PMC9062254_01
(A) Patient 1. Anterior inferior pancreaticoduodenal artery (AIPDA) aneurysm with hypertrophy of gastroduodenal artery (GDA) and reversal of flow through the pancreaticoduodenal arcade via the superior mesenteric artery (SMA) suggesting proximal coeliac trunk stenosis marked CA (coeliac axis). Common hepatic artery (CHA), posterior inferior pancreaticoduodenal artery (PIPDA), and anterior superior pancreaticoduodenal artery (ASPDA) marked for reference. (B) Patient 1. Post successful coil embolisation of the inferior pancreaticoduodenal artery (IPDA) aneurysm. (C) Patient 1. Computed tomography angiography sagittal section showing proximal coeliac stenosis with retroperitoneal haemorrhage associated with IPDA aneurysm rupture, prior to median arcuate ligament compression release. (D) Patient 1. Final sagittal plane image of patient 1 CA post-release and stenting of the residual coeliac stenosis.
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Also noted was hypertrophy of the gastroduodenal artery, a CA stenosis, and reversal of flow through the pancreaticoduodenal arcade via the superior mesenteric artery (SMA) (Fig. 1A). Despite some coil prolapse into the origin of the posterior IPDA, there was no residual filling of the aneurysm and all other arcades remained patent (Fig. 1B). CTA showed a residual 75% CA stenosis (Fig. 1C). Coeliac trunk stenting was initially attempted, but due to poor stent expansion from the residual MAL fibre an open release was necessary. Once the remaining band was released the stent was re-angioplastied (Fig. 1D).
PMC9062254_02
(A) Patient 2. Digital subtraction angiography showing the bleeding inferior pancreaticoduodenal artery (IPDA) aneurysm. (B) Patient 2. Post-endovascular coiling with retrograde filling of the pancreaticoduodenal arcade and proximal coeliac axis (CA). Common hepatic artery (CHA) and gastroduodenal artery (GDA) have been marked for reference. (C) Patient 2. Computed tomography angiography sagittal scan prior to treatment showing proximal coeliac stenosis with large retroperitoneal haemorrhage associated with IPDA aneurysm rupture. (D) Patient 2. Post-intervention duplex ultrasound showing antegrade flow in CA and superior mesenteric artery (SMA). AIPDA = anterior inferior pancreaticoduodenal artery; ASPDA = anterior superior pancreaticoduodenal artery; PIPDA = posterior inferior pancreaticoduodenal artery; PSPDA = posterior superior pancreaticoduodenal artery.
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Abdominal CTA identified a ruptured aneurysm arising from a branch of the anterior IPDA close to its origin, as well as a proximal CA stenosis (Fig. 2C). Urgent coil embolisation of the bleeding branch of the IPDA was performed, accessed by a 6 French sheath in the right femoral artery (Fig. 2A). A C2 catheter was used for SMA cannulation, and this platform allowed five 2 x 4 cm ruby coils to be deployed via the 2.4F (Progreat-Terumo) microcatheter (Fig. 2B). At the patient's request, a post-operative mesenteric duplex ultrasound was performed instead of CTA, which confirmed antegrade flow and a widely patent CA at three months (Fig. 2D).