#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

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


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.

Keywords:
Pancreatic arteriovenous malformation, Diagnostic angiography, Abdominal MRI, MR cholangiopancreatography, Acute pancreatitis


Autoři: Jernej Vidmar 1,2*;  Mirko Omejc 3;  Rok Dežman 4;  Peter Popovič 4
Působiště autorů: Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloska cesta , 1000 Ljubljana, Slovenia. 1;  Jozef Stefan Institute, Laboratory of Magnetic Resonance Imaging, Ljubljana, Slovenia. 2;  Clinical Department of Abdominal Surgery, University Medical Centre, Ljubljana, Slovenia. 3;  Institute of Radiology, University Medical Centre, Ljubljana, Slovenia. 4
Vyšlo v časopise: BMC Gastroenterology 2016, 16:68
Kategorie: Case report
prolekare.web.journal.doi_sk: https://doi.org/10.1186/s12876-016-0485-5

© 2016 The Author(s).
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The electronic version of this article is the complete one and can be found online at: http://bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-016-0485-5

Souhrn

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.

Keywords:
Pancreatic arteriovenous malformation, Diagnostic angiography, Abdominal MRI, MR cholangiopancreatography, Acute pancreatitis


Zdroje

1. Chou SC, Shyr YM, Wang SE. Pancreatic arteriovenous malformation. J Gastrointest Surg. 2013;17:1240–6.

2. Kanno A, Satoh K, Kimura K, Masamune A, Asakura T, Egawa S, Sunamura M, Watanabe M, Shimosegawa T. Acute pancreatitis due to pancreatic arteriovenous malformation: 2 case reports and review of the literature. Pancreas. 2006;32:422–5.

3. Song KB, Kim SC, Park JB, Kim YH, Jung YS, Kim MH, Lee SK, Lee SS, Seo DW, Park do H, et al. Surgical outcomes of pancreatic arteriovenous malformation in a single center and review of literature. Pancreas. 2012;41:388–96.

4. Dresler CM, Fortner JG, McDermott K, Bajorunas DR. Metabolic consequences of (regional) total pancreatectomy. Ann Surg. 1991;214:131–40.

5. Kodama Y, Saito H, Hiramatsu K, Takeuchi S, Takamura A. A case of pancreatic arteriovenous malformation treated by transcatheter arterial embolization and transjugular intrahepatic portosystemic shunt. Nihon Shokakibyo Gakkai Zasshi. 2001;98:320–4.

6. Grasso RF, Cazzato RL, Luppi G, Faiella E, Del Vescovo R, Giurazza F, Borzomati D, Coppola R, Zobel BB. Pancreatic arteriovenous malformation involving the duodenum embolized with ethylene-vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol. 2012;35:958–62.

7. Chuang VP, Pulmano CM, Walter JF, Cho KJ. Angiography of pancreatic arteriovenuos malformation. AJR Am J Roentgenol. 1977;129:1015–8.

8. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F, Hongo M, Richter JE, Spechler SJ, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45:172–80.

9. Meyer CT, Troncale FJ, Galloway S, Sheahan DG. Arteriovenous malformations of the bowel: an analysis of 22 cases and a review of the literature. Medicine (Baltimore). 1981;60:36–48.

10. Lee BB, Kim DI, Huh S, Kim HH, Choo IW, Byun HS, Do YS. New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg. 2001;33:764–72.

11. Sato M, Kishi K, Shirai S, Suwa K, Kimura M, Kawai N, Tanihata H, Yamada K, Terada M, Yamaue H. Radiation therapy for a massive arteriovenous malformation of the pancreas. AJR Am J Roentgenol. 2003;181:1627–8.

12. Tatsuta T, Endo T, Watanabe K, Hasui K, Sawada N, Igarashi G, Mikami K, Shibutani K, Tsushima F, Takai Y, Fukuda S. A successful case of transcatheter arterial embolization with n-butyl-2-cyanoacrylate for pancreatic arteriovenous malformation. Intern Med. 2014;53:2683–7.

13. Nishiyama R, Kawanishi Y, Mitsuhashi H, Kanai T, Ohba K, Mori T, Hamabe N, Watahiki Y, Nakamura S. Management of pancreatic arteriovenous malformation. J Hepatobiliary Pancreat Surg. 2000;7:438–42.

14. Gincul R, Dumortier J, Ciocirlan M, Adham M, Queneau PE, Ponchon T, Pilleul F. Treatment of arteriovenous malformation of the pancreas: a case report. Eur J Gastroenterol Hepatol. 2010;22:116–20.

15. Kiriyama S, Gabata T, Takada T, Hirata K, Yoshida M, Mayumi T, Hirota M, Kadoya M, Yamanouchi E, Hattori T, et al. New diagnostic criteria of acute pancreatitis. J Hepatobiliary Pancreat Sci. 2010;17:24–36.

16. Hunt TH, Gelfand DW. Complications of gastrointestinal radiologic procedures: III. Complications of diagnostic and interventional angiography. Gastrointest Radiol. 1981;6:57–67.

17. Cynamon J, Atar E, Steiner A, Hoppenfeld BM, Jagust MB, Rosado M, Sprayregen S. Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding. J Vasc Interv Radiol. 2003;14:211–6.

18. Golzarian J, Sapoval MR, Kundu S, Hunter DW, Brountzos EN, Geschwind JF, Murphy TP, Spies JB, Wallace MJ, de Baere T, Cardella JF. Guidelines for Peripheral and Visceral Vascular Embolization Training: joint writing groups of the Standards of Practice Committees for the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and Canadian Interventional Radiology Association (CIRA). J Vasc Interv Radiol. 2010;21:436–41.

19. Strickland NH, Rampling MW, Dawson P, Martin G. Contrast media-induced effects on blood rheology and their importance in angiography. Clin Radiol. 1992;45:240–2.

20. Laurent A, Durussel JJ, Dufaux J, Penhouet L, Bailly AL, Bonneau M, Merland JJ. Effects of contrast media on blood rheology: comparison in humans, pigs, and sheep. Cardiovasc Intervent Radiol. 1999;22:62–6.

21. Reinhart WH, Pleisch B, Harris LG, Lutolf M. Influence of contrast media (iopromide, ioxaglate, gadolinium-DOTA) on blood viscosity, erythrocyte morphology and platelet function. Clin Hemorheol Microcirc. 2005;32:227–39.

22. Yakes WF, Rossi P, Odink H. How I do it. Arteriovenous malformation management. Cardiovasc Intervent Radiol. 1996;19:65–71.

23. Ohgiya Y, Hashimoto T, Gokan T, Watanabe S, Kuroda M, Hirose M, Matsui S, Nobusawa H, Kitanosono T, Munechika H. Dynamic MRI for distinguishing high-flow from low-flow peripheral vascular malformations. AJR Am J Roentgenol. 2005;185:1131–7.

24. Dubois J, Soulez G, Oliva VL, Berthiaume MJ, Lapierre C, Therasse E. Soft-tissue venous malformations in adult patients: imaging and therapeutic issues. Radiographics. 2001;21:1519–31.

25. Turley RS, Lidsky ME, Markovic JN, Shortell CK. Emerging role of contrast-enhanced MRI in diagnosing vascular malformations. Future Cardiol. 2014;10:479–86.

26. Trop I, Dubois J, Guibaud L, Grignon A, Patriquin H, McCuaig C, Garel LA. Soft-tissue venous malformations in pediatric and young adult patients: diagnosis with Doppler US. Radiology. 1999;212:841–5.

Štítky
Gastroenterológia a hepatológia
Prihlásenie
Zabudnuté heslo

Zadajte e-mailovú adresu, s ktorou ste vytvárali účet. Budú Vám na ňu zasielané informácie k nastaveniu nového hesla.

Prihlásenie

Nemáte účet?  Registrujte sa

#ADS_BOTTOM_SCRIPTS#