Endovascular management of a ruptured pancreaticoduodenal artery aneurysm in a patient with median arcuate ligament syndrome

Pancreaticoduodenal artery aneurysm is an uncommon vascular entity within the visceral circulation, yet it carries a high risk of rupture and life-threatening hemorrhage, even when the aneurysm is small. We report a case of a 57-year-old male who presented with acute epigastric pain and signs of hypovolemic anemia. Contrast-enhanced computed tomography revealed a large retroperitoneal hematoma associated with multiple aneurysms arising from the pancreaticoduodenal arteries. Notably, the celiac artery demonstrated characteristic compression by the median arcuate ligament, consistent with median arcuate ligament syndrome (MALS). The patient underwent emergency endovascular embolization using a combination of fibered coils and N-butyl cyanoacrylate–Lipiodol mixture, resulting in complete occlusion of the aneurysmal segments and rapid clinical stabilization. This case underscores the pivotal role of cross-sectional imaging in identifying underlying vascular anomalies such as MALS and highlights the efficacy and safety of selective endovascular embolization in managing complex visceral aneurysms. Long-term follow-up is essential to detect potential recurrence or organ ischemia related to altered mesenteric hemodynamics.