Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review
© Habib et al.; licensee BioMed Central Ltd. 2013
Received: 30 March 2012
Accepted: 25 March 2013
Published: 16 April 2013
Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.
Visceral artery aneurysms (VAA) are infrequent conditions characterized by a wide range of clinical presentations and various clinical outcomes. Depending on the mechanism of formation and etiologic factors, they can be divided into true aneurysms or pseudoaneurysms. True aneurysms are the results of vessel wall abnormalities while pseudoaneurysms occur after vascular injuries or erosions such as in trauma or inflammation , (i.e. pancreatitis, autoimmune disorders, vascular intervention, laparoscopic cholecystectomy and hepatic transplantation .
They have been reported in almost all the visceral arteries  but are most commonly seen in the splenic artery (46%), followed by the renal artery (22%), the hepatic artery (16.2%) and the pancreaticoduodenal artery (1.3%) . Those involving the gastroduodenal artery comprise only 1.5% of all reported VAA  and most of them are pseudoaneurysms due to their high occurrence rates in the setting of pancreatitis. Thus, true aneurysms in the pancreaticoduodeal and gastroduodenal arteries are extremely rare and represent only 3.5% of all VAA . In a review of the English literature over a 25 year period from 1970 to 1995, pancreatitis was found to be the most common associated condition with gastroduodenal artery aneurysm accounting for 47% of all cases followed by ethanol abuse (25%), peptic ulcer disease (17%) and cholecystectomy (3%) [5, 7, 8]. Other reported causes include congenital abnormalities (such as Marfan syndrome and Ehlers- Danlos syndrome ), liver cirrhosis , other vascular abnormalities such as fibro-muscular dysplasia, polyarteritis nodosa and predisposing events such trauma and septic emboli .
The pathogenesis of GDA aneurysms is not fully understood. Trauma, hypertension and atherosclerosis have been cited as potential risk factors for true aneurysms . The pathophysiologic changes that underlay the development of true gastroduodenal artery aneurysms comprise mainly atherosclerosis of the celiac artery with subsequent stenosis but also rarely congenital absence of the celiac axis . These two circumstances can be distinguished by the morphology of the collaterals that develop. The collateral vessels that form early on have usually parallel walls, are of uniform caliber and are limited to one or two vessels. In contrary, arteriosclerotic collaterals are more abundant, dilated and tortuous and hence more prone to aneursymal formation within the vessel’s wall. This occurs regardless of the location of the stenosis .
The pancreaticoduodenal artery is the main collateral pathway between the celiac axis and the superior mesenteric artery. Increased blood flow in the pancreaticoduodenal artery, as compensation for celiac artery stenosis, may cause a pancreaticoduodenal artery aneurysm . The same theory suggests that occlusion or stenosis of the superior mesenteric artery or celiac axis could be an etiologic factor predisposing to the formation of a gastroduodenal artery aneurysm [13, 15, 16].
As for pseudoaneurysms, inflammation with the most common cause being pancreatitis, results in vascular wall destruction that is mediated by pancreatic proteolytic enzymes leading to pseudoaneurysm formation .
Common presenting symptoms of GDA
1. Rupture (hematemesis, melena, shock)
2. Abdominal pain
3. Gastric outlet obstruction
4. Compressive symptoms (nausea, vomiting)
5. Hemobilia/ Hemosuccus pancreaticus
6. Pulsatile abdominal mass/ Bruit
Prior to the era of sophisticated imaging modalities the majority of cases of GDA aneurysms were undiagnosed until rupture occurred. Currently with the various imaging studies available, an increasingly larger number of cases are being incidentally detected in asymptomatic patients.
Doppler US may reveal turbulent arterial blood flow within or adjacent to a pseudocyst which is also suspicious for an aneurysm.
Plain X-ray of the abdomen is a rarely helpful study but may show shell-like calcifications in an atherosclerotic aneurysm .
New modalities such as Contrast-enhanced 3-dimensional magnetic resonance angiography or multi-detector row computed tomography have been reported to be as effective as visceral angiography in the diagnosis of abdominal vascular lesions [31, 32]. Other diagnostic studies are available including Pulse Doppler US, color Doppler US, endoscopic ultrasound and magnetic resonance imaging [33–35] but are less frequently used.
Endovascular options include embolization of the aneurysms or stent graft deployment [41, 42] (Figure 3). Some anatomical conditions are required though for technical feasibility of these procedures (saccular aneurysm with a narrow neck, fusiform aneurysm with adequate collateral flow, aneurysm of a vessel supplying an organ that has multiple arterial sources) [41, 43].
Even though this less aggressive option plays an important role in high risk surgical candidates, it has its potential complications such as visceral ischemia resulting in sacrifice of the involved visceral vessel, end-organ thrombosis, and late-term vessel recanalization. Transcatheter embolization is the most popular endovascular intervention performed despite the potential risk of visceral ischemia and organ infarction . Other complications include coil/stent migration [45, 46], intra-procedural aneurysm dissection, or rupture , embolisms, access artery pseudoaneurysms and contrast-induced nephropathy. In contrast, surgical interventions have their own share of complications such as paralytic ileus, wound infection, massive bleeding, or acute pancreatitis . These complications have a significantly higher rate of occurrence in patients with previous abdominal surgery where adhesions are present, making the endovascular approach the preferred treatment option in those patients .
Despite the fact that endovascular treatments do not represent a standard option and require both a specific training and a learning curve, the development of new technologies, such as the multilayer stent, could offer a new alternative to VAA treatment, particularly in high-risk patients .
In conclusion, physicians might only encounter GDA aneurysms as an incidental finding on CT scans. In unfortunate patients, rupture might occur and lead to a fatal outcome if an emergent intervention is not made. Depending on the patient’s condition, the decision to proceed with angiography or surgery should be taken without any delay to prevent the worst outcome.
- Iyori K, Horigome M, Yumoto S, Yamadera Y, Saigusa Y, Iida F: Aneurysm of the gastroduodenal artery associated with absence of the celiac axis: report of a case. Surg Today 2004,34(4):360–362. Epub 2004/03/31 10.1007/s00595-003-2698-9PubMedView ArticleGoogle Scholar
- Chong WW, Tan SG, Htoo MM: Endovascular treatment of gastroduodenal artery aneurysm. Asian Cardiovasc Thorac Ann 2008,16(1):68–72. Epub 2008/02/05PubMedView ArticleGoogle Scholar
- Morita Y, Kawamura N, Saito H, Shinohara M, Irie G, Okushiba S: [Diagnosis and embolotherapy of aneurysm of the gastroduodenal artery]. Rinsho Hoshasen Clin Radiography 1988,33(5):555–561. Epub 1988/05/01Google Scholar
- Matsuzaki Y, Inoue T, Kuwajima K, Ito Y, Okauchi Y, Kondo H: Aneurysm of the gastroduodenal artery. Int Med (Tokyo, Japan) 1998,37(11):930–933. Epub 1998/12/30 10.2169/internalmedicine.37.930View ArticleGoogle Scholar
- Shanley CJ, Shah NL, Messina LM: Uncommon splanchnic artery aneurysms: pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and colic. Ann Vasc Surg 1996,10(5):506–515. Epub 1996/09/01 10.1007/BF02000601PubMedView ArticleGoogle Scholar
- Deterling RA Jr: Aneurysm of the visceral arteries. J Cardiovasc Surg 1971,12(4):309–322. Epub 1971/07/01Google Scholar
- White AF, Baum S, Buranasiri S: Aneurysms secondary to pancreatitis. AJR Am J Roentgenol 1976,127(3):393–396. Epub 1976/09/01 10.2214/ajr.127.3.393PubMedView ArticleGoogle Scholar
- Kueper MA, Ludescher B, Koenigsrainer I, Kirschniak A, Mueller K, Wiskirchen J: Successful coil embolization of a ruptured gastroduodenal artery aneurysm. Vasc Endovascular Surg 2007,41(6):568–571. Epub 2008/01/02PubMedView ArticleGoogle Scholar
- Koyazounda A, Jaillot P, Persico J, Thouret JM, Grand A: Aneurysm of the gastroduodenal artery ruptured into the peritoneum. Treatment by embolization. Presse Medicale (Paris, France: 1983 1994,23(14):661–4. Epub 1994/04/09. Anevrysme de l'artere gastro-duodenale rompu en peritoine libre. Traitement par embolisationGoogle Scholar
- Matsuno Y, Mori Y, Umeda Y, Imaizumi M, Takiya H: Surgical repair of true gastroduodenal artery aneurysm: a case report. Vasc Endovascular Surg 2008,42(5):497–499. Epub 2008/11/13 10.1177/1538574408316916PubMedView ArticleGoogle Scholar
- Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G: The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 2007,45(2):276–283. discussion 83. Epub 2007/02/01Google Scholar
- Coll DP, Ierardi R, Kerstein MD, Yost S, Wilson A, Matsumoto T: Aneurysms of the pancreaticoduodenal arteries: a change in management. Ann Vasc Surg 1998,12(3):286–291. Epub 1998/05/20 10.1007/s100169900155PubMedView ArticleGoogle Scholar
- Gouny P, Fukui S, Aymard A, Decaix B, Mory H, Merland JJ: Aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. Ann Vasc Surg 1994,8(3):281–284. Epub 1994/05/01 10.1007/BF02018176PubMedView ArticleGoogle Scholar
- Quandalle P, Chambon JP, Marache P, Saudemont A, Maes B: Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Vasc Surg 1990,4(6):540–545. Epub 1990/11/01 10.1016/S0890-5096(06)60835-2PubMedView ArticleGoogle Scholar
- Vogler C, Faiss J, Krause FJ, Schwamborn G: [Aneurysm of the gastroduodenal artery with aplasia of the celiac trunk]. Der Chirurg Zeitschrift fur alle Gebiete der operativen Medizen 1991,62(6):503–504. Epub 1991/06/01. Aneurysma der Arteria gastroduodenalis mit Aplasie des Truncus coeliacusPubMedGoogle Scholar
- Schweizer W, Gries NC, Maddern G, Triller J: Splenic infarction complicating ligation of a gastroduodenal artery aneurysm. Dig Surg 1999,16(3):236–237. Epub 1999/08/07 10.1159/000018714PubMedView ArticleGoogle Scholar
- Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD: Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery 2005,137(3):323–328. Epub 2005/03/05 10.1016/j.surg.2004.10.009PubMedView ArticleGoogle Scholar
- Lee PC, Rhee RY, Gordon RY, Fung JJ, Webster MW: Management of splenic artery aneurysms: the significance of portal and essential hypertension. J Am Coll Surg 1999,189(5):483–490. Epub 1999/11/05 10.1016/S1072-7515(99)00168-4PubMedView ArticleGoogle Scholar
- Moore E, Matthews MR, Minion DJ, Quick R, Schwarcz TH, Loh FK: Surgical management of peripancreatic arterial aneurysms. J Vasc Surg Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 2004,40(2):247–253. Epub 2004/08/07Google Scholar
- Rowsell C, Moore TL, Streutker CJ: Aneurysm of the gastroduodenal artery presenting as a bleeding duodenal ulcer. Clin Gastroenterology Hepatol Offic Clin Pract J Am Gastroenterological Assoc 2006,4(10):xxviii. Epub 2006/06/08Google Scholar
- Skok P, Sinkovic A: Acute hemorrhage into the peritoneal cavity--a complication of chronic pancreatitis with pseudocyst: a case report from clinical practice. Hepatogastroenterology 1999,46(25):518–521. Epub 1999/05/06PubMedGoogle Scholar
- Eckhauser FE, Stanley JC, Zelenock GB, Borlaza GS, Freier DT, Lindenauer SM: Gastroduodenal and pancreaticoduodenal artery aneurysms: a complication of pancreatitis causing spontaneous gastrointestinal hemorrhage. Surgery 1980,88(3):335–344. Epub 1980/09/01PubMedGoogle Scholar
- Iyomasa S, Matsuzaki Y, Hiei K, Sakaguchi H, Matsunaga H, Yamaguchi Y: Pancreaticoduodenal artery aneurysm: a case report and review of the literature. J Vasc Surg Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 1995,22(2):161–166. Epub 1995/08/01Google Scholar
- Harris K, Chalhoub M, Koirala A: Gastroduodenal artery aneurysm rupture in hospitalized patients: An overlooked diagnosis. World J Gastrointest Surg 2010,2(9):291–294. Epub 2010/12/17 10.4240/wjgs.v2.i9.291PubMed CentralPubMedView ArticleGoogle Scholar
- Bassaly I, Schwartz IR, Pinchuck A, Lerner R: Aneurysm of the gastroduodenal artery presenting as common duct obstruction with jaundice. Review of literature. Am J Gastroenterol 1973,59(5):435–440. Epub 1973/05/01PubMedGoogle Scholar
- Bohl JL, Dossett LA, Grau AM: Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice. J Gastrointest Surg Offic J Soc Surg Alimentary Tract 2007,11(12):1752–1754. Epub 2007/07/20 10.1007/s11605-007-0231-yView ArticleGoogle Scholar
- Fodor M, Fodor L, Ciuce C: Gastroduodenal artery pseudoaneurysm ruptured in the common bile duct. Acta Chir Belg 2010,110(1):103–105. Epub 2010/03/24PubMedGoogle Scholar
- Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen MF: Massive extra-enteric gastrointestinal hemorrhage secondary to splanchnic artery aneurysms. Hepatogastroenterology 1997,44(16):1152–1156. Epub 1997/07/01PubMedGoogle Scholar
- Boudghene F, L'Hermine C, Bigot JM: Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Int Radiol JVIR 1993,4(4):551–558. Epub 1993/07/01 10.1016/S1051-0443(93)71920-XView ArticleGoogle Scholar
- Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson BR, Hansen MF: Pseudoaneurysms complicating pancreatitis: detection by CT. Radiology 1986,161(2):447. Epub 1986/11/01PubMedView ArticleGoogle Scholar
- Pilleul F, Beuf O: Diagnosis of splanchnic artery aneurysms and pseudoaneurysms, with special reference to contrast enhanced 3D magnetic resonance angiography: a review. Acta Radiol (Stockholm, Sweden: 1987) 2004,45(7):702–708. Epub 2004/12/31 10.1080/02841850410001358Google Scholar
- Frauenfelder T, Wildermuth S, Marincek B, Boehm T: Nontraumatic emergent abdominal vascular conditions: advantages of multi-detector row CT and three-dimensional imaging. RadioGraphics Rev Publ Radiol Soc North Am Inc 2004,24(2):481–496. Epub 2004/03/18Google Scholar
- Katsumori T, Yamane T, Yokoyama Y Nihon Cho-onpa Igakukaishi (JSUM Proceedings). Ultrasonographic findings of a case of gastroduodenal and splenic artery aneurysms by B-mode, two dimensional and pulsed Doppler US 1990.Google Scholar
- el-Dosoky MM, Reeders JW, Dol J, Bienfait HP: Radiological diagnosis of gastroduodenal artery pseudoaneurysm in acute pancreatitis. Eur J Radiol 1994,18(3):235–237. Epub 1994/08/01 10.1016/0720-048X(94)90343-3PubMedView ArticleGoogle Scholar
- Ochi T, Suzuki T, Yoshioka N, Ogawa Y, Inagaki T, Suzuki S: [A case of aneurysm of the gastroduodenal artery diagnosed by endoscopic ultrasonography--review of literatures in Japan]. Nihon Shokakibyo Gakkai zasshi Jpn J Gastro-enterology 1992,89(2):522–527. Epub 1992/02/01Google Scholar
- Grotemeyer D, Duran M, Park EJ, Hoffmann N, Blondin D, Iskandar F: Visceral artery aneurysms--follow-up of 23 patients with 31 aneurysms after surgical or interventional therapy. Langenbeck's archives Surg Deutsche Gesellschaft fur Chirurgie 2009,394(6):1093–1100. Epub 2009/03/13 10.1007/s00423-009-0482-zView ArticleGoogle Scholar
- Germanos S, Soonawalla Z, Stratopoulos C, Friend PJ: Pseudoaneurysm of the gastroduodenal artery in chronic pancreatitis. J Am Coll Surg 2009,208(2):316. Epub 2009/02/21 10.1016/j.jamcollsurg.2008.06.318PubMedView ArticleGoogle Scholar
- Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL: Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004,18(6):695–703. Epub 2004/12/16 10.1007/s10016-004-0112-8PubMedView ArticleGoogle Scholar
- Sessa C, Vokrri L, Porcu P, Maurin M, Stahl JP, Magne JL: Abdominal aortic aneurysm and Coxiella burnetii infection: report of three cases and review of the literature. J Vasc Surg Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 2005,42(1):153–158.Google Scholar
- Sachdev U, Baril DT, Ellozy SH, Lookstein RA, Silverberg D, Jacobs TS: Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 2006,44(4):718–724. Epub 2006/10/03Google Scholar
- Saltzberg SS, Maldonado TS, Lamparello PJ, Cayne NS, Nalbandian MM, Rosen RJ: Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg 2005,19(4):507. Epub 2005/06/30 10.1007/s10016-005-4725-3PubMedView ArticleGoogle Scholar
- Piffaretti G, Tozzi M, Carrafiello G, Caronno R, Lagana D, Recaldini C: A case of gastroduodenal artery aneurysm in a HIV-positive patient treated by combined percutaneous thrombin injection and endovascular coil embolization. J Cardiovasc Surg 2008,49(5):659–661. Epub 2008/08/02Google Scholar
- Carmeci C, McClenathan J: Visceral artery aneurysms as seen in a community hospital. Am J Surg 2000,179(6):486–489. Epub 2000/09/27 10.1016/S0002-9610(00)00380-9PubMedView ArticleGoogle Scholar
- Kasirajan K, Greenberg RK, Clair D, Ouriel K: Endovascular management of visceral artery aneurysm. J Endovasc Ther Offic J Inter Soc Endovasc Specialists 2001,8(2):150–155. Epub 2001/05/19 10.1583/1545-1550(2001)008<0150:EMOVAA>2.0.CO;2View ArticleGoogle Scholar
- Dinter DJ, Rexin M, Kaehler G, Neff W: Fatal coil migration into the stomach 10 years after endovascular celiac aneurysm repair. J Vasc Intervent Radiol JVIR 2007,18(1 Pt 1):117–120. Epub 2007/02/14View ArticleGoogle Scholar
- Takahashi T, Shimada K, Kobayashi N, Kakita A: Migration of steel-wire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case. Surg Today 2001,31(5):458–462. Epub 2001/05/31 10.1007/s005950170141PubMedView ArticleGoogle Scholar
- Ferrero E, Ferri M, Viazzo A, Robaldo A, Carbonatto P, Pecchio A: Visceral artery aneurysms, an experience on 32 cases in a single center: treatment from surgery to multilayer stent. Ann Vasc Surg 2011,25(7):923–935. Epub 2011/08/13 10.1016/j.avsg.2011.04.006PubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.