Rapid progression of multiple splanchnic artery aneurysms

Blood flow modification might prevent secondary rupture of multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis stenosis

A pancreaticoduodenal artery arcade aneurysm (PDAA) is rare and often associated with celiac axis stenosis by the median arcuate ligament. Although rupture risk of the PDAA is not related to its size, treatment guidelines are absent. Here we describe a 59-year-old woman with multiple ruptured PDAAs associated with celiac axis stenosis who was successfully treated with coil embolization. As follow-up computed tomography revealed rapid expansion of residual PDAAs and new gastric artery dissection, median arcuate ligament resection was followed by aorta-common hepatic artery bypass, which resulted in aneurysmal regression. Blood flow modification might prevent secondary rupture of PDAA associated with celiac axis stenosis.

The Management of Superior Mesenteric Artery Aneurysm: Experience with 16 Cases in a Single Center

BACKGROUND

Superior mesenteric artery aneurysm (SMAA) represents a rare but potentially fatal condition. This study aimed to present the individual management protocol of SMAA in our center and to discuss a potential preliminary treatment algorithm.

METHODS

SMAA patients treated in our center between January 2007 and December 2014 were retrospectively reviewed on January 2015.

RESULTS

Sixteen patients with SMAA were identified, including 1 female and 15 males, with a mean age of 48.9 ± 12.9 years. Three patients (3/16, 18.8%) were treated by multiple overlapping bare stents and one (1/16, 6.3%) initially by a single bare stent. Two cases (2/16, 12.5%) were treated by a covered stent implantation, but one of those suffered from SMAA rupture 7 days later, whereas the other had inner-stent thrombosis one month after discharge and died from multiple organ-dysfunction syndrome. Nine patients (9/16, 56.2%) received conservative therapy, one of who received multiple overlapping bare stents implantations for persistent abdominal pain. One patient underwent open surgery. There were 2 major complications, with no death during hospitalization and 1 death during follow-up.

CONCLUSIONS

SMAA treatment needs to be individually prescribed, based on clinical manifestation, anatomy, and etiology. Multiple overlapping bare stents are safe and effective in selective patients with SMAA, and covered stents should be used with caution to avoid covering proximal branches; open surgery should be reserved for patients with suspected intestinal necrosis.

A Case of Superior Mesenteric Artery Aneurysm Mimicking an Abdominal Aortic Aneurysm and Presenting as a Pulsating Abdominal Mass

A 62-year-old male with a smoking history of 30 pack-years presented with a 1-year history of a periumbilical pulsating mass. He had been treated for hypertension for 2 years. Physical examination revealed a huge pulsating mass in the periumbilical abdomen. Femoral and popliteal arterial pulses were palpable. Computed tomography showed arterial dissection in the proximal segment of the superior mesenteric artery, a huge aneurysm (52×50 mm) with mural thrombus and two smaller aneurysms (20×20 mm) in the right ileocolic and ileal branches, along with atherosclerotic changes. Interposition using the great saphenous vein was performed after aneurysmal isolation and ligation of jejunal branches in the sac. Distal flow was reestablished by end-to-end and end-to-side anastomoses of the right ileocolic and ileal branches, respectively. No complications were observed at 1-year follow-up.

Multiple Pancreatoduodenal Artery Arcade Aneurysms Associated with Celiac Axis Root Segmental Stenosis Presenting as Aneurysm Rupture

A 57-year-old woman was admitted to our unit suffering from hemorrhagic shock and upper abdominal pain. An enhanced computerized tomography (CT) scan evidenced a large retroperitoneal hematoma due to visceral arteries aneurysm rupture and a significant celiac axis root segmental stenosis due to median arcuate ligament compression. A selective splanchnic arteries angiography showed 3 saccular pancreaticoduodenal artery arcade aneurysm (PDAAs), 2 in the inferior posterior pancreaticoduodenal artery, and 1 smaller in the superior anterior pancreaticoduodenal artery. The largest aneurysm showed evident rupture signs. Both inferior PDAAs were successfully treated via endovascular coil embolization. The celiac trunk stenosis and small inferior PDAA did not require treatment. A CT scan control at 1-year follow-up did not reveal any new PDAAs. In cases of celiac artery trunk (CAT) steno-occlusive lesions, multiple aneurysms can develop in the pancreaticoduodenal arcade. PDAAs should be treated because of high rupture risk, regardless of diameter. Although endovascular treatment via coil embolization represents the treatment of choice nowadays, a simultaneous treatment of the associated CAT lesions is still debated. However, in cases of aneurysm embolization alone, one cannot exclude that other PDAAs might develop in these patients in the future. Close monitoring and accurate long-term follow-up is highly recommended in these cases.

Multiple aneurysms of the inferior pancreaticoduodenal artery: a rare complication of acute pancreatitis

Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon, representing nearly 2% of all visceral aneurysms, and sporadically associated with celiac artery stenosis. Multiple IPDA aneurysms have been rarely reported. We report a case of a 53-year-old female patient with a history of prior pancreatitis, who presented with two IPDA aneurysms combined with median arcuate ligament-syndrome-like stenosis of the celiac trunk. The patient was treated successfully with coil embolization under local anesthesia. The procedure is described and illustrated in detail and the advantages and technical considerations of such an approach are also being discussed.

Therapeutic management of superior mesenteric artery aneurysms

OBJECTIVE

Superior mesenteric artery (SMA) aneurysms are rare but life-threatening entities. This study summarizes our experience in providing therapeutic management for true aneurysms of the SMA.

METHODS

Between February 1998 and March 2010, 10 patients were diagnosed with true SMA aneurysms in our hospital. Medical data for demographics, clinical presentation, diagnosis, aneurysm characteristics, treatment modalities, outcomes, and follow-up were retrospectively analyzed.

RESULTS

Ten patients (six women, four men) were enrolled with a mean age of 56.7 years (range, 42-69 years). One patient (10%) had aneurysm rupture and presented with abdominal pain, and seven (70%) were asymptomatic. The size of nonruptured aneurysms ranged from 1.2 to 8.0 cm (mean, 3.5 cm). Of 10 patients, five received endovascular stent graft repair, two were treated surgically, two were observed, and one with aneurysm rupture died of hemorrhagic shock before surgery. The two surgical patients underwent SMA reconstruction after aneurysmectomy, and segmental bowel resection was performed in one patient after reconstruction. The overall mortality rate was 10%. Postoperative gastroparesis was identified in one patient (14.3%). Mean operation time was 3.6 hours in the surgical group and 1.3 hours in the endovascular group. Mean postoperative hospital stay for the two groups was 20.0 days and 2.2 days, respectively. Mean follow-up was 30.9 months (range, 3-72 months). Endoleak was found in one patient 3 months after endovascular repair.

CONCLUSION

True SMA aneurysms are uncommon entities with definite rupture risk and mortality. Compared with surgical intervention, endovascular stent graft placement is associated with less trauma and rapid recovery. It may be a promising alternative to surgical intervention. The most appropriate treatment depends on the characteristics of the lesion and the condition of the patient.