Nonoperative management of visceral aneurysms and pseudoaneurysms

Successful endoscopic combined with endovascular haemostasis of a ruptured pseudoaneurysm of the duodenal bulb: A case report

Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be fatal. We present here a case of a man in his late 70s who was transferred to our hospital with persistent gastrointestinal bleeding. One month prior to his admission, he had undergone surgery for a fracture to his left knee. Endoscopic examination found pulsating blood vessels on a duodenal ulcer, which suddenly ruptured and caused significant bleeding. Immediate endoscopic haemostasis was administered and the bleeding decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, the patient underwent interventional radiology that culminated in a diagnosis of a pseudoaneurysm originating from gastroduodenal artery (GDA); successful embolization was achieved. Tests showed that the patient had Helicobacter pylori infection. We hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient's left knee fracture and surgery a month previously had contributed to this predisposition for a pseudoaneurysm.

Maternal deaths in Australia from ruptured splenic artery aneurysms

The rupture of a splenic artery aneurysm (SAA) in pregnancy is a highly lethal condition, but so rare, that most obstetricians would not encounter it during their career. In the seven official 'Maternal Deaths in Australia' reports, that covered 21 years from 1997 to 2017, among a total of 449 direct and indirect deaths, there were nine deaths (2%) from a ruptured SAA. These cases, and other cases from the literature and the Cochrane Library, are reviewed. The aim of the review is to raise awareness among clinicians of this potentially fatal condition.

Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Endovascular management of traumatic pseudoaneurysms

Background

Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Methods

Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Results

Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5–17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Conclusions

Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

A Rare Surgical Case of Giant Jejunal Artery Aneurysm in a Young Patient

Aneurysms of the abdominal visceral arteries are infrequently encountered. Jejunal artery aneurysm (JAA) is one of the rarest visceral aneurysms, especially in young patients. Endovascular surgery tends to be an effective treatment for visceral artery aneurysms. Here, we report a case of symptomatic JAA with a peripheral dilated vessel in a young patient. However, in consideration of the patient's anatomic suitability and young age, we chose open surgical intervention with intraoperative angiography. Thus, we could resect the aneurysm and the peripheral dilated vessel, preserve the bowel, and leave no devices that could cause further complication. The choice of the most appropriate treatment should depend on aneurysm characteristics and the background of the patient.

Colon perforation due to embolization coil for internal iliac aneurysm

Coil migration is an extremely rare but hazardous complication of aneurysmal coil embolization. Only 1 case report has described coil migration following endovascular exclusion to gastrointestinal (GI) tract. We report the experience of a case of colon penetration caused by embolization coil placed for internal iliac aneurysm. A 66-year-old man visited the Emergency Department for hematochezia that had persisted for 3 months. Stent insertion and coil embolization of left internal iliac artery aneurysm had been performed on the patient 18 months ago. Colonoscopy was performed. It suggested penetration of sigmoid colon by embolization coil and diverticulum. Angiography revealed extravasation of contrast media at left internal iliac artery. Covered stent deployment was done in the left internal iliac artery. One week after the stent insertion, the patient underwent anterior resection, aneurysm resection, and coil removal. The patient recovered without complications. He was discharged at 2 weeks after the operation.

Endovascular Stent Exclusion of a Hepatic Artery Pseudoaneurysm

Presented is a patient with an iatrogenic hepatic artery pseudoaneurysm that was treated by endovascular stent grafting. Endovascular stent grafting of a hepatic artery pseudoaneurysm offers a safe and potentially less morbid alternative to an open repair. The report stresses the necessity of careful preoperative evaluation with angiography to determine the feasibility of the procedure. An aggressive approach to treating hepatic artery pseudoaneurysms is advocated because of the poor correlation between size and their tendency to rupture. With an increasing rate of diagnosis of visceral artery aneurysms in elderly, debilitated patients, endovascular repair is anticipated to have an increasing role and should be considered a first-line therapy in anatomically suitable candidates.

Endovascular Treatment of Mycotic Hepatic Artery Aneurysm in the Hostile Abdomen

Mycotic hepatic artery aneurysms are rare. This report documents a case in which a mycotic hepatic artery aneurysm was associated with Crohn's disease, renal adenocarcinoma, and a urinary tract infection. Endovascular management of this mycotic hepatic artery aneurysm was successful in the setting of a hostile abdomen based on multiple previous operations, a stoma, and a scarred abdomen.

Treatment of a Celiac Artery Aneurysm with Endovascular Stent Grafting

As a result of more sophisticated and more commonly performed investigative procedures, aneurysms of the visceral abdominal vasculature, including celiac artery aneurysms, are increasingly recognized. Traditional therapy for visceral artery aneurysms has been limited to open aneurysmectomy or aneurysmorrhaphy to prevent catastrophic aneurysmal rupture. However, these procedures are associated with significant postoperative morbidity and mortality despite technical successes. High complication rates are likely related to poor preoperative conditions among the patient population typically presenting with these visceral artery aneurysms. This report introduces an alternative therapy for visceral artery aneurysms and highlights the potential for catheter-based interventions. This case report depicts a 61-yearold morbidly obese woman diagnosed with a 10-centimeter celiac artery aneurysm during investigation of upper abdominal pain. Given the patient's poor medical condition, punctuated by hemodynamic instability, open operation was avoided, and percutaneous embolization was not feasible owing to a large aneurysm neck. Therefore, inflow to the celiac artery aneurysm was excluded by placing a modular stent graft component within the abdominal aorta at the celiac artery orifice. During the intervening 12 months since stent graft deployment, the aneurysm sac diameter has steadily decreased, as determined by serial computed tomography scans. This report underscores the potential for catheter-based techniques to offer new therapeutic options for patients with visceral artery aneurysms. Careful individualization is required given the highly variable size, location, and character of such lesions.

Endovascular Management of Visceral Artery Aneurysm

Purpose:

To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques.

Methods:

Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 ± 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels.

Results:

Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 ± 29.6 months.

Conclusions:

Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.

Visceral Artery Aneurysms: A Symptomatic Aneurysm of the Ileocolic Artery

Visceral artery aneurysm is a rare but clinically important form of vascular pathology, showing a high mortality rate in emergency surgery. Most often these aneurysms cause no symptoms and are therefore incidental findings. Reports on ileocolic artery aneurysms are rare and often anecdotal. Therapeutic procedures can be performed either surgically or by interventional therapeutic techniques. This article presents a case of ruptured ileocolic artery aneurysm and reviews the literature on this topic.

Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients

PURPOSE

The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm.

METHODS

Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms.

RESULTS

False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P<0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible.

CONCLUSIONS

Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.

Visceral artery aneurysms: Incidence, management, and outcome analysis in a tertiary care center over one decade. Eur Radiol. 2015;25:2004-2014. [PMID: 25693662 PMCID: PMC4457909 DOI: 10.1007/s00330-015-3599-1]

Objectives

To evaluate the incidence, management, and outcome of visceral artery aneurysms (VAA) over one decade.

Methods

233 patients with 253 VAA were analyzed according to location, diameter, aneurysm type, aetiology, rupture, management, and outcome.

Results

VAA were localized at the splenic artery, coeliac trunk, renal artery, hepatic artery, superior mesenteric artery, and other locations. The aetiology was degenerative, iatrogenic after medical procedures, connective tissue disease, and others. The rate of rupture was much higher in pseudoaneurysms than true aneurysms (76.3 % vs.3.1 %). Fifty-nine VAA were treated by intervention (n = 45) or surgery (n = 14). Interventions included embolization with coils or glue, covered stents, or combinations of these. Thirty-five cases with ruptured VAA were treated on an emergency basis. There was no difference in size between ruptured and non-ruptured VAA. After interventional treatment, the 30-day mortality was 6.7 % in ruptured VAA compared to no mortality in non-ruptured cases. Follow-up included CT and/or MRI after a mean period of 18.0 ± 26.8 months. The current status of the patient was obtained by a structured telephone survey.

Conclusions

Pseudoaneurysms of visceral arteries have a high risk for rupture. Aneurysm size seems to be no reliable predictor for rupture. Interventional treatment is safe and effective for management of VAA.

Key Points

• Diagnosis of visceral artery aneurysms is increasing due to CT and MRI.

• Diameter of visceral arterial aneurysms is no reliable predictor for rupture.

• False aneurysms/pseudoaneurysms and symptomatic cases need emergency treatment.

• Interventional treatment is safe and effective.

Renal artery aneurysms

A renal artery aneurysm is defined as a dilated segment of renal artery that exceeds twice the diameter of a normal renal artery. Although rare, the diagnosis and incidence of this entity have been steadily increasing due to the routine use of cross-sectional imaging. In certain cases, renal artery aneurysms may be clinically important and potentially lethal. However, knowledge of their occurrence, their natural history, and their prognosis with or without treatment is still limited. This article aims to review the recent literature concerning renal artery aneurysms, with special consideration given to physiopathology, indications for treatment, different technical options, post-procedure complications and treatment outcomes.

Infective endocarditis associated superior mesenteric artery pseudoaneurysm

BACKGROUND

Since William Osler first described mycotic aneurysms in the setting of endocarditis in 1885, few pseudoaneurysms (PAs) of the superior mesenteric artery (SMA) have been reported in the literature. We report 2 cases of SMA PA related to infective endocarditis that were managed with open surgery.

RESULTS

Here we report 2 cases of SMA PAs treated with different surgical techniques. A 59-year-old male with a history of intravenous drug use presented with abdominal pain and was found to have Streptococcus viridans endocarditis and an SMA PA. A laparotomy was performed, and proximal and distal control of the SMA PA was obtained. After ensuring that Doppler signals were still present in the distal mesentery and the entirety of the bowel was viable, the SMA was ligated proximal and distal to the PA. The patient recovered uneventfully. The second case is a 35-year-old female who presented with abdominal pain and was found to have Streptococcos gordonii endocarditis and an SMA PA for which the patient was initially observed. After several weeks, the patient's condition deteriorated and the patient underwent open ligation of the SMA, proximal and distal to the PA, with a bypass from the infrarenal abdominal aorta to a distal unnamed SMA branch and resection of 3 ft of ischemic small bowel. The patient continued to have recurrent bowel ischemia over the next several weeks and ultimately died.

CONCLUSIONS

SMA PAs associated with infective endocarditis are rare, but carry a high risk of rupture and associated morbidity and mortality. Delay in surgical management may increase this risk.

Embolization of splenic artery aneurysm associated with gastrointestinal bleeding: case report

The splenic artery is the visceral vessel that is most often affected by aneurysmal disease. Occasionally, gastrointestinal bleeding may signify that the aneurysm is in communication with the digestive tract. We report on the case of a 64-year-old multiparous patient with intermittent digestive bleeding caused by a splenic artery aneurysm who was successfully treated with endovascular embolization.

Successful transarterial embolization for recurrent pseudoaneurysm of the right hepatic artery with acute cholecystitis. Clin J Gastroenterol. 2014;7:164-169. [PMID: 26183635 DOI: 10.1007/s12328-013-0450-6]

Pseudoaneurysm of the right hepatic artery is an extremely rare complication of acute cholecystitis. We report a patient with a right hepatic artery pseudoaneurysm associated with acute cholecystitis who was treated successfully by transarterial embolization. We also review the literature on right hepatic artery pseudoaneurysm secondary to acute cholecystitis. A 50-year-old male visited Fujieda General Municipal Hospital with an episode of sudden headache. He was diagnosed with a subarachnoid hemorrhage and treated successfully by microcoil embolization on hospital day 4. On hospital day 54, he developed fever and right upper quadrant tenderness. Abdominal ultrasonography revealed acute cholecystitis, while color Doppler imaging showed a low-echogenic mass with a pulsatile wave pattern inside the gallbladder. Contrast-enhanced computed tomography (CE-CT) demonstrated a pseudoaneurysm in the gallbladder, and angiography disclosed a right hepatic artery pseudoaneurysm. Selective transarterial embolization (TAE) was then performed using a steel coil. Abdominal pain and fever continued after TAE, with CE-CT showing re-bleeding from the previous pseudoaneurysm. Selective angiography identified extravasation at the same place as the previous pseudoaneurysm from the posterior superior pancreaticoduodenal artery and the inferior pancreaticoduodenal artery via the epicholedochal arterial plexus. TAE was performed resulting in successful occlusion of the pseudoaneurysm.

Complex renal artery aneurysm managed with hand-assisted laparoscopic nephrectomy, ex vivo repair, and autotransplantation

A 58-year-old woman had an incidentally found complex right renal artery aneurysm (RAA) during a clinical work-up for diverticulitis. The aneurysm measured 2.5 cm in diameter and was located at the right renal artery bifurcation. She was hospitalized and underwent hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA and autotransplantation into the right iliac fossa. The same incision was used to remove the kidney from the retroperitoneum as was used to transplant into the right lower quadrant. She tolerated the procedure well. Her postoperative course was uncomplicated. Hand-assisted laparoscopic nephrectomy with ex vivo repair of a complicated RAA and autotransplantation is feasible and safe.

Long-term outcomes of coil packing for visceral aneurysms: correlation between packing density and incidence of coil compaction or recanalization

PURPOSE

To evaluate the correlation between packing density and the incidence of coil compaction or recanalization of visceral artery aneurysms (VAAs) after coil packing.

MATERIALS AND METHODS

Between July 2004 and April 2012, coil packing was performed for 46 true visceral aneurysms (16 splenic, 11 pancreaticoduodenal, eight renal, six hepatic, three superior mesenteric, one right gastric, and one gastroepiploic) in 42 patients. The size and volume of the aneurysm, packing density, and the incidences of compaction and recanalization were evaluated retrospectively.

RESULTS

The mean follow-up period was 37 months ± 8 (range, 11-80 mo). The mean packing density was 19% ± 8 (range, 5%-42%), mean aneurysm size was 19 mm ± 8 (range, 5-40 mm), and mean volume was 4,108 mm(3) ± 5,435 (range, 72-26,235 mm(3)). Compaction and recanalization occurred in two (4%) and 12 aneurysms (26%), respectively. The mean packing density was significantly lower in aneurysms with compaction or recanalization than in unaffected aneurysms (12% vs 22%; P = .00014). There was a significant difference in mean packing density between small (< 20 mm; 22%) and large (≥ 20 mm) aneurysms (15%; P = .0045). The mean size and volume were significantly larger for coil-compacted or recanalized aneurysms than for unaffected aneurysms (P < .05). In aneurysms with a packing density of at least 24%, no compaction or recanalization occurred.

CONCLUSIONS

Coil compaction or recanalization after coil packing for VAAs more often occurs after insufficient embolization with low packing density and in patients with large aneurysms.

Hepatic artery pseudoaneurysms: a single-center experience

BACKGROUND

The management of hepatic artery aneurysms has evolved largely because of changes in etiology and presentation, and advances in endovascular therapy. Although many case reports have been published on the condition, few have been from developing countries and few have compared patient outcomes after angioembolization and surgery.

PATIENTS AND METHODS

This study retrospectively analyzed patients admitted with hepatic artery pseudoaneurysms between 1999 and 2011. The patients were divided into those who presented before 2007 (surgery group) and after 2007 (embolization group), and their demographic characteristics, presentation, and investigations; the technical and clinical success of treatment; and in-hospital mortality were studied.

RESULTS

A total of 29 patients were studied, 17 of whom men, with a median age of 42 years. Of these 29 patients, 8 underwent surgery and 21 had embolization (24 total procedures). No mortality was seen in the surgery group, and their hospital stay was longer and transfusion requirement higher than those in the embolization group, in whom technical success was achieved in all procedures and clinical success in 19 of 24 (79%). Clinical failure and complications were seen when common hepatic artery aneurysms were embolized. Three patients (14%) died in the embolization group from ischemic hepatitis and bowel gangrene, coagulopathy, and a leak from a previous pancreaticojejunal anastomosis.

CONCLUSIONS

Both surgery and angioembolization are equally effective for hepatic artery pseudoaneurysms, but the latter has the advantages of more rapid bleeding control, shorter hospital stay, and lower transfusion requirement.

Successful coil embolization for life-threatening hemorrhage in childhood leukemia induction therapy

An 11-year-old boy was experienced severe life-threatening hemorrhage from a branch of the superior mesenteric artery (SMA) after acute lymphoblastic leukemia induction therapy. The patient had a history of attention deficit hyperactivity disorder (ADHD), diagnosed at 3 years of age. Subsequent to discontinuing his psychotropic medication, the patient's mental status deteriorated and treatment with midazolam for 3 weeks was necessary to allow the completion of the leukemia induction regimen. On day 51, although there was no indication of thrombocytopenia or a coagulation disorder, the patient began to hemorrhage suddenly from anal with resulting hypovolemic shock, and large-volume blood transfusion was initiated. Although upper and lower endoscopy failed to determine the location of the hemorrhage, angiography enabled us to determine that it was a branch of the SMA (the middle colic artery #6), and selective arterial embolization was used to arrest the bleeding. There could have been underlying causes, such as, a probable malformation or aneurysm in that area, although there was no indication before or after the event. This is a rare case of arterial hemorrhage from a branch of the SMA that occurred in a pediatric patient idiopathically during the induction therapy of leukemia.

Renal artery aneurysm in robotic donor nephrectomy: a case report

OBJECTIVES

With the current disparity between donor organ availability and recipient need, creative techniques help optimize the use of available organs. We present a case of a woman, who was worked-up as a kidney donor, who was incidentally found to have a saccular aneurysm on her renal artery. The patient was asymptomatic, normotensive, and had normal renal function.

MATERIALS AND METHODS

We performed a laparoscopic robotic donor nephrectomy, repaired the aneurysm on the back table, and transplanted the organ into the recipient.

RESULTS

The donor underwent a successful robotic nephrectomy, successfully eradicating any risk of aneurysmal complications; the recipient received an anatomically normal organ with excellent function.

CONCLUSIONS

An altruistic act by the donor identified a potentially fatal lesion, which was not only remedied, but the intended donation proceeded when a creative approach was used.

Aneurysmectomy and revascularization of a large hepatic artery aneurysm

Aneurysms of the hepatic artery are rare, but are associated with significant mortality because of their lack of symptoms at presentation and risk of rupture. We report a case of an enlarging 4-cm hepatic artery aneurysm involving the proximal common hepatic artery to the bifurcation of the right and left hepatic arteries which was found incidentally on ultrasound examination. Endovascular treatment with a stent was considered, but because of the location of the aneurysm as well as the presence of significant thrombosis involving the right and left hepatic arteries, aneurysmectomy and revascularization using saphenous vein was performed. Doppler ultrasound measurements demonstrated good flow through the graft postoperatively and at 1-month follow-up. Although a variety of endovascular techniques exist to treat hepatic artery aneurysms, our results indicate that open excision and revascularization may be required and can have a good outcome.

Splenic artery aneurysm that gradually increased in size over 4 years until threatening rupture

A 47-year-old man was referred to our hospital due to a splenic artery aneurysm. The course of the disease was monitored by ultrasound every 6 months. At each examination, the tumor was found to have increased in size by several millimeters, but the sonographer decided that the increase was within the range of error. After 4 years, the tumor showed a rapid increase in size. With a diagnosis of threatened rupture, the patient's life was saved by surgical intervention. In this case, the observations were only compared to the findings from the previous examination, and the slight increase in tumor size was considered within the range of error. It is important to compare the findings not only with those from the previous examination but also with earlier results.

Visceral artery aneurysms: review of current management options

Visceral artery aneurysms are relatively rare clinical entities, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. For this reason, elective repair is preferable in the appropriately chosen patient. In general, splenic artery aneurysms measuring 2 cm or larger and those found in women of childbearing age and in persons undergoing liver transplantation should be treated. Hepatic artery aneurysms 2 cm or larger and those that are multiple or nonatherosclerotic in nature should be repaired in the appropriate patient due to a higher risk of rupture. Endovascular coil embolization has excellent success rates and is the first-line treatment for anatomically suitable splenic artery aneurysms and intrahepatic hepatic artery aneurysms. However, reperfusion is an important complication of endovascular management. Aneurysms involving the celiac, superior mesenteric, pancreaticoduodenal, gastroduodenal, and inferior mesenteric arteries, as well as visceral artery pseudoaneurysms, are unpredictable and should be repaired in the appropriate medical patient. These aneurysms are often amenable to ligation due to the presence of collateral circulation. Endovascular management is particularly useful in the treatment of pseudoaneurysms where comorbidities and previous surgery make open surgical repair less desirable. Mt Sinai J Med 77:296-303, 2010. (c) 2010 Mount Sinai School of Medicine.

Emergency stent graft implantation for ruptured visceral artery pseudoaneurysm

BACKGROUND

Literature series that include visceral artery pseudoaneurysms rarely separate them from true aneurysms, although they address different issues. Guidelines for optimal management of these lesions are lacking. We report our experience of stent graft treatment of these lesions with midterm results.

METHODS

We retrospectively reviewed all patients with a visceral pseudoaneurysm who were treated with a stent graft in our institution. Patient history, clinical characteristics, procedure details, and outcome were recorded and analyzed.

RESULTS

From March 2004 to June 2009, 10 consecutive patients (9 men), who were a mean age of 59 years, were treated for symptomatic visceral artery pseudoaneurysm, with hemorrhagic shock in 8 patients (80%), after pancreaticoduodenectomy in 8, gastrectomy in 1, and abdominal trauma in 1. A mean of 24 days (range, 7-60 days) passed between the initial surgery or trauma and pseudoaneurysm diagnosis. Septic complications were associated in six patients (60%). The pseudoaneurysm was in the hepatic artery in 8 patients, the splenic artery in 1, and the superior mesenteric artery in 1. Technical and clinical success was achieved in 80% of patients. Two failures of catheterization were followed by redo surgery and death (20%). No patients died postoperatively, and no complications among the patients who were treated successfully. Mean follow-up was 37 months (range, 10-63 months). All stent grafts were patent, with no signs of infection. Two patients died secondary to neoplasm. No rebleeding or recurrent aneurysms were noted.

CONCLUSION

Stent graft exclusion of visceral artery pseudoaneurysm seems to be a valid therapeutic approach regardless of the patient's septic or hemodynamic status.

Endovascular therapy as a treatment for ruptured pancreaticoduodenal artery aneurysms

Pancreaticoduodenal artery aneurysms (PDAAs) are uncommon. The treatment and prognosis for ruptured PDAAs have changed in recent years. A demonstrative case is reported. A review of the literature has been made and the case of a healthy man operated on an emergency basis because of a massive hemoperitoneum secondary to a ruptured PDAA is reported and analyzed with regard to the clinical presentation, radiologic findings, management, and outcome. A bleeding point was not detected at operation. An intraoperative arteriogram did not show active bleeding. The pancreas appeared infiltrated and oozing blood. The abdomen was gauze packed and the patient transferred for endovascular therapy (ET). Then, an arteriogram showed a bleeding PDAA. After embolization, bleeding ceased and the patient recovered. According to our literature survey, less than 200 cases of true and false PDAAs have been reported. For ruptured PDAAs, surgery is associated with high mortality since the bleeding point is usually not identified at operation. Similarly, intraoperative arteriograms are often fruitless due to the patient's poor hemodynamics plus suboptimal quality of the portable equipment. As shown in the present case and according to the specialized medical literature, ET has often been successful in the management of these patients and may be chosen as a first option for the treatment of ruptured PDAAs.

Aneurisma de artéria esplênica corrigido por embolização com molas

O aneurisma da artéria esplênica é uma entidade clínica rara, embora seja o mais frequente entre os aneurismas viscerais, sendo encontrado em 0,8% da população. Apresenta-se mais frequentemente em mulheres, na proporção de 4:1, e raramente provoca sintomas ou sinais clínicos. Desenvolve-se de forma assintomática e, na maioria dos casos, é diagnosticado por meio de exames indicados para elucidar queixas clínicas decorrentes de outras doenças ou quando apresenta complicações por vezes fatais, como a rotura. A possibilidade de rotura dos aneurismas de artéria esplênica com diâmetro inferior a 2 cm é baixa; entretanto, os que apresentam diâmetro igual ou maior que 3 cm são usualmente encaminhados para tratamento cirúrgico, devido ao alto risco de rotura. O tratamento eletivo é indicado nos casos não complicados, sendo a embolização com molas um método interessante por evitar o tratamento cirúrgico convencional.

Right hepatic artery false aneurysm secondary to acalculous cholecystitis

The present report describes a case of an extrahepatic right hepatic artery pseudoaneurysm caused by acalculous cholecystitis. An 85-year-old man was admitted with abdominal pain, cachexia and jaundice. A CT scan showed a saccular false right hepatic artery aneurysm within a soft tissue and fluid mass that was causing biliary obstruction. The soft tissue mass raised the possibility of malignant disease, but this resolved slowly after a period of time and on reviewing the patient's history the only upper gastrointestinal problem noted was an episode of acalculous cholecystitis 3 months previously, which was believed to be the cause of the pseudoaneurysm. The false aneurysm was treated successfully with coil embolisation and the patient recovered fully from this illness.

Successful embolization assisted by covered stents for a pseudoaneurysm following pancreatic surgery

Delayed intra-abdominal hemorrhage after pancreatic surgery is a potentially lethal complication. Transarterial coil embolization and/or the placing of an endovascular stent are minimally invasive and effective procedures. An artery that is extensively eroded and rendered friable due to operative skeletonization or postoperative inflammation sometimes contributes to delayed intra-abdominal hemorrhage or rebleeding after coil embolization. This report presents a case of successful management of postoperative hemorrhage in a-74-year-old Japanese male. He experienced bleeding from a pseudoaneurysm of the brittle hepatic artery following total pancreatectomy. Initially the pseudoaneurysm was successfully treated with covered coronary stent-grafts, but rebleeding occurred 1 mo later due to the brittleness of the artery. Rebleeding was definitively managed by the complete packing of the stent by coil embolization. He remains stable at 18 mo following the final embolization. A stent graft can be used for protecting a brittle artery to avoid injury by coil embolization.

Therapeutic angiography for giant bleeding gastro-duodenal artery pseudoaneurysm

We present the case of an 18-year-old female transferred to our center from an outside hospital due to persistent gastrointestinal bleeding. Two weeks prior to her transfer she underwent duodenal omentopexy for a perforated duodenal peptic ulcer. The patient underwent a computed tomography angiogram which identified the source of bleeding as a giant gastro-duodenal artery (GDA) pseudoaneurysm. The patient was taken to interventional radiology where successful microcoil embolization was performed. We present this rare case of a giant GDA pseudoaneurysm together with imaging and a review of the medical literature regarding prevalence, etiology and treatment options for visceral arterial aneurysms.

Aneurysms of the splenic artery - a review. Surgeon. 2010;8:223-231. [PMID: 20569943 DOI: 10.1016/j.surge.2009.11.011]

Splenic artery aneurysm is the third most common intra-abdominal aneurysm with a prevalence as high as 10% in some studies. Widespread use of abdominal imaging has resulted in the increasing detection of asymptomatic incidental aneurysms. In this manuscript we review the changing incidence, risk factors and evolving therapeutic options in the era of minimally invasive therapy and have developed a treatment algorithm for practical use. Aneurysms with a low risk of rupture may be treated conservatively but require regular imaging to ascertain progress. Available evidence suggests that splenic artery aneurysms that are symptomatic, enlarging, more than 2 cm in diameter or those detected in pregnancy, childbearing age or following liver transplantation are at high risk of rupture and should undergo active treatment. Prophylactic screening should be reserved for those with multiple risk factors, such as pregnancy in liver transplant recipients. All false aneurysms should also be treated. The primary therapeutic approach should be endovascular therapy by either embolization or stent grafting.

Hepatic artery pseudo aneurysm rupture precipitated by pneumonia: An Unusual Case

We present a unique case of hepatic artery pseudo aneurysm rupture associated with pneumonia. A 67 year old woman admitted to our hospital with productive cough, pleuritic chest pain and shortness of breath. She was diagnosed to have community acquired pneumonia and was treated with antibiotics. On third day of admission she developed acute abdominal pain and haemorrhagic shock. Contrast CT scan showed left hepatic artery pseudo aneurysm rupture, a rare emergency condition associated with high mortality rate. She underwent percutaneous endovascular coiling and made a complete recovery.

Sonographic detection of an aneurysm of the gastroepiploic artery

Gastroepiploic artery aneurysm (GEAA) is very rare.1 Furthermore, most GEAA cases are diagnosed after their rupture. We report a case of asymptomatic GEAA. The patient was a 61-year-old man. Sonography (US) revealed a 2-cm anechoic mass in the epigastrium near the anterior abdominal wall. Color Doppler US and contrast-enhanced US showed arterial flow within the mass leading to the diagnosisof visceral artery aneurysm. CT and angiography confirmed the diagnosis of right GEAA, and the aneurysm was treated successfully with embolization. Follow-up US 6 months later confirmed the absence of blood flow within the lesion.

Spontaneous hemoperitoneum from a ruptured mesenteric branch arterial aneurysm: report of a case

We report a case of spontaneous intraperitoneal hemorrhage from a ruptured mesenteric branch artery aneurysm in a patient presenting with syncope. A 54-year-old woman was brought to our emergency department as a medical code, following two syncopal episodes. Computed tomography, carried out to rule out aortic aneurysmal disease, revealed hemoperitoneum without evidence of solid organ injury. Emergency exploratory laparotomy revealed a large jejunal mesenteric hematoma accompanying a ruptured mesenteric branch artery aneurysm with active extravasation. We ligated and excised the lesion and diagnosis was confirmed on final pathologic examination. We report this case because general surgeons should be aware of these vascular lesions and the basic guidelines for treatment.

Hepatic artery aneurysm erosion into the stomach: an unusual cause of gastrointestinal bleeding

BACKGROUND

Hepatic artery aneurysms are the second most common visceral aneurysms. The natural history of hepatic artery aneurysms typically results in enlargement, rupture, and life-threatening hemorrhage. Atherosclerosis, traditionally, has been the most common cause of hepatic artery aneurysm.

OBJECTIVE

A case of a hepatic artery aneurysm invading the stomach is presented to draw attention to the clinical presentation of this potentially catastrophic entity.

CASE REPORT

A 74-year-old man presented to the Emergency Department (ED) with hematemesis. He was hemodynamically stable with a hemoglobin of 10.5. Abdominal CT imaging revealed a hepatic artery aneurysm that eroded into the stomach. The erosion was successfully repaired operatively and the aneurysm was embolized.

CONCLUSION

The most common symptom is epigastric pain. The clinical and radiological findings of a hepatic artery aneurysm eroding into the stomach with subsequent upper and lower gastrointestinal hemorrhage, as highlighted in the case reported, have received little prior attention in the medical literature.