Kristine C Orion1, Alireza Najafian2, Bryan A Ehlert2, Mahmoud B Malas2, James H Black2, Christopher J Abularrage3. 1. Division of Vascular Surgery & Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT. 2. Division of Vascular Surgery & Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. 3. Division of Vascular Surgery & Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: cabular1@jhmi.edu.
Abstract
BACKGROUND: There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAA) due to the fact that they are exceedingly rare. We sought to evaluate risk factors for rupture, as well as compare the outcomes of open and endovascular surgery. METHODS: We performed a retrospective review of all PDAAs over a 15-year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo Grade I. RESULTS: A total of 21 PDAAs was identified (mean size 20 mm, interquartile range 8-32). Eight patients (38%) were male with an average age at diagnosis of 54.3 ± 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, while 5 patients (24%) presented with rupture. Six patients (29%) had an open repair, including 4 aneurysm ligations and 2 emergent Whipple procedures. Eleven patients underwent an endovascular intervention including 10 (48%) embolizations and 1 stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and 0% of endovascular patients (P = 0.01). Death occurred in 2 ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P = 0.02); however, size of the aneurysm was not (P = 0.77). There was a trend toward an increased rupture rate in those with celiac stenosis (P = 0.10). CONCLUSIONS: In one of the largest series of PDAA to date, only male gender was associated with rupture. Furthermore, size of the aneurysm was not associated with rupture and should not be considered a criterion for repair. While technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice.
BACKGROUND: There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAA) due to the fact that they are exceedingly rare. We sought to evaluate risk factors for rupture, as well as compare the outcomes of open and endovascular surgery. METHODS: We performed a retrospective review of all PDAAs over a 15-year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo Grade I. RESULTS: A total of 21 PDAAs was identified (mean size 20 mm, interquartile range 8-32). Eight patients (38%) were male with an average age at diagnosis of 54.3 ± 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, while 5 patients (24%) presented with rupture. Six patients (29%) had an open repair, including 4 aneurysm ligations and 2 emergent Whipple procedures. Eleven patients underwent an endovascular intervention including 10 (48%) embolizations and 1 stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and 0% of endovascular patients (P = 0.01). Death occurred in 2 ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P = 0.02); however, size of the aneurysm was not (P = 0.77). There was a trend toward an increased rupture rate in those with celiac stenosis (P = 0.10). CONCLUSIONS: In one of the largest series of PDAA to date, only male gender was associated with rupture. Furthermore, size of the aneurysm was not associated with rupture and should not be considered a criterion for repair. While technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice.