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.

Experience with four aneurysms of the pancreaticoduodenal From the Department of Surgery, Northwestern artery is reviewed and compared to the reported experience of University Medical School, 303 East Chicago Avenue, 19 other cases. In view of the common presentation of such Chicago, Illinois lesions as intra-abdominal hemorrhage preceded by non- specific abdominal pain and other digestive symptoms, it is sug- gested that angiography performed preoperatively or intra- operatively allows definitive diagnosis and leads to specific could have allowed a definitive diagnosis to be made therapy. prior to rupture of the aneurysm. These were unavail- able at the time that this patient was being treated in the A LTHOUGH aneurysms of the pancreaticoduo- mid- 1950's. denal artery are uncommon, the catastrophic mode of presentation of these lesions requires urgent Case 2. A 73-year-old man with a past history of severe athero- sclerotic cardiovascular disease, arthritis, and a seizure disorder was surgical care. Availability of selective catheter admitted to the Emergency Room of the Northwestern Memorial arteriography allows prompt definitive diagnosis which Hospital with a 6-week history of abdominal bloating, pain and aids in selecting appropriate surgical management of eructation. A sudden onset of abdominal pain and fainting had these lesions. occurred just prior to admission. A recent previous upper gastro- The preoperative diagnosis has rarely been made in intestinal series, cholecystogram, and barium enema had shown no abnormalities. the past and, now that angiography allows an accurate The patient was found to be in shock with cyanosis, cold, clammy diagnosis to be made, this review of cases presenting extremities, and an unobtainable blood pressure; pulse, 50 and regu- at the Northwestern University McGaw Medical lar. The abdomen was distended and rigid. Rapid infusion of Center has been made in order to formulate a plan for crystalloid and colloid solutions raised the blood pressure to 70/50. diagnosis and treatment. A lateral abdominal roentgenogram showed aortic calcification without aneurysm formation. Continued intravenous infusions were given as the patient was Case Reports taken to the operating suite. Exploration of the abdomen revealed Case 1. A 69-year-old man was seen at the Northwestern University free peritoneal blood, a large retroperitoneal hematoma extending Medical Center Hospitals with a three-year history of dysphagia, into the small bowel mesentery. Medial mobilization of the duo- weight loss and chest pain. A very large Zenker's diverticulum was denum revealed the inferior pancreaticoduodenal artery aneurysm, diagnosed, the patient was prepared for surgical correction by fluid which had ruptured into the peritoneal and retroperitoneal spaces. and blood volume replacement, and diverticulectomy was performed Postoperatively, the convalescence was complicated by recurrent successfully. On postoperative day 12, the patient vomited coffee- gastrointestinal bleeding, respiratory insufficiency, pneumonia, brown material twice. Nasogastric suction and intravenous fluids congestive heart failure and pleural effusions. Improvement was were instituted. In 48 hours, the patient experienced right upper slow until the 27th postoperative day, when the patient died quadrant pain, hypotension, tachycardia and abdominal distension. suddenly. Autopsy revealed an acute anterolateral myocardial in- Treatment with blood transfusions and intravenous fluids was un- farction. successful and autopsy revealed a ruptured aneurysm of the superior pancreaticoduodenal artery with retroperitoneal and free peritoneal Comment. Although this patient was seen at a time hemorrhage, as well as a duodenal wall hematoma. when sophisticated diagnostic techniques were avail- able, the presence of acute circulatory collapse and Comment. In this case, techniques of definitive of catheter such as shock prevented use emergency arteriog- diagnosis of upper gastrointestinal bleeding raphy. In a less urgent situation, this might have been with a contrast esophagogastroscopy combined performed. Similarly, when conventional contrast swallow and possibly supplemented by angiography studies failed to reveal the cause of a patient's 6-week- old complaints, consideration may have been given to Submitted for publication June 7, 1976. and the diagnosis of pan- Supported in part by the Northwestern University Vascular splanchnic arteriography Research Fund. creaticoduodenal artery aneurysm could have been * Current address: Vanderbilt University Medical Center. made.

111 112 VERTA AND OTHERS 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 pancreatico- duodenal artery. This was treated by aneurysmectomy, followed by an uneventful cholecystectomy. The postoperative course was complicated by a minor cerebro- vascular accident but recovery from this as well as the surgical pro- cedure was gradual and complete.

Comment. This case demonstrates diagnostic dif- ficulties because of the presence of two simultaneously occurring pathologic processes, the contribution of either of which to the overall clinical picture is im- possible 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.

Discussion FIG. 1. Diagram illustrating location of the pancreaticoduodenal Although aneurysm formation of minor visceral aneurysms described in the text. arteries is uncommon and rupture of these aneurysms is even less common, these lesions do exist and their Case 3. A 53-year-old woman was admitted to the Northwestern University Medical Center Hospitals because of sudden onset of effects upon patients are devastating. In an 80-year diffuse, severe abdominal pain. The pain had begun in the right period, up to 1975, 19 aneurysms of the pancreatico- upper quadrant when she lifted a heavy object and had persisted over duodenal artery were reported.9 Review of these cases a 12-hour period. During this time, the patient had fainted twice. (Table 1) indicates that non-specific abdominal pain, The past history was negative except for treatment of sigmoid often occurring in the right upper quadrant, is a com- diverticulitis. Physical examination was unrevealing. The hematocrit mon rupture was 36% and the white blood count, 15,300. During the physical characteristic. Symptoms precede frank of examination, the patient fainted and her blood pressure became the aneurysm in nearly every case. Rupture of the unobtainable. She was taken to the operating suite while blood aneurysm eventually creates manifestations of shock volume replacement was begun. but the bleeding is most commonly into the retro- Surgical exploration revealed a large free accumulation of blood in peritoneal or intraperitoneal space rather than into the the peritoneal cavity and a large hematoma extending into the small bowel and colonic mesenteries. Medial mobilization ofthe duodenum gastrointestinal tract. There are reports ofbleeding into revealed a ruptured aneurysm of the inferior pancreaticoduodenal the pancreatic duct25 and bleeding secondary to a artery. This was treated by aneurysmectomy and the patient re- penetrating duodenal ulcer,' but these are uncommon. covered slowly but uneventfully. Since symptoms precede onset of catastrophic hemorrhage, it is logical to assume that diagnostic tech- Comment. The 12-hour period of symptoms follow- niques can be employed to make preoperative and ing acute rupture of the pancreaticoduodenal artery prerupture diagnosis. That this is true is proven by the aneurysm indicates that time was available in this as report of Spanos22 and by analysis of the four cases well as the previous two cases for proper preoperative from the Northwestern University Medical Center. evaluation by diagnostic techniques that are presently Aneurysms of the pancreaticoduodenal artery occur available. to a great extent in patients in the arteriosclerotic age group and are associated with peripheral athero- Case 4. A 64-year-old man was seen at the Northwestern Univer- sclerosis (Table 1). Theoretically, such small visceral Medical Center Hospitals with a history of epigastric and upper sity aneurysms may be associated with other arterial abdominal pain radiating to the back, associated with nausea and vomiting. The pain increased following a meal of lamb chops and dysplasias and indeed, Shallow21 demonstrated ap- coffee, and spread to the lower quadrants. There was no prior history parent failure of fusion of the media and adventitia of of peptic ulcer disease. the arterial bifurcations of visceral aneurysms, indicat- Physical examination revealed an elderly Caucasiani man in obvious ing that this was a similar situation to that seen in intra- distress. He was unable to find a comfortable position in bed. There cranial berry aneurysms. This report has not been con- was tenderness and guarding which was poorly localized in the right upper quadrant. Laboratory examination revealed a white blood firmed by other investigators. Further substantiating count of 14,000 and a normal hemoglobin. A double-dose oral the theory that atherosclerosis is a common ac- Vol. 186 . No. I PANCREATICODUODENAL ARTERIAL ANEURYSMS 113 TABLE 1. Summary of Reported Cases of Pancreaticoduodenal Artery Aneurysms Cause of Author and Year Sex Chief Symptom Aneurysm Outcome Comment Ferguson, 18959 M Abdominal pain Not stated Death Keusenhoff, 193412 M Abdominal pain Atherosclerosis Death Bortalozzi, 19352 M Epigastric pain, jaundice Atherosclerosis Death Concomitant carcinoma of pancreas Shallow et al. 194621 M Epigastric pain Congenital Death Four aneurysms of inferior pan- creaticoduodenal artery van Ouwerker, 1951 17 M Epigastric pain Atherosclerosis Survival Sampsel et al. 195219 M Chronic intermittent jaundice Atherosclerosis Death Hendrick, 195210 M Recurrent gallbladder-like Not stated Survival symptoms Catanzaro et al. 19575 F Epigastric pain Not stated Survival Kelley et al. 19641" F Right upper quadrant pain Atherosclerosis Survival Lannik and Ruskin, 196513 M Abdominal pain Atherosclerosis Survival Blair and Yeager, 19661 M Gastrointestinal bleeding Atherosclerosis Survival Duodenal ulcer penetrating an- eurysm of superior PDA Carter and Gosney, 19664 M Abdominal pain Not stated Survival West et al. 196725 M Gastrointestinal bleeding Trauma Death West et al. 196725 M Severe chronic anemia Atherosclerosis Death Bleeding into pancreatic duct Deterling, 19717 M Not stated Atherosclerosis Survival Deterling, 19717 M Jaundice Atherosclerosis Survival Hemophilia Douglas et al. 19718 M Abdominal pain, G.I. bleeding Not stated Survival Re-exploration after angiography Schneider and Zana, 197220 M Gastrointestinal bleeding Not stated Death Spanos et al. 197422 M Abdominal pain Not stated Survival Re-exploration after angiography Case 1 M Abdominal pain Atherosclerosis Death Case 2 M Abdominal pain Atherosclerosis Death Massive myocardial infarction Case 3 F Abdominal pain Atherosclerosis Survival Case 4 M Epigastric pain Atherosclerosis Survival Concomitant cholecystitis

companying feature of pancreaticoduodenal artery reported, 4 patients have survived.7'8'20'22 It seems that aneurysms is a report by Brewer and Marcus,3 who the major reasons for the better rate of survival relate studied 28 patients with spontaneous intraperitoneal to: more aggressive preoperative management includ- hemorrhage and found only 8 in whom both hyperten- ing massive intravenous crystalloid and colloid infu- sion and atherosclerosis were not present. Marks and sions, aggressive surgical treatment including radical Freedlander15 confirmed this, noting that 56% of their resection of adjacent perianeurysmal structures, and patients had atherosclerosis or hypertension as well. increased use of selective visceral angiography pre- Extensive reviews by Stanley23 and by Deterling7 also operatively and intraoperatively for localization of support this observation. obscure sites of intra-abdominal hemorrhage. That Trauma, of course, can be a cause of aneurysms of surgical exploration alone without adjuvant studies is visceral vessels, including those of the pancreatico- inadequate is supported by the view of Retzlaff et al. ,18 duodenal artery. Pertinent to this is the observation of who indicate that exploratory laparotomy reveals the West, Bernhardt and Bowers.25 source of such bleeding in only 30% of such cases, When all visceral artery aneurysms are considered, whereas Spanos22 suggests that angiography identifies the report of Stanley23 indicates that 94% of these are the source in at least 50o of all cases. found in males and these lesions carry a 50%o mortality. Since patients with ruptured pancreaticoduodenal But in recent years, in the last 5 cases encountered and artery aneurysms are either in shock or have a history 114 VERTA AND OTHERS Ann. Surg. * July 1977 of syncope with hypotension, it is frequently tempting 2. Bortalozzi, M.: Aneurisma Fusiform dell'arteria Pancreatico- duodenale Inferiore. Pathologica, 27:622, 1935. to bypass visceral angiography in favor of prompt 3. Brewer, A. C. and Marcus, R.: Massive Spontaneous Intra- surgical exploration. However, it is clear that selective peritoneal Hemorrhage. Br. J. Surg. 36:198, 1947. angiography should be performed in those cases in 4. Carter, R. and Gosney, W. G.: Abdominal Apoplexy. Report of Six Cases and Review of the Literature. Am. J. Surg. 111:388, which sufficient time exists for a properly done selec- 1966. tive study. Selective celiac and superior mesenteric 5. Catanzaro, F. P., Merlino, A. and Palumbo, J. A.: Aneurysm angiography should be done in patients with pain, Occurring in the Pancreaticoduodenal Arteries Treated by Excision. N. Engl. J. Med., 256:847, 1957. hemorrhage, and shock, the origin of which is not 6. Crane, C.: Arteriosclerotic Aneurysm of the Abdominal Aorta: detectable by conventional means. Also, it should be Some Pathological and Clinical Correlations. N. Engl. J. done in those patients who have right upper quadrant Med., 253:954, 1955. 7. Deterling, R. A.: Aneurysm of the Visceral Arteries. J. Cardio- curvilinear calcifications suggestive of aneurysm, and vasc. Surg., 12:309, 1971. in those patients who have an unexplained bruit or mass 8. Douglas, J. B., Gillespie, J. A. and Wilding, R. P.: Bleeding in the abdomen.29 Pancreaticoduodenal Artery Aneurysm. Br. J. Surg., 58:397, 1971. Clearly, 4 of 5 patients with splanchnic artery 9. Ferguson, F.: Aneurysm of the Superior Pancreatico-duodenal aneurysms seek medical attention at the time of rup- Artery. Proc. New York Path. Soc., 1895; p. 24. ture25 and it is not always practical to take time for a full 10. Hendrick, J. A.: Treatment of Aneurysm of Pancreatico- Duodenal Artery by Excision. Ann. Surg., 144:1051, 1956. angiographic study. However, once surgical explora- 11. Kelley, H. G., Knoernschild, H. E. and Marable, S. A.: tion has been performed and a large retroperitoneal Aneurysms ofthe Pancreaticoduodenal Arteries; A Review of hematoma of obscure origin is noted, intraoperative the Literature and Case Report. Am. J. Surg., 107:644, 1964. arteriography using injections in the superior mesen- 12. Keusenhoff, W. von: Eine Aussergewohnliche spontane, zum Tode Fuhrende Blutung aus der Arteria pancreatico- teric artery and celiac axis can be done to define the Duodenalis. Zentralbl. Chir., 61:1834, 1934. origin of the hemorrhage.22 When the aneurysm has 13. Lannik, W. M. and Ruskin, H. D.: Aneurysm of Superior Pan- been identified, operation can proceed with confidence. creaticoduodenal Artery. Successful Treatment by Resection. New York J. Med., 65:910, 1965. Definitive management of ruptured aneurysms of the 14. Longmire, W. P., Jr. and Rose, A. J., III: Hemoductal Pan- pancreaticoduodenal artery is straightforward. Volume creatitis. Surg. Gynecol. Obstet. 136:246, 1973. is of prime importance to re-establish 15. Marks, M. and Freedlander, S. O.: Spontaneous Intra-abdominal correction Hemorrhage. Ann. Surg., 121:191, 1945. cardiovascular stability. Excision of the aneurysm is 16. Nevin, S. and Williams, D.: The Pathogenesis of Multiple definitive therapy and there is no need to restore arterial Aneurysms. Lancet, 2:955, 1937. 17. van Ouwerkerk, L. W.: Aneurysm of the Arteria Pancreatico- continuity. duodenalis. Arch. Chir. Neerl., 3:11, 1951. As splanchnic angiography is used more and more in 18. Retzlaff, J. A., Hagedom, A. B. and Bartholomew, L. G.: the diagnosis of obscure gastrointestinal symptoms, it Abdominal Exploration for Gastrointestinal Bleeding of Obscure Origin. JAMA, 177:104, 1961. is to be expected that asymptomatic pancreatico- 19. Sampsel, J. W., Barry, F. M. and Steele, H. D.: Aneurysm of duodenal aneuryms will be found. Treatment of these an Anomalous Pancreaticoduodenal Artery; Case Report and lesions by resection is definitive. However, the arterio- Review of the Literature. Arch. Surg., 64:74, 1952. of such and the of 20. Schneider, F. and Zana, J.: Aneurysm of the Superior Pan- sclerotic age group patients presence creaticoduodenal Artery Rupturing into the Duodenum with associated disease processes will influence surgical Fatal Outcome. Orv. Hetil., 113:1240, 1972. decisions. 21. Shallow, T. A., Herbut, P. A. and Wagner, F. B., Jr.: Abdominal Apoplexy Secondary to Ruptured "Congenital" Aneurysm; Multiple Aneurysms of Inferior Pancreaticoduodenal Artery Acknowledgment with Rupture of One. Surgery, 19:177, 1964. 22. Spanos, P. K., Kloppedal, E. A. and Murray, C. A., III: The authors would like to thank Dr. Arthur DeBoer for his permis- Aneurysms of the Gastro-duodenal and Pancreaticoduodenal sion to include Case 1 in this report. Arteries. Am. J. Surg., 127:345, 1974. 23. Stanley, J. C., Thompson, N. W. and Fry, W. J.: Splanchnic Artery Aneurysms. Arch. Surg., 101:689, 1970. References 24. Sweetman, W. R. and Weinstein, J. J.: Hepatic and Celiac- Artery Aneurysms. JAMA, 197:221, 1966. 1. Blair, F. L. and Yeager, W. R.: Aneurysm of Superior Pancreat- 25. West, J. E., Bernhardt, H. and Bowers, R. F.: Aneurysms of icoduodenal Artery: Case report. Am. Surg., 32:53, 1966. the Pancreaticoduodenal Artery. Am. J. Surg., 115:835, 1968.