Unveiling the unexpected: spontaneous ruptured pancreaticoduodenal artery pseudoaneurysm with retroperitoneal hematoma requiring pancreaticoduodenectomy

Introduction

Pancreaticoduodenal artery aneurysms comprise of 2% of all visceral artery aneurysms (1,2). They are classified as true aneurysms or pseudoaneurysms based on arterial wall involvement. Pancreaticoduodenal artery pseudoaneurysms (PDAPs) are often linked to pancreatitis and blunt abdominal trauma. PDAP rupture can result in life-threatening gastrointestinal hemorrhage with a mortality rate exceeding 25% which poses significant challenges in management and treatment (1,3). We present a case of a patient who developed a spontaneous retroperitoneal hematoma (SRH) and was found to have multiple fusiform PDAPs with bleeding that led to hypovolemic shock. The patient required urgent embolization followed by a pancreaticoduodenectomy procedure for stabilization.

Case presentation

A 46-year-old female with no significant past medical history presented with worsening diffuse abdominal pain radiating to the right flank over a 3-day period. Her surgical history was notable for three uncomplicated cesarean sections with no hemorrhage. She denied use of anticoagulants, antiplatelets, and nonsteroidal anti-inflammatory agents (including aspirin). There was no personal or family history of known bleeding disorders and she denied any abdominal trauma that she was aware of.

Vitals were within normal limits on admission. Physical examination revealed tenderness in the right upper quadrant of the abdomen with a negative Murphy’s sign and no costovertebral angle tenderness. An abdominal ultrasound showed no gallstones or gallbladder inflammation concerning for cholecystitis and no pancreatic inflammation suggesting acute pancreatitis. Liver function test including alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and a lipase level were all within normal limits. A computed tomography (CT) of the abdomen and pelvis (CTAP) revealed a 14 cm × 5.5 cm × 11.3 cm SRH in the peripancreatic region with extension into the lower abdomen (Figure 1A). CT angiography showed no arterial blush within the hematoma, active extravasation, or aneurysms. Conservative management with nasogastric tube suctioning, hemoglobin monitoring every 6 hours, and vital signs checks every 1 to 2 hours was initiated.

Figure 1 Computed tomography of the abdomen and pelvis in sagittal view. The SRH expanded from the first day of admission (A) to the second day (B) indicated by the red arrows. SRH, spontaneous retroperitoneal hematoma.

On hospital day 2 the patient experienced an exacerbation of abdominal pain at around 8 am. Her hemoglobin dropped from 12.7 g/dL on admission to 7.8 g/dL. A repeat CTAP showed an expanding SRH (Figure 1B). Subsequent CT angiogram revealed several fusiform pseudoaneurysms of the superior and inferior pancreaticoduodenal arteries measuring between 0.75 and 1.4 cm in diameter near the pancreatic head with active extravasation of the superior and inferior pancreaticoduodenal arteries (Figure 2). Interventional radiology performed a 170 minutes selective catheterization of the superior and inferior pancreaticoduodneal arteries for coil embolization of multiple fusiform PDAPs with vascular access from the right common femoral artery. Embolization was successfully completed in the superior pancreaticoduodenal artery using Interlock coils. Attempts to catheterize the inferior pancreaticoduodenal artery was unsuccessfully due to its tortuosity and fragility. The procedure was completed under moderate sedation with midazolam and fentanyl and vascular access was closed using a StarClose device (Redwood City, CA, USA).

Figure 2 Arteriography with selective catheterization of the abdomen. Extravasation from the superior (yellow arrow) and inferior (red arrow) pancreaticoduodenal artery pseudoaneurysms.

The patient was transferred to the intensive care unit that evening for ongoing management of hypovolemic shock. She required massive transfusion protocol (7 units of packed red blood cells, 3 units of platelets, and 3 units of fresh frozen plasma) and norepinephrine. She was intubated and sedated with dexmedetomidine. Given her severe hypotension, which precluded exploratory laparotomy, she was transferred to another facility for evaluation by a hepatobiliary surgeon for an urgent pancreaticoduodenectomy procedure.

The transfer was complete on hospital day 3 in the morning and the pancreaticoduodenectomy procedure was started that very afternoon. At the start of the pancreaticoduodenectomy the abdomen was entered via a midline laparotomy and assessed. The duodenum and head of the pancreas were mobilized and the superior mesenteric vein was identified and isolated. Dissection continued along the stomach and remaining duodenum to determine the proximal extent of resection. The porta hepatis structures were skeletonized and the gallbladder was removed. During dissection of the uncinate process off the superior mesenteric vessels, active arterial bleeding from the inferior pancreaticoduodenal artery was encountered; the vessel was isolated and controlled using suture ligation and bipolar cautery with hemostasis confirmed. The common hepatic duct was transected followed by mobilization and division of the proximal jejunum approximately 15 cm distal to the ligament of Treitz. The neck of the pancreas was then transected and the specimen was freed from its remaining attachments to the superior mesenteric vein, portal vein, and superior mesenteric artery. The resection included the pancreatic head, duodenum, proximal jejunum, common bile duct, gallbladder, and a portion of the stomach.

Gastrointestinal reconstruction was subsequently performed to reestablish continuity. Three anastomoses were performed pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy and two Jackson-Pratt drains placed near the pancreatojejunostomy and hepaticojejunostomy anastomosis. Total procedure time was approximately 360 minutes. Her recovery post procedure was uneventful with toleration of diet slowly at hospital day 6 and drains removed on hospital day 10 after the procedure. She was discharged on hospital day 14 with no complications at that moment.

The patient returned for follow up outpatient 4 weeks after discharge from the hospital where she has no complaints and was recovering slowly.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

We presented a case of a SRH in a young female without traditional risk factors. The pathogenesis of SRH is not fully understood but may involve arteriosclerosis, microvascular injury, vascular abnormalities, or unrecognized trauma (4). Approximately two-thirds of SRH cases are seen in elderly adults on anticoagulant or antiplatelet therapy (5). Diagnosis requires high clinical suspicion as symptoms are often vague. CTAP and CT angiography are essential for identifying SRH and detecting active extravasation as demonstrated in this case. SRH often self-tamponade allowing conservative management with close monitoring. However, embolization is an option for persistent bleeding. This patient’s clinical course was further complicated by multiple PDAPs.

Unlike true aneurysms which involve all three layers of the arterial wall, pseudoaneurysms result from intimal and medial disruptions confining blood into the adventitia layer. Pseudoaneurysms are associated with conditions such as pancreatitis, abdominal trauma, iatrogenic injury, or inflammation of adjacent tissues (1,6,7). In our patient expansion of the SRH may have led to inflammation near the pancreatic head contributing to development of multiple PDAPs.

PDAPs have a propensity to rupture often leading to life-threatening gastrointestinal hemorrhage (8). The risk of rupture has not been shown to correlate with aneurysm size emphasizing the need for early recognition and prompt intervention (2,8). Although there are no formal guidelines on when to treat PDAPs, many experts advocate for immediate management with endovascular exclusion or surgical ligation upon diagnosis (6).

Open surgical repair with aneurysm ligation, resection, or vascular reconstruction was initially considered the gold standard of care for managing PDAPs. The advent of advanced imaging and percutaneous transcatheter embolization has become the preferred approach in hemodynamically stable patients. Compared to open surgery embolization is less invasive, demonstrates high success rates, and is associated with shorter hospital stays (1,2). The most common complications with embolization include coil migration, aneurysm reperfusion, inadvertent vessel occlusion, or infections (1). Our patient underwent successful embolization of the superior pancreaticoduodenal artery achieving immediate hemostasis. However due to the anatomical fragility and access limitations of the inferior pancreaticoduodenal artery embolization was not feasible necessitating definitive surgical intervention.

Surgical intervention via pancreatoduodenectomy for PDAPs or other nontraumatic emergencies is exceptionally rare and generally reserved for situations where embolization fails or is not feasible. In a single center series, Lupascu et al. reported that 5 of 134 patients (3.7%) required an emergency “backwards Whipple” for uncontrollable bleeding after failed embolization, with morbidity and mortality rates of 60% and 20% respectively (9). Similarly, Fickenscher et al. reviewed 11 cases of emergency pancreaticoduodenectomy for benign non-trauma indications and found a 36.4% complication rate and 9.1% 90-day mortality; their broader literature review estimated overall mortality at 25.8%, though specialized centers reported rates below 10% (10). More recently, Li et al. described 9 patients undergoing emergency undergoing emergency pancreaticoduodenectomy for non-traumatic causes, with 2 postoperative deaths (22%) and a high complication rate (85.7%) most of which were managed conservatively (11). Collective, these studies underscore that while emergency pancreaticoduodenectomy can be life-saving, it carries substantial risks, highlighting why it remains a last-resort intervention.

This case highlights the rare need for pancreaticoduodenectomy to control hemorrhage from PDAPs. While endovascular embolization is the preferred treatment anatomical challenges or technical failure can necessitate surgical intervention. The use of a pancreaticoduodenectomy in this setting is exceptionally uncommon with only isolated cases reported in the literature. Given the high morbidity and mortality associated with emergent pancreaticoduodenectomy, as described by Asari et al., surgery remains the last resort. This case reinforces the importance of a tailored, multidisciplinary approach when managing this life-threatening vascular emergency.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-212/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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