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CASE REPORT
Year : 2022 | Volume
: 9
| Issue : 5 | Page : 411-414
Giant true inferior pancreaticoduodenal artery aneurysm associated with celiac axis occlusion: A first case of successful treatment with covered balloon-expandable stent grafting using VBX
Animesh Singla1, Ye Tan Cai2, Krishna Kotecha2, Walid Mohabbat2
1 Vascular Surgery Department, Royal North Shore Hospital, St Leonards; Faculty of Medicine and Health, Sydney University, Sydney, NSW, Australia
2 Vascular Surgery Department, Royal North Shore Hospital, St Leonards, Australia
Correspondence Address:
Dr. Animesh Singla
Vascular Surgery Department, Royal North Shore Hospital, St Leonards; Faculty of Medicine and Health, Sydney University, Sydney, NSW
Australia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_42_22
Giant visceral artery aneurysms are uncommon. Branch vessel aneurysms, particularly of the pancreaticoduodenal territory are challenging to treat due to their location, anatomy, and access to an aneurysm. While open surgical resection is associated with significant morbidity, endovascular treatment is becoming increasingly mainstream. The utilization of coil embolization, particularly in the setting of rupture has been well described. Access and platform in these settings often involve the celiac axis. We describe unusual care of a large inferior pancreaticoduodenal aneurysm and associated retroperitoneal bleed, being fed through an ectatic superior mesenteric artery. This was associated with an occluded celiac axis. Due to the unusually large proximal and distal landing zones, a covered balloon-expandable stent was deployable with the successful exclusion of the aneurysm. This is the first reported case report of successful management of retroperitoneal rupture and associated pancreaticoduodenal aneurysm treated with a covered stent graft. This technique allowed for rapid access and exclusion of the aneurysm. In addition, it allowed the preservation of foregut flow through the collateral pathway and successfully excluded the large aneurysm.
Keywords: Covered stent grafting, giant visceral aneurysm, pancreaticoduodenal branch aneurysm
Visceral artery aneurysms are a rare entity.[1] Branch vessels, and in particularly inferior pancreaticoduodenal artery (IPDA) aneurysms represent 2% of all visceral artery aneurysms.[2] IPDAs are exceedingly rare, and often associated with concurrent celiac axis stenosis.[3] Pathogenesis is believed to be associated with increased flow through the pancreaticoduodenal arcade in the setting of celiac axis stenosis or occlusion, vasculitides, and underlying connective tissue disorders. Pseudoaneurysms of the IPDA in particular are associated with postpancreatic/biliary surgical complications, postpancreatitis, and septic embolization.[4] Endovascular and open surgical treatment techniques of IPDAs have been described. Given the associated anatomy of IPDAs, endovascular treatment options have often focused on various catheter embolization techniques, including primary coiling or stent-assisted coiling. This article shares the only case report of successfully covered stent grafting of an IPDA in association with an occluded celiac axis, without the requirement of embolization while preserving in-line flow.
Case ReportA 58-year-old male presented with sudden-onset epigastric pain radiating to his left flank, present for the prior 24 h. His past medical history included type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and atrial fibrillation (on warfarin). His past surgical history included morbid obesity (with 100 kg weight loss after bariatric surgery), prior Hartmann's procedure (secondary to perforated diverticulitis), open cholecystectomy, and incision hernia repair with inlay mesh. There was no prior history of pancreatitis.
On presentation, he was hemodynamically stable with a heart rate of 60 beats per minute and blood pressure of 140/60 mmHg. His abdominal examination was soft, with generalized tenderness. His blood revealed an international normalized ratio of 2.9.
Computed tomography angiography (CTA) demonstrated a large retroperitoneal hematoma over the visceral aorta. There was generalized ectasia of the main superior mesenteric artery and a large 4 cm × 3.5 cm saccular, bilobed aneurysm arising from the IPDA [Figure 1]. This was associated with a dilated pancreaticoduodenal arcade and celiac axis occlusion [Figure 2]. There was also a small associated blush thought to be arising from a small branch of the inferior phrenic artery [Figure 1].
Figure 1: (a) Sagittal view of IPDA, illustrating the bilobed, saccular appearance. (b) Coronal view illustrating the location of IPDA and associated retroperitoneal hematoma superiorly. IPDA: Inferior pancreaticoduodenal artery
Figure 2: (a) Sagittal view illustrating mesenteric circulation, with celiac occlusion, reconstitution through the pancreatic arcade. (b) Axial view illustrating landing zones proximally and distal with the neck of IPDA. IPDA: Inferior pancreaticoduodenal arteryThe coagulopathy was initially reversed with Vitamin K and Prothrombinex-VF (dosing). After a multidisciplinary discussion, a decision was made for endovascular treatment, in particular, due to a history suggestive of a hostile surgical abdomen. Due to the celiac artery occlusion, preservation of the IPDA with stent grafting over embolization was prioritized to maintain perfusion to the celiac axis. Under general anesthesia, ultrasound-guided access was performed using micropuncture of the right common femoral artery. Five Fr Terumo sheath was placed. A diagnostic aortogram was performed using a pigtail catheter [Figure 3]. Initially, a Van Schie 3 catheter platform was used to cannulate the left inferior phrenic artery. A small pseudoaneurysm was seen, although no overt blush. A 2.7 Fr Progreat catheter was advanced and a 3 mm detachable concerto coil was deployed. Attention was then turned to the IPDA. Access was exchanged for an 8.5 Fr Agilis Steerable sheath, which was angled and placed into the spinal muscular atrophy (SMA) [Figure 4]a. Following this, a glide catheter and glide wire was used to traverse into the inferior pancreaticoduodenal branch, across the aneurysm. After confirmation of distal intraluminal entry, a 0.035 Rosen wire was exchanged to provide a secure platform over which to track the stent graft. About 3000 units of heparin were given [Figure 4]b. After a masking run in Lao 15°, an 8 mm × 39 mm VBX (GoreTM) was deployed [Figure 5]. The final angiogram showed patent inline flow through the pancreaticoduodenal arcade into the celiac axis, and preserved antegrade SMA flow [Figure 5]b. Perclose hemostasis was performed with 6 Fr ProGlide.
Figure 3: Pigtail operative aorto-mesenteric angiogram illustrating IPDA
Figure 4: (a) Steerable sheath with ectatic SMA, IPDA with proximal, and distal landing zones. (b) Platform with 0.035 wire traversing IPDA landing zones. IPDA: Inferior pancreaticoduodenal artery, SMA: Spinal muscular atrophy
Figure 5: (a) Operative angiogram showing “bareback” advancement of VBX. (b) Successful deployment with the exclusion of IPDA with a stent graft. IPDA: Inferior pancreaticoduodenal arteryThe patient was postoperatively commenced on aspirin (with 300 mg loading). He was discharged on day 7 postoperatively after confirming re-warfarnisation to therapeutic level without clinical signs of re-bleeding. Postoperative CTA showed complete exclusion of aneurysms with a reduction in the size of retroperitoneal hematoma [Figure 6]. A complete vasculitic screen was performed on admission, and the final serology was negative on the latest follow-up. The stent remained patent at a 4-week follow-up with good apposition and exclusion of aneurysms. Follow-up long-term for this patient will be necessary to ensure patency of the stent graft, and the maintenance of an adequate proximal and distal seal without endoleak.
Figure 6: (a) Axial postoperative CT angiogram demonstrating proximal landing zone of the stent graft. (b) Axial postoperative CT angiogram demonstrating distal landing zone of the stent graft. CT: Computed tomography Discussion Visceral artery aneurysms are well recognized, although rare. The presence of branch vessels, and particularly IPDA represents approximately 2% of all visceral artery aneurysms or 0.02% of all aneurysms.[2] These IPDAs can be divided into two categories: true and false aneurysms. False aneurysms have been well described, especially postpancreatic/upper gastrointestinal surgery, postpancreatitis, trauma, or sepsis (Gram-negative bacteremia).[5]
True aneurysms are less frequently understood, with likely hemodynamic, mechanical, and biological risk factors. Underlying vasculitides include polyarteritis nodosa, bechet's, segmental arterial mediolysis, and other small/medium vessel vasculitis. IPDAs are associated more frequently with celiac axis stenosis or occlusion.[3] The presence of a celiac axis lesion is thought to promote increased hemodynamic flow through this arcade, and subsequent predisposition to aneurysmal degeneration.[5] Finally, the presence of underlying connective tissue disorder cannot be ignored, in particular, vascular type Ehlers–Danlos (Type 4).[6] This case presents a patient with underlying celiac axis occlusion, which undoubtedly contributed to the prominence of the pancreaticoduodenal arcade. The contribution of prior morbid obesity, gastrointestinal surgical history, or underlying arteriopathy may have also contributed.
Open and endovascular surgical options exist to treat giant visceral artery aneurysms. Open surgical techniques include aneurysmorrhaphy, aneurysm excision, interposition grafting, en bloc excision with pancreatic resection, or in more extreme circumstances, a Whipple procedure.[7],[8] In our patient, this would have carried significant morbidity. Not only due to the hostile abdomen and prior surgeries but also significant obesity and associated postoperative complications. As a result, endovascular treatment was pursued.
There are prior case reports of successful endovascular treatment of IPDAs using catheter-directed embolization or stent-assisted coiling using uncovered stent grafting.[1],[2],[3],[4],[5],[9] We described a unique technique in treating the IPDA in our aneurysm. Prior access and platforms involved 5 F or 6 Fr sheaths, with the use of embolization platforms to deploy coils/embolization glue (Onyx).[9] At our institution, we have routinely used a steerable sheath to allow for rapid visceral vessel access and ease of deployment of various stent grafts. They hold particular promise in hemodynamically unstable patients. Second, due to the smaller caliber vessels, the ability to place an on-label-covered stent graft has not previously been described. In this particular case, the presence of a prominent pancreaticoduodenal arcade allowed for useable proximal and distal landing zones. As a result, a balloon-expandable-covered stent was able to be deployed with on-label use. The ability to utilize a balloon-expandable stent allowed for exact deployment to ensure adequate seal and exclusion of the aneurysm. VBX is a new-generation balloon-expandable-covered stent. It consists of expanded polytetrofluroethelene [ePTFE] supported by nitinol meshwork, with enough flexibility to traverse safely outside the sheath.[10] This allowed us to use this stent graft without having an entire sheath across into the pancreaticoduodenal artery. Overall, with the requirement for deployment of a single stent graft, the operative time was significantly shortened. In the setting of unwell or critically ill patients, this technique may allow for rapid treatment of the ruptured aneurysm.
ConclusionThis is the first reported case in the literature describing the successful use of a covered balloon-expandable stent to exclude a giant IPDA. Presence of an appropriate-sized proximal and distal landing zone allowed for use of the stent graft. The large vessel ectasia may have been related to underlying arteriopathy, but contributed to by the celiac axis occlusion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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