Common splanchnic artery aneurysms: splenic, hepatic, and celiac

Management of Coeliac and Hepatic Artery Aneurysms: An Experience of 84 Cases

OBJECTIVE

To report outcomes following open or endovascular treatment of true hepatic and coeliac artery aneurysms at a single referral centre.

METHODS

This was a retrospective cohort study of consecutive patients treated for true hepatic and coeliac artery aneurysms between May 2002 and December 2021. Outcome measures included complications, graft patency, and survival rate.

RESULTS

Overall, 84 patients were included with a median age of 63 years (interquartile range 55, 79). The majority (76%) of the patients were men. Frequent comorbidities included a history of tobacco (69%), hypertension (65%), hyperlipidaemia (32%), and diabetes (15%). Multiple synchronous aneurysms were detected in 22 patients (26%). There were 33 (39%) symptomatic aneurysms (abdominal pain without rupture [n = 18], rupture [n = 10], and sepsis [n = 5]). Seventeen patients (20%) had mycotic aetiology. Fifty patients (60%) underwent endovascular treatment with either covered stent placement (n = 29) or coil embolisation (n = 21), and 34 patients (40%) were treated with open surgery using allogenic iliac artery (n = 15), autologous saphenous vein (n = 15), GoreTex graft (n = 2), or ligation (n = 2). The complication rate was 32% in the open group and 18% in the endovascular group (p = .048). The overall 90 day post-operative mortality rate was 1.2%, five year primary patency was 90.0%, five year survival rate was 81.2%, and mean follow up was 6.9 ± 4.2 years.

CONCLUSION

Endovascular treatment is the preferred approach whenever technically possible. Despite higher post-operative morbidity, an open approach with vascular reconstruction using autologous or allogenic vascular grafts yields acceptable long term results.

Giant Coeliac Artery Aneurysm Treated with a Hybrid Approach: A Case Report

Introduction

Coeliac artery aneurysms are rare and have a high mortality rate when ruptured. Although they are often asymptomatic, treatment is recommended for patients with true coeliac aneurysms >2.5 cm, noted enlargement, or associated symptoms. Less invasive endovascular treatment is predominantly performed for coeliac artery aneurysms, while open surgery is preferred for patients with compression symptoms. Here, a case of symptomatic giant coeliac artery aneurysm that was successfully treated with hybrid surgery is reported.

Report

A 73 year old man was referred with continuous epigastric discomfort and loss of appetite for two weeks. Abdominal ultrasound and computed tomography revealed a 12 cm aneurysm of the coeliac artery. The splenic and common hepatic arteries were severely distorted and compressed by the aneurysm, making their origins unclear. Considering the risk of rupture, semi-urgent surgery was performed with interruption of the inflow and outflow arteries using open and endovascular techniques together with aneurysmorrhaphy. Vascular reconstruction was omitted because abundant collateral flow to the liver and spleen was confirmed on angiography.

Discussion

With the hybrid approach, aneurysmorrhaphy was performed safely with minimal incision and dissection. Short term outcomes were satisfactory, with complete resolution of compression symptoms and remarkable sac shrinkage at 12 months. Owing to the possibility of the pancreaticoduodenal arcade developing as a collateral pathway, periodic surveillance for de novo aneurysms is warranted.

The management of spontaneous isolated celiac artery dissection: A case report and literature review

OBJECTIVES

Spontaneous isolated celiac artery dissection (SICAD) without associated aortic dissection is a rare disease. Complications are ischemia, aneurysm formation, and rupture. Different treatment options have been reported for managing SICAD, including conservative management, endovascular intervention, and open surgery. Despite the increased recognition of this disease, there are no consensus guidelines on management of this condition. To improve the knowledge and treatment of this disease, a case of SICAD was reported.

METHODS AND RESULTS

We describe the case of a 57-year-old woman with SICAD whose symptoms improved after endovascular treatment when conservative treatment failed and systematically analyze the management strategy for patients with SICAD.

CONCLUSIONS

SICAD is a rare disease and has no universally agreed upon guidelines for treatment. Most patients can be first treated conservatively for dissection with strict blood pressure control, antithrombotic therapy, and intensive surveillance. For SICAD patients with aneurysms located in the celiac trunk, stent grafts can be used in such patients without affecting the branch blood supply.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Coil embolization of asymptomatic left gastric artery aneurysm: Case report and literature review

Patients with visceral artery aneurysms are rare, and the reported incidence of left gastric aneurysm (LGA) is only 4%. At present, although there is little knowledge about such disease, it is generally believed that appropriate treatment should be planned to prevent some dangerous aneurysms from rupturing. We introduced a case of 83-year-old patient with LGA who underwent endovascular aneurysm repair. The 6-month follow-up computed tomography angiography showed complete thrombosis in the aneurysm lumen. In addition, to insight the management strategy on LGAs deeply, a literature review concerning this entity published in recent 35 years was performed.

[Complicated visceral artery aneurysms in chronic pancreatitis]

Visceral artery aneurysms are rare and occur only in 0.01-0.2% of people. According to various authors, incidence of aneurysm rupture is 10-20% with mortality rate of 20-70% depending on localization and dimensions. One of the causes of visceral artery aneurysms, in particular common hepatic artery aneurysm, is chronic pancreatitis. Incidence of this complication is 2-10%. The first clinical manifestation is often hemorrhagic shock following false aneurysm rupture and bleeding into abdominal cavity, gastrointestinal tract or retroperitoneal space. Common hepatic artery aneurysm is complicated by bleeding in 35% of cases, and mortality may be up to 75%. Treatment of visceral artery aneurysm following chronic pancreatitis and post-necrotic parapancreatic cyst includes several stages. Endovascular methods are the first stage of treatment. The second stage is elimination of the cause of visceral artery false aneurysm (surgery for chronic pancreatitis). We present 3 patients with visceral artery aneurysms and chronic pancreatitis.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients: A case report and review of literature

BACKGROUND

The rupture of a splenic artery aneurysm (SAA) in pregnancy is an uncommon condition. However, it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment. Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases, the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.

CASE SUMMARY

We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy. After emergent initial resuscitation, the patient was diagnosed with a ruptured SAA through digital angiography. Immediately upon diagnosis, she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot. Next, surgery was performed to remove the hematoma under stable conditions. Although the fetus was found to be dead during resuscitation, the woman recovered without complications and was discharged 15 d postoperatively.

CONCLUSION

Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Treatment of celiac artery rupture with a hybrid procedure involving aortic stent grafting and open surgery in a patient with neurofibromatosis type 1

Neurofibromatosis type 1 is associated with vascular fragility, and vascular disease is the second leading cause of death in these patients. A 42-year-old woman with neurofibromatosis type 1 was transferred to our hospital owing to shock. A computed tomography scan revealed a ruptured celiac artery aneurysm, which had expanded from 14 to 26 mm in 1 day. The survival rate of patients with celiac artery rupture is extremely low, and there is no consensus on treatment. Here, we successfully performed a hybrid procedure with emergent implantation of aortic stent grafts for life-saving treatment and subsequent laparotomy for complete hemostasis.

Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review

BACKGROUND

Visceral artery aneurysms (VAA) are rare with an incidence of up to 0.2% and mortality of up to 40%. Aneurysms larger than 5 cm are referred to as giant visceral artery aneurysms (GVAA). We present a case of a celiac artery aneurysm of 14 cm which required endovascular and surgical management. A review of the literature with focus on treatment is also provided.

CASE PRESENTATION

In this case report, a 76-year-old male presented with postprandial nausea and vomitus. An ultrasound and computed tomography scan showed an aneurysm of the celiac artery of approximately 14 cm. Initial treatment was conducted with coiling. Despite this treatment, patient presented again with the same complaints, most likely due to gastric outlet syndrome caused by the aneurysm sac. Partial open removal of the aneurysm sac was performed with release of the duodenum. Due to recurring dysphagia and postprandial nausea, a gastroenterostomy was created, which was later supplemented with a Roux-en-Y anastomosis due to gastroparesis. Patient recovered uneventful after the Roux-en-Y and was discharged from the hospital.

CONCLUSION

Giant visceral artery aneurysms sometimes need multimodal treatment. We showed that an endovascular first approach of a giant visceral artery aneurysm is not only technically feasible, but it also facilitates subsequent open surgery due to limiting blood loss and reducing the need for extensive mobilisation of the viscera to gain arterial control.

Endovascular treatment of an asymptomatic hepatic artery aneurism: case report

We report a case of an asymptomatic, 77-year-old, male patient with arterial hypertension and no other comorbidities or risk factors for coronary disease. During a routine abdominal ultrasound examination, he was diagnosed with a hepatic vascular mass with an approximate diameter of 5 cm. Abdominal computed angiotomography was requested, showing an aneurysm of the hepatic artery, with maximum diameter of up to 5.2 cm, longest longitudinal axis of 7.2 cm, and a maximum true lumen caliber of 3.0 cm. We opted for endovascular aneurysm repair with implantation of three sequential Lifestream covered vascular stents (7x58mm, 8x58mm, and 8x37mm), successfully diverting the flow through the stents and excluding the aneurysm. The patient remains asymptomatic and free from clinical complications 2 years after the procedure. Control examinations with arterial duplex ultrasound 6 and 12 months after the procedure showed good flow through the stents with no leakage into the aneurysmal sac.

Management of a common and proper hepatic artery aneurysm

First-line management of hepatic artery aneurysms is via an endovascular approach. However, unfavorable anatomy may preclude this. We present a patient with an aneurysm involving most of the common hepatic artery and the entire proper hepatic artery including the emergence of the right and left hepatic artery and the gastroduodenal artery. The endovascular approach was not feasible due to unfavorable anatomy. The patient was successfully treated with an open bifurcated Dacron graft.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

Ruptured idiopathic hepatic artery pseudoaneurysm causing portal vein thrombosis with portal hypertension and variceal bleeding

Portal vein thrombosis (PVT) is an important cause of noncirrhotic portal hypertension. Noncancerous extrinsic compression of portal vein to drive PVT formation is rare, but important to identify. A 64-year-old female with idiopathic hepatic artery pseudoaneurysm (HAPA) rupture 7 months prior presented with acute-onset hematemesis and melena and was found to have prehepatic portal hypertensive variceal bleeding. Her HAPA-related retroperitoneal hematoma had resulted in portal vein compression, thrombosis, and cavernous transformation despite prompt stent graft placement across the ruptured HAPA, and required definitive treatment by transjugular intrahepatic portosystemic shunt creation with portal vein reconstruction utilizing a trans-splenic access. This case highlights the importance of interval abdominal imaging and hypercoagulability screening for noncirrhotic patients at-risk for PVT, which identified the patient as a heterozygous carrier of Factor V Leiden.

Endovascular management of giant visceral artery aneurysms

Endovascular management of small visceral artery aneurysms is an established treatment with satisfactory outcomes. However, when size exceeds 5 cm visceral aneurysms are considered as “giant” (giant visceral artery aneurysms or GVAAs) and management is significantly more complex. Between August 2007 and June 2019 eleven cases of GVAAs that were endovascularly treated were retrospectively reviewed and included in this single center study. Mean size was 80 mm (± 26.3 mm) x 46 mm (+ \-11.8 mm). Nine of the lesions were true aneurysms, and two were pseudoaneurysms. In 8 patients, the lesion was causing compression symptoms in the surrounding organs, one patient developed a contained rupture while 2 patients were completely asymptomatic. However, all patients were hemodynamically stable at the time of treatment. Technical success was defined as immediate complete exclusion of the aneurysmal sac, and clinical success as complete relief from clinical symptoms. Follow-up was performed with CT angiography, ultrasound and clinical examination. Mean follow-up was 45 months (range 6–84). Technical and clinical success were both 91%. Complications were one lack of control of contained rupture that was subsequently operated, one case of self-limiting non-target spleen embolization and one case of splenic abscess. Three patients died, one due to the contained rupture 15 days after procedure, the other two for other causes and occurred during the long-term follow-up. This series suggests that endovascular treatment of giant visceral artery aneurysms and pseudoaneuryms is a valid minimally invasive solution with very satisfactory immediate and long-term outcomes unless the aneurysm is already ruptured. A variety of endovascular tools may be required for successful treatment.

Management of life-threatening hemoperitoneum with minimally invasive percutaneous superselective arterial embolization

The management of spontaneous hemoperitoneum centers on clinical suspicion, fluid resuscitation, appropriate early imaging, and therapeutic intervention. Traditionally, explorative laparotomy has been the treatment of choice for idiopathic spontaneous intraabdominal hemorrhage, but as less invasive percutaneous techniques have matured, superselective arterial embolization may play a critical role in emergent treatment. This case report describes a 65-year-old woman with large-volume hemoperitoneum. At angiography, a single pseudoaneurysm of the middle colic artery was identified and treated with superselective endovascular methods.

Experience of managing superior mesenteric artery aneurysm and its midterm follow-up results with 18 cases

OBJECTIVES

To characterize the clinical features, treatment, and prognosis of superior mesenteric artery aneurysms and provide evidence for clinical decision-making.

METHODS

We retrospectively reviewed the diagnosis and treatment of 18 cases of superior mesenteric artery aneurysm admitted to our center from 2003 to 2020, including demographic data, risk factors, clinical manifestations, diagnosis, treatment strategies, and follow-up results.

RESULTS

The average age of the patients was 49.1 years, and males accounted 83.3%. The development of the disease was associated with infection, hypertension, pancreatitis, and trauma, but no significant associations with atherosclerosis were noted by our results. Nine patients were diagnosed with true aneurysm, seven patients with pseudoaneurysm, and two patients with dissecting aneurysm. Rupture of aneurysm occurred in three patients (16.7%), and one of them died before surgery. The surgery success rate was 94.1%, and open surgery was performed on nine patients, endovascular surgery on three patients, and conservative treatment on three patients. The follow-up rate was 77.8% (14/18), and the average follow-up time was 48.2 months. The mortality and reintervention rate during follow-up was 0. The two-year patency rate of artificial vessels and covered stents was 50%.

CONCLUSION

The clinical manifestations and features of superior mesenteric artery aneurysms vary between patients. Careful evaluation of vascular anatomy and personalized treatment strategy are critical in the management of superior mesenteric artery aneurysms. Midterm follow-up results of superior mesenteric artery aneurysms are satisfactory.

Gastroduodenal Artery Pseudoaneurysm Causing Obstructive Jaundice

Background: Visceral artery aneurysms and pseudoaneurysms are uncommon phenomena with a high mortality rate in cases of rupture. These rare vascular pathologies are usually asymptomatic and are therefore generally discovered incidentally on computed tomography or magnetic resonance imaging examination. Current therapeutic options have trended toward a minimally invasive approach because of evolving endovascular treatment options, with open operations typically reserved for cases of intraabdominal hemorrhage.

Case Report: We describe a case of gastroduodenal artery pseudoaneurysm manifesting as obstructive jaundice and pancreatitis because of extrahepatic compression of the common bile duct and pancreatic duct by mass effect. Open repair was ultimately required secondary to arterial anatomy that was not amenable to any endovascular treatment approach.

Conclusion: While endovascular options are the preferred treatment modality for visceral artery aneurysms and pseudo-aneurysms, some cases require definitive open repair for a variety of reasons, including unsuitable anatomy.

Life-Threatening Rupture of an Idiopathic Left Hepatic Artery Pseudoaneurysm Successfully Treated with Endovascular Coil Embolization

Hepatic artery pseudoaneurysm is a rare condition; they are multifactorial, most of them locating in the extrahepatic vasculature and the mortality associated to its rupture may reach up to 70%. We report a 77 years old female who was admitted due to headache and uncontrolled hypertension and that on her second hospital day developed sudden hemodynamic instability, abdominal pain, fatigue, skin-mucosa pallor, and anemia. Abdominal CT scan with contrast showed a left hepatic artery pseudoaneurysm associated with extensive hemoperitoneum. Patient required emergent hemodynamic stabilization and finally was treated successfully with a superselective endovascular coil embolization. Our patient represents an atypical case of a spontaneous rupture of an idiopathic hepatic artery pseudoaneurysm. Hence, the importance of having a high index of clinical suspicion. Endovascular coil embolization has become the first-line treatment.

Treatment of visceral artery aneurysms and pseudoaneurysms with the use of cerebral flow diverting stents: initial experience

Background

Flow-diverter stents (FDS) are designed to maintain laminar flow in the parent artery and sidebranches and to promote thrombosis of the aneurysm. Although these devices were developed for use in intracranial circulation, FDS could be employed to treat aneurysms regardless of their location, when anatomic factors may limit the efficacy of classic endovascular techniques. The objective of this study is to describe the initial experience of a single center in the treatment of visceral artery aneurysms and pseudoaneurysms (VAA-VAP) with cerebral FDS, analyzing safety, efficacy and 1-year outcome. Between 2016 and 2018 six patients (4 women, mean age 57.6) underwent treatment with FDS of 4 VAA and 2 VAP located in renal (4), hepatic (1) and splenic arteries (1). Mean aneurysm diameter was 14.3 mm (range 8–22). All the aneurysms had sidebranches arising from the neck or had an unfavorable dome-to-neck ratio. Technical success, safety, efficacy and 1-year outcome were analyzed. Follow-ups (FU) with Color-Doppler US and CTA ranged from 12 to 36 (mean 20) months.

Results

Technical success was achieved in all cases. There were no aneurysm rupture nor reperfusion after exclusion. Five out of six (83.3%) FDS were patent at each FU; all the aneurysms showed shrinkage with a mean dimensional reduction rate of 55.8%. Sac thrombosis was observed in 4 aneurysms at 1 (n = 3) and at 12-month FUs. There was one sidebranch occlusion with evidence of a small area of kidney hypoperfusion at the 12-month FU, which was asymptomatic. In one patient, a reintervention was needed because CTA showed a severe in-stent stenosis, which was symptomatic. Mean hospitalization was 4.1 days.

Conclusions

Treatment of morphologically complex VAA and VAP with cerebral FDS proved to be safe and efficient. Stronger evidence from larger populations are required.

Endovascular flow-diversion of visceral and renal artery aneurysms using dual-layer braided nitinol carotid stents

BACKGROUND

Visceral and renal artery aneurysms (VRAAs) are uncommon but are associated with a high mortality rate in the event of rupture. Endovascular treatment is now first line in many centres, but preservation of arterial flow may be difficult in unfavourable anatomy including wide necked aneurysms, parent artery tortuosity and proximity to arterial bifurcations. Endovascular stenting, and in particular flow-diversion, is used in neurovascular intervention to treat intracranial aneurysms but is less often utilised in the treatment of VRAAs. The CASPER stent is a low profile dual-layer braided nitinol stent designed for carotid stenting with embolic protection and flow-diversion properties. We report the novel use of the CASPER stent for the treatment of VRAAs. We present a case series describing the treatment of six patients with VRAAs using the CASPER stent.

RESULTS

Six patients with unruptured VRAAs were treated electively. There were three splenic artery aneurysms and three renalartery aneurysms. Aneurysms were treated with the CASPER stent, with or without loose aneurysm coil packing or liquid embolic depending on size and morphology. All stents were successfully deployed with no immediate or periprocedural complications. Four aneurysms completely occluded after serial imaging follow up with one case requiring repeat CASPER stenting for complete occlusion. In one patient a single aneurysm remained patent at last follow up, A single case was complicated by delated splenic infarction and surgical splenectomy.

CONCLUSION

Preliminary experience with the CASPER stent suggests it is technically feasible and effective for use in the treatment of VRAAs.

Frequency and causes of delayed diagnosis of visceral artery pseudoaneurysms with CT: Lessons learned

Objective

Visceral artery pseudoaneurysms (VAPA) are associated with a high morbidity and mortality, but sometimes are missed in initial computed tomography (CT) examinations. The aims of this study were to determine the frequency and causes of misdiagnoses of VAPA with CT.

Materials and Methods

We retrospectively identified 77 patients with VAPA in our database who underwent contrast-enhanced CT. The frequency of delayed diagnosis was determined and the reasons were noted. We identified the etiology of VAPA, measured size, and noted the affected vessels.

Results

Forty-five of the 77 patients (58 %) had a delayed diagnosis of VAPA. There was no difference in the rate of missed VAPA in symptomatic compared to asymptomatic patients (p = 0.255). The majority of VAPA were associated with previous surgery or interventions (n = 48/62 %). The major affected vessel was the hepatic (n = 31) followed by the splenic artery (n = 17). The main reasons for misdiagnosis were a missed arterial phase in CT (n = 16/36 %), artifacts masking the aneurysm (n = 9/20 %), overlooked pseudoaneurysm (n = 19/42 %), and misinterpretation by attending radiologists (n = 1/2 %). Missed VAPA were smaller (median 8 mm) than those VAPA that were initially diagnosed (median 13 mm, p < 0.01), but occurred with a similar frequency in larger and smaller visceral arteries (p = 0.601).

Conclusions

Our study showed that 58 % of VAPA were diagnosed with delay, with the following four reasons for misdiagnosis: Lack of an arterial contrast phase in CT, no techniques for artifact reduction, and lack of awareness of the radiologists. Avoiding delayed diagnosis will most probably improve outcome of patients with VAPA.

Early presentation of ruptured post-traumatic hepatic artery pseudoaneurysm

Visceral artery aneurysms (VAA) are an uncommon but well recognized condition. Hepatic artery aneurysms (HAA) represent 14-20% of all visceral artery aneurysms. Post traumatic hepatic artery pseudoaneurysm is an uncommon delayed complication of blunt liver trauma. Here we present a case of a 27 year old male with blunt abdominal trauma who developed a post traumatic pseudoaneurysm of the hepatic artery just proximal to its bifurcation into the left and right branches. The pseudoaneurysm ruptured within 12 hours of injury and he required double ligation of the hepatic artery as well as right and left hepatic arteries. However, the bleeding continued through the retrograde flow from the gastroduodenal artery and hence, ligation of gastrodudenal artery was also done. The decision of complete devasularisation of liver was taken as an emergency lifesaving procedure. The patient recovered and was discharged without sequel.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

Giant celiac artery aneurysm

Celiac artery aneurysms (CAAs) are rare but potentially devastating lesions. Given the high rates of mortality on rupture at large sizes, they should be treated promptly with either surgical or endovascular interventions in appropriate-risk patients. Several options exist for treatment, including surgical repair and endovascular embolization with or without stent or stent graft placement. Because of their rarity, there are few reports of successfully treated CAA lesions. Herein, we describe successful endovascular treatment of one of the largest CAAs reported in the literature.

Hemobilia from a right hepatic artery pseudoaneurysm due to chronic cholecystitis

Splanchnic pseudoaneurysms are rare causes of hemobilia. Specifically, hepatic artery pseudoaneurysms from infectious or inflammatory etiology are even more rare. In this article, we describe our encounter with a 72-year-old female presenting with obstructive jaundice and acute blood loss anemia. Upper endoscopy indicated hemobilia and endoscopic retrograde cholangiopancreatography was completed with stent in place. Post endoscopic retrograde cholangiopancreatography, computed tomography angiogram indicated a right hepatic artery pseudoaneurysm which was the cause of her hemobilia. The patient was ultimately treated with selective coil embolization and interval cholecystectomy.

A hybrid procedure for middle colic artery aneurysm complicated by chronic juxtarenal segmental aortic occlusion

Here we describe a hybrid procedure, that is, a combination of open isolation and coil embolization, to treat a saccular middle colic artery aneurysm deep behind the pancreas. The middle colic artery provided the collateral blood flow necessary to bypass a chronic segmental aortic occlusion. For preservation of the collateral vessels, we surgically excluded and bypassed the aneurysm and then performed endovascular embolization of the pancreaticoduodenal arteries flowing into the aneurysm, resulting in complete isolation of the aneurysm without jeopardizing blood flow. This hybrid procedure for visceral artery aneurysms can be effective when the collateral vessels need to be preserved.

Percutaneous ethanol ablation of intrahepatic arterial pseudoaneurysm: A case report

Hepatic arterial pseudoaneurysm is a rare but potentially fatal condition that requires prompt management. We report a case of hepatic arterial pseudoaneurysm developed after radiofrequency ablation of a hepatocellular carcinoma. The patient was successfully treated with percutaneous absolute ethanol injection under ultrasound guidance. Follow-up studies with ultrasound and computed tomography for 2 years after treatment revealed no evidence of local recurrence of hepatocellular carcinoma and of the pseudoaneurysm.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Ruptured Visceral Artery Aneurysms: A Deadly Cause of Epigastric Pain

Visceral artery aneurysms (VAA) are rare, life-threatening disease processes that often affect the celiac, superior mesenteric, or inferior mesenteric arteries and their respective branches. The splenic, hepatic, superior mesenteric, and tripod celiac arteries are most commonly affected and have high rupture and mortality rates. This case describes splenic and celiac artery aneurysms in a patient that led to hemorrhagic shock and multisystem organ failure despite timely diagnosis and ligation. A brief review of the literature further elucidates the key risk factors in identifying patients with VAAs and their treatment course.

Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Visceral artery aneurysms (VAAs) are a rare, but serious clinical entity as rupture confers a high rate of mortality. Data regarding the prevalence, treatment, and prognosis of VAAs is largely from case series, as true randomized trials are lacking. The incidence of VAAs has risen over the decades with advances in imaging technology, availability, and utilization. Even in the presence of symptoms, the prompt diagnosis of VAAs may be challenging as symptoms are often nonspecific and varied. Although there are no definitive treatment guidelines, asymptomatic VAAs require treatment in the following scenarios: when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplant. Similar to therapeutic trends in other vascular beds, advances in endovascular devices and techniques have driven an "endovascular first" approach for the treatment of VAAs. However, although the success rates of endovascular repair are impressive, surgical intervention is still necessary in treating centers. This paper reviews the pathophysiology, clinical features, anatomic characteristics, and management strategies required for the effective diagnosis and treatment of VAAs.

Percutaneous Embolization of a Saccular Omental Artery Aneurysm

Omental artery aneurysms are a unique subset of splanchnic artery aneurysms that are associated with intraperitoneal hemorrhage and high mortality rates. Detecting omental artery aneurysms prior to rupture is especially challenging; as such there are limited data surrounding unruptured aneurysms. Various methods of treating ruptured omental artery aneurysms have been previously described including omentectomy and transcatheter arterial embolization. Because of the mortality rate associated with ruptures, elective intervention in unruptured splanchnic artery aneurysms is recommended regardless of their size. This report details the successful embolization of an unruptured omental artery aneurysm utilizing a percutaneous approach.

Time-resolved magnetic resonance angiography as a follow-up method for visceral artery aneurysm treated with coil-embolisation

Purpose

The purpose of this study is to assess the feasibility and usefulness of time-resolved magnetic resonance angiography (TR-MRA) for follow-up of visceral artery aneurysms (VAAs) after embolotherapy.

Material and methods

Twenty-one VAAs (11 splenic, six renal, three internal iliac, and one superior pancreaticoduodenal artery aneurysms) in 18 patients (median age, 64 years; range, 36-88 years) previously treated by embolisation with platinum coils, were evaluated. The mean size of the aneurysm was 10.5 cm³ (range, 0.3-132 cm³). Among them, 19 lesions were treated by aneurysmal packing with or without distal-to-proximal embolisation. For the remaining two lesions, distal-to-proximal embolization alone was performed. The mean observation period after embolotherapy was 35 weeks (range, 4-216). All patients underwent TR-MRA following an intravenous bolus injection of gadolinium chelate. Recanalisation was diagnosed when any portion of the aneurysmal sac was enhanced in the arterial phase.

Results

On TR-MRA, two lesions were diagnosed as recanalised. They were confirmed by transcatheter arteriography and re-treated by embolotherapy. For the remaining 19 lesions, there were no findings of recanalisation on TR-MRA.

Conclusions

TR-MRA appears to be a feasible method for follow-up examination of VAAs treated by embolotherapy.

Hepatic artery aneurysm causing gastrointestinal haemorrhage - Case report and literature review

INTRODUCTION

True hepatic artery aneurysms (HAAs) are rare, and when complicated by gastrointestinal haemorrhage, it becomes an even rarer disease entity. The mortality is high and imaging may fail to provide the diagnosis. We present a case of a true hepatic artery aneurysm complicated by a fistula to the duodenum which was first recognised during surgery.

PRESENTATION OF CASE

A 77-year-old man presented with upper gastrointestinal haemorrhage. Upper endoscopy revealed an ulceration in the duodenal bulb, which was refractory to endoscopic treatment. Computed tomography and angiography did not reveal the source of haemorrhage and as such, the diagnosis was delayed, until laparotomy was performed. Resection of the HAA and graft placement resulted in complete haemostasis.

DISCUSSION

True hepatic aneurysms communicating with the gastrointestinal tract have only been presented in case reports and short case series. Arteriosclerosis is a relatively common risk factor, but the underlying pathology is unknown. Meanwhile, gastrointestinal haemorrhage is a symptom of other, more common diseases in the gastrointestinal tract, and these factors, complicate the diagnostic workup.

CONCLUSION

In the case of treatment refractory duodenal haemorrhage, a visceral aneurysm should be considered. Even though angiography is performed, a HAA may remain undetected due to bleeding cessation. Improved computed tomography modalities could aid in the detection of gastrointestinal haemorrhage from HAAs, and ensure timely treatment by endovascular methods or surgery if the diagnosis is kept in mind in the initial evaluation.

Hepatic artery aneurysm: an unusual cause of upper gastrointestinal bleed

An 86-year-old woman presented to hospital with melaena. This was her third presentation with the same symptom. There was no obvious source of bleeding on her oesophagogastroduodenoscopy; however, it did show a previously clipped Dieulafoy lesion. CT angiography showed an aneurysm arising from the hepatic artery. Selective coeliac artery angiogram showed aneurysmal dilatation of the distal part of the coeliac trunk and confirmed the presence of the common hepatic artery aneurysm. The aneurysm was coiled by the interventional radiologist. Final angiogram showed good flow through the hepatic artery with obliteration of the inferior patch. The procedure was uncomplicated and the patient was discharged shortly afterwards.

Endovascular treatment of visceral artery aneurysms and pseudoaneurysms with stent-graft: Analysis of immediate and long-term results

INTRODUCTION

The aim of this study is to analyze the safety and efficacy of stent-graft endovascular treatment for visceral artery aneurysms and pseudoaneurysms.

METHODS

Multicentric retrospective series of patients with visceral aneurysms and pseudoaneurysms treated by means of stent graft. The following variables were analyzed: Age, sex, type of lesion (aneurysms/pseudoaneurysms), localization, rate of success, intraprocedural and long term complication rate (SIR classification). Follow-up was performed under clinical and radiological assessment.

RESULTS

Twenty-five patients (16 men), with a mean age of 59 (range 27-79), were treated. The indication was aneurysm in 19 patients and pseudoaneurysms in 6. The localizations were: splenic artery (12), hepatic artery (5), renal artery (4), celiac trunk (3) and gastroduodenal artery (1). Successful treatment rate was 96% (24/25 patients). Intraprocedural complication rate was 12% (4% major; 8% minor). Complete occlusion was demonstrated during follow up (mean 33 months, range 6-72) in the 24 patients with technical success. Two stent migrations (2/24; 8%) and 4stent thrombosis (4/24; 16%) were detected. Mortality rate was 0%.

CONCLUSION

In our study, stent-graft endovascular treatment of visceral aneurysmns and pseudoaneurysms has demonstrated to be safe and is effective in the long-term in both elective and emergent cases, with a high rate of successful treatment and a low complication rate.

Visceral artery pseudoaneurysms: two case reports and a review of the literature

BACKGROUND

Visceral artery pseudoaneurysms are relatively rare but have a high mortality rate in case of rupture. Their detection in the last decades is rising due to an increased use of computed tomography and angiography. However, due to the nonspecific nature of the clinical symptoms and signs, diagnosis is often delayed or missed. We describe two cases of patients presenting with nonspecific abdominal complaints and anemia leading to a diagnosis of visceral pseudoaneurysm. Both cases are successfully treated with a different endovascular intervention.

CASE PRESENTATION

The first case is a 67-year-old Caucasian man presenting with diffuse abdominal pain, vomiting, diarrhea, and weight loss. Digital angiography showed a complex pseudoaneurysm of the superior mesenteric artery. The patient was treated with stent placement and selective embolization of the afferent branches. The second patient is a 78-year-old Caucasian man with a history of chronic pancreatitis admitted with epigastric pain, rectal bleeding and melena. Angiography showed a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated with coil embolization.

CONCLUSIONS

We report two cases of visceral pseudoaneurysms and review the literature concerning etiology, presentation, diagnosis, and treatment. Visceral artery pseudoaneurysms should be considered in the differential diagnosis of a patient with nonspecific abdominal symptoms. Diagnosis is often made with computed tomography or computed tomography angiography but digital angiography remains the gold standard. Treatment options include surgical, endovascular or percutaneous interventions. The choice of treatment is case specific.

Endovascular Repair of Concomitant Celiac and Splenic Artery Aneurysms Using a Combination of Coil Embolization and Aortic Cuff Stent Graft

Large celiac artery aneurysms are associated with a high rupture and mortality risk. Traditionally, open surgical repair has been the mainstay of treatment. Endovascular alternatives have been increasingly described, ranging from coil embolization to exclusion with covered stent grafts. Certain features such as a short wide neck, small vessel diameters, and severe vessel tortuosity can limit these two options. We describe a 75-year-old man with a splenic and celiac trunk aneurysm that was treated using a combination of coil embolization to occlude the outflow artery and aneurysm sac, followed by an aortic stent graft cuff to block the inflow. This resulted in successful exclusion of the splenic and celiac artery aneurysms while preserving flow to both the spleen and liver through collateral pathways.

Laparoscopic Left Gastric Artery Aneurysm Resection

Aneurysmal degeneration of the visceral branches of the abdominal aorta is a rare and potentially life-threatening disease entity. Visceral artery aneurysms (VAAs) are exceedingly rare and have a prevalence of 0.1 to 2%. The left gastric artery aneurysm (LGAA) is even more rare and accounts for less than 4% of all VAAs. There is scarce literature on treatment of LGAA by embolization; however, to date successful laparoscopic repair of an LGAA has not been described. We describe the successful treatment of an LGAA by laparoscopic ligation and resection in a 68-year-old male patient.

Multifocal Intrahepatic Artery Aneurysm with FDG-avid Thrombosis Simulating Metastasis: Report of a Rare Case

Hepatic artery aneurysm (HAA), although rare, represents a serious diagnostic and therapeutic challenge due to high rupture rate and associated mortality. Early detection and accurate diagnosis are essential for successful management. Here, we present an extremely rare case of multi-focal intrahepatic HAA with confined intrahepatic rupture and hypermetabolic activity at PET imaging, simulating metastasis of melanoma. A retrospective review found only two other HAA at our institution between 2000 and 2015, both of which involved the extrahepatic artery. This report highlights the importance of clinical, radiological, and pathological correlation in the management of this rare condition.