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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Embolisation of the gastroduodenal artery and superior pancreatico duodenal artery
Embolisation of the gastroduodenal artery and superior pancreatico duodenal artery
Contributed by : Vismay Panchal
Contributed by : Vismay Panchal
Introduction:
Introduction:
Pancreatitis isbroadly classified into acute pancreatitis and chronic pancreatitis, based on clinical course and histopathological features.(1,2) . Acute pancreatitis is an acute inflammatory process that may involve peripancreatic tissues and distant organ systems, commonly presenting with severe epigastric pain radiating to the back, nausea, and vomiting. The most frequent etiologies include gallstones and alcohol consumption, followed by hypertriglyceridemia, drugs, trauma and post-procedural causes such as ERCP.
Pancreatitis isbroadly classified into acute pancreatitis and chronic pancreatitis, based on clinical course and histopathological features.(1,2) . Acute pancreatitis is an acute inflammatory process that may involve peripancreatic tissues and distant organ systems, commonly presenting with severe epigastric pain radiating to the back, nausea, and vomiting. The most frequent etiologies include gallstones and alcohol consumption, followed by hypertriglyceridemia, drugs, trauma and post-procedural causes such as ERCP.
Chronic pancreatitis, on the other hand, is characterized by progressive inflammatory changes leading to irreversible fibrosis, ductal alterations, and eventual loss of pancreatic function, resulting in malabsorption and diabetes mellitus. (1,2).
Chronic pancreatitis, on the other hand, is characterized by progressive inflammatory changes leading to irreversible fibrosis, ductal alterations, and eventual loss of pancreatic function, resulting in malabsorption and diabetes mellitus. (1,2).
Among the vascular complications, pseudoaneurysm formation is a rare but potentially life-threatening entity occurs due to enzymatic digestion and weakening of the arterial wall by pancreatic enzymes in the setting of acute or chronic pancreatitis (3,4). Unlike true aneurysms, pseudoaneurysms lack all three layers of the arterial wall and are prone to rupture, leading to massive hemorrhage (4,5).
Among the vascular complications, pseudoaneurysm formation is a rare but potentially life-threatening entity occurs due to enzymatic digestion and weakening of the arterial wall by pancreatic enzymes in the setting of acute or chronic pancreatitis (3,4). Unlike true aneurysms, pseudoaneurysms lack all three layers of the arterial wall and are prone to rupture, leading to massive hemorrhage (4,5).
Clinically, patients may present with abdominal pain, gastrointestinal bleeding, or hemodynamic instability, especially if rupture occurs (4,5). Early detection is crucial, as mortality rates are significantly high in untreated cases (5).
Clinically, patients may present with abdominal pain, gastrointestinal bleeding, or hemodynamic instability, especially if rupture occurs (4,5). Early detection is crucial, as mortality rates are significantly high in untreated cases (5).
Imaging plays a pivotal role, with contrast-enhanced CT (CECT) being the modality of choice for initial detection, demonstrating a well-defined enhancing lesion within or adjacent to the pancreas (2,6). Digital Subtraction Angiography (DSA) remains the gold standard for diagnosis and allows for simultaneous therapeutic intervention (7).
Imaging plays a pivotal role, with contrast-enhanced CT (CECT) being the modality of choice for initial detection, demonstrating a well-defined enhancing lesion within or adjacent to the pancreas (2,6). Digital Subtraction Angiography (DSA) remains the gold standard for diagnosis and allows for simultaneous therapeutic intervention (7).
This report describes a case of pancreatitis complicated by a pseudoaneurysm of the Gastroduodenal Artery, presenting with a high risk of life-threatening hemorrhage.
This report describes a case of pancreatitis complicated by a pseudoaneurysm of the Gastroduodenal Artery, presenting with a high risk of life-threatening hemorrhage.
The patient was successfully managed with endovascular embolization. This case highlights the critical importance of early imaging diagnosis and underscores the pivotal role of interventional radiology in effectively managing vascular complications of pancreatitis and preventing catastrophic outcomes.
The patient was successfully managed with endovascular embolization. This case highlights the critical importance of early imaging diagnosis and underscores the pivotal role of interventional radiology in effectively managing vascular complications of pancreatitis and preventing catastrophic outcomes.
Case presentation:
Case presentation:
A 55 year old man presented with acute severe abdominal pain and progressive hemodynamic instability. The patient had had a similar episode of pain previous week. The patient informed about an episode of alcohol binge in the previous week and has been having pain since then.
A 55 year old man presented with acute severe abdominal pain and progressive hemodynamic instability. The patient had had a similar episode of pain previous week. The patient informed about an episode of alcohol binge in the previous week and has been having pain since then.
Laboratory evaluation revealed a significant drop in hemoglobin, raising suspicion of intra-abdominal hemorrhage.
Laboratory evaluation revealed a significant drop in hemoglobin, raising suspicion of intra-abdominal hemorrhage.
Radiological findings :
Radiological findings :
Contrast-enhanced CT scan of the abdomen (triphasic) was performed.
Contrast-enhanced CT scan of the abdomen (triphasic) was performed.
A large, well defined heterogeneous lesion measuring approximately 6.5 x 5.7 x 8.5 cm was seen in the peripancreatic region predominantly near the head of the pancreas.
A large, well defined heterogeneous lesion measuring approximately 6.5 x 5.7 x 8.5 cm was seen in the peripancreatic region predominantly near the head of the pancreas.
There was intense focal contrast opacification in the arterial phase consistent with active contrast filling. Heterogeneous enhancement in the venous phase was suggestive of partial thrombosis/ongoing blood flow into the lesion.
There was intense focal contrast opacification in the arterial phase consistent with active contrast filling. Heterogeneous enhancement in the venous phase was suggestive of partial thrombosis/ongoing blood flow into the lesion.
A communication with a branch of coeliac axis most likely with gastroduodenal artery (GDA) was seen - suggestive of psuedo anuerysm of the gastroduodenal artery (GDA).
A communication with a branch of coeliac axis most likely with gastroduodenal artery (GDA) was seen - suggestive of psuedo anuerysm of the gastroduodenal artery (GDA).
The volume rendered image showed a large pseudoaneurysm in close proximity to the superior and inferior gastroduodenal arteries
The volume rendered image showed a large pseudoaneurysm in close proximity to the superior and inferior gastroduodenal arteries
A diagnosis of a pseudoaneurysm of gastroduodenal branches of the superior mesenteric artery was made and referred to vascular interventional radiology for further management.
A diagnosis of a pseudoaneurysm of gastroduodenal branches of the superior mesenteric artery was made and referred to vascular interventional radiology for further management.
Fig. 1
Fig. 2
Fig. 3
FIG 1. Axial image of the CECT showing filling of the aneurysm
FIG 2. Coronal MIP image of CECT showing anuerysm with supply from GDA.
FIG 3. Volume rendered inage - shows a large pseudoaneurysm in close proximity to the superior and inferior GDA.
Relevant Anatomy:
Relevant Anatomy:
The gastroduodenal artery (GDA), a branch of the common hepatic artery, supplies the pylorus, proximal duodenum, and pancreatic head. It gives rise to the superior pancreaticoduodenal arteries, which form the pancreaticoduodenal arcade with inferior pancreaticoduodenal arteries branches of the SMA.(8). Anastomosis between celiac trunk and SMA is common site in pancreatitis-related pseudoaneurysm (8).
The gastroduodenal artery (GDA), a branch of the common hepatic artery, supplies the pylorus, proximal duodenum, and pancreatic head. It gives rise to the superior pancreaticoduodenal arteries, which form the pancreaticoduodenal arcade with inferior pancreaticoduodenal arteries branches of the SMA.(8). Anastomosis between celiac trunk and SMA is common site in pancreatitis-related pseudoaneurysm (8).
The arcade consists of anterior and posterior superior (from GDA) and inferior pancreatic duodenal artery (from SMA).
The arcade consists of anterior and posterior superior (from GDA) and inferior pancreatic duodenal artery (from SMA).
Pancreaticoduodenal arcade is a the collateral pathway between the coeliac axis and SMA, making GDA vulnerable to pseudoaneurysm formation in case of pancreatitis.
Pancreaticoduodenal arcade is a the collateral pathway between the coeliac axis and SMA, making GDA vulnerable to pseudoaneurysm formation in case of pancreatitis.
FIG 4: Antomy of the pancreatico duodenal arcade reigon.
FIG 5, 6: Arterial supply of the pancreatico duodenal arcade reigon.
Interventional technique :
Interventional technique :
TAfter explaining the condition, its potential sequelea and the procedure with its benefits and risks, necessary written informed consent was obtained. The procedure was performed under monitored anaesthesia care.
TAfter explaining the condition, its potential sequelea and the procedure with its benefits and risks, necessary written informed consent was obtained. The procedure was performed under monitored anaesthesia care.
Through right femoral artery access, the celiac axis was catherised with a C1 catheter.
Through right femoral artery access, the celiac axis was catherised with a C1 catheter.
Using a microctheter, the GDA was ctheterised ; selective angiogram showed the anatpmy of the pseudoaneurysm. Following this, selective catheterization of superior pancreatico-duodonal artery was done (Fig, 7)
Using a microctheter, the GDA was ctheterised ; selective angiogram showed the anatpmy of the pseudoaneurysm. Following this, selective catheterization of superior pancreatico-duodonal artery was done (Fig, 7)
Supply from the SMA was evaluated by selective catherisation of inferior pancreaticoduodenal atery using a micro catheter (Fig. 8)
Supply from the SMA was evaluated by selective catherisation of inferior pancreaticoduodenal atery using a micro catheter (Fig. 8)
Three 4 mm x 170 mm, 3 mm x 70 mm and 3 mm x 70 mm size pushable coils were deployed in the superior pancreaticoduodenal artery (Fig. 9).
Three 4 mm x 170 mm, 3 mm x 70 mm and 3 mm x 70 mm size pushable coils were deployed in the superior pancreaticoduodenal artery (Fig. 9).
Fig. 7
Fig. 8
Fig. 9
FIG 7: Selective angiogram of the Superior pancreatico-duodonal artery - active blush seen in the region of pancreatico duodenal arcade.
FIG 8: Angiogram of inferior pancreatico duodenal artery shows active blush in the pancreatico duodenal arcade.
FIG 9: . Three 4 mm x 170 mm, 3 mm x 70 mm and 3 mm x 70 mm size pushable coils deployed in the superior pancreaticoduodenal artery.
Post coiling selective angiogram showed active blush – suggestive of other feeders also supplying the aneurysm.
Post coiling selective angiogram showed active blush – suggestive of other feeders also supplying the aneurysm.
Catheterisation of the SMA using C1 catheter was done.
Catheterisation of the SMA using C1 catheter was done.
Selective cannulation of the inferior pancreaticoduodenal artery done using a microcatheter. Two more coils (3 mm x 70 mm sized ) were deployed in the inferior pancreaticoduodenal artery
Selective cannulation of the inferior pancreaticoduodenal artery done using a microcatheter. Two more coils (3 mm x 70 mm sized ) were deployed in the inferior pancreaticoduodenal artery
Check angiogram showed no active blush in the pseudoaneurysm
Check angiogram showed no active blush in the pseudoaneurysm
FIG 10: Two more coils (3 mm x 70 mm sized ) deployed in the inferior pancreaticoduodenal artery ( Anterior and posterior branch).
Clinical outcome:
Clinical outcome:
There was immediate hemodynamic improvement in the patient with reduced
There was immediate hemodynamic improvement in the patient with reduced
requirement of pressor supports. There was no further drop in hemoglobin and Hb values improvedwith PCV transfusion. The patient was then shifted to ward
requirement of pressor supports. There was no further drop in hemoglobin and Hb values improvedwith PCV transfusion. The patient was then shifted to ward
and kept under observation for two days, during which he had a stable course following
and kept under observation for two days, during which he had a stable course following
which he was discharged.
which he was discharged.
Discussion
Discussion
Pancreatitis-related vascular complications are uncommon but potentially life- threatening, with pseudoaneurysm formation being one of the most serious entities (3–5). The pathogenesis involves enzymatic degradation of adjacent arterial walls by pancreatic enzymes, leading to loss of vessel integrity and pseudoaneurysm formation. Arteries in close proximity to the pancreas, particularly the Gastroduodenal Artery and pancreaticoduodenal arcades, are most commonly involved (3,4,8).
Pancreatitis-related vascular complications are uncommon but potentially life- threatening, with pseudoaneurysm formation being one of the most serious entities (3–5). The pathogenesis involves enzymatic degradation of adjacent arterial walls by pancreatic enzymes, leading to loss of vessel integrity and pseudoaneurysm formation. Arteries in close proximity to the pancreas, particularly the Gastroduodenal Artery and pancreaticoduodenal arcades, are most commonly involved (3,4,8).
Clinical presentation can vary from abdominal pain to massive gastrointestinal hemorrhage or hypovolemic shock following rupture, with untreated cases carrying high mortality rates (4,5). Early recognition is therefore essential. Contrast-enhanced CT serves as the initial imaging modality while Digital Subtraction Angiography remains the gold standard for definitive diagnosis as well as therapeutic planning (2,6,7).Endovascular embolization has emerged as the treatment of choice due to its high success rate and lower morbidity compared to surgery (5–7). In cases involving the pancreaticoduodenal arcade, evaluation of both celiac and superior mesenteric arterialsupply is crucial due to rich collateral circulation. Techniques such as the “sandwich method,” targeting both inflow and outflow vessels, help prevent persistent perfusion and rebleeding (8).
Clinical presentation can vary from abdominal pain to massive gastrointestinal hemorrhage or hypovolemic shock following rupture, with untreated cases carrying high mortality rates (4,5). Early recognition is therefore essential. Contrast-enhanced CT serves as the initial imaging modality while Digital Subtraction Angiography remains the gold standard for definitive diagnosis as well as therapeutic planning (2,6,7).Endovascular embolization has emerged as the treatment of choice due to its high success rate and lower morbidity compared to surgery (5–7). In cases involving the pancreaticoduodenal arcade, evaluation of both celiac and superior mesenteric arterialsupply is crucial due to rich collateral circulation. Techniques such as the “sandwich method,” targeting both inflow and outflow vessels, help prevent persistent perfusion and rebleeding (8).
This case emphasizes the importance of timely imaging and targeted endovascular intervention, highlighting the pivotal role of interventional radiology in reducing morbidity and preventing catastrophic hemorrhagic complications in pancreatitis.
This case emphasizes the importance of timely imaging and targeted endovascular intervention, highlighting the pivotal role of interventional radiology in reducing morbidity and preventing catastrophic hemorrhagic complications in pancreatitis.
Early recognition and prompt intervention are crucial to prevent catastrophic hemorrhage and mortality.
Early recognition and prompt intervention are crucial to prevent catastrophic hemorrhage and mortality.
Angiography delineates precisely the pseudoaneurysm sac, feeding artery, and collateral pathways. The “sandwich technique” with proximal and distal coil embolization, with or without liquid embolic agents, is commonly employed to prevent retrograde filling. Post-embolization angiography confirms complete exclusion of the lesion while preserving flow in adjacent arterial arcades.
Angiography delineates precisely the pseudoaneurysm sac, feeding artery, and collateral pathways. The “sandwich technique” with proximal and distal coil embolization, with or without liquid embolic agents, is commonly employed to prevent retrograde filling. Post-embolization angiography confirms complete exclusion of the lesion while preserving flow in adjacent arterial arcades.
Expected complication of embolisation.
Expected complication of embolisation.
1. Non-target embolization
1. Non-target embolization
2. Duodenal ischemia
2. Duodenal ischemia
3. Coil migration
3. Coil migration
4. Rebleeding
4. Rebleeding
References
References
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