Pancreaticoduodenal Arterial Aneurysms MICHAEL J. VERTA, JR., M.D., RICHARD H. DEAN, M.D.,* JAMES S. T. YAO, M.D., PH.D., JULIUS CONN, JR., M.D., W. HARRISON MEHN, M.D., JOHN J. BERGAN, M.D.

From the Department of Surgery, Northwestern University Medical School, 303 East Chicago Avenue, Chicago, Illinois

Experience with four aneurysms of the pancreaticoduodenal artery is reviewed and compared to the reported experience of 19 other cases. In view of the common presentation of such lesions as intra-abdominal hemorrhage preceded by nonspecific abdominal pain and other digestive symptoms, it is suggested that angiography performed preoperatively or intraoperatively allows definitive diagnosis and leads to specific therapy.

could have allowed a definitive diagnosis to be made prior to rupture of the aneurysm. These were unavailable at the time that this patient was being treated in the mid- 1950's.

A LTHOUGH aneurysms of the pancreaticoduodenal artery are uncommon, the catastrophic

Case 2. A 73-year-old man with a past history of severe atherosclerotic cardiovascular disease, arthritis, and a seizure disorder was admitted to the Emergency Room of the Northwestern Memorial Hospital with a 6-week history of abdominal bloating, pain and eructation. A sudden onset of abdominal pain and fainting had occurred just prior to admission. A recent previous upper gastrointestinal series, cholecystogram, and barium enema had shown no abnormalities. The patient was found to be in shock with cyanosis, cold, clammy extremities, and an unobtainable blood pressure; pulse, 50 and regular. The abdomen was distended and rigid. Rapid infusion of crystalloid and colloid solutions raised the blood pressure to 70/50. A lateral abdominal roentgenogram showed aortic calcification without aneurysm formation. Continued intravenous infusions were given as the patient was taken to the operating suite. Exploration of the abdomen revealed free peritoneal blood, a large retroperitoneal hematoma extending into the small bowel mesentery. Medial mobilization of the duodenum revealed the inferior pancreaticoduodenal artery aneurysm, which had ruptured into the peritoneal and retroperitoneal spaces. Postoperatively, the convalescence was complicated by recurrent gastrointestinal bleeding, respiratory insufficiency, pneumonia, congestive heart failure and pleural effusions. Improvement was slow until the 27th postoperative day, when the patient died suddenly. Autopsy revealed an acute anterolateral myocardial infarction.

mode of presentation of these lesions requires urgent surgical care. Availability of selective catheter arteriography allows prompt definitive diagnosis which aids in selecting appropriate surgical management of these lesions. The preoperative diagnosis has rarely been made in the past and, now that angiography allows an accurate diagnosis to be made, this review of cases presenting at the Northwestern University McGaw Medical Center has been made in order to formulate a plan for diagnosis and treatment. Case Reports Case 1. A 69-year-old man was seen at the Northwestern University Medical Center Hospitals with a three-year history of dysphagia, weight loss and chest pain. A very large Zenker's diverticulum was diagnosed, the patient was prepared for surgical correction by fluid and blood volume replacement, and diverticulectomy was performed successfully. On postoperative day 12, the patient vomited coffeebrown material twice. Nasogastric suction and intravenous fluids were instituted. In 48 hours, the patient experienced right upper quadrant pain, hypotension, tachycardia and abdominal distension. Treatment with blood transfusions and intravenous fluids was unsuccessful and autopsy revealed a ruptured aneurysm of the superior pancreaticoduodenal artery with retroperitoneal and free peritoneal hemorrhage, as well as a duodenal wall hematoma.

Comment. Although this patient was seen at a time when sophisticated diagnostic techniques were available, the presence of acute circulatory collapse and shock prevented use of emergency catheter arteriography. In a less urgent situation, this might have been performed. Similarly, when conventional contrast studies failed to reveal the cause of a patient's 6-weekold complaints, consideration may have been given to splanchnic arteriography and the diagnosis of pancreaticoduodenal artery aneurysm could have been made.

Comment. In this case, techniques of definitive diagnosis of upper gastrointestinal bleeding such as esophagogastroscopy combined with a contrast swallow and possibly supplemented by angiography Submitted for publication June 7, 1976. Supported in part by the Northwestern University Vascular Research Fund. * Current address: Vanderbilt University Medical Center. 111

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Ann. Surg. * July 1977

cholecystogram did not visualize the gallbladder. No abdominal masses or abnormal calcifications were seen. Surgical exploration revealed acute calculous cholecystitis as well as a large retroperitoneal hematoma. Medial mobilization of the duodenum revealed a ruptured aneurysm of the inferior pancreaticoduodenal artery. This was treated by aneurysmectomy, followed by an uneventful cholecystectomy. The postoperative course was complicated by a minor cerebrovascular accident but recovery from this as well as the surgical procedure was gradual and complete.

Comment. This case demonstrates diagnostic difficulties because of the presence of two simultaneously occurring pathologic processes, the contribution of either of which to the overall clinical picture is impossible to assess. Had exploration not revealed so promptly the source of the hematoma, intra-operative visceral angiography by hand injection would have been the next logical step.

FIG. 1. Diagram illustrating location of the pancreaticoduodenal described in the text.

aneurysms

Case 3. A 53-year-old woman was admitted to the Northwestern University Medical Center Hospitals because of sudden onset of diffuse, severe abdominal pain. The pain had begun in the right upper quadrant when she lifted a heavy object and had persisted over a 12-hour period. During this time, the patient had fainted twice. The past history was negative except for treatment of sigmoid diverticulitis. Physical examination was unrevealing. The hematocrit was 36% and the white blood count, 15,300. During the physical examination, the patient fainted and her blood pressure became unobtainable. She was taken to the operating suite while blood volume replacement was begun. Surgical exploration revealed a large free accumulation of blood in the peritoneal cavity and a large hematoma extending into the small bowel and colonic mesenteries. Medial mobilization of the duodenum revealed a ruptured aneurysm of the inferior pancreaticoduodenal artery. This was treated by aneurysmectomy and the patient recovered slowly but uneventfully.

Comment. The 12-hour period of symptoms following acute rupture of the pancreaticoduodenal artery aneurysm indicates that time was available in this as well as the previous two cases for proper preoperative evaluation by diagnostic techniques that are presently available. Case 4. A 64-year-old man was seen at the Northwestern University Medical Center Hospitals with a history of epigastric and upper abdominal pain radiating to the back, associated with nausea and vomiting. The pain increased following a meal of lamb chops and coffee, and spread to the lower quadrants. There was no prior history of peptic ulcer disease. Physical examination revealed an elderly Caucasiani man in obvious distress. He was unable to find a comfortable position in bed. There was tenderness and guarding which was poorly localized in the right upper quadrant. Laboratory examination revealed a white blood count of 14,000 and a normal hemoglobin. A double-dose oral

Discussion Although aneurysm formation of minor visceral arteries is uncommon and rupture of these aneurysms is even less common, these lesions do exist and their effects upon patients are devastating. In an 80-year period, up to 1975, 19 aneurysms of the pancreaticoduodenal artery were reported.9 Review of these cases (Table 1) indicates that non-specific abdominal pain, often occurring in the right upper quadrant, is a common characteristic. Symptoms precede frank rupture of the aneurysm in nearly every case. Rupture of the aneurysm eventually creates manifestations of shock but the bleeding is most commonly into the retroperitoneal or intraperitoneal space rather than into the gastrointestinal tract. There are reports of bleeding into the pancreatic duct25 and bleeding secondary to a penetrating duodenal ulcer,' but these are uncommon. Since symptoms precede onset of catastrophic hemorrhage, it is logical to assume that diagnostic techniques can be employed to make preoperative and prerupture diagnosis. That this is true is proven by the report of Spanos22 and by analysis of the four cases from the Northwestern University Medical Center. Aneurysms of the pancreaticoduodenal artery occur to a great extent in patients in the arteriosclerotic age group and are associated with peripheral atherosclerosis (Table 1). Theoretically, such small visceral aneurysms may be associated with other arterial dysplasias and indeed, Shallow21 demonstrated apparent failure of fusion of the media and adventitia of the arterial bifurcations of visceral aneurysms, indicating that this was a similar situation to that seen in intracranial berry aneurysms. This report has not been confirmed by other investigators. Further substantiating the theory that atherosclerosis is a common ac-

Vol. 186 . No. I

Author and Year

Sex

Chief Symptom

Cause of Aneurysm

Outcome

Ferguson, 18959

M

Abdominal pain

Not stated

Death

Keusenhoff, 193412

M

Abdominal pain

Bortalozzi, 19352

M

Epigastric pain, jaundice

Atherosclerosis Atherosclerosis

Death

Shallow et al. 194621

M

Epigastric pain

Congenital

Death

Ouwerker, 1951 17 Sampsel et al. 195219 Hendrick, 195210

M

Epigastric pain Chronic intermittent jaundice Recurrent gallbladder-like

Atherosclerosis Atherosclerosis Not stated

Survival Death Survival

Not stated Atherosclerosis Atherosclerosis Atherosclerosis

Survival Survival Survival Survival

Not stated Trauma

Survival Death Death Survival Survival Survival Death Survival Death Death Survival Survival

van

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PANCREATICODUODENAL ARTERIAL ANEURYSMS TABLE 1. Summary of Reported Cases of Pancreaticoduodenal Artery Aneurysms

M M

Comment

Death

Concomitant carcinoma of pancreas Four aneurysms of inferior pancreaticoduodenal artery

symptoms

Catanzaro et al. 19575 Kelley et al. 19641" Lannik and Ruskin, 196513 Blair and Yeager, 19661

F

Epigastric pain

F

Right upper quadrant pain Abdominal pain Gastrointestinal bleeding

Carter and Gosney, 19664 West et al. 196725 West et al. 196725 Deterling, 19717 Deterling, 19717 Douglas et al. 19718 Schneider and Zana, 197220 Spanos et al. 197422 Case 1 Case 2 Case 3 Case 4

M

M M

M M

M M M

M M M M F M

Abdominal pain Gastrointestinal bleeding Severe chronic anemia Not stated Jaundice

Abdominal pain, G.I. bleeding Gastrointestinal bleeding Abdominal pain Abdominal pain Abdominal pain Abdominal pain Epigastric pain

companying feature of pancreaticoduodenal artery aneurysms is a report by Brewer and Marcus,3 who studied 28 patients with spontaneous intraperitoneal hemorrhage and found only 8 in whom both hypertension and atherosclerosis were not present. Marks and Freedlander15 confirmed this, noting that 56% of their patients had atherosclerosis or hypertension as well. Extensive reviews by Stanley23 and by Deterling7 also support this observation. Trauma, of course, can be a cause of aneurysms of visceral vessels, including those of the pancreaticoduodenal artery. Pertinent to this is the observation of West, Bernhardt and Bowers.25 When all visceral artery aneurysms are considered, the report of Stanley23 indicates that 94% of these are found in males and these lesions carry a 50%o mortality. But in recent years, in the last 5 cases encountered and

Atherosclerosis Atherosclerosis Atherosclerosis Not stated Not stated Not stated Atherosclerosis Atherosclerosis Atherosclerosis Atherosclerosis

Duodenal ulcer penetrating aneurysm of superior PDA

Bleeding into pancreatic duct

Hemophilia Re-exploration after angiography Re-exploration after angiography Massive myocardial infarction

Concomitant cholecystitis

reported, 4 patients have survived.7'8'20'22 It seems that the major reasons for the better rate of survival relate to: more aggressive preoperative management including massive intravenous crystalloid and colloid infusions, aggressive surgical treatment including radical resection of adjacent perianeurysmal structures, and increased use of selective visceral angiography preoperatively and intraoperatively for localization of obscure sites of intra-abdominal hemorrhage. That surgical exploration alone without adjuvant studies is inadequate is supported by the view of Retzlaff et al. ,18 who indicate that exploratory laparotomy reveals the source of such bleeding in only 30% of such cases, whereas Spanos22 suggests that angiography identifies the source in at least 50o of all cases. Since patients with ruptured pancreaticoduodenal artery aneurysms are either in shock or have a history

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of syncope with hypotension, it is frequently tempting to bypass visceral angiography in favor of prompt surgical exploration. However, it is clear that selective angiography should be performed in those cases in which sufficient time exists for a properly done selective study. Selective celiac and superior mesenteric angiography should be done in patients with pain, hemorrhage, and shock, the origin of which is not detectable by conventional means. Also, it should be done in those patients who have right upper quadrant curvilinear calcifications suggestive of aneurysm, and in those patients who have an unexplained bruit or mass in the abdomen.29 Clearly, 4 of 5 patients with splanchnic artery aneurysms seek medical attention at the time of rupture25 and it is not always practical to take time for a full angiographic study. However, once surgical exploration has been performed and a large retroperitoneal hematoma of obscure origin is noted, intraoperative arteriography using injections in the superior mesenteric artery and celiac axis can be done to define the origin of the hemorrhage.22 When the aneurysm has been identified, operation can proceed with confidence. Definitive management of ruptured aneurysms of the pancreaticoduodenal artery is straightforward. Volume correction is of prime importance to re-establish cardiovascular stability. Excision of the aneurysm is definitive therapy and there is no need to restore arterial continuity. As splanchnic angiography is used more and more in the diagnosis of obscure gastrointestinal symptoms, it is to be expected that asymptomatic pancreaticoduodenal aneuryms will be found. Treatment of these lesions by resection is definitive. However, the arteriosclerotic age group of such patients and the presence of associated disease processes will influence surgical

decisions. Acknowledgment

Ann. Surg. * July 1977

2. Bortalozzi, M.: Aneurisma Fusiform dell'arteria Pancreaticoduodenale Inferiore. Pathologica, 27:622, 1935. 3. Brewer, A. C. and Marcus, R.: Massive Spontaneous Intraperitoneal Hemorrhage. Br. J. Surg. 36:198, 1947. 4. Carter, R. and Gosney, W. G.: Abdominal Apoplexy. Report of Six Cases and Review of the Literature. Am. J. Surg. 111:388, 1966. 5. Catanzaro, F. P., Merlino, A. and Palumbo, J. A.: Aneurysm Occurring in the Pancreaticoduodenal Arteries Treated by Excision. N. Engl. J. Med., 256:847, 1957. 6. Crane, C.: Arteriosclerotic Aneurysm of the Abdominal Aorta: Some Pathological and Clinical Correlations. N. Engl. J. Med., 253:954, 1955. 7. Deterling, R. A.: Aneurysm of the Visceral Arteries. J. Cardiovasc. Surg., 12:309, 1971. 8. Douglas, J. B., Gillespie, J. A. and Wilding, R. P.: Bleeding Pancreaticoduodenal Artery Aneurysm. Br. J. Surg., 58:397, 1971. 9. Ferguson, F.: Aneurysm of the Superior Pancreatico-duodenal Artery. Proc. New York Path. Soc., 1895; p. 24. 10. Hendrick, J. A.: Treatment of Aneurysm of PancreaticoDuodenal Artery by Excision. Ann. Surg., 144:1051, 1956. 11. Kelley, H. G., Knoernschild, H. E. and Marable, S. A.: Aneurysms of the Pancreaticoduodenal Arteries; A Review of the Literature and Case Report. Am. J. Surg., 107:644, 1964. 12. Keusenhoff, W. von: Eine Aussergewohnliche spontane, zum Tode Fuhrende Blutung aus der Arteria pancreaticoDuodenalis. Zentralbl. Chir., 61:1834, 1934. 13. Lannik, W. M. and Ruskin, H. D.: Aneurysm of Superior Pancreaticoduodenal Artery. Successful Treatment by Resection. New York J. Med., 65:910, 1965. 14. Longmire, W. P., Jr. and Rose, A. J., III: Hemoductal Pancreatitis. Surg. Gynecol. Obstet. 136:246, 1973. 15. Marks, M. and Freedlander, S. O.: Spontaneous Intra-abdominal Hemorrhage. Ann. Surg., 121:191, 1945. 16. Nevin, S. and Williams, D.: The Pathogenesis of Multiple Aneurysms. Lancet, 2:955, 1937. 17. van Ouwerkerk, L. W.: Aneurysm of the Arteria Pancreaticoduodenalis. Arch. Chir. Neerl., 3:11, 1951. 18. Retzlaff, J. A., Hagedom, A. B. and Bartholomew, L. G.: Abdominal Exploration for Gastrointestinal Bleeding of Obscure Origin. JAMA, 177:104, 1961. 19. Sampsel, J. W., Barry, F. M. and Steele, H. D.: Aneurysm of an Anomalous Pancreaticoduodenal Artery; Case Report and Review of the Literature. Arch. Surg., 64:74, 1952. 20. Schneider, F. and Zana, J.: Aneurysm of the Superior Pancreaticoduodenal Artery Rupturing into the Duodenum with Fatal Outcome. Orv. Hetil., 113:1240, 1972. 21. Shallow, T. A., Herbut, P. A. and Wagner, F. B., Jr.: Abdominal

22.

The authors would like to thank Dr. Arthur DeBoer for his permission to include Case 1 in this report. 23.

References

24.

1. Blair, F. L. and Yeager, W. R.: Aneurysm of Superior Pancreaticoduodenal Artery: Case report. Am. Surg., 32:53, 1966.

25.

Apoplexy Secondary to Ruptured "Congenital" Aneurysm; Multiple Aneurysms of Inferior Pancreaticoduodenal Artery with Rupture of One. Surgery, 19:177, 1964. Spanos, P. K., Kloppedal, E. A. and Murray, C. A., III: Aneurysms of the Gastro-duodenal and Pancreaticoduodenal Arteries. Am. J. Surg., 127:345, 1974. Stanley, J. C., Thompson, N. W. and Fry, W. J.: Splanchnic Artery Aneurysms. Arch. Surg., 101:689, 1970. Sweetman, W. R. and Weinstein, J. J.: Hepatic and CeliacArtery Aneurysms. JAMA, 197:221, 1966. West, J. E., Bernhardt, H. and Bowers, R. F.: Aneurysms of the Pancreaticoduodenal Artery. Am. J. Surg., 115:835, 1968.

Pancreaticoduodenal arterial aneurysms.

Pancreaticoduodenal Arterial Aneurysms MICHAEL J. VERTA, JR., M.D., RICHARD H. DEAN, M.D.,* JAMES S. T. YAO, M.D., PH.D., JULIUS CONN, JR., M.D., W. H...
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