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“Superior Pancreaticoduodenal Artery Pseudoaneurysm Mimicking a Cystic. Neoplasm with Worrisome Features”. Matheus Cavalcante Franco, MD, MSc, John ...

Accepted Manuscript “Superior Pancreaticoduodenal Artery Pseudoaneurysm Mimicking a Cystic Neoplasm with Worrisome Features” Matheus Cavalcante Franco, MD, MSc, John J. Vargo, MD, MPH, Prabhleen Chahal, MD PII:

S2468-4481(16)30071-6

DOI:

10.1016/j.vgie.2016.11.002

Reference:

VGIE 44

To appear in:

VideoGIE

Received Date: 19 September 2016 Revised Date:

8 November 2016

Accepted Date: 12 November 2016

Please cite this article as: Franco MC, Vargo JJ, Chahal P, “Superior Pancreaticoduodenal Artery Pseudoaneurysm Mimicking a Cystic Neoplasm with Worrisome Features”, VideoGIE (2016), doi: 10.1016/j.vgie.2016.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT A. Title: “Superior Pancreaticoduodenal Artery Pseudoaneurysm Mimicking a Cystic Neoplasm with Worrisome Features”

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B. Institution: Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.

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C. Authors: 1. Matheus Cavalcante Franco

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Degree: MD, MSc 2. John J. Vargo Degree: MD, MPH 3. Prabhleen Chahal

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Degree: MD

D. Corresponding author information:

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Prabhleen Chahal, MD Department of Gastroenterology and Hepatology Digestive Disease Institute Cleveland Clinic 9500 Euclid Avenue, A31 Cleveland, Ohio 44195 Tel: (216) 444- 6521, Fax: (216) 444 – 6284 Email: [email protected] E. Financial Support: None F. Disclosures: Matheus C Franco: No relevant disclosures John J Vargo: No relevant disclosures Prabhleen Chahal: No relevant disclosures

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Superior pancreaticoduodenal artery neoplasm with worrisome features

pseudoaneurysm mimicking

a cystic

A 61-year-old female presented with poor appetite, unintentional weight loss (>

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30 lbs in 1 year), and intermittent diarrhea. She had a CT scan done in 2012 from an outside hospital, which showed no significant abnormalities. Further investigation with MRI revealed a 1.4 cm cystic lesion in the body of the pancreas with wall thickness and enhancing nodule, suggestive of a cystic neoplasm with worrisome features (Fig. 1A

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and B). The patient was then referred for EUS with possible EUS-guided fine-needle aspiration (EUS-FNA).

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EUS showed the pancreatic lesion with the same worrisome features described previously during the MRI (Fig. 1C). However, examination with Doppler revealed an intense vascular flow in the lesion. The intensely pulsating mass with connection with a surrounding artery raised concern for the diagnosis of pseudoaneusym with partial thrombosis mimicking the solid components (Fig. 1D). A CT angiogram confirmed the pancreatic pseudoaneurysm arising off the superior pancreaticoduodenal artery (Fig.

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1E). The patient was then successfully treated with angiographic embolization (Fig. 1F). The patient had no pain or bleeding episodes in the 3-month follow-up. Interval CT scan of percutaneous embolization showed complete exclusion of the aneurysm with no evidence of recanalization. The underlying etiology of her diarrhea was presumed to be

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irritable bowel syndrome with unremarkable work-up of infectious, inflammatory, or secretory etiology. Our patient endorsed a year-long history of significant personal

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stressors in her life before her presentation. This is an unusual case of a pancreatic pseudoaneurysm mimicking a cystic

neoplasm in a patient with no medical history of pancreatitis (Video 1). The presentation may range from an incidental finding up to hemodynamic collapse from severe bleeding. EUS is an important tool in this diagnosis. Moreover, examination of a lesion referred for EUS-FNA with Doppler is always recommended to avoid the puncture of vascular structures. Although the EUS-guided treatment is not the criterion standard for

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pseudoaneurysms,

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successful

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embolization with thrombin. Legends:

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Figure 1. A, MRI revealed a cystic lesion in the body of pancreas with wall thickness. B, An enhancing nodule was seen in the MRI, suggestive of a cystic neoplasm with worrisome features. C, EUS showing the pancreatic lesion with worrisome features described previously by the MRI. D, Examination with Doppler revealed an intense vascular flow, and connection of the lesion with a surrounding artery. E, CT angiogram confirmed the superior pancreaticoduodenal artery pseudoanurysm. F, Image after treatment with angiographic embolization.

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Video 1. Video demonstration of pancreatic pseudoaneurysm mimicking a cystic neoplasm with worrisome features.

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