embolic agent migration and parent artery occlusion.3


Additional considerations


include revascularizing the celiac artery or collaterals before or after embolization, especially if the risk of jeopardizing foregut perfusion is high.5,11


A multidisciplinary


approach between vascular surgery and IR can play a valuable role.


References


1. Hovsepian DM and Kos S. Visceral aneurysms. Handbook of Interventional Radiologic Procedures, by Krishna Kandarpa et al., Lippincott Williams & Wilkins. 2016:240-245.


Photos courtesy of R. Torrance Andrews, MD, FSIR


might have some type of vasculitis or collagen vascular disease with which I was unfamiliar.


What post or posts were most valuable to you and why? There were several pointing out that, while this was a new finding for me, it had been described in the past with celiac artery occlusion. Thomas Gregory Walker, MD, FSIR, from MGH, provided a list of published articles describing the scenario I was seeing.


Will you, or have you changed your practice patterns based upon responses you've seen on SIR Connect? Please describe any changes you are considering. I do routinely adjust my practice on the basis of conversations on SIR Connect. The collective knowledge and experience of SIR Connect participants is a deep well from which can be drawn a great deal of expertise at no cost and with very little effort. And it’s great to know that the conversation is exactly that: a back-and- forth exchange that can be accessed in near-real-time as needed.


Additional commentary: Visceral arterial aneurysms occur in 2% of the population, often in asymptomatic patients or those with non-specific abdominal pain during cross-sectional imaging.1 Approximately 22% of patients with visceral aneurysms present with emergent rupture.1–4


Mesenteric


aneurysms account for approximately 6% of visceral arterial aneurysms1


and may


involve the gastroduodenal or PDA as true or false aneurysms, commonly due to trauma or erosion from pancreatitis or a duodenal ulcer.1,5


Multiple aneurysms


within medium-sized vessel branches of the large abdominal aortic vessels can


28 IRQ | WINTER 2022


be seen in collagen vascular disease, vasculitis and conditions such as segmental arterial mediolysis (SAM).6 As in the index case, mesenteric arterial aneurysms have also been associated with concomitant celiac artery occlusion in rare cases.3,5,7,8,9


2. Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: Risk factor analysis and therapeutic opinion. Eur. J. Vasc. Endovasc. Surg. 2007;33(3):293–301. doi.org/10.1016/j. ejvs.2006.09.016.


3. Ducasse E, Roy F, Chevalier J, Massouille D, Smith M, Speciale F, Fiorani P, Puppinck P. Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: Current management. J. Vasc. Surg. Cases. 2004;39(4). doi.org/10.1016/j.jvs.2003.09.049.


The pathophysiology of


this pattern of aneurysms is still uncertain, thought in part to be attributed to redistribution and elevations in blood flow to collaterals causing endothelial shear stress and vessel dilation.5


In patients with


celiac artery occlusion, PDA aneurysms tend to occur more frequently than their gastroduodenal counterparts.5


PDA artery is most commonly affected, typically within 5 mm of its origin from the SMA.5,7


This is clinically important, as


pancreaticoduodenal arcade aneurysms have an increased risk of rupture and mortality irrespective of size, thus often warranting early treatment.8,9


Pre-procedural imaging workup with contrast-enhanced CT or MR angiography is essential and allows for better depiction of visceral arterial anatomy, identification of congenital or anatomic variants, branching, collateral flow and detecting the presence of bleeding into the peritoneal cavity from a ruptured aneurysm.1,3


Treatment includes surgery,


embolization therapy and celiac trunk lesion treatment.3


The technical success


of transcatheter arterial embolization of visceral arterial aneurysms overall ranges from 67–92%.1,4,10


Endovascular therapy


has typically been favored as the initial intervention of choice.5,7


Embolic agents


for visceral aneurysms have traditionally included coil packing, liquid embolic agents or covered stents; however, stent graft approach can occasionally prove difficult due to complex branching vessel anatomy in the foregut.1,5


Important peri-procedural concerns include special care to prevent The inferior


4. Chadha M, Chaitanya A. Visceral artery aneurysms: Diagnosis and percutaneous management. Tech. Vasc. Interv. September 2009;26(3):196–206. doi. org/10.1055/s-0029-1225670.


5. Vandy FC. Sell AS, Eliason JL, Coleman DM, Rectenwald JE, Stanley JC. Pancreaticoduodenal and Gastroduodenal artery aneurysms associated with celiac artery occlusive disease. Ann. Vasc. Surg. May 2017;41:32–40. doi.org/10.1016/j. avsg.2016.09.018.


6. Chao CP. Segmental arterial mediolysis. Semin. Interv. Radiol. September 2009;26(3):224–32. doi. org/10.1055/s-0029-1225666.


7. Flood K, Nicholson AA. Inferior pancreaticoduodenal artery aneurysms associated with occlusive lesions of the celiac axis: Diagnosis, treatment options, outcomes, and review of the literature. Cardiovasc. Intervent. Radiol. June 2013;36(3):578–87. doi. org/10.1007/s00270-012-0473-2.


8. Sanal B, Nas OF, Hacikurt K, Hakyemez KH, Erdogan C. Retrievable stent-assisted coiling technique using a solitaire stent: Treatment of pancreaticoduodenal artery aneurysm associated with celiac artery occlusion. Vasc. Endovascular Surg. February 2016;50(2):84–87. doi.org/10.1177/1538574416631644.


9. Kitaoka T, Deguchi J, Kamiya C, Suzuki J, Sato O. Pancreaticoduodenal artery aneurysm formation with superior mesenteric artery stenosis. Ann. Vasc. Dis. 2014;7(3):312–15. doi.org/10.3400/avd. cr.14-00040.


10. Chiesa R, Astore D, Guzzo G, Frigerio S, Tshomba Y, Castellano R, Liberato de Moura MR, Melissano G. Visceral artery aneurysms. Ann. Vasc. Surg. January 2005;19(1):42–48. doi.org/10.1007/ s10016-004-0150-2.


11. Bageacu S, Cuilleron M, Kaczmarek D, Porcheron J. True aneurysms of the pancreaticoduodenal artery: Successful non-operative management. Surgery. May 2006;135(5):608–16. doi.org/10.1016/j. surg.2005.10.015.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


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