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

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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

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

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