Rupture of embolised coeliac artery pseudoaneurysm into the stomach: is coil embolisation an effective treatment for coeliac anastomotic pseudoaneurysm?

Surgical repair of a symptomatic celiac artery aneurysm with resection and end-to-end anastomosis

A true aneurysm of the celiac artery is a rare form of a visceral aneurysm, constituting ∼4% of visceral aneurysms. Mortality in ruptured cases is high; thus, early recognition and treatment are crucial. Recent guidelines suggest endovascular therapy; however, numerous complications are associated with endoluminal treatment. Open repair in select cases, using an individualized strategy fit for the patient's anatomy still provides excellent early and long-term results. Our patient was treated with open surgical resection and end-to-end anastomosis of the celiac and common hepatic arteries. A 43-month follow-up computed tomography angiogram revealed excellent hepatic artery patency and no pseudoaneurysm formation.

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.

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.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Visceral Artery Aneurysms

Visceral artery aneurysms (VAA) frequently present as life-threatening emergencies. The purpose of this study was to review our experience with VAA treatment. Between 1988 and April 2002, 31 VAA were treated in 28 patients (14 males, 14 females) with average age of 55 +/- 15 years. The most common locations were the splenic artery (16) and the hepatic artery (7). Three patients underwent emergency surgery, 22 patients had elective open surgery, and 7 patients underwent endovascular treatment. In the surgical group the perioperative mortality rate was 3.6%. The perioperative morbidity rate was 7.1% (one case of respiratory distress manifested in the immediate postoperative period and one urgent case of bilious fistula). In the endovascular group none of the patients died; the perioperative morbidity rate was of 14.3% (one case of hepatic artery thrombosis after failure of gastroduodenal artery aneurysm embolization). Failure of the procedure was 42.9% (3 cases of aneurysm recanalization). In conclusion, we believe that an aggressive surgical approach is justified, even in the case of asymptomatic VAA, because of the low morbidity and mortality rates. Endovascular treatment should be reserved for selected cases.

Aortoenteric fistula due to endoleak coil embolization after endovascular AAA repair

PURPOSE

To report a late complication associated with embolization coils used to treat an endoleak after endovascular abdominal aortic aneurysm (AAA) repair.

CASE REPORT

A 79-year-old man with a 5.8-cm AAA underwent endovascular repair with an Ancure graft in 1997. A persistent type I endoleak was identified on serial postoperative computed tomographic scans. Three transarterial coil embolization procedures were performed to treat an endoleak from the proximal and right distal attachment sites with outflow by the inferior mesenteric and lumbar arteries. Coil embolization was ultimately successful in sealing the endoleak, and the AAA decreased in size. Four years later, the patient developed an aortoenteric fistula due to erosion of the metallic embolization coils into the duodenum. The endograft was explanted and an extra-anatomical bypass inserted.

CONCLUSIONS

Coil embolization to treat endoleaks can, on rare occasions, be the cause of aortoenteric fistula. Lifelong follow-up of stent-graft patients is required.

Nonoperative treatment for a ruptured pseudoaneurysm of the celiac trunk: report of a case

We report the case of a 67-year-old man in whom hemorrhage from a ruptured celiac trunk pseudoaneurysm, which occurred as a consequence of leakage at the site of gastroduodenostomy, was successfully controlled by transcatheter arterial embolization (TAE) with stainless steel coils and N-butyl cyanoacrylate (NBCA). The occurrence of a pseudoaneurysm of the celiac trunk associated with anastomotic leakage is etiologically rare. We compiled reports from the literature on TAE for ruptured aneurysms of the celiac trunk, and compared its therapeutic value with that of surgical treatment. Operative death occurred in 4 of a series of 43 patients with aneurysms of the celiac trunk that were surgically treated (9.3%). In 5 patients with ruptured aneurysms, the operative mortality rate was 40% (2/5). Conversely, while the unsuccessful rate of TAE therapy was 17% (1/6), the mortality rate was nil. The patient whose case is presented here was affected by methicillin-resistant staphylococcus aureus (MRSA) at the site of leakage and in the lung. Under septic conditions such as hemorrhage secondary to pancreatitis, the mortality rate of surgical therapy was 23%-29%, whereas the success rate of TAE therapy was 79% and the mortality rate was 4%. Based on these findings, it is suggested that TAE therapy is a viable alternative to surgery for patients even with ruptured pseudoaneurysms of the celiac trunk.