Endovascular management of a ruptured pancreaticoduodenal artery pseudoaneurysm using a stent-graft: a case report and literature review

Background: Pancreaticoduodenal artery (PDA) pseudoaneurysms are rare vascular complications, accounting for approximately 2% of all visceral artery aneurysms. They are often associated with chronic pancreatitis and have a high risk of rupture, which can be life-threatening. Case presentation: A 45-year-old male with a history of chronic alcoholic pancreatitis presented with recurrent epigastric pain radiating to the back, associated with anorexia and significant weight loss. He had undergone multiple prior endoscopies and biopsies without a definitive diagnosis. During endoscopy at our institution, a pulsatile submucosal mass in the duodenum was identified, prompting CT angiography, which revealed a pseudoaneurysm of the superior posterior PDA with an arteriovenous fistula. Shortly afterward, the patient developed massive gastrointestinal (GI) bleeding and hemodynamic instability. Emergency angiography was attempted; however, coil embolization failed due to intra-procedural rupture. A covered stent (CeloNova 4.0 mm × 23 mm) was deployed, successfully excluding the pseudoaneurysm and stabilizing the patient. Discussion: PDA pseudoaneurysms are diagnostically challenging and often missed on standard imaging and endoscopy. Our case demonstrates the importance of maintaining a high index of suspicion in patients with chronic pancreatitis and unexplained GI findings. Endovascular therapy is the preferred treatment, with coil embolization as the standard approach; however, in cases of rupture, arteriovenous fistula, or failed embolization, covered stent grafting is a life-saving alternative. Conclusion: This case highlights a rare presentation of a ruptured PDA pseudoaneurysm with an AV fistula, initially missed despite multiple prior evaluations, successfully managed with a covered stent following failed embolization. Prompt recognition and flexible endovascular techniques are critical in preventing mortality in such complex vascular emergencies.