PMC7422076_01
Contrast-enhanced CT shows a large retroperitoneal hemorrhage with an area of active extravasation between the duodenum and the pancreas (arrow).
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A contrast-enhanced CT scan of the abdomen and pelvis revealed a large retroperitoneal hematoma with a lobulated focus of active contrast extravasation interposed between the pancreatic head and the duodenum (Figure 1).
External compression of the proximal celiac artery by the median arcuate ligament is confirmed on sagittal maximal intensity imaging.
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Finally, a high-grade proximal celiac artery stenosis was noted consistent with median arcuate ligament compression (Figure 2).
Arteriogram of the SMA demonstrates the brisk collateral flow to celiac branches including the hepatic artery proper (white arrowhead) and splenic artery (black arrowhead) via multiple pancreaticoduodenal collaterals (small white arrows).
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Mesenteric angiography confirmed median arcuate ligament compression that was well compensated through brisk extensive collateral flow from the SMA via the pancreaticoduodenal arcade (Figure 3).
A small aneurysm was discovered with the interrogation of a distal branch of the inferior PDA.
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Further interrogation showed the abnormal aneurysmal pancreaticoduodenal vessel, but the structure was unable to be reached given only a small network of feeding arteries measuring 1 mm or less (Figure 4).
(a, b) Bilobed saccular pseudoaneurysm (arrow) was seen with the interrogation of the superior PDA, and this feeding vessel was subsequently embolized.
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Using digital subtraction angiography (DSA), a prominent superior PDA branch supplying the aneurysm was identified and treated with coil embolization (Figures 5(a) and 5(b)).
3D volume rendering of SMA arteriogram reveals a DSA occult small accessory inferior pancreaticoduodenal artery feeding the bilobed pseudoaneurysm.
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The gantry angle was optimized from the 3D volume rendering (Figure 6), and image overlay of live fluoroscopy allowed for quick vessel selection with the microcatheter/microwire.
(a, b) Pre- and postembolization of the final inferior PDA feeding the bilobed PSA (arrowheads) which finally led to complete thrombosis.
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After verification with DSA, the vessel was treated with coil embolization (Figures 7(a) and 7(b)) thrombosing the PSA.