Inferior Pancreaticoduodenal Artery Aneurysm Associated with Obstruction of the Celiac Trunk and Cancer of the Head of the Pancreas

Aneurysm of the visceral arteries is a rare condition and it represents around 1% of all arterial aneurisms. Aneurysm of the inferior pancreaticoduodenal artery represents around 2% of all visceral aneurysms. Aneurysm associated with occlusion of the coeliac trunk is very rare condition and there are only about 40 cases presented in the literature. In our study, we presented 56 year-old female admitted to hospital with obstructive jaundice. CT scan diagnosed tumor of the head of pancreas and CT angiography confirmed aneurysm of the inferior pancreaticoduodenal artery which was successfully operated at our clinic.


Case report
A 56 year-old female with obstructive jaundice was admitted at our clinic.US and CT scan confirmed the tumor of the head of pancreas and CT angiography diagnosed aneurysm of the inferior pancreaticoduodenal artery with obstruction of celiac artery.(Figure 1.).Painless jaundice was the cause of doctor's appointment and aneurysm of the pancreaticoduodenal artery was discovered accidentally, as it was asymptomatic.
With the usage of upper median laparotomy, we opened the abdominal cavity, removed tumor together with the he ad of the pancreas, duodenum and gastric antrum.By ca reful preparation we showed aneurysms of the artery pancreaticoduodenal, which was ligated and resected at the origin of the upper mesenteric artery (Figure 2.).Upon the resection, we tested a sufficiency of the collateral circulation (Figure 2.).As surgery lasted for about 5 hours and there were no signs of ischemia of the liver, spleen and stomach stum p, there was no need for revascularization of the celiac trunk.
Biliodigestive reconstruction and reconstruction of the digestive tract was performed according to standard Whipple method.The postoperative course was satisfactory.Subsequent histological analysis confirmed adenocarcinoma of the pancreatic head.

Discussion
Aneurysms of visceral arteries are very rare but lifethreatening states.They present only about 1-2% of all aneurysms, and pancreaticoduodenal artery is a very rare place for the aneurysm occurrence.Only about 40 cases of aneurysms of the pancreaticoduodenal arteries associated with thrombosis or occlusion of the celiac trunk has been reported in the literature. 1 That state is not considered to be particularly coincidental, because by the occlusion of the main celiac, a liver, spleen and stomach are vascularized through the upper mesenteric artery across the pancreaticoduodenal arcade.Chronically hypertension leads to weakness of the arterial wall, and causes dilation and aneurysm formation.Aneurysm can be associated with the development of abundant collateral circulation. 2,3The aneurysm itself is asymptomatic at first, then with nonspecific abdominal symptoms, and may lead to rupture and potentially life-threatening intraabdominal hemorrhage.Less asymptomatic aneurysm inci dentally detected by CT examination.Some patients may have signs of mesenteric ischemia due to stenosis or associated extraluminal compression of mesenteric artery.
Rupture of an aneurysm in the retropertoneal space is a severe condition that is manifested by severe abdominal pain, and may be developed and hypovolemic shock if the rupture at the free abdominal cavity.Extremely rare is rupture of the digestive tract (stomach, duodenum, small and large intestine).The incidence of rupture is not directly proportional to the size of the aneurysm and it is difficult to predict the potential risk of rupture.Therefore, it is necessary to treat all types of diagnosed aneurisms. 2,3en conventional selective angiography or CT angiography diagnoses visceral artery aneurysms, it is necessery to preform a dynamic evaluation of collateral blood flow and diagnose the possible obstruction of the main splanhnich artery.CT angiography isa more recent and very successful non-invasive method to achieve an accurate diagnosis.Two-and three-dimensional video clearly shows the localization of the aneurysm and possible visceral artery stenosis.Endovascular stenting of the occluded visceral arteries and transcatheter embolization of aneurysms are the best option treatment for diagnosing the asymptomatic aneurysms.Transcateter embolization is the method of interventional radiology which can have complications (aneurysm rupture, intestinal ischemia, etc.).Surgical treatment involves ligation and resection,and, when po ssible, a reconstruction.Some authors advocate revascularization of the celiac trunk in the case of poorly developed collateral circulation. 4,5nclusions Aneurysms of the pancreaticoduodenal artery with obstruction of coeliac truk are very rare conditions.Correlation with pancreatic carcinoma is coincidental, and surgical treatment is the method of choice due to the basic disease.Radicality of oncological procedure is a specified option and surgical resection of aneurysm is the treatment of choice.It is not necessery to perform reconstruction of pancreaticoduodenal artery because of the conducted and extensive surgical procedure for the malignant disease (cephalic duodenopancreatectomy).Furthermore, due to the well-developed collateral circulation, it is usually not necessary to open the main tree celiac trunk, and the cephalic duodenopancreatectomy itself is used to amputate the irrigation area of pancreaticoduodenal arcades.

Figure 1 .
Figure 1.CT angiography aneurysm of the inferior pancreaticoduodenal artery

Jovan Ćulum¹, Darko Golić², Aleksandar Guzijan³, Darko Jović 4 , Branislava Jakovljević 4 , Aleksandar Jakovljević 4 , Davor Grahovac 3
Obstruction of the Celiac Trunk and Cancer of the Head of the Pancreas ABSTRACT Aneurysm of the visceral arteries is a rare condition and it represents around 1% of all arterial aneurisms.Aneurysm of the inferior pancreaticoduodenal artery represents around 2% of all visceral aneurysms.Aneurysm associated with occlusion of the coeliac trunk is very rare condition and there are only about 40 cases presented in the literature.In our study, we presented 56 year-old female admitted to hospital with obstructive jaundice.CT scan diagnosed tumor of the head of pancreas and CT angiography confirmed aneurysm of the inferior pancreaticoduodenal artery which was successfully operated at our clinic.
Figure 2. Aneurysms of the artery pancreaticoduodenal