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Interventional Case Record
Interventional Case Record
Ruptured inferior pancreaticoduodenal artery aneurysm with proximal ostial celiac trunk stenosis: balloon-assisted front-door back-door coil embolization
Ruptured inferior pancreaticoduodenal artery aneurysm with proximal ostial celiac trunk stenosis: balloon-assisted front-door back-door coil embolization
Contributed by : Shrishti Patil
Contributed by : Shrishti Patil
Introduction:
Introduction:
Pancreaticoduodenal artery (PDA) aneurysms account for approximately 2% of all visceral artery aneurysms, yet they occupy a disproportionate place in vascular practice because their rupture risk is independent of diameter. Aneurysms as small as 2 mm have ruptured with fatal consequences, and there is therefore no observation threshold: treatment is indicated at the time of diagnosis irrespective of size. [1,2,3]
Pancreaticoduodenal artery (PDA) aneurysms account for approximately 2% of all visceral artery aneurysms, yet they occupy a disproportionate place in vascular practice because their rupture risk is independent of diameter. Aneurysms as small as 2 mm have ruptured with fatal consequences, and there is therefore no observation threshold: treatment is indicated at the time of diagnosis irrespective of size. [1,2,3]
Between 50% and 74% of PDA aneurysms coexist with stenosis or occlusion of the celiac axis, most commonly extrinsic compression by the median arcuate ligament (MAL). [1,2,4 ] The mechanism was first proposed by Sutton and Lawton in 1973 and subsequently characterized by Murata et al., w pinch ho demonstrated that celiac inflow restriction diverts superior mesenteric artery (SMA) flow retrogradely through the pancreaticoduodenal arcades to reconstitute the celiac territory. The resulting chronic elevation in flow and wall shear stress produces arcade hypertrophy, tortuosity and, ultimately, aneurysm formation. [2,3]
Between 50% and 74% of PDA aneurysms coexist with stenosis or occlusion of the celiac axis, most commonly extrinsic compression by the median arcuate ligament (MAL). [1,2,4 ] The mechanism was first proposed by Sutton and Lawton in 1973 and subsequently characterized by Murata et al., w pinch ho demonstrated that celiac inflow restriction diverts superior mesenteric artery (SMA) flow retrogradely through the pancreaticoduodenal arcades to reconstitute the celiac territory. The resulting chronic elevation in flow and wall shear stress produces arcade hypertrophy, tortuosity and, ultimately, aneurysm formation. [2,3]
Endovascular embolization is accepted as the first-line treatment because it permits simultaneous diagnosis and treatment with low physiological cost. [1,2,4] The therapeutic difficulty in these patients is not access to the aneurysm but preservation of perfusion: where the celiac axis is critically stenosed, the pancreaticoduodenal arcade is the sole conduit for hepatic, splenic and gastric arterial supply, and an arcade-sacrificing embolization can precipitate hepatic infarction or duodenal ischemia. [1,5.6] Selective isolation of the aneurysm with preservation of arcade continuity is therefore the technical objective.
Endovascular embolization is accepted as the first-line treatment because it permits simultaneous diagnosis and treatment with low physiological cost. [1,2,4] The therapeutic difficulty in these patients is not access to the aneurysm but preservation of perfusion: where the celiac axis is critically stenosed, the pancreaticoduodenal arcade is the sole conduit for hepatic, splenic and gastric arterial supply, and an arcade-sacrificing embolization can precipitate hepatic infarction or duodenal ischemia. [1,5.6] Selective isolation of the aneurysm with preservation of arcade continuity is therefore the technical objective.
We report a case of a ruptured aneurysm of the posterior branch of the inferior pancreaticoduodenal artery presenting with a large retroperitoneal hematoma and hemoperitoneum, in which both angiography and cross-sectional imaging demonstrated significant stenosis of the ostioproximal segment of the celiac trunk with post-stenotic dilatation, and in which there was retrograde filling of the celiac territory through the pancreaticoduodenal arcade. The aneurysm was treated by balloon-assisted front-door back-door coil embolization with preservation of the anterior arcade.
We report a case of a ruptured aneurysm of the posterior branch of the inferior pancreaticoduodenal artery presenting with a large retroperitoneal hematoma and hemoperitoneum, in which both angiography and cross-sectional imaging demonstrated significant stenosis of the ostioproximal segment of the celiac trunk with post-stenotic dilatation, and in which there was retrograde filling of the celiac territory through the pancreaticoduodenal arcade. The aneurysm was treated by balloon-assisted front-door back-door coil embolization with preservation of the anterior arcade.
Case presentation
Case presentation
A 54-year-old man presented with acute-onset upper abdominal pain of 3 days' duration, associated with vomiting and melena. There was no antecedent history of blunt abdominal trauma, alcohol binge, gallstone pancreatitis, peptic ulcer disease, or prior abdominal surgery or intervention. He had no history of hypertension, diabetes, or other significant medical conditions.
A 54-year-old man presented with acute-onset upper abdominal pain of 3 days' duration, associated with vomiting and melena. There was no antecedent history of blunt abdominal trauma, alcohol binge, gallstone pancreatitis, peptic ulcer disease, or prior abdominal surgery or intervention. He had no history of hypertension, diabetes, or other significant medical conditions.
On examination the patient was hemodynamically stable. The abdomen was soft, with epigastric tenderness and fullness, without guarding or rigidity. Bowel sounds were present.
On examination the patient was hemodynamically stable. The abdomen was soft, with epigastric tenderness and fullness, without guarding or rigidity. Bowel sounds were present.
He was referred to our institution with a contrast-enhanced computed tomography (CECT) of the abdomen and pelvis performed on 11.08.2026 at the referring hospital, which demonstrated an inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm with a large retroperitoneal hematoma.
He was referred to our institution with a contrast-enhanced computed tomography (CECT) of the abdomen and pelvis performed on 11.08.2026 at the referring hospital, which demonstrated an inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm with a large retroperitoneal hematoma.
Laboratory evaluation showed a hemoglobin of 8.6 g/dL and a leucocytosis of 18,000/mm³. The platelet count and coagulation profile were unremarkable, and renal function was preserved (serum creatinine 1.0 mg/dL). Liver function tests showed mild derangement (SGPT 174 IU/L, SGOT 54 IU/L) with hypoalbuminemia of 3.3 g/dL. Serum amylase and lipase, performed to exclude concurrent acute pancreatitis, were 87 IU/L and 32.5 IU/L respectively. The complete laboratory profile is summarised in Table 1.
Laboratory evaluation showed a hemoglobin of 8.6 g/dL and a leucocytosis of 18,000/mm³. The platelet count and coagulation profile were unremarkable, and renal function was preserved (serum creatinine 1.0 mg/dL). Liver function tests showed mild derangement (SGPT 174 IU/L, SGOT 54 IU/L) with hypoalbuminemia of 3.3 g/dL. Serum amylase and lipase, performed to exclude concurrent acute pancreatitis, were 87 IU/L and 32.5 IU/L respectively. The complete laboratory profile is summarised in Table 1.
Table 1 : Laboratory investigations
Imaging Findings:
Imaging Findings:
CECT Abdomen and Pelvis :
CECT Abdomen and Pelvis :
There is ostial stenosis celiac trunk, with post-stenotic dilatation, likely caused by the thickened diaphragmatic crura. There is prominent collateral circulation via the pancreaticoduodenal arcade. A saccular aneurysm measuring 14x10 mm is seen arising from the inferior pancreaticoduodenal arter. There is a loculated hematoma surrounding the aneurysm, which encases the uncinate process of the pancreas. It measures approximately 14.7 × 8.2 × 7.9 cm. Mild surrounding mesenteric fat stranding is noted. There is mild hemoperitoneum.
There is ostial stenosis celiac trunk, with post-stenotic dilatation, likely caused by the thickened diaphragmatic crura. There is prominent collateral circulation via the pancreaticoduodenal arcade. A saccular aneurysm measuring 14x10 mm is seen arising from the inferior pancreaticoduodenal arter. There is a loculated hematoma surrounding the aneurysm, which encases the uncinate process of the pancreas. It measures approximately 14.7 × 8.2 × 7.9 cm. Mild surrounding mesenteric fat stranding is noted. There is mild hemoperitoneum.
The pancreas shows normal contrast enhancement, with no evidence of necrosis. There is mild peripancreatic fat stranding. The main pancreatic duct is not dilated. (Figures 1,2,3 and 4)
The pancreas shows normal contrast enhancement, with no evidence of necrosis. There is mild peripancreatic fat stranding. The main pancreatic duct is not dilated. (Figures 1,2,3 and 4)
Figure 1: CECT arterial phase axial section shows a saccular aneurysm arising from the inferior pancreaticoduodenal artery with loculated hematoma surrounding the aneurysm
Figure 2 CECT arterial phase axial section shows a large loculated retroperitoneal hematoma
Figure 3 : CECT arterial phase sagittal section shows ostial narrowing of the celiac trunk with post stenotic dilatation and thickening of the diaphragmatic crura
Figure 4 :Volume rendered image shows the aneurysm arising from inferior pancreaticoduodenal artery
Interventional Technique:
Interventional Technique:
The procedure was performed after prior written informed consent, under strict aseptic precautions, local anesthesia and ultrasound guidance.
The procedure was performed after prior written informed consent, under strict aseptic precautions, local anesthesia and ultrasound guidance.
Vascular Access:
Vascular Access:
A 5-French sheath was placed in the right common femoral artery under ultrasound guidance.
A 5-French sheath was placed in the right common femoral artery under ultrasound guidance.
Diagnostic Angiography:
Diagnostic Angiography:
Selective cannulation of the celiac artery was attempted first. The catheter could not be engaged in the ostium, a finding attributed to high-grade ostial stenosis.
Selective cannulation of the celiac artery was attempted first. The catheter could not be engaged in the ostium, a finding attributed to high-grade ostial stenosis.
Selective cannulation of the superior mesenteric artery was then performed using a 4F Sim-1 catheter. The angiogram demonstrated a prominent pancreaticoduodenal arcade with a saccular aneurysm arising from the inferior pancreaticoduodenal artery. The celiac circulation was seen to fill retrogradely through the pancreaticoduodenal arcade, confirming that the arcade was the dominant route of hepatic and splenic perfusion.
Selective cannulation of the superior mesenteric artery was then performed using a 4F Sim-1 catheter. The angiogram demonstrated a prominent pancreaticoduodenal arcade with a saccular aneurysm arising from the inferior pancreaticoduodenal artery. The celiac circulation was seen to fill retrogradely through the pancreaticoduodenal arcade, confirming that the arcade was the dominant route of hepatic and splenic perfusion.
A Progreat microcatheter was used to selectively cannulate the inferior pancreaticoduodenal artery. (Figures 5 and 6)
A Progreat microcatheter was used to selectively cannulate the inferior pancreaticoduodenal artery. (Figures 5 and 6)
Figure 5 : SMA angiogram shows prominent pancreaticoduodenal arcade with retrograde filling of celiac artery territory
Figure 6 : SMA angiogram shows saccular aneurysm arising from the inferior pancreaticoduodenal artery
Flow Control:
Flow Control:
During initial coil deployment the hyperdynamic collateral circulation carried the coil antegrade along the pancreaticoduodenal arcade, and it migrated as far as the origin of the gastroduodenal artery (Video 1). In view of this, a second 7-French access was obtained via the left common femoral artery, and a balloon of 6 × 20 mm was inflated within the superior mesenteric artery to reduce arcade inflow. Temporary inflow reduction was used to limit further coil migration and non-target embolization during subsequent deployment (Video 2).
During initial coil deployment the hyperdynamic collateral circulation carried the coil antegrade along the pancreaticoduodenal arcade, and it migrated as far as the origin of the gastroduodenal artery (Video 1). In view of this, a second 7-French access was obtained via the left common femoral artery, and a balloon of 6 × 20 mm was inflated within the superior mesenteric artery to reduce arcade inflow. Temporary inflow reduction was used to limit further coil migration and non-target embolization during subsequent deployment (Video 2).
video1.mp4video2.mp4Video 1 : SMA angiogram showing coil migration due to hyperdynamic circulation
Video 2 : SMA angiogram showing balloon inflation to reduce flow and non-target embolization
Coil embolization was performed by the front-door back-door (isolation) technique, with sequential occlusion of the efferent and afferent limbs of the aneurysm-bearing segment across the inferior pancreaticoduodenal artery.
Coil embolization was performed by the front-door back-door (isolation) technique, with sequential occlusion of the efferent and afferent limbs of the aneurysm-bearing segment across the inferior pancreaticoduodenal artery.
Eight coils were deployed: 6 × 160 mm, 6 × 70 mm, 8 × 140 mm (× 2), 8 × 70 mm (× 2) and 10 × 140 mm (× 2). (Figure 7)
Eight coils were deployed: 6 × 160 mm, 6 × 70 mm, 8 × 140 mm (× 2), 8 × 70 mm (× 2) and 10 × 140 mm (× 2). (Figure 7)
Completion Angiography:
Completion Angiography:
The post-coiling angiogram revealed complete exclusion of the aneurysm, with normal flow in the common hepatic artery, the superior mesenteric artery and the anterior branches of the pancreaticoduodenal arcade. The procedure was uneventful, and no immediate post-procedural complications were noted (Figure 8).
The post-coiling angiogram revealed complete exclusion of the aneurysm, with normal flow in the common hepatic artery, the superior mesenteric artery and the anterior branches of the pancreaticoduodenal arcade. The procedure was uneventful, and no immediate post-procedural complications were noted (Figure 8).
Figure 7: SMA angiogram post embolization shows no visualized aneurysm
Figure 8 : The post embolization SMA angiogram shows no filling of the aneurysm. The CHA and part of the PDA (arrow) are opacified hrough other peripancreatic arcades.
Clinical Outcome:
Clinical Outcome:
The patient recovered uneventfully and was discharged 7 days after the procedure. He remained hemodynamically stable following embolization, with no clinical or biochemical evidence of rebleeding or hepatic ischemia. There was no significant hemoglobin drop after the procedure.
The patient recovered uneventfully and was discharged 7 days after the procedure. He remained hemodynamically stable following embolization, with no clinical or biochemical evidence of rebleeding or hepatic ischemia. There was no significant hemoglobin drop after the procedure.
Follow-up CECT (26.08.2026, POD-13): on comparison with the previous CT, there is complete exclusion of the aneurysm arising from the inferior pancreaticoduodenal artery, and reduction in the size (12.2 × 6.1 × 6.7 cm) and organization of the hematoma surrounding the uncinate process of the pancreas. There is no THAD, liver demonstrates normal enhancement (Video 3).
Follow-up CECT (26.08.2026, POD-13): on comparison with the previous CT, there is complete exclusion of the aneurysm arising from the inferior pancreaticoduodenal artery, and reduction in the size (12.2 × 6.1 × 6.7 cm) and organization of the hematoma surrounding the uncinate process of the pancreas. There is no THAD, liver demonstrates normal enhancement (Video 3).
video3.mp4Post procedure complications to be aware of
Post procedure complications to be aware of
• Coil migration and non-target embolization — the principal intraprocedural complication in a hyperdynamic, collateral-dependent arcade; mitigated by temporary balloon occlusion of the superior mesenteric artery
• Coil migration and non-target embolization — the principal intraprocedural complication in a hyperdynamic, collateral-dependent arcade; mitigated by temporary balloon occlusion of the superior mesenteric artery
• Hepatic ischemia or infarction — where the arcade is the dominant hepatic inflow in the presence of celiac stenosis, arcade sacrifice may render the liver ischemic; completion angiography must document preserved common hepatic artery opacification before the procedure is declared complete [1]
• Hepatic ischemia or infarction — where the arcade is the dominant hepatic inflow in the presence of celiac stenosis, arcade sacrifice may render the liver ischemic; completion angiography must document preserved common hepatic artery opacification before the procedure is declared complete [1]
• Incomplete exclusion with recurrent hemorrhage from retrograde back-door filling — the specific rationale for the isolation technique
• Incomplete exclusion with recurrent hemorrhage from retrograde back-door filling — the specific rationale for the isolation technique
• Aneurysm recurrence or de novo aneurysm formation at another arcade site if the underlying hemodynamic driver, namely the celiac stenosis, is left uncorrected [11]
• Aneurysm recurrence or de novo aneurysm formation at another arcade site if the underlying hemodynamic driver, namely the celiac stenosis, is left uncorrected [11]
• Post-embolization syndrome
• Post-embolization syndrome
• Access-site complications — hematoma, pseudoaneurysm or arteriovenous fistula
• Access-site complications — hematoma, pseudoaneurysm or arteriovenous fistula
• Contrast-induced nephropathy, particularly following a large-volume diagnostic and therapeutic contrast load
• Contrast-induced nephropathy, particularly following a large-volume diagnostic and therapeutic contrast load
Discussion
Discussion
Relevant Anatomy:
Relevant Anatomy:
The anterior and posterior pancreaticoduodenal arcades constitute the principal and most constant anastomosis between the foregut and midgut circulations. The superior pancreaticoduodenal arteries arise from the gastroduodenal artery, itself a branch of the common hepatic artery from the celiac axis, while the inferior pancreaticoduodenal artery arises from the proximal superior mesenteric artery; the two unite around the head of the pancreas and duodenal C-loop. Accessory communications include the arc of Bühler and the dorsal pancreatic artery.
The anterior and posterior pancreaticoduodenal arcades constitute the principal and most constant anastomosis between the foregut and midgut circulations. The superior pancreaticoduodenal arteries arise from the gastroduodenal artery, itself a branch of the common hepatic artery from the celiac axis, while the inferior pancreaticoduodenal artery arises from the proximal superior mesenteric artery; the two unite around the head of the pancreas and duodenal C-loop. Accessory communications include the arc of Bühler and the dorsal pancreatic artery.
The median arcuate ligament is a fibrous arch formed by the fusion of the right and left crura of the diaphragm, lying anterior to the aorta at the level of the twelfth thoracic vertebra. [2,12] The celiac axis normally arises between T11 and L1, but the level of origin varies considerably between individuals; when the celiac origin is high or the ligament low-lying, the ligament indents the superior aspect of the celiac origin, producing the characteristic hooked appearance on sagittal imaging. [1,7]
The median arcuate ligament is a fibrous arch formed by the fusion of the right and left crura of the diaphragm, lying anterior to the aorta at the level of the twelfth thoracic vertebra. [2,12] The celiac axis normally arises between T11 and L1, but the level of origin varies considerably between individuals; when the celiac origin is high or the ligament low-lying, the ligament indents the superior aspect of the celiac origin, producing the characteristic hooked appearance on sagittal imaging. [1,7]
Chronic restriction of celiac inflow reverses the direction of flow in the gastroduodenal artery and pancreaticoduodenal arcades, which then carry superior mesenteric blood retrogradely to supply the hepatic, splenic and gastric territories. Two consequences follow, and both were operative in this patient. First, the chronically hyperdynamic arcade dilates, becomes tortuous and forms aneurysms. [2,8] Second, the arcade ceases to be a redundant collateral and becomes the sole hepatic lifeline, which fundamentally changes the risk profile of embolization: the operator must occlude the aneurysm without dividing the conduit on which the liver depends. [1,3]
Chronic restriction of celiac inflow reverses the direction of flow in the gastroduodenal artery and pancreaticoduodenal arcades, which then carry superior mesenteric blood retrogradely to supply the hepatic, splenic and gastric territories. Two consequences follow, and both were operative in this patient. First, the chronically hyperdynamic arcade dilates, becomes tortuous and forms aneurysms. [2,8] Second, the arcade ceases to be a redundant collateral and becomes the sole hepatic lifeline, which fundamentally changes the risk profile of embolization: the operator must occlude the aneurysm without dividing the conduit on which the liver depends. [1,3]
The median arcuate ligament syndrome was first described by Harjola in 1963 and characterized as a clinical syndrome by Dunbar and colleagues in 1965. [7,8] Radiological celiac compression is far commoner than the clinical syndrome: it has been reported in up to one third of autopsy series and in approximately 6.7% of asymptomatic patients on CT, whereas symptomatic disease affects around 0.4% of the population. [9,10] The great majority of affected individuals are therefore asymptomatic, and in a substantial subset the first clinical manifestation of celiac compression is the rupture of a collateral aneurysm. [9,11]
The median arcuate ligament syndrome was first described by Harjola in 1963 and characterized as a clinical syndrome by Dunbar and colleagues in 1965. [7,8] Radiological celiac compression is far commoner than the clinical syndrome: it has been reported in up to one third of autopsy series and in approximately 6.7% of asymptomatic patients on CT, whereas symptomatic disease affects around 0.4% of the population. [9,10] The great majority of affected individuals are therefore asymptomatic, and in a substantial subset the first clinical manifestation of celiac compression is the rupture of a collateral aneurysm. [9,11]
This case precisely follows that pattern. There was no antecedent history of postprandial pain, weight loss or abdominal bruit; the celiac lesion declared itself only when the arcade aneurysm bled. CT angiography demonstrated significant stenosis of the ostioproximal segment of the celiac trunk with post-stenotic dilatation, and the angiogram demonstrated the functional consequence of that lesion: an ostium that could not be engaged, and a celiac territory sustained entirely by retrograde arcade flow. Post-stenotic dilatation is the more informative of the two anatomical signs, because caliber reduction alone is a common incidental observation, whereas post-stenotic dilatation implies a pressure gradient and therefore a lesion of genuine hemodynamic in importance. [10]
This case precisely follows that pattern. There was no antecedent history of postprandial pain, weight loss or abdominal bruit; the celiac lesion declared itself only when the arcade aneurysm bled. CT angiography demonstrated significant stenosis of the ostioproximal segment of the celiac trunk with post-stenotic dilatation, and the angiogram demonstrated the functional consequence of that lesion: an ostium that could not be engaged, and a celiac territory sustained entirely by retrograde arcade flow. Post-stenotic dilatation is the more informative of the two anatomical signs, because caliber reduction alone is a common incidental observation, whereas post-stenotic dilatation implies a pressure gradient and therefore a lesion of genuine hemodynamic in importance. [10]
What the present imaging does not yet establish is the cause of the celiac lesion, and that distinction determines whether definitive treatment is required. Extrinsic compression by the median arcuate ligament produces a characteristic hooked indentation of the superior surface of the celiac origin, is dynamic, and is accentuated in expiration and attenuated in deep inspiration; it is appreciated on sagittal reformats and is systematically under-called on axial review. [10,1] Intrinsic atherosclerotic ostial disease produces a fixed, often calcified, concentric narrowing that does not vary with respiration and is not amenable to ligament release.
What the present imaging does not yet establish is the cause of the celiac lesion, and that distinction determines whether definitive treatment is required. Extrinsic compression by the median arcuate ligament produces a characteristic hooked indentation of the superior surface of the celiac origin, is dynamic, and is accentuated in expiration and attenuated in deep inspiration; it is appreciated on sagittal reformats and is systematically under-called on axial review. [10,1] Intrinsic atherosclerotic ostial disease produces a fixed, often calcified, concentric narrowing that does not vary with respiration and is not amenable to ligament release.
The distinction between a true aneurysm of the arcade and an inflammatory pseudoaneurysm has practical consequences, and was not straightforward here, since the initial scan also demonstrated pancreatic edema and peripancreatic fat stranding. Peripancreatic inflammation is a recognized cause of pancreaticoduodenal and gastroduodenal pseudoaneurysm, and both entities are treated in the first instance by embolization. They diverge in follow-up: an inflammatory pseudoaneurysm is treated definitively once the aneurysm is occluded and the pancreatitis settles, whereas a hemodynamic arcade aneurysm carries a persistent risk of recurrence at other arcade sites for as long as the celiac stenosis remains uncorrected. [11,15] In this patient, the resolution of pancreatic edema on the follow-up study, in the presence of an ostioproximal celiac stenosis with post-stenotic dilatation and an established retrograde collateral circuit, point towards the fact that the peripancreatic inflammatory change was a consequence of the contained hemorrhage rather than its cause.
The distinction between a true aneurysm of the arcade and an inflammatory pseudoaneurysm has practical consequences, and was not straightforward here, since the initial scan also demonstrated pancreatic edema and peripancreatic fat stranding. Peripancreatic inflammation is a recognized cause of pancreaticoduodenal and gastroduodenal pseudoaneurysm, and both entities are treated in the first instance by embolization. They diverge in follow-up: an inflammatory pseudoaneurysm is treated definitively once the aneurysm is occluded and the pancreatitis settles, whereas a hemodynamic arcade aneurysm carries a persistent risk of recurrence at other arcade sites for as long as the celiac stenosis remains uncorrected. [11,15] In this patient, the resolution of pancreatic edema on the follow-up study, in the presence of an ostioproximal celiac stenosis with post-stenotic dilatation and an established retrograde collateral circuit, point towards the fact that the peripancreatic inflammatory change was a consequence of the contained hemorrhage rather than its cause.
Rather than performing an open surgery on the ligament to release it and augment celiac inflow before embolization, the aneurysm-bearing segment was isolated while the anterior branches of the arcade were deliberately preserved, and completion angiography documented persistent opacification of the common hepatic artery. Preservation of the anterior arcade is the critical technical detail: it maintains an alternative retrograde route to the celiac territory once the posterior circuit has been occluded.
Rather than performing an open surgery on the ligament to release it and augment celiac inflow before embolization, the aneurysm-bearing segment was isolated while the anterior branches of the arcade were deliberately preserved, and completion angiography documented persistent opacification of the common hepatic artery. Preservation of the anterior arcade is the critical technical detail: it maintains an alternative retrograde route to the celiac territory once the posterior circuit has been occluded.
Key Teaching Points:
Key Teaching Points:
• Pancreaticoduodenal arcade aneurysms rupture irrespective of size; there is no safe diameter and no role for surveillance once the diagnosis is made [1,2,3]
• Pancreaticoduodenal arcade aneurysms rupture irrespective of size; there is no safe diameter and no role for surveillance once the diagnosis is made [1,2,3]
• Between half and three-quarters of these aneurysms are associated with celiac axis stenosis or occlusion, most commonly median arcuate ligament compression; the aneurysm is a hemodynamic consequence, not an isolated lesion [1,4]
• Between half and three-quarters of these aneurysms are associated with celiac axis stenosis or occlusion, most commonly median arcuate ligament compression; the aneurysm is a hemodynamic consequence, not an isolated lesion [1,4]
• Before embolizing the arcade, establish where the liver gets its blood from. If the arcade is the dominant hepatic conduit, the aneurysm must be isolated without dividing the conduit, and completion angiography must document preserved common hepatic arterial flow [1]
• Before embolizing the arcade, establish where the liver gets its blood from. If the arcade is the dominant hepatic conduit, the aneurysm must be isolated without dividing the conduit, and completion angiography must document preserved common hepatic arterial flow [1]
• Front-door back-door isolation, not sac packing, is the correct technique in a collateral loop; single-limb occlusion permits continued retrograde filling and rebleeding
• Front-door back-door isolation, not sac packing, is the correct technique in a collateral loop; single-limb occlusion permits continued retrograde filling and rebleeding
• Balloon-assisted flow control in the parent superior mesenteric artery is a simple and effective adjunct when arcade flow is hyperdynamic, reducing the risk of coil migration into the mesenteric or hepatic circulation
• Balloon-assisted flow control in the parent superior mesenteric artery is a simple and effective adjunct when arcade flow is hyperdynamic, reducing the risk of coil migration into the mesenteric or hepatic circulation
• Embolization treats the aneurysm, not the cause. Definitive correction of the celiac stenosis by median arcuate ligament release should be considered to reduce the risk of recurrent aneurysm formation and recurrent hemorrhage, although the evidence for this remains inconsistent [1,15]
• Embolization treats the aneurysm, not the cause. Definitive correction of the celiac stenosis by median arcuate ligament release should be considered to reduce the risk of recurrent aneurysm formation and recurrent hemorrhage, although the evidence for this remains inconsistent [1,15]
• Watch for duodenal stenosis in the second and third weeks after inferior pancreaticoduodenal artery embolization; it presents with gastric distension and vomiting in the absence of pain, and is usually reversible with conservative treatment [5, 9]
• Watch for duodenal stenosis in the second and third weeks after inferior pancreaticoduodenal artery embolization; it presents with gastric distension and vomiting in the absence of pain, and is usually reversible with conservative treatment [5, 9]
References
References
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