PMC4813082_01
Axial CECT scan images demonstrating multiple tortuous arterial channels forming a racemose network in the pancreatic body (black arrows) with opacification of the portal vein (white arrow in B) in the early arterial phase. Note is also made of small pseudocyst in the vicinity of the PAVM (arrowhead in A)
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F1
Contrast-enhanced computed tomographic (CECT) scan of the abdomen performed on a Discovery 750HD 64-row spectral CT scanner (General Electric, Wisconsin, USA) revealed mild peripancreatic fat stranding with a small pseudocyst involving the head and body of pancreas [Figure 1A and B], suggesting acute pancreatitis. In addition, there was evidence of a network of multiple tortuous arterial channels involving the body of pancreas with early opacification of the splenic and portal vein [Figure 1], consistent with a PAVM.
(A and B) Celiac artery angiogram demonstrating the common hepatic (thick white arrow), dorsal pancreatic (short thin white arrow), splenic (long white arrow) and the LGA (long black arrows). PAVM is also seen (short black arrow) with early opacification of the portal vein (PV) (white arrowheads) and splenic parenchymal enhancement (black arrowheads). (C) LGA angiogram (black arrow) showing the PAVM. (D) Post embolization angiogram shows occlusion of the concerned artery and the embolic material (black arrowheads). (E) DPA (short white arrow) angiogram (F) Post embolization image shows minimal residual staining of the pancreas (short black arrow)
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F2
A 5F guiding catheter (C2; Cook) was used to cannulate the celiac artery and angiogram was done which revealed an interlacing network of arterial channels in the region of pancreas with early opacification of the portal vein [Figure 2A and B]. Terumo, Japan), the branches of celiac artery [common hepatic including the gastroduodenal artery, dorsal pancreatic artery (DPA), splenic artery, and left gastric artery (LGA)] were sequentially cannulated and angiograms were done which revealed that the PAVM was supplied by branches from the LGA and DPA [Figure 2C and E]. The major feeding artery arising from the LGA was first embolized using a 2 ml mixture of n-butyl-2-cyanoacrylate glue (Gesika; Medicon, Chennai, India) and lipiodol (Guerbet, Aulnay-sous-Bois, France) combined in a 1:1 ratio. Subsequent check angiogram revealed complete embolization of the concerned branch, without any significant opacification of the portal vein [Figure 2D]. The DPA was then partially embolized using 1 ml of the same mixture [Figure 2E and F].
Images from the pre intervention (A) and post intervention (B, C and D) CECT scans of the patient demonstrating deposition of embolic material on the 3-day follow-up image (black arrow in B) with a progressive regression in the size of the PAVM (black arrows in C and D) as well as a decrease in the opacification of portal vein (white arrows) and splenic vein (arrowheads) on the 3-month (C) and 8- month's follow-up image (D)
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F3
A follow-up CECT scan done 3 days later revealed significant decrease in the size of the PAVM compared to the pre-procedural scan, with patchy deposition of the liquid embolic material within it [Figure 3A and B]. Follow-up CECT scans at 1 and 8 months interval demonstrated progressive decrease in the size of the PAVM and portal venous filling [Figure 3C and D].