Inferior Pancreaticoduodenal Artery Aneurysms: Diagnostic Challenges and Management Outcomes

Abstract

Background

Inferior pancreaticoduodenal artery (IPDA) aneurysms are rare visceral artery aneurysms with high rupture rates and significant mortality. Nonspecific clinical presentation frequently leads to diagnostic delay. We conducted a systematic review to characterize clinical features, diagnostic pitfalls, treatment modalities, and outcomes.

Methods

A systematic review following PRISMA 2020 guidelines was performed. PubMed, Cochrane Library, and Google Scholar were searched from inception through January 2025. Case reports and series describing adult patients with IPDA aneurysms were included. Fisher exact test was used for categorical comparisons. An illustrative fatal index case is presented.

Results

113 patients from 81 publications were analyzed. Mean age was 60.3 ± 12.0 years with male predominance (62.3%). Rupture occurred in 70.2% of cases. Overall mortality was 9.6% (10/104). Abdominal pain was the most common presentation (71.7%). Diagnostic pitfall was documented in 47.4% of cases. Celiac axis stenosis was identified in 71.7% of patients. Endovascular treatment was associated with numerically lower mortality than open surgery (3.5% vs 14.3%; OR 0.22; 95% CI: 0.04-1.28; P = 0.08; non-significant). Retroperitoneal hemorrhage predominated among ruptured cases (58.9%).

Conclusions

Inferior pancreaticoduodenal artery aneurysms present significant diagnostic challenges due to nonspecific symptoms. High clinical suspicion is warranted in patients with unexplained abdominal pain, particularly those with celiac axis stenosis. A stepwise approach—stabilization, endovascular therapy first, and surgical backup—is endorsed by current guidelines. Multidisciplinary team involvement is essential. Mortality is driven primarily by the systemic consequences of hemorrhagic shock rather than by procedural failure; whether earlier recognition reduces mortality cannot be determined from this data set and warrants prospective study.

Keywords

inferior pancreaticoduodenal artery visceral artery aneurysm rupture endovascular treatment celiac axis stenosis systematic review

Introduction

Visceral artery aneurysms (VAAs) account for 0.1-0.2% of all arterial aneurysms, with pancreaticoduodenal artery aneurysms (PDAAs) representing approximately 2% of VAAs.^1–3 First documented by Ferguson in 1895,¹ PDAAs carry significant clinical importance due to rupture rates and mortality approaching 50%.^4,5

The inferior pancreaticoduodenal artery (IPDA) arises from the superior mesenteric artery and contributes to the pancreaticoduodenal arcade—a critical collateral pathway between the celiac and superior mesenteric systems.⁶ Celiac axis stenosis, particularly from median arcuate ligament syndrome, increases collateral flow and shear stress, predisposing to aneurysm formation.^3,7,8,9 Other etiologies include atherosclerosis, pancreatitis, and connective tissue disorders.^10,11,12

Clinical presentation is nonspecific: patients may be asymptomatic, present with vague abdominal pain, or develop acute hemorrhage.^4,5,13 Less common presentations include obstructive jaundice^8,14,15 and gastrointestinal bleeding.^11,16,17 Retroperitoneal rupture delays diagnosis, and aneurysm size does not reliably predict rupture risk.^2,4,9,13 Consequently, initial misdiagnosis as pancreatitis or peptic ulcer disease is common.^{18,19,20,21,22}

Current guidelines recommend treatment for asymptomatic PDAAs ≥15 mm (ESVS 2025, Class IIa),²³ with endovascular therapy as first-line in stable patients (CIRSE 2024, SVS 2020).^24,25 Outcomes favor endovascular repair in appropriately selected patients.^2,26,27

We present a systematic review of IPDA aneurysms focusing on diagnostic challenges, treatment modalities, and outcomes, anchored by a fatal index case of ruptured IPDA aneurysm concurrent with acute diverticulitis—illustrating the diagnostic complexity and importance of high clinical suspicion in unexplained abdominal pain.

Methods

Study Design and Registration

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.²⁸ Due to the descriptive nature of the review and predominance of case reports, the protocol was not registered in PROSPERO (Figure 1).

Figure 1.

Flow diagram of study selection. Illustration of the process of literature identification, screening, eligibility assessment, and inclusion of studies in the present systematic review

Literature Search Strategy

A comprehensive literature search was conducted using PubMed, Cochrane Library, and Google Scholar from database inception through January 2025. The search strategy combined Medical Subject Headings (MeSH) terms and free-text keywords including: “inferior pancreaticoduodenal artery aneurysm,” “pancreaticoduodenal artery aneurysm,” “IPDA aneurysm,” “PDAA,” “visceral artery aneurysm,” “rupture,” “bleeding,” and “hemorrhage.” Reference lists of included articles were manually screened to identify additional eligible publications.

Eligibility Criteria

Inclusion criteria were (1) case reports or case series; (2) adult patients (≥18 years); (3) true aneurysm or pseudoaneurysm of the inferior pancreaticoduodenal artery; (4) sufficient clinical detail for data extraction. Exclusion criteria were (1) aneurysms of other pancreaticoduodenal branches without clear IPDA involvement; (2) gastroduodenal artery aneurysms without IPDA involvement; (3) purely iatrogenic or post-surgical vascular injuries; (4) pediatric patients; (5) review articles without original case data; (6) non-English language publications without available translation; (7) full text not available.

Study Selection and Data Extraction

Two investigators independently screened titles and abstracts, followed by full-text review of potentially eligible articles. Disagreements were resolved by consensus with a third reviewer. Data were extracted using a standardized form including patient demographics (age, sex), clinical presentation, hemodynamic status at presentation, laboratory findings, imaging modalities, aneurysm characteristics (size, location, rupture status, compartment), suspected etiology, treatment approach, and clinical outcomes (survival, mortality, cause of death).

Quality Assessment

Methodological quality of included case reports was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports.²⁹ This tool evaluates 8 domains: (Q1) patient demographics, (Q2) clinical presentation, (Q3) diagnostic methods, (Q4) diagnosis substantiation, (Q5) intervention description, (Q6) outcome reporting, (Q7) follow-up duration, and (Q8) complications reporting. Each domain was scored as “Yes” or “No,” with total scores ranging from 0 to 8.

Definition

The anatomy is shown in Figure 2.

Figure 2.

Illustration of the anatomy

Statistical Analysis

Descriptive statistics were used to summarize patient characteristics. Continuous variables are presented as mean ± standard deviation (SD) with range; categorical variables as counts and percentages. Comparisons between groups were performed using Fisher exact test for categorical variables. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for mortality comparisons. Statistical significance was defined as P < 0.05. All analyses were performed using Python 3.11 with the SciPy statistical package (version 1.11).

Data extraction was locked on 15 January 2026; all reported denominators in the text, tables, and Figure 2 reflect this locked version.

Results

Literature Search and Study Selection

The database search identified 679 records (PubMed: 411; Cochrane Library and Google Scholar: 268). After the removal of 47 duplicates, 632 records underwent title and abstract screening. Of these, 505 were excluded based on screening criteria. Full-text assessment was performed for 127 articles, of which 46 were excluded (Figure 1). Reasons for exclusion were different artery involvement (n = 16), unruptured aneurysm without sufficient clinical data (n = 12), full text unavailable (n = 8), general review without original case data (n = 5), non-English language (n = 3), and iatrogenic etiology (n = 2). 81 publications were included in the final analysis, comprising 113 patients.^{2,8,9,12–15,17,22,27,30–79} Figure 1 illustrates literature search.

Patient Demographics and Baseline Characteristics

Demographic data are presented in Table 1. Mean age was 60.3 ± 12.0 years (range 23-84; n = 107). The largest age group was 50-59 years (38/106, 35.8%), followed by 60-69 years (28/106, 26.4%), ≥70 years (26/106, 24.5%), and <50 years (14/106, 13.2%). Male patients predominated (66/106, 62.3%). Rupture at presentation occurred in 73 of 104 patients (70.2%); 31 patients (29.8%) presented with intact aneurysms.

Table 1.

Patient Demographics and Baseline Characteristics (n = 113)

Characteristic	Value
Total patients	113
Total articles	81
Age, mean ± SD (range), years	60.3 ± 12.0 (23-84)
Age distribution (n = 106)
<50 years	14 (13.2%)
50-59 years	38 (35.8%)
60-69 years	28 (26.4%)
≥70 years	26 (24.5%)
Sex (n = 106)
Male	66 (62.3%)
Female	40 (37.7%)
Rupture status at presentation (n = 104)
Ruptured	73 (70.2%)
Non-ruptured	31 (29.8%)

Clinical Presentation

Clinical presentation data are summarized in Table 2. Abdominal or epigastric pain was the most common symptom (81/113, 71.7%), followed by nausea or vomiting (25/113, 22.1%), asymptomatic or incidental discovery (22/113, 19.5%), gastrointestinal bleeding (14/113, 12.4%), and syncope or collapse (12/113, 10.6%). Hemodynamic instability or shock at presentation was documented in 26 of 111 patients (23.6%); 19 patients (17.3%) were hemodynamically stable.

Table 2.

Clinical Presentation and Diagnostic Findings (n = 113)

Variable	n (%)
Presenting symptoms*
Abdominal/epigastric pain	81 (71.7%)
Nausea/vomiting	25 (22.1%)
Asymptomatic/incidental	22 (19.5%)
GI bleeding (hematemesis/melena)	14 (12.4%)
Syncope/collapse	12 (10.6%)
Hemodynamic status at presentation (n = 110)
Stable	19 (17.3%)
Unstable/shock	26 (23.6%)
Not specified	65 (59.1%)
Diagnostic pitfall documented (n = 95)	45 (47.4%)
Suspected etiology (n = 106)
Celiac axis stenosis/occlusion	76 (71.7%)
Median arcuate ligament syndrome	30 (28.3%)
Pancreatitis-related	10 (9.4%)
Idiopathic	11 (10.4%)

*Categories not mutually exclusive.

Diagnostic Findings

Diagnostic pitfall or initial misdiagnosis was documented in 45 of 95 patients (47.4%) (Table 2). Celiac axis stenosis or occlusion was the most commonly identified etiology (76/106, 71.7%), followed by median arcuate ligament syndrome (30/106, 28.3%), pancreatitis-related etiology (10/106, 9.4%), and idiopathic etiology (11/106, 10.4%).

Rupture Characteristics

Among 73 patients with ruptured aneurysms, retroperitoneal hemorrhage was most common (43/73, 58.9%), followed by combined retroperitoneal and intraperitoneal hemorrhage (18/73, 24.7%), and isolated intraperitoneal hemorrhage (12/73, 16.4%) (Table 4).

Treatment Modalities

Treatment data are presented in Table 3. Endovascular intervention was performed in 57 of 107 patients (53.3%), open surgical repair in 28 patients (26.2%), hybrid approaches in 12 patients (11.2%), and conservative management in 10 patients (9.3%).

Table 3.

Treatment Modalities (n = 107)

Treatment	n (%)
Endovascular	57 (53.3%)
Open surgical	28 (26.2%)
Hybrid (endovascular + surgical)	12 (11.2%)
Conservative/other	10 (9.3%)

Outcomes

Outcome data are presented in Table 4. Overall mortality was 9.6% (10/104). Mortality among patients with ruptured aneurysms was 11.0% (8/73) compared with 6.5% (2/31) in patients with non-ruptured aneurysms (OR 2.0; 95% CI: 0.4-10.1; P = 0.49). Mortality by treatment modality was 3.5% (2/57) for endovascular treatment, 14.3% (4/28) for open surgical intervention, and 25.0% (3/12) for hybrid approaches. Compared with open surgical repair, endovascular treatment was associated with lower mortality (OR 0.22, 95% CI: 0.04-1.28; P = 0.08). Hybrid approaches were not included in the comparative statistical analysis due to their heterogeneous and salvage-based nature.

Table 4.

Clinical Outcomes and Mortality

Variable	n/N (%)	OR (95% CI)	P-value
Overall mortality	10/104 (9.6%)	—	—
Mortality by rupture status
Ruptured	8/73 (11.0%)	2.0 (0.4-10.1)	0.49
Non-ruptured	2/31 (6.5%)	Reference
Mortality by treatment modality
Endovascular	2/57 (3.5%)	0.22 (0.04-1.28)	0.08
Open surgical	4/28 (14.3%)	Reference	—
Hybrid	3/12 (25.0%)	—	—
Rupture compartment (n = 73)
Retroperitoneal only	43 (58.9%)	—	—
Both compartments	18 (24.7%)	—	—
Intraperitoneal only	12 (16.4%)	—	—

OR, odds ratio; CI, confidence interval. Fisher exact test used for comparisons.

Odds ratio for mortality compares endovascular treatment versus open surgical repair.

Discussion

Inferior pancreaticoduodenal artery aneurysms represent a rare but life-threatening vascular pathology. This systematic review of 113 patients from 81 publications provides critical insights into diagnostic challenges, management strategies, and outcomes. We illustrate these findings with a fatal index case that exemplifies the diagnostic complexity and management challenges inherent to this condition.

The Diagnostic Challenge: Maintaining High Clinical Suspicion

The most significant finding of this review is the high rate of diagnostic pitfall, documented in 47.4% of patients (Table 2). The nonspecific presentation—predominantly abdominal pain (71.7%)—overlaps with numerous common conditions including pancreatitis, peptic ulcer disease, and acute diverticulitis.^{4,5,17,18,44,64,72}

Our index case exemplifies this challenge. A man in his early 70s presented with 3 days of left lower quadrant pain. His medical history of recurrent diverticulitis, combined with elevated C-reactive protein (8.5 mg/dL) and CT-confirmed sigmoid diverticulitis, created a compelling clinical picture. However, the same CT revealed unexpected high-attenuation retroperitoneal and intraperitoneal fluid with a mass near the pancreatic head. CT angiography subsequently demonstrated a 1.5 cm anteroinferior pancreaticoduodenal artery aneurysm (Figures 3 and 4).

Figure 3.

CT angiography demonstrating active hemorrhage. (A) Axial image showing contrast extravasation from the pancreaticoduodenal artery aneurysm (purple arrow). (B) Coronal image displaying the same extravasation site (purple arrow)

Figure 4.

CTA of inferior pancreaticoduodenal artery aneurysm (IPDA). (A) Sagittal (partially rotated) view showing IPDA aneurysm (purple arrow). (B) Coronal view demonstrating the same aneurysm (purple arrow). (C) 3D volume-rendered coronal reconstruction depicting the IPDA aneurysm (purple arrow) in relation to surrounding vasculature

The elevated inflammatory markers, initially attributed to diverticulitis, may have been partially caused by retroperitoneal hemorrhage, as extravasated blood triggers an inflammatory response.^20,48,64 This highlights how concurrent pathology can serve as a diagnostic distractor, potentially delaying recognition of a vascular catastrophe. The differential diagnosis in our case included complicated diverticulitis with perforation (excluded by absence of free air), ruptured abdominal aortic aneurysm (excluded by CTA), and hemorrhagic pancreatitis (excluded by normal pancreatic appearance).

The retroperitoneal location of most ruptures (58.9% in our cohort, Table 4) further complicates early diagnosis. Retroperitoneal hemorrhage may initially produce contained bleeding without classic peritoneal signs, allowing transient hemodynamic stability despite ongoing blood loss.^{4,13,18,22,70,72} Emergent abdominal ultrasound searching for free intraperitoneal fluid may be falsely negative.^1,4,22,44,72

Due to the rarity of IPDA aneurysms, they are not typically included in the differential diagnosis for emergency department presentations. Clinicians should maintain a high index of suspicion in patients presenting with unexplained abdominal or epigastric pain, particularly when initial imaging reveals unexpected retroperitoneal findings or when clinical deterioration is disproportionate to the presumed diagnosis.

The Critical Role of Celiac Axis Stenosis

Celiac axis stenosis or occlusion was identified in 71.7% of patients in our cohort (Table 2), with median arcuate ligament syndrome specifically documented in 28.3%. This strong association reflects the hemodynamic basis of IPDA aneurysm formation: celiac axis compromise increases collateral flow through the pancreaticoduodenal arcade, elevating shear stress and predisposing to aneurysmal degeneration.^{3,6,7,9,13,15,26,72}

This prevalence, however, is conditional on the presence of an IPDA aneurysm and cannot be inverted to estimate the absolute risk of aneurysm formation or rupture in the broader celiac-stenosis population, which to our knowledge remains unquantified in the literature. We therefore frame the inclusion of IPDA aneurysm in the differential diagnosis of unexplained abdominal pain in patients with known celiac stenosis as a clinical hypothesis warranting prospective evaluation, rather than as a quantified risk-stratification recommendation.^{4,5,6,34,43,78,79} Notably, in our index case no prior cross-sectional imaging was available, and no celiac axis stenosis or median arcuate ligament syndrome was identified on postoperative imaging, suggesting that a subset of IPDA aneurysms may arise through degenerative mechanisms independent of celiac pathology.

CT Angiography: The Diagnostic Gold Standard

Once clinical suspicion arises, CT angiography is the diagnostic modality of choice, offering rapid, noninvasive visualization of the aneurysm and its relationship to surrounding vessels.^4,5,42,64,72 In our index case, non-contrast CT performed for suspected diverticulitis incidentally revealed retroperitoneal hemorrhage, prompting CTA that confirmed the diagnosis.⁷⁹ This stepwise imaging approach—initial CT followed by CTA when vascular pathology is suspected—is appropriate and should not be delayed by concerns about contrast nephropathy in hemodynamically unstable patients.^4,6

Stabilization First: The Importance of Hemodynamic Resuscitation

The cornerstone of management is rapid hemodynamic stabilization. In our index case, the patient experienced syncope with hypotension (systolic blood pressure 80 mmHg) and hemoglobin drop from 12.5 g/dL to 6 g/dL shortly after CTA. Massive transfusion protocol was initiated immediately. Patients presenting with hemorrhagic shock require aggressive resuscitation with blood products before and during definitive intervention.^{5,15,18,38,72,75}

The Stepwise Treatment Approach: Endovascular First

Mortality was numerically lower among patients treated endovascularly (3.5%) than among those undergoing open repair (14.3%) or hybrid approaches (25.0%) (Table 4), but the comparison of endovascular vs open repair did not reach statistical significance (OR 0.22; 95% CI: 0.04-1.28; P = 0.08). The wide confidence interval, the small number of mortality events (n = 6 across the 2 arms), and the susceptibility of case-report-based data to selection bias and confounding by indication preclude any causal inference. Accordingly, this descriptive observation should be regarded as hypothesis-generating; it is consistent with, but does not independently establish, the endovascular-first strategy endorsed on the basis of expert consensus by current CIRSE 2024, SVS 2020, and ESVS 2025 guidelines.^{9,13,23,24,25,72}

These findings support a stepwise management approach. Per CIRSE 2024 and SVS 2020 guidelines, transcatheter embolization is the preferred treatment for PDAA when technically feasible.^24,25 In our systematic review, endovascular treatment was the most commonly employed modality (53.3%, Table 3) with the lowest mortality. According to the 2025 ESVS guidelines, endovascular or open surgical treatment should be considered for asymptomatic pancreaticoduodenal artery aneurysms ≥15 mm (Recommendation 88, Class IIa).²³

However, endovascular therapy is not always feasible. In our index case, multidisciplinary consultation deemed embolization hazardous due to the aneurysm's proximity to both celiac and superior mesenteric arteries, risking compromise of visceral perfusion. This decision, made collaboratively by interventional radiology and vascular surgery, illustrates the importance of individualized treatment planning based on anatomical considerations.^{6,26,66,71,76}

Surgical Intervention: When Endovascular Therapy Fails or Is Not Feasible

When endovascular therapy is not possible or when patients deteriorate despite resuscitation, surgical intervention is required. In our index case, the patient deteriorated rapidly with abdominal distension, tachycardia (150 bpm), and respiratory distress, prompting emergency laparotomy with awake intubation.

Intraoperatively, significant hemoperitoneum was encountered, and the patient arrested. Due to difficulty obtaining supraceliac aortic control, left anterolateral thoracotomy with descending aortic cross-clamping was performed for 23 minutes. This resuscitative maneuver restored circulation and enabled continued resuscitation. Surgical teams managing ruptured PDAA must be prepared for this eventuality and skilled in damage-control techniques.^5,13,48,71

Access to the zone-1 retroperitoneal hematoma was achieved through the lesser sac. The bleeding aneurysm on the right inferior-anterior surface of the pancreas was controlled with 3-0 Prolene suture ligation of proximal and distal vessels. Collateral circulation was confirmed by palpable hepatoduodenal ligament pulse. Understanding vascular anatomy is crucial for the management of these patients; simple ligation may be sufficient if collateral circulation is intact and there is no celiac artery stenosis, eliminating the need for complex revascularization.^{6,13,38,60,78}

A damage control approach with temporary abdominal closure using negative-pressure vacuum-assisted device was employed to prevent the lethal triad of acidosis, hypothermia, and coagulopathy. Second-look laparotomy at 36 hours confirmed hemostasis and adequate visceral perfusion, verified by handheld Doppler assessment of hepatic, gastroduodenal, and superior mesenteric arteries.

The Importance of Multidisciplinary Team Management

Our index case underscores the critical importance of multidisciplinary team (MDT) involvement. Optimal management requires coordinated input from emergency medicine, interventional radiology, vascular surgery, and general surgery.^{5,6,17,26,31,72,76} Early consultation allowed rapid assessment of treatment options and facilitated the decision to proceed with emergency surgery when endovascular therapy was deemed too hazardous.

Ideally, management of ruptured PDAA should occur in centers with 24-hour availability of interventional radiology, vascular surgery expertise, and critical care capabilities. Hybrid operating rooms combining surgical and angiographic capabilities provide optimal conditions for these complex cases, allowing seamless transition between endovascular and open approaches.^{5,6,26,32,40,71}

Lessons From a Fatal Outcome

Despite successful surgical hemorrhage control and confirmation of adequate visceral perfusion, our index patient developed fulminant liver failure (ALT/AST >2000 U/L, direct bilirubin 2.5 mg/dL, INR 1.5) within 48 hours postoperatively. Doppler ultrasound confirmed preserved hepatic arterial and portal venous flow, ruling out vascular occlusion. The liver failure was attributed to prolonged hypoperfusion during hemorrhagic shock compounded by 23 minutes of aortic cross-clamping. Formal angiography confirmed complete aneurysm exclusion without residual bleeding. Histopathology confirmed a true aneurysm with degenerative changes; microbiological cultures were negative. Despite intensive care, the patient died on postoperative day 14.

This outcome reflects a critical principle: intervention, while necessary, may be insufficient to reverse the systemic consequences of prolonged hemorrhagic shock and physiological insult. Our systematic review supports this observation—overall mortality was 9.6% (Table 4), and deaths were driven primarily by systemic complications rather than procedural failure.

The interval from symptom onset to definitive treatment is plausibly a determinant of outcome, but this hypothesis is not testable within the present data set, as time-from-symptom-onset-to-treatment was not systematically reported in the source publications and was therefore not extracted. Whether earlier recognition translates into reduced mortality should be addressed prospectively in registry-based studies. Within the limits of this case-report-based synthesis, the available data are consistent with mortality being driven primarily by the systemic consequences of hemorrhagic shock rather than by technical failure of definitive intervention.

Limitations

This systematic review has limitations inherent to case-report-based evidence, which sits at the lower tiers of the evidence hierarchy (OCEBM Levels IV–V) and supports descriptive rather than causal conclusions. Publication bias likely favors unusual presentations and severe outcomes. Era effects, spanning several decades of evolving endovascular technology, introduce time-related heterogeneity that cannot be adjusted for in a synthesis of this type. Heterogeneity in reporting precluded standardized outcome assessment, and time-from-symptom-onset-to-treatment was not consistently reported in the source publications. The comparison of treatment modalities was underpowered (n = 6 mortality events across the 2 arms), did not reach statistical significance (OR 0.22; 95% CI: 0.04-1.28; P = 0.08), and is susceptible to confounding by indication, since anatomically complex or hemodynamically deteriorating patients are preferentially directed to open or hybrid repair. The hybrid arm was excluded from the formal comparison because of its salvage-based and heterogeneous nature, which is itself a manifestation of this confounding. Accordingly, the present findings should be interpreted as hypothesis-generating and as supportive low-level evidence consistent with current expert-consensus guidelines, rather than as primary evidence establishing a treatment standard (Supplemental Material).

Conclusions

Inferior pancreaticoduodenal artery aneurysms are rare but potentially fatal vascular lesions characterized by nonspecific presentation and frequent diagnostic delay. This systematic review of 113 patients, anchored by a fatal index case, supports the following conclusions:

1. High index of suspicion is essential. Diagnostic pitfall occurred in 47.4% of cases. Clinicians should consider IPDA aneurysm in patients with unexplained abdominal pain, particularly those with known celiac axis stenosis (present in 71.7% of cases) or unexpected retroperitoneal findings on imaging.

2. CT angiography is the diagnostic gold standard and should not be delayed when vascular pathology is suspected.

3. Stepwise treatment approach optimizes outcomes:

◦ Stabilize: Immediate hemodynamic resuscitation with massive transfusion protocol.

◦ Endovascular-first approach, when anatomically feasible, is endorsed by current guidelines (CIRSE 2024, SVS 2020, ESVS 2025); descriptive findings from this review (mortality 3.5% vs 14.3% for open surgery; OR 0.22, 95% CI: 0.04-1.28; P = 0.08, non-significant) are consistent with this recommendation but do not independently establish it.

◦ Surgical backup: Emergency laparotomy when endovascular therapy fails or is not feasible, with preparedness for resuscitative thoracotomy in profound shock.

4. Multidisciplinary team involvement is mandatory, including emergency medicine, interventional radiology, vascular surgery, and general surgery.

5. Mortality is driven primarily by the systemic consequences of hemorrhagic shock. Deaths are attributable primarily to physiological insult (acidosis, coagulopathy, multi-organ failure) rather than to technical failure of definitive intervention. Whether earlier recognition reduces mortality cannot be determined from this data set, as time-from-symptom-onset-to-treatment was not systematically reported in source publications and was therefore not extracted; this question warrants prospective evaluation in registry-based studies.

Supplemental Material

Supplemental material - Inferior Pancreaticoduodenal Artery Aneurysms: Diagnostic Challenges and Management Outcomes—A Systematic Review of 113 Cases

Supplemental material for Inferior Pancreaticoduodenal Artery Aneurysms: Diagnostic Challenges and Management Outcomes—A Systematic Review of 113 Cases by Rotem Horowitz, Shai Hoffman, Moshe Argaman, Veronika Dadaev, Waseem Shakkur, and Fahim Kanani, MD in The American Surgeon™

Footnotes

ORCID iDs

Rotem Horowitz

Fahim Kanani

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material is available online.

References

Ferguson

. Aneurysm of superior pancreaticoduodenal artery. Proc N Y Pathol Soc. 1895;24:45-49.

Coll

Ierardi

Kerstein

Yost

Wilson

Matsumoto

. Pancreaticoduodenal artery aneurysms: treatment evolution. Ann Vasc Surg. 1998;12:286-291.

Quandalle

Chambon

Marache

Saudemont

Maes

. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: report of two cases and review of the literature. Ann Chir Vasc. 1990;4:540-545.

Orion

Najafian

Ehlert

Malas

Black

3rd Abularrage

. Gender predicts rupture of pancreaticoduodenal artery aneurysms. Ann Vasc Surg. 2016;36:1-6.

Stoecker

Eddinger

Glaser

, et al. A large series of true pancreaticoduodenal artery aneurysms. J Vasc Surg. 2022;75(5):1634-1642.

Hirano

Tokui

Nakamura

, et al. Understanding vascular anatomy is key to successful endovascular treatment of pancreaticoduodenal artery aneurysms. Ann Vasc Dis. 2020;13(3):330-334.

Shimbara

Shintakuya

Honmyo

Nakagawa

Kohashi

. Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: a case report. Int J Surg Case Rep. 2023;106:108041.

Asrih

Allali

Morère

Guibert

Kherad

. Pancreaticoduodenal artery pseudoaneurysm associated with pancreatic fibroinflammatory mass and duodenal obstruction. Am J Case Rep. 2024;25:e943879.

Brocker

Maher

Smith

. True pancreaticoduodenal aneurysms with celiac stenosis or occlusion. Am J Surg. 2012;204:762-768.

10.

Gupta

Krishna

Kochhar

, et al. Hemorrhage complicating the course of severe acute pancreatitis. Ann Hepatobiliary Pancreat Surg. 2020;24(3):292-300.

11.

Eckhauser

Stanley

Zelenock

Borlaza

Freier

Lindenauer

. Gastroduodenal and pancreaticoduodenal artery aneurysms: a complication of pancreatitis causing spontaneous gastrointestinal hemorrhage. Surgery (St Louis). 1980;88(3):335-344.

12.

Tarazov

Ignashov

Pavlovskij

Novikova

. Pancreaticoduodenal artery aneurysm associated with celiac axis stenosis: combined angiographic and surgical treatment. Dig Dis Sci. 2001;46:1232-1235.

13.

Vandy

Sell

Eliason

Coleman

Rectenwald

Stanley

. Pancreaticoduodenal and gastroduodenal artery aneurysms associated with celiac artery occlusive disease. Ann Vasc Surg. 2017;41:32-40.

14.

Ohira

Kimura

Takeuchi

Matsushita

Masuda

Shimizu

. Pancreaticoduodenal artery aneurysm involving papilla of Vater successfully treated with endovascular approach despite intraoperative rupture. Ann Vasc Surg. 2013;27:802e9-802e12.

15.

Degheili

El Chediak

Dergham

MYR

Al-Kutoubi

Hallal

. Pancreaticoduodenal artery aneurysm associated with celiac trunk stenosis: case illustration and literature review. Case Rep Radiol. 2017;2017:6989673.

16.

Ahmed

Abid

Hosmane

Mathew

. Unusual case of upper gastrointestinal haemorrhage secondary to a ruptured gastroduodenal artery pseudoaneurysm: case presentation and literature review. BMJ Case Rep. 2020;13(11):e236463.

17.

Mitrovic

Dugalic

Kovac

, et al. Successful embolization of posterior inferior pancreaticoduodenal artery pseudoaneurysm on the grounds of chronic pancreatitis: case report and literature review. Medicina (Coimbra). 2020;56:617.

18.

Granke

Hollier

Bowen

. Pancreaticoduodenal artery aneurysm: changing patterns. South Med J. 1990;83:918-921.

19.

Corder

Williams

. Optimal operative treatment in acute septic complications of diverticular disease. Ann R Coll Surg Engl. 1990;72(2):82-86.

20.

Kniemeyer

Edelmann

Reber

. Vaskuläre Ursachen des akuten Abdomens: Haben wir Fortschritte erzielt? Visc Med. 2002;18(5):332-339.

21.

Inoue

Tanaka

. A case of cecal diverticulitis complicated by pseudoaneurysm in the ileocolic artery. Cureus. 2022;14(6):e26123.

22.

Guijt

van Delden

Koedam

van Keulen

Reekers

. Rupture of true aneurysms of the pancreaticoduodenal arcade: treatment with transcatheter arterial embolization. Cardiovasc Interv Radiol. 2004;27:166-168.

23.

ESVS Guidelines Committee . Editor's Choice – European Society for Vascular Surgery (ESVS) Clinical practice Guidelines on the management of diseases of the mesenteric and renal arteries and veins. Eur J Vasc Endovasc Surg. 2025;70(2):153-218.

24.

Rossi

Krokidis

Kashef

Peynircioglu

Tipaldi

. Defined (Chair), Cardiovascular and interventional radiological society of Europe (CIRSE) guidelines on endovascular treatment of visceral artery aneurysms. Cardiovasc Interv Radiol. 2024;47(1):26-35.

25.

Chaer

Abularrage

Coleman

Eslami

Kashyap

Rockman

Murad

. Defined (Chair), Society for vascular Surgery (SVS) guidelines on the management of visceral artery aneurysms. J Vasc Surg. 2020;72(1S):3S-39S.

26.

Illuminati

Hostalrich

Pasqua

Nardi

Chaufour

Ricco

. Outcomes after open and endovascular repair of non-ruptured true pancreaticoduodenal and gastroduodenal artery aneurysms associated with coeliac artery compression: a multicentre retrospective study. Eur J Vasc Endovasc Surg. 2021;61(6):945-953.

27.

Murata

Tajima

Fukunaga

, et al. Management of pancreaticoduodenal artery aneurysms: results of superselective transcatheter embolization. AJR Am J Roentgenol. 2006;187:W290-W298.

28.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J. 2021;372:n71.

29.

Munn

Barker

Moola

, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth. 2020;18(10):2127-2133.

30.

Rim

Cieslak

Wang

. Bleeding pseudoaneurysm of the inferior pancreaticoduodenal artery as an endoscopic retrograde cholangiopancreatography complication. ACG Case Rep J. 2021;8:e00695.

31.

Lewis

Refson

. A pancreaticoduodenal artery aneurysm. BMJ Case Rep. 2015;2015:bcr2014207408.

32.

George

Besant

Cleveland

Al-Mukhtar

. Pseudoaneurysm of the inferior pancreaticoduodenal artery due to cholecystitis. Report. 2019;2:11.

33.

Terayama

Tanaka

Soga

, et al. The benefits of extrinsic ligament release for potentially hemodynamically unstable pancreaticoduodenal arcade aneurysm with median arcuate ligament syndrome: a case report. BMC Surg. 2019;19:50.

34.

Shin

Hong

Kim

. Ruptured pancreaticoduodenal artery aneurysm in a patient with celiac artery dissection: a case report. Vasc Endovasc Surg. 2023;57:768-770.

35.

Jibiki

Inoue

Iwai

Sugano

Igari

Koike

. Treatment of three pancreaticoduodenal artery aneurysms associated with celiac artery occlusion and splenic artery aneurysm: a case report and review of the literature. Eur J Vasc Endovasc Surg. 2005;29:213-217.

36.

Bloch

Shaughnessy

Cambria

Prushik

Shean

Conrad

. Pancreaticoduodenal artery aneurysm in a patient with celiac artery atresia. Ann Vasc Surg. 2025;111:165-169.

37.

Sharif

O’Donnell

Johnston

Lau

. Successful surgical management of a ruptured true pancreaticoduodenal artery aneurysm following failed transcatheter embolization. Vascular. 2007;15:231-234.

38.

Abon

JCR

Lopez

MPJ

Berberabe

Cinco

. Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding. BMJ Case Rep. 2021;14:e247359.

39.

Sakatani

Doi

Kitayama

, et al. Pancreaticoduodenal artery aneurysm associated with coeliac artery occlusion from an aortic intramural hematoma. World J Gastroenterol. 2016;22:4259-4263.

40.

Aryal

Komokata

Ueno

, et al. A 2-stage surgical and endovascular treatment of rare multiple aneurysms of pancreatic arteries. Ann Vasc Surg. 2017;40:295e9-295e13.

41.

Salomon du Mont

Lorandon

Behr

Leclerc

Ducroux

Rinckenbach

. Ruptured pancreaticoduodenal artery aneurysm due to a median arcuate ligament treated solely by revascularization of the celiac trunk. Ann Vasc Surg. 2017;43:310.e13-310.e16.

42.

Watanabe

Kohtake

Furui

Takeshita

Ishikawa

Morita

. Celiac artery dissection seen with ruptured pancreaticoduodenal arcade aneurysms in two cases of celiac artery stenosis from compression by median arcuate ligament. J Vasc Surg. 2012;56:1114-1118.

43.

Moore-Stovall

. Ruptured pancreaticoduodenal arterial aneurysms: diagnosis and treatment by angiographic intervention. J Natl Med Assoc. 1995;87:149-151.

44.

Izumi

Ryu

Cho

, et al. Ruptured pancreaticoduodenal artery aneurysm treated by superselective transcatheter arterial embolization and preserving vascularity of pancreaticoduodenal arcades. J Hepatobiliary Pancreat Surg. 2004;11:145-148.

45.

Cui

Liu

. Gastrointestinal bleeding caused by rupture of a posterior inferior pancreaticoduodenal artery pseudoaneurysm: a case report. Medicine (Baltim). 2022;101(48):e32123.

46.

Ogino

Sato

Banno

Arakawa

Hara

. Embolization in a patient with ruptured anterior inferior pancreaticoduodenal arterial aneurysm with median arcuate ligament syndrome. Cardiovasc Interv Radiol. 2002;25:318-319.

47.

De Santis

Bruni

Da Ros

Brait

CMC

Scevola

Di Cintio

. Multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis root segmental stenosis presenting as aneurysm rupture. Ann Vasc Surg. 2015;29:1657.e1-1657.e7.

48.

Liu

. A case report of spontaneous rupture of pancreaticoduodenal artery aneurysm. Asian J Surg. 2023;46:3304-3305.

49.

Sugiyama

Sakamoto

Sueyoshi

Hazama

Fukuda

Uetani

. Transcatheter arterial embolization of ruptured pancreaticoduodenal artery aneurysms associated with celiac artery stenosis. J Vasc Surg. 2008;47:133-139.

50.

Otsuka

Sato

Aoki

Nakagawa

Inokuchi

. Optimal treatment for ruptured pancreaticoduodenal artery aneurysm caused by celiac artery obstruction due to celiac artery dissection. Vasc Endovasc Surg. 2018;52:564-568.

51.

Yomogida

Hasegawa

Mizuta

Horikawa

Koshida

Kawakami

. A rare case of severe pulmonary embolism complicated by the rupture of a pancreaticoduodenal artery aneurysm due to median arcuate ligament syndrome and left-sided inferior vena cava. Intern Med. 2025;64:2328-2331.

52.

Kabaroudis

Papaziogas

. Spontaneous retroperitoneal hematoma caused by aneurysm of the inferior pancreaticoduodenal artery. Am J Surg. 2002;184:174-175.

53.

Peterson

Resnick

Eskandari

. Coil embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac artery occlusion. Cardiovasc Surg. 2003;11:515-519.

54.

Hasegawa

Seiji

Ota

, et al. Rapid development of new aneurysms in the adjacent pancreatic arcade arteries after urgent embolization of pancreaticoduodenal artery aneurysms in cases with celiac stenosis. J Vasc Intervent Radiol. 2018;29:1306-1308.e2.

55.

Nakayama

Osumi

Mizuno

, et al. A case of laparoscopic surgery for pancreaticoduodenal artery aneurysm caused by median arcuate ligament syndrome. Asian J Endosc Surg. 2025;18:e70060.

56.

Takao

Doi

Watanabe

Yoshioka

Ohtomo

. Natural history of true pancreaticoduodenal artery aneurysms. Br J Radiol. 2010;83:744-746.

57.

Jang

Kim

, et al. Percutaneous N-butyl-cyanoacrylate embolization for treating ruptured pancreaticoduodenal aneurysm: a case report. Medicina (Coimbra). 2022;58:1320.

58.

Popov

Sagic

Radovanovic

Antonic

Nenezic

Radak

. Pancreaticoduodenal artery pseudoaneurysm embolization. Vascular. 2008;16:48-52.

59.

Paty

PSK

Cordero

Jr Darling

III Chang

Shah

Leather

. Aneurysms of the pancreaticoduodenal artery. J Vasc Surg. 1996;23:710-713.

60.

Kamarajah

Kharkhanis

Duddy

, et al. Management of pancreaticoduodenal artery aneurysm associated with coeliac artery stenosis. Ann R Coll Surg Engl. 2019;101:e105-e107.

61.

Hori

Yamamoto

Harada

, et al. Inferior pancreaticoduodenal artery aneurysm related with groove pancreatitis persistently repeated hemosuccus pancreaticus even after coil embolization. Am J Case Rep. 2019;20:567-574.

62.

Armstrong

Stadtlander

Grove

. Pancreaticoduodenal artery aneurysm associated with median arcuate ligament syndrome. Ann Vasc Surg. 2014;28:741.e1-741.e5.

63.

Akmenkalne

Ghoneim

Nash

, et al. Staged treatment for pancreaticoduodenal artery aneurysm with celiac artery revascularisation: case report and systematic review, 6. Mesentery Peritoneum; 2022:AB039.

64.

Nie

, et al. Ruptured small pancreaticoduodenal artery aneurysm: clinical features similar to pancreatitis: a case report. Medicine (Baltim). 2023;102(9):e32821.

65.

Jalili

Javadrashid

Alvandfar

, et al. Obstructive jaundice as a rare complication of multiple pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: a case report and review of the literature. J Med Case Rep. 2023;17:385.

66.

Fetti

Puia

Comşa

Stanca

Puia

Al Hajjar

. Inferior pancreaticoduodenal artery aneurysm with superior mesenteric artery stenosis. J Gastrointest Liver Dis. 2020;29:115-118.

67.

Hamlin

Gallo

Petrochko

Wilson

Sheth

. Pancreaticoduodenal artery aneurysm complicated by median arcuate ligament syndrome. Vasc Endovasc Surg. 2024;58:213-217.

68.

Park

. Ruptured pancreaticoduodenal artery aneurysm with pancreatitis treated using endovascular and endoscopic methods. Korean J Gastroenterol. 2021;77:194-198.

69.

Ishihara

Matsui

Katoh

, et al. Pancreaticoduodenal artery aneurysm rupture presenting as duodenal obstruction successfully treated with early transcatheter arterial embolization: a case report of suspected segmental arterial mediolysis. Intern Med. 2023;62:3479-3482.

70.

Yoneyama

Tsuchie

Kuno

, et al. Aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization. J Hepatobiliary Pancreat Surg. 1998;5:104-107.

71.

Negmadjanov

Motta

De Grandis

Lee

. A hybrid approach in the management of a large pancreaticoduodenal artery aneurysm. Ann Vasc Surg. 2022;79:441.e1-441.e5.

72.

Tan

EWK

Shelat

Monteiro

Low

. Spontaneous retroperitoneal haemorrhage from pancreatoduodenal artery rupture and associated complications. BMJ Case Rep. 2022;15:e250383.

73.

Kurisu

Matsuki

Kawachi

Taki

. Rupture of a pancreaticoduodenal artery aneurysm into the common bile duct resulting in fatal suppurative cholangitis: report of a case. Surg Today. 2005;35:94-96.

74.

Iyomasa

Matsuzaki

Hiei

Sakaguchi

Matsunaga

Yamaguchi

. Pancreaticoduodenal artery aneurysm: report and review of the literature. J Vasc Surg. 1995;22:161-166.

75.

Sugaya

Suzuki

Wada

, et al. Transarterial embolization for ruptured pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis combined with median arcuate ligament syndrome: a case report. Clin J Gastroenterol. 2023;16:859-863.

76.

Weber

Pfeifer

Tato

Reiser

Rieger

. Transcatheter coil embolization of an aneurysm of the pancreatico-duodenal artery with occluded celiac trunk. Cardiovasc Interv Radiol. 2005;28:259-261.

77.

Mitrovic Jovanovic

Tadic

Jankovic

, et al. Endovascular treatment of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery as a complication of chronic pancreatitis: a case report. J Int Med Res. 2022;50:1-8.

78.

Yin

Wan

Chen

Mao

. Obstructive jaundice caused by pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: case report and review of the literature. Ann Vasc Surg. 2015;29:1016.e1-1016.e6.

79.

Nessuno

La Rocca

Frusciante

Pericoli

. A rare case of spontaneous rupture of an inferior pancreaticoduodenal artery aneurysm treated with endovascular procedure. Clin Case Rep Int. 2023;7:1537.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.40 MB

0.00 MB