Transcatheter Embolization of a Pancreaticoduodenal Artery Aneurysm Associated with Celiac Axis Stenosisce

Purpose: Pancreaticoduodenal artery (PDA) aneurysms are rare visceral aneurysms, accounting for only about 2% of all splanchnic aneurysms. Most PDA aneurysms are discovered incidentally or at the time of rupture, and the mortality rate associated with rupture approaches 50%. The risk of rupture is unrelated to the size of the aneurysm; therefore, PDA aneurysm are generally treated upon discovery. Importantly, celiac trunk stenosis has been reported to be associated with PDA aneurysms in as many as 50% to 80% of patients; thus, it is imperative to maintain adequate perfusion to the celiac territory during treatment.

Materials and Methods: A 72-year-old man presented with left flank pain that had started 3 days ago. A noncontrast computed tomography (CT) scan of the abdomen and pelvis was performed to rule out renal calculi, which revealed an incidentally noted 2.6-cm aneurysm arising from a branch of the superior mesenteric artery (SMA). A CTA of the abdomen and pelvis confirmed that the aneurysm was arising from the PDA branch of the SMA and demonstrated severe celiac stenosis. Interventional radiology (IR) was consulted for evaluation and treatment of the SMA aneurysm.

Results: A visceral angiogram revealed a patent SMA with hypertrophied inferior and superior PDAs. There was severe stenosis of the celiac artery. Two arterial branches projected cranially from the aneurysm sac to supply the jejunum. A 7-mm, 19-mm in length VBX (Gore Inc., Flagstaff, AZ) stent graft was advanced and deployed to exclude the aneurysm with concurrent exclusion of the two cranially oriented arterial branches supplying the jejunum. Because of retraction of the stent into the aneurysm, the stent was extended with a second VBX stent graft, and both balloon-mounted stents were postdilated to 7 mm. Completion angiography was then performed, which showed normal flow within the SMA as well as no filling of the aneurysm sac.

Conclusions: PDA aneurysms are rare entities but are associated with celiac trunk stenosis because of altered hemodynamics. Flow redistribution results in increased blood flow within the small branches of the SMA with resultant dilatation and aneurysmal formation of these arteries. Historically, invasive surgical treatment options have been used; however, our case demonstrates the utility of IR in the noninvasive management of PDA aneurysms via selective angiography and coil embolization.