Inferior Pancreaticoduodenal Artery Aneurysm With Superior Mesenteric Artery Occlusion - An Extremely Rare Case Of Visceral Artery Aneurysms

摘要

Background: Although visceral artery aneurysms (VAA) are rare, they have a high potential for fatal rupture with a very high mortality rate if not promptly diagnosed and treated.Case presentation: We report an interesting case of inferior pancreaticoduodenal artery aneurysm (IPDAA) with massive retroperitoneal hemorrhage in a 71-year-old man who presented with persistent epigastric and periumbilical pain for one month. Contrast-enhanced computed tomography (CT) revealed a ruptured IPDAA with superior mesenteric artery (SMA) occlusion. The SMA occlusion had caused necrosis of the small intestines. The ruptured IPDAA was confirmed by selective abdominal angiography. Percutaneous transcatheter coil embolotherapy (PTCE) was successfully employed to treat the patient. All previously described cases of IPDAA have been associated with celiac artery occlusion or stenosis. To the best of our knowledge, this is the second reported case of IPDA aneurysm with superior mesenteric artery (SMA) occlusion in the medical literature. The subject of this article is to present our experience with an exceedingly rare case of IPDAA and to review the medical literature on management of visceral artery aneurysms.Conclusion: Hemorrhage from VAA requires prompt diagnosis and management to prevent or decrease the morbidity and mortality associated with these aneurysms. Introduction Visceral artery aneurysms (VAAs) are rare but life-threatening abnormalities of the splanchnic vasculature. About 22-23 % of VAAs eventually rupture resulting in an overall mortalitiy of 8%-9% (1) The most common detected VAAs involve the splenic artery aneurysms (60%), followed by hepatic artery aneurysm (20%) (2-3). The majority of VAAs are usually seen in elderly patients with co-morbidities including hypertension and coronary artery disease. Smaller visceral vessel aneurysms such as the pancreaticoduodenal artery aneurysm (PDA) are uncommon and account for only 2-3 % of VAAs (4-6). Furthermore, IPDA aneurysms are extremely rare and due to their distinct and often fatal presentation, they pose a diagnostic and management challenge to surgeons especially in emergency settings (7-16). The incidence of patients presenting with a ruptured aneurysm is usually as high as 60-75% with an operative mortality rate of 50% (17-22). PDA aneurysms are reported as either pseudoaneurysm or false aneurysm or true aneurysm depending on the nature of the aneurysm. False PDAAs are more common than true aneurysms and are often associated with acute or chronic pancreatitis, laparoscopic cholecystectomy, septic emboli and abdominal trauma; whereas true PDAAs are reported with celiac artery stenosis or occlusion and account for only 2% of VAAs (23). Pseudoaneurysms usually have a higher risk of rupture than true aneurysms. Studies have shown that larger diameter aneurysms have a higher risk for rupture. Patients with PDAAs usually present with abdominal pain, tachycardia, and jaundice. The ruptured aneurysm can lead to hemorrhage in the peritoneal cavity, retroperitoneal space, in the biliary tract or in the gastrointestinal tract (9, 11-13, 15)Due to the developments in interventional radiology and the widespread use of CT and angiography, the detections rates of IPDAAs have significantly increased. Although, surgical treatment involving either bypass or ligation has been an effective tool in the management of VAAs in the past (20-22, 24), recently, endovascular management techniques have become the treatment of choice in patients with VAAs, especially in emergency cases (25-32). In this case report, we present a patient with inferior pancreaticoduodenal artery (IPDA) aneurysm and rupture successfully managed with PTCE. Case Report A 71-year-old man presented to our hospital emergency department with persistent spasmodic epigastric and periumbilical abdominal pain associated with one episode of vomiting. The pain was not associated with indigestion. His past medical history included hypertension