Limits...
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 after the diagnostic angiography revealed a progressive decrease of the serpinginous formations as well as a cystic lesion gradually increasing in size (a, b). Fat-suppressed T2-weighted MR images depicted fluid characteristics in the neck of the pancreas (c, red arrow) and in the peripancreatic fat (c, red asterisk) indicating an area of intra-parenchymal necrosis along with some peripancreatic edema. MR cholangiopancreatography confirmed minor peripancreatic fluid collection in the neck of the pancreas (d, red arrow). Long-term CT follow-up showed no evidence of previous vascular malformation along with the remaining peripancreatic fluid collection (e, f, white arrows)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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

Fig3: US after the diagnostic angiography revealed a progressive decrease of the serpinginous formations as well as a cystic lesion gradually increasing in size (a, b). Fat-suppressed T2-weighted MR images depicted fluid characteristics in the neck of the pancreas (c, red arrow) and in the peripancreatic fat (c, red asterisk) indicating an area of intra-parenchymal necrosis along with some peripancreatic edema. MR cholangiopancreatography confirmed minor peripancreatic fluid collection in the neck of the pancreas (d, red arrow). Long-term CT follow-up showed no evidence of previous vascular malformation along with the remaining peripancreatic fluid collection (e, f, white arrows)

Mentions: Among the laboratory tests performed in the 24 h following the diagnostic angiography, that for pancreatic enzymes showed a sudden intensive increase above the normal range: up to 15-fold for amylase and 40-fold for lipase. Other laboratory tests, including tumor markers such as CEA, CA19-9 and chromogranin, were unremarkable. The initial US follow-up was performed three days after DSA and revealed a reduction in the serpinginous areas along with a decrease in blood flow signals (Fig. 3a and b). Follow-up employing an abdominal MRI also depicted similar serpinginous formations located in the neck of the pancreas (Fig. 3c, red arrow). The formations displayed MR characteristics of fluid (Fig. 3c) along with no flow voids and were consequently characterized as the fluid remnants of the thrombosed PAVM or differentially, a demarcated area of intraparenchymal necrosis having already occurred. The larger area of fluid remnants near the pancreas (Fig. 3c, red arrow) was characterized as a peripancreatic fluid collection, subsequently also detected by MR cholangiopancreatography (Fig. 3d, red arrow). Besides intrapancreatic changes, areas of hyperintensive signal were also found on MR images of the peripancreatic fat (Fig. 3c, red asterix), consistent with small amounts of peripancreatic fluid and edema.Fig. 3


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

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

US after the diagnostic angiography revealed a progressive decrease of the serpinginous formations as well as a cystic lesion gradually increasing in size (a, b). Fat-suppressed T2-weighted MR images depicted fluid characteristics in the neck of the pancreas (c, red arrow) and in the peripancreatic fat (c, red asterisk) indicating an area of intra-parenchymal necrosis along with some peripancreatic edema. MR cholangiopancreatography confirmed minor peripancreatic fluid collection in the neck of the pancreas (d, red arrow). Long-term CT follow-up showed no evidence of previous vascular malformation along with the remaining peripancreatic fluid collection (e, f, white arrows)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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

Fig3: US after the diagnostic angiography revealed a progressive decrease of the serpinginous formations as well as a cystic lesion gradually increasing in size (a, b). Fat-suppressed T2-weighted MR images depicted fluid characteristics in the neck of the pancreas (c, red arrow) and in the peripancreatic fat (c, red asterisk) indicating an area of intra-parenchymal necrosis along with some peripancreatic edema. MR cholangiopancreatography confirmed minor peripancreatic fluid collection in the neck of the pancreas (d, red arrow). Long-term CT follow-up showed no evidence of previous vascular malformation along with the remaining peripancreatic fluid collection (e, f, white arrows)
Mentions: Among the laboratory tests performed in the 24 h following the diagnostic angiography, that for pancreatic enzymes showed a sudden intensive increase above the normal range: up to 15-fold for amylase and 40-fold for lipase. Other laboratory tests, including tumor markers such as CEA, CA19-9 and chromogranin, were unremarkable. The initial US follow-up was performed three days after DSA and revealed a reduction in the serpinginous areas along with a decrease in blood flow signals (Fig. 3a and b). Follow-up employing an abdominal MRI also depicted similar serpinginous formations located in the neck of the pancreas (Fig. 3c, red arrow). The formations displayed MR characteristics of fluid (Fig. 3c) along with no flow voids and were consequently characterized as the fluid remnants of the thrombosed PAVM or differentially, a demarcated area of intraparenchymal necrosis having already occurred. The larger area of fluid remnants near the pancreas (Fig. 3c, red arrow) was characterized as a peripancreatic fluid collection, subsequently also detected by MR cholangiopancreatography (Fig. 3d, red arrow). Besides intrapancreatic changes, areas of hyperintensive signal were also found on MR images of the peripancreatic fat (Fig. 3c, red asterix), consistent with small amounts of peripancreatic fluid and edema.Fig. 3

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