managed to stop the bleeding in all ruptured aneurysms. In contrast, the detection of pancreaticoduodenal artery aneurysms during surgery may fail in approximately 70% of cases [12, 20] because of their localization behind or within the parenchyma of the pancreas. Surgery may be questionable because arterial ligation (with or without aneurysm resection) is not always feasible, and partial pancreatectomy can be necessary [17-19]. In one patient in whom we tried to perform transcatheter arterial embolization 12 years ago, we could not even pack the aneurysm (i.e., we embolized only the afferent artery with microcoils). Use of the current, new coaxial catheter system or N-butyl cyanoacrylate injection technique [21] might be considered if we were able to do packing of or isolate the pancreaticoduodenal artery aneurysm.

In 1979, Lina et al. [15] reported aneurysm rupture secondary to transcatheter embolization. However, they did not have a coaxial catheter system at that time. To our knowledge, there have been no reports of pancreaticoduodenal aneurysm rupture secondary to transcatheter embolization since the development of the coaxial catheter system. Therefore, aneurysm rupture during the procedure should be excluded as a disadvantage of transcatheter arterial embolization.

Pancreaticoduodenal artery aneurysms can be differentiated into true and false aneurysms; the latter result from pancreatitis, abdominal trauma, surgery, or septic emboli. They often rupture into the gastrointestinal tract, whereas true aneurysms are frequently associated with stenosis or occlusion of the celiac axis and rupture into the retroperitoneal space. In patients with false pancreaticoduodenal artery aneurysms, transcatheter arterial embolization preserves vascularization of the celiac territory because false aneurysms are not usually associated with celiac artery stenosis. With regard to the third disadvantage of transcatheter arterial embolization, the controversy remains whether transcatheter arterial embolization should be done in patients with celiac artery stenosis or occlusion because transcatheter arterial embolization in vessels without major collaterals should have a higher recurrence of pancreaticoduodenal artery aneurysm or ischemic injury. Sutton and Lawton [22] postulated that stenosis of the celiac axis resulting in an increased flow through the pancreaticoduodenal artery favors the development of pancreaticoduodenal artery aneurysms. Some surgeons emphasize that the basic treatment is revascularization of the celiac trunk stenosis or occlusion [11-12, 16-19]. Two patients with celiac trunk stenosis in our series, however, had a good course without ischemic dysfunction of the liver, spleen, or duodenum, and also no recurrence of pancreaticoduodenal artery aneurysm. Some patients in other reports have had good courses without ischemic dysfunction of the liver, spleen, or duodenum [23-26]. Savastano et al. [23] reported that, although they performed embolization of pancreaticoduodenal artery aneurysms in two patients with celiac trunk stenosis and occlusion caused by compression of the median arcuate ligament, there was no recurrence of aneurysm seen at follow-ups of more than 3 years. To our knowledge, there have been no reports of the recurrence of pancreaticoduodenal artery aneurysm caused by celiac trunk stenosis or occlusion after embolization [23-27].

With regard to embolization technique of pancreaticoduodenal artery aneurysms, the best embolization technique is thought to be isolation with coils, N-butyl cyanoacrylate, or both, regardless of true or pseudoaneurysms. However, isolation may be absolutely impossible in half of cases. The second feasible technique, especially in the cases with pseudoaneurysm, may be embolization of the afferent artery after packing of the aneurysm. Though our sample size of the patient population was small, we have no cases in which the second feasible method resulted in failure. If a microcatheter cannot be advanced close to the aneurysm, transcatheter arterial embolization may be an insufficient method regardless of decreasing blood flow. In such a case, direct percutaneous embolization technique can be useful in selected patients. In this method, N-butyl cyanoacrylate, not coils, should be used as embolization materials.

Preoperative angiography has played an important role in facilitating surgical management [12]. Coil embolization is useful to decrease blood flow and to temporarily stop bleeding, even if embolization of the efferent artery cannot be achieved. The less invasive transcatheter arterial embolization, by which diagnosis and treatment can be performed simultaneously, should be performed as an initial treatment.

In conclusion, transcatheter arterial embolization should be an initial treatment for ruptured or unruptured pancreaticoduodenal artery aneurysms regardless of whether surgery needs to be performed, and it is an initial safe and effective method of therapy in both elective and emergency cases.

References

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Murata, S. Articles by Kuramoto, K. Search for Related Content PubMed PubMed Citation Articles by Murata, S. Articles by Kuramoto, K. Social Bookmarking                      What's this?