Interventional Management of Arc of Buhler Aneurysm

ABSTRACT

The Arc of Buhler (AOB) represents a persistence of the ventral anastomosis between the superior mesenteric artery (SMA) and the celiac arterial systems. The exact incidence of the AOB is not known, but it is believed to be ≤ 4%. Aneurysms of this rare anomaly are even more uncommon. We report a case of an aneurysm of the AOB with an intact pancreaticoduodenal artery arcade (PDAA) and near occlusive celiac origin stenosis. Stenoses or occlusions of the celiac origin have been reported in association with AOB aneurysms, as well as in patients with PDAA aneurysms. Transcatheter embolization (TCE) was successfully performed, thereby excluding the AOB aneurysm while preserving flow through the PDAA. To our knowledge, this is the first report of successful percutaneous treatment of an AOB aneurysm. The pathophysiology and management AOB and PDAA aneurysms are reviewed. Review of the literature suggests that TCE, when feasible, is at least as effective as conventional surgery in patients with PDAA aneurysms, but with lower morbidity and mortality. Based on this data and our experience, we believe that TCE should be the initial treatment of choice in patients with PDAA or AOB aneurysms.

KEYWORDS

Visceral aneurysm - pancreaticoduodenal arcade - Arc of Buhler - pancreaticoduodenal artery

REFERENCES

• 1 Buhler A. Uber eine anastomose zwischen den stammen der A. coeliaca und der A. mesenterica superior.  Morpholog Jahrb. 1904;  32 185-187
• 2 Tandler J. Uber die varietaten der arteria coeliaca und deren entwicklung.  Anat Hefte. 1904;  25 472-500
• 3 Grabbe E, Bucheler E. Buhler's anastomosis.  Rofo. 1980;  132 541-546
• 4 Kugai T, Nakamoto T, Tamaki N et al.. Aneurysm of an artery of Buhler: an unusual case.  J Vasc Surg. 1996;  23 537-538
• 5 Myers J L, Losseff S V, Gomes M N. Surgical repair of an aneurysm of the Arc of Buhler in a patient with von Recklinghausen's disease.  Eur J Vasc Endovasc Surg. 1998;  16 540-542
• 6 Saad W E, Davies M G, Sahler L et al.. Arc of Buhler: incidence and diameter in asymptomatic individuals.  Vasc Endovascular Surg. 2005;  39 347-349
• 7 McNulty J G, Hickey N, Khosa F, O'Brien P, O'Callaghan J P. Surgical and radiological significance of variants of Buhler's anastomotic artery: a report of three cases.  Surg Radiol Anat. 2001;  23 277-280
• 8 Song S Y, Chung J W, Kwon J W et al.. Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation.  Radiographics. 2002;  22 881-893
• 9 Moore E, Matthews M R, Minion D J et al.. Surgical management of peripancreatic arterial aneurysms.  J Vasc Surg. 2004;  40 247-253
• 10 Bageacu S, Cuilleron M, Kaczmarek D, Porcheron J. True aneurysms of the pancreaticoduodenal artery: successful non-operative management.  Surgery. 2006;  139 608-616
• 11 Sutton D, Lawton G. Coeliac stenosis or occlusion with aneurysm of the collateral supply.  Clin Radiol. 1973;  24 49-53
• 12 Proud G, Chamberlain J. Aneurysm formation on the small pancreatic arteries in association with coeliac axis compression.  Ann R Coll Surg Engl. 1978;  60 294-297
• 13 Neschis D G, Safford S D, Golden M A. Management of pancreaticoduodenal artery aneurysms presenting as catastrophic intraabdominal bleeding.  Surgery. 1998;  123 8-12
• 14 Iyomasa S, Matsuzaki Y, Hiei K, Sakaguchi H, Matsunaga H, Yamaguchi Y. Pancreaticoduodenal artery aneurysm: a case report and review of the literature.  J Vasc Surg. 1995;  22 161-166
• 15 Lina J R, Jaques P, Mandell V. Aneurysm rupture secondary to transcatheter embolization.  AJR Am J Roentgenol. 1979;  132 553-556
• 16 Coll D P, Ierardi R, Kerstein M D, Yost S, Wilson A, Matsumoto T. Aneurysms of the pancreaticoduodenal arteries: a change in management.  Ann Vasc Surg. 1998;  12 286-291