Pancreaticoduodenal Artery Aneurysm Associated with Celiac Axis Stenosis Treated by Combined Therapy

Abstract

Pancreaticoduodenal artery aneurysm (PDAA) is a rare splanchnic aneurysm. Its etiology is thought to be an increase in blood flow and pressure in the pancreaticoduodenal artery region caused by celiac axis stenosis. We report a case of PDAA treated by combined therapy consisting of aorto-hepatic bypass grafting and a coil embolization of the aneurysm. A 61-year-old man undergoing a routine physical examination was found to have an asymptomatic pancreatic tumor on abdominal ultrasonography. A helical CT scan revealed a 15-mm × 20-mm aneurysm arising from a proximal mesenteric artery branch on axial images. Reformatted volume-rendered three-dimensional and sagittal multiplanar images showed a calcified aneurysm arising from the inferior pancreaticoduodenal artery and a “hooked” appearance of the celiac artery. On laparotomy, we explored the celiac artery and hepatic artery, and the stenosis of the celiac axis was found to be due to compression by the arcuate ligament. However, considering the probable incomplete release of the compression by division of the ligament, we elected to create an aorto-hepatic bypass using a saphenous vein graft. After completion of the bypass grafting, the patient was moved to an angiography suite and underwent successful coil embolization of the aneurysm using several coils via a 5-Fr catheter through the superior mesenteric artery. The clinical course of the patient was uneventful, with a low-grade increase in serum amylase level, and the patient was discharged on postoperative day 21. Combined therapy consisting of bypass grafting and transarterial embolization provides a less invasive therapy for PDAA, and avoids the potentially serious pancreatic juice leakage which can result from manipulating the pancreatic parenchyma.