Re: Embolization of pancreaticoduodenal aneurysms associated with occlusive disease of the celiac artery

We read with interest the paper by Uher et al. concerning aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery [1], and we would like to add the following considerations. Aneurysms of the pancreaticoduodenal artery associated with stenosis or occlusion of the celiac artery can also rupture when the aneurysm is very small [2]. Therefore, superior mesenteric angiograms should be evaluated very carefully to detect these lesions whenever the gastroduodenal artery serves as a collateral pathway to the celiac artery. We agree with Uher et al. [1] when they state that embolization should be the primary therapeutic choice in the case of a ruptured aneurysm: the successful longterm results support this approach [2]. However, we feel that embolization should be primarily attempted in patients with a nonruptured aneurysm when the vascular anatomy is suitable for selective catheterization because an arterial ligation or an aneurysm resection are not always feasible, and a major operation (i.e., a partial pancreatectomy) might be necessary [3, 4]. As concerns their case 4, we disagree with Uher et al. who rejected the hypothesis that the gastrointestinal bleeding was caused by the aneurysms of the pancreaticoduodenal artery. This case resembles cases of gastrointestinal hemorrhage from pancreatic pseudoaneurysms. In these circumstances, endoscopy of the upper digestive tract often fails to detect the bleeding through the ampulla of Vater because the bleeding is often selflimiting and no mucosal abnormalities are associated [5]. Therefore, a negative endoscopy cannot rule out a parenchymal source of gastrointestinal bleeding. Did the level of serum amylases increase after every episode of gastrointestinal bleeding suffered by the patient of case 4? Did the gastrointestinal bleeding recur after the discharge from the hospital? In any case, although the previous multiorgan transplantation could make the operation difficult to perform, why was surgery not planned? These aneurysms, in fact, can rupture, as was reported by Uher et al. in their case 2. Aneurysms of the pancreaticoduodenal artery associated with occlusive disease of the celiac artery may be life-threatening lesions. Transcatheter embolization, because it is noninvasive and highly reliable, should be the primary therapeutic choice to treat both ruptured and nonruptured aneurysms. Nevertheless, when adverse vascular anatomy prevents or jeopardizes the arterial liver supply and contraindicates the embolization, surgery should be always considered as a second therapeutic option because conservative management of these aneurysms may be hazardous for the patient.