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Thrombosis of pancreatic arteriovenous malformation induced by diagnostic angiography: case report.

Vidmar J, Omejc M, Dežman R, Popovič P - BMC Gastroenterol (2016)

Bottom Line: The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges.The factors associated with the obliteration of PAVM during or after DSA are poorly understood.In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent.

View Article: PubMed Central - PubMed

Affiliation: Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloska cesta 4, 1000, Ljubljana, Slovenia. jernej.vidmar@gmail.com.

ABSTRACT

Background: We report on a case of pancreatic arteriovenous malformation (PAVM) that obliterated shortly after diagnostic angiography (DSA). PAVM is a rare anomaly that presents with upper abdominal pain, signs of acute pancreatitis and massive gastrointestinal bleeding. The management of PAVM is rather complex, with complete treatment usually accomplished only by a total extirpation of the affected organ or at least its involved portion. DSA prior to treatment decisions is helpful for characterizing symptomatic PAVM, since it can clearly depict the related vascular networks. In addition, interventional therapy can be performed immediately after diagnosis.

Case presentation: A 39-old male was admitted due to recurring upper abdominal pain that lasted several weeks. Initial examination revealed the absence of fever or jaundice, and the laboratory tests, including that for pancreatic enzymes, were unremarkable. An abdominal ultrasound (US) showed morphological and Doppler anomalies in the pancreas that were consistent with a vascular formation. A subsequent DSA depicted a medium-sized nidus, receiving blood supply from multiple origins but with no dominant artery. Coil embolization was not possible due to the small caliber of the feeding vessels. In addition, sclerotherapy was not performed so as to avoid an unnecessary wash out to the non-targeted duodenum. Consequently, the patient received no specific treatment for his symptomatic PAVM. A large increase in pancreatic enzymes was noticed shortly after the DSA procedure. Imaging follow-up by means of CT and MRI showed small amounts of peripancreatic fluid along with a limited area of intra-parenchymal necrosis, indicating necrotizing pancreatitis. In the post-angiography follow-up the patient was hemodynamically stable the entire time and was treated conservatively. The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges. Long-term follow-up by way of a contrast-enhanced CT revealed no recanalization of the thrombosed PAVM.

Conclusion: The factors associated with the obliteration of PAVM during or after DSA are poorly understood. In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent. Asymptomatic PAVM, as diagnosed with non-invasive imaging techniques, should not be evaluated with DSA due to the potential risk of severe complications, such as acute pancreatitis.

No MeSH data available.


Related in: MedlinePlus

US imaging showed a structurally heterogeneous and thickened neck of the pancreas, hardly differentiated from the surrounding fat and without any dilatation of the main pancreatic duct (a). Contrast-enhanced CT examination through the pancreas demonstrated a mosaic hypervascular area at the same site as the initial US (b–d, red arrows)
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Fig1: US imaging showed a structurally heterogeneous and thickened neck of the pancreas, hardly differentiated from the surrounding fat and without any dilatation of the main pancreatic duct (a). Contrast-enhanced CT examination through the pancreas demonstrated a mosaic hypervascular area at the same site as the initial US (b–d, red arrows)

Mentions: B-mode ultrasound (US) showed a structurally heterogeneous and thickened neck of the pancreas, which was poorly differentiated from the surrounding fat (Fig. 1a). No dilatation of the main pancreatic duct was found. Color Doppler US demonstrated an intensive mosaic appearance in the hypoechogenic area of the lesion, and spectral Doppler analysis disclosed arterial and venous blood flow signals within the lesion. Morphological changes along with the Doppler pattern found at the initial US examination indicated a possible ongoing vascular formation within the pancreas. Subsequently, computed tomography (CT) confirmed a medium-sized (up to 4 cm) formation in the neck of the pancreas. The formation showed arterial (Fig. 1b, red arrow) and venous (Fig. 1c and d) serpinginous enhancement consistent with pancreatic vascular malformation (PAVM). A multidisciplinary team, including a surgeon, an interventional radiologist and a radiotherapist, considered various therapeutic approaches. As an alternative to a pancreaticoduodenectomy and radiotherapy, a minimally invasive treatment based on percutaneous embolization was proposed to and accepted by the patient. A CT scan was post-processed to obtain a clear vascular map of the arterial and venous pancreatic supply.Fig. 1


Thrombosis of pancreatic arteriovenous malformation induced by diagnostic angiography: case report.

Vidmar J, Omejc M, Dežman R, Popovič P - BMC Gastroenterol (2016)

US imaging showed a structurally heterogeneous and thickened neck of the pancreas, hardly differentiated from the surrounding fat and without any dilatation of the main pancreatic duct (a). Contrast-enhanced CT examination through the pancreas demonstrated a mosaic hypervascular area at the same site as the initial US (b–d, red arrows)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4940768&req=5

Fig1: US imaging showed a structurally heterogeneous and thickened neck of the pancreas, hardly differentiated from the surrounding fat and without any dilatation of the main pancreatic duct (a). Contrast-enhanced CT examination through the pancreas demonstrated a mosaic hypervascular area at the same site as the initial US (b–d, red arrows)
Mentions: B-mode ultrasound (US) showed a structurally heterogeneous and thickened neck of the pancreas, which was poorly differentiated from the surrounding fat (Fig. 1a). No dilatation of the main pancreatic duct was found. Color Doppler US demonstrated an intensive mosaic appearance in the hypoechogenic area of the lesion, and spectral Doppler analysis disclosed arterial and venous blood flow signals within the lesion. Morphological changes along with the Doppler pattern found at the initial US examination indicated a possible ongoing vascular formation within the pancreas. Subsequently, computed tomography (CT) confirmed a medium-sized (up to 4 cm) formation in the neck of the pancreas. The formation showed arterial (Fig. 1b, red arrow) and venous (Fig. 1c and d) serpinginous enhancement consistent with pancreatic vascular malformation (PAVM). A multidisciplinary team, including a surgeon, an interventional radiologist and a radiotherapist, considered various therapeutic approaches. As an alternative to a pancreaticoduodenectomy and radiotherapy, a minimally invasive treatment based on percutaneous embolization was proposed to and accepted by the patient. A CT scan was post-processed to obtain a clear vascular map of the arterial and venous pancreatic supply.Fig. 1

Bottom Line: The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges.The factors associated with the obliteration of PAVM during or after DSA are poorly understood.In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent.

View Article: PubMed Central - PubMed

Affiliation: Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloska cesta 4, 1000, Ljubljana, Slovenia. jernej.vidmar@gmail.com.

ABSTRACT

Background: We report on a case of pancreatic arteriovenous malformation (PAVM) that obliterated shortly after diagnostic angiography (DSA). PAVM is a rare anomaly that presents with upper abdominal pain, signs of acute pancreatitis and massive gastrointestinal bleeding. The management of PAVM is rather complex, with complete treatment usually accomplished only by a total extirpation of the affected organ or at least its involved portion. DSA prior to treatment decisions is helpful for characterizing symptomatic PAVM, since it can clearly depict the related vascular networks. In addition, interventional therapy can be performed immediately after diagnosis.

Case presentation: A 39-old male was admitted due to recurring upper abdominal pain that lasted several weeks. Initial examination revealed the absence of fever or jaundice, and the laboratory tests, including that for pancreatic enzymes, were unremarkable. An abdominal ultrasound (US) showed morphological and Doppler anomalies in the pancreas that were consistent with a vascular formation. A subsequent DSA depicted a medium-sized nidus, receiving blood supply from multiple origins but with no dominant artery. Coil embolization was not possible due to the small caliber of the feeding vessels. In addition, sclerotherapy was not performed so as to avoid an unnecessary wash out to the non-targeted duodenum. Consequently, the patient received no specific treatment for his symptomatic PAVM. A large increase in pancreatic enzymes was noticed shortly after the DSA procedure. Imaging follow-up by means of CT and MRI showed small amounts of peripancreatic fluid along with a limited area of intra-parenchymal necrosis, indicating necrotizing pancreatitis. In the post-angiography follow-up the patient was hemodynamically stable the entire time and was treated conservatively. The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges. Long-term follow-up by way of a contrast-enhanced CT revealed no recanalization of the thrombosed PAVM.

Conclusion: The factors associated with the obliteration of PAVM during or after DSA are poorly understood. In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent. Asymptomatic PAVM, as diagnosed with non-invasive imaging techniques, should not be evaluated with DSA due to the potential risk of severe complications, such as acute pancreatitis.

No MeSH data available.


Related in: MedlinePlus