title: The presentation and management of aneurysms of the pancreaticoduodenal arcade.
abstract: OBJECTIVE
  Gastroduodenal artery aneurysms (GDAAs) and pancreaticoduodenal artery aneurysms (PDAAs) are uncommon lesions associated, however, with a significant risk of rupture. This study describes the clinical presentation, associated imaging findings, and operative strategies for these aneurysms.
  
  
  METHODS
  The records of all patients with GDAAs or PDAAs identified through an institutional database by axial imaging between 1994 and 2014 were retrospectively reviewed. Data on presenting symptoms, comorbid conditions, imaging findings, and outcomes after operative intervention were collected and examined.
  
  
  RESULTS
  We identified 11 GDAAs and 25 PDAAs in 35 patients. Mean size of the GDAAs was 31.1 mm (range, 10-60 mm) and mean size of the PDAAs was 19.1 mm (range, 10-48 mm). At presentation, 13 aneurysms (36%) were symptomatic and seven aneurysms (19.4%) were ruptured. Median size of ruptured aneurysms was 20 mm (range, 10-60 mm). On axial imaging, 24 aneurysms (67%) were associated with a severe stenosis or occlusion of the celiac axis origin, and 11 aneurysms (31%) were thought to be associated with compression of the celiac axis in the setting of median arcuate ligament syndrome. Twenty-four aneurysms (67%) underwent repair. Of these aneurysms, 18 (75%) were successfully managed with primary endovascular repair (coil embolization with or without celiac stent), whereas endovascular therapy failed in two (8%) and required open repair. Four aneurysms (17%) were treated with primary open repair. Overall 30-day morbidity and mortality after aneurysm repair were 29% and 4%, respectively.
  
  
  CONCLUSIONS
  GDAAs and PDAAs are uncommon lesions that are often associated with a celiac axis stenosis/occlusion leading to altered hemodynamics in the pancreaticoduodenal arcade. These aneurysms are prone to rupture regardless of size, and intervention is accordingly recommended for all aneurysms upon recognition. Despite the concordant celiac axis obstruction and concern for maintenance of hepatic circulation, endovascular repair of these aneurysms is generally successful and should be considered as the initial operative approach.
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Corey
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Emel A
authors.initials: EA
authors.lastname: Ergul
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Cambria
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Virendra I
authors.initials: VI
authors.lastname: Patel
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Lancaster
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Kwolek
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass. Electronic address: mconrad@partners.org.
authors.forename: Mark F
authors.initials: MF
authors.lastname: Conrad
mesh_terms: D000368:Aged; D000783:Aneurysm / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D001158:Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001900:Boston; D002445:Celiac Artery / Q000002:abnormalities; D000072226:Computed Tomography Angiography; D003251:Constriction, Pathologic / Q000150:complications; D061887:Conversion to Open Surgery / Q000009:adverse effects / Q000401:mortality; D016208:Databases, Factual; D004386:Duodenum / Q000098:blood supply*; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008102:Liver Circulation; D008297:Male; D000074742:Median Arcuate Ligament Syndrome; D008875:Middle Aged; D010179:Pancreas / Q000098:blood supply*; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013270:Stomach / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome