Successful surgical treatment of a patient with multiple visceral artery aneurysms due to fibromuscular dysplasia

Endovascular treatment of chronic mesenteric ischaemia secondary to a superior mesenteric artery pseudoaneurysm: a modified neurointerventional technique

A man in his late 60s presented with intermittent abdominal pain, nausea, vomiting and approximately 40 pounds of weight loss over the course of a year, most concerning for chronic mesenteric ischaemia. Given a prior negative workup, a CT angiogram was performed and revealed a wide neck mid-superior mesenteric artery pseudoaneurysm (PSA). As PSAs are susceptible to thrombus formation and distal emboli, this incidental finding was considered a possible explanation for his intermittent symptoms and thus required treatment. Anatomical constraints precluded traditional coiling or covered stent placement, so the interventional radiology team used a neurointerventional technique and performed a successful balloon-assisted coil embolisation of the PSA with subsequent resolution of the patient's symptoms. More than 3 years postprocedure, the patient remains asymptomatic with no complications.

Rare Mesenteric Arterial Diseases: Fibromuscular Dysplasia and Segmental Arterial Mediolysis and Literature Review

Fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases that cause aneurysm, occlusion, and thromboses. These diseases are rarely seen in mesenteric arterial lesions; however, as they can be lethal if appropriate management is not provided, the accumulation of clinical information from cases is essential. We herein report the cases of a 57-year-old man diagnosed with FMD and a 63-year-old man diagnosed with SAM. We conclude that an early diagnosis with imaging modalities and clinical information followed by the appropriate treatment improves the prognosis of these arterial diseases.

Diagnosis and management of fibromuscular dysplasia and segmental arterial mediolysis in gastroenterology field: A mini-review

The vascular diseases including aneurysm, occlusion, and thromboses in the mesenteric lesions could cause severe symptoms and appropriate diagnosis and treatment are essential for managing patients. With the development and improvement of imaging modalities, diagnostic frequency of these vascular diseases in abdominal lesions is increasing even with the small changes in the vasculatures. Among various vascular diseases, fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases which need to be diagnosed urgently because these diseases could affect various organs and be lethal if the appropriate management is not provided. However, because FMD and SAM are rare, the cause, prevalence, clinical characteristics including the symptoms, findings in the imaging studies, pathological findings, management, and prognoses have not been systematically summarized. Therefore, there have been neither standard diagnostic criteria nor therapeutic methodologies established, to date. To systematically summarize the information and to compare these disease entities, we have summarized the characteristics of FMD and SAM in the gastroenterological regions by reviewing the cases reported thus far. The information summarized will be helpful for physicians treating these patients in an emergency care unit and for the differential diagnosis of other diseases showing severe abdominal pain.

Mesenteric Arteriovenous Dysplasia/Vasculopathy Is Distinct From Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic vasculopathy that usually affects the carotid and renal arteries. We have observed FMD-like vascular changes in specimens resected for ischemia or Crohn's disease (CD). On the basis of a systematic clinicopathologic review of these 11 cases identified between 1982 and 2014, we describe a distinct mesenteric vasculopathy that involves both arteries and veins [mesenteric arteriovenous dysplasia/vasculopathy (MAVD/V)] and is characterized by (1) concentric/eccentric smooth muscle collarette around the tunica media of both the artery and the vein in ≥2 foci, (2) varying degrees of intimal and medial hyperplasia and adventitial fibrosis, and (3) lack of inflammation or thrombi. MAVD/V cases were clinically diagnosed as CD (45%), mass/lesion (27%), ischemia (9%), obstruction (9%), or rectal prolapse (9%). Abdominal pain for >1 year was the most common symptom. Most patients were women (M:F=1:2.7; mean age, 63 y). Mucosal changes mimicking CD, such as architectural distortion (55%), multifocal ulcers (73%), and pyloric gland metaplasia (64%), were common; however, no granulomas or transmural lymphoid aggregates were identified. Ischemic pattern of injury was seen in 4 cases. Upon follow-up (mean, 31.2 mo), 8 patients were found to be asymptomatic, 2 had died of unrelated causes, and 1 was lost to follow-up. We propose the name MAVD/V for a distinct noninflammatory, nonatherosclerotic, localized form of mesenteric vasculopathy that involves both arteries and veins, distinct from FMD. Unlike FMD, surgical resection appears to be curative, with a favorable clinical outcome. Awareness of this vascular entity is important as patients may be potentially misdiagnosed as having CD and ischemic bowel disease.

Intensive Long Distance Running as a Possible Cause of Multiple Splanchnic Arterial Aneurysms: A Case Report

This is a case report that suggests the possible association between multiple splanchnic arterial aneurysms and long-distance running. The clinical features of one patient admitted at Chungbuk National University Hospital for treatment of multiple splanchnic arterial aneurysms were reviewed. A 54-year-old man had a recurrent, intermittent and epigastric pain for 2 months. There was no abnormality in gastroscopy and colonoscopy. An abdominal computed tomography angiography documented calcified superior mesenteric artery (SMA) and splenic artery aneurysms. The patient had a history of recreational long-distance running for over 10 years. His average running time per week was more than 10 hours. There was no evidence of systemic arteritis, connective tissue disorder or infectious process that may have caused the aneurysms. He did not take any drugs. The SMA aneurysm was opened, and the aneurysmal segment of SMA was replaced with a vein graft. The splenic aneurysm was observed. The patient recovered without any sequelae.

Massive mesenteric panniculitis due to fibromuscular dysplasia of the inferior mesenteric artery: a case report

Background

Fibromuscular dysplasia (FMD) is a nonatheromatous, noninflammatory arterial disorder of unknown etiology resulting in vessel stenosis and/or aneurysm formation. The renal and cephalocervical (mainly carotid arteries) arterial beds are classically involved; involvement of visceral arteries is rare. Mesenteric panniculitis (MP) is an inflammatory process of mesenteric fat considered to be of unknown etiology. The majority of cases involve the small bowel mesentery; colorectal MP is rare. To our knowledge, no example of MP due to FMD has been described.

Case presentation

A 52 year old man presented with steadily worsening lower abdominal pain. Investigation revealed ischemic rectosigmoid mucosa associated with a large mesenteric mass of unknown nature. Angiography showed the disease was limited to the distribution of the inferior mesenteric artery. Subsequent symptoms of large bowel obstruction necessitated a left hemicolectomy. Pathologic examination showed bowel wall necrosis and massive panniculitis of the rectosigmoid due to FMD. Subsequent angiographic imaging of other vascular beds was negative.

Conclusions

Several features of this case are noteworthy: FMD limited to the inferior mesenteric artery has not been previously reported, FMD has not previously been implicated as a cause of MP, and the massive extent of panniculitis. An accompanying literature review of cases of visceral FMD, traditionally believed to almost exclusively affect females, highlights a greater than anticipated number of males (33 %), and a gender difference regarding concomitant involvement of cephalocervical and/or renal vascular beds (32 % in males versus 80 % in females). The latter observation may have implications regarding the value of radiologic screening of other vascular beds, particularly in asymptomatic males, in patients presenting with visceral artery FMD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0303-5) contains supplementary material, which is available to authorized users.

Clinical features and endovascular management of iliac artery fibromuscular dysplasia

PURPOSE

To identify the spectrum of clinical presentation of iliac artery fibromuscular dysplasia (FMD) and to evaluate the outcomes of endovascular management of iliac artery FMD for claudication.

MATERIALS AND METHODS

All patients in a single institution with a diagnosis of FMD between January 1980 and December 2010 were identified. Iliac artery FMD was present in 14 patients. Associated risk factors included hypertension (79%), hyperlipidemia (64%), smoking history (36%), coronary artery disease (21%), diabetes (0%), and obesity (36%).

RESULTS

In eight (57%) patients, iliac artery FMD was incidentally found on imaging. Lifestyle-limiting claudication involving one or both extremities was present in six (43%) patients. All six patients were reported to have mild peripheral arterial disease based on ankle-brachial index measurements (0.7-0.9). These six patients underwent 10 endovascular procedures for claudication, including angioplasty (n = 8) and self-expanding stent placement (n = 2). Mean symptom-free survival was 56.3 months.

CONCLUSIONS

Iliac artery FMD that is amenable to endovascular treatment may be found incidentally or may manifest with disabling claudication.

Acute remodeling of an adjoining aneurysm after endovascular treatment of a ruptured splanchnic arterial aneurysm: a case of clinically diagnosed segmental arterial mediolysis

A 61-year-old woman with multiple splanchnic arterial aneurysms (SAAs) was transferred to our hospital in a state of shock. She underwent coil embolization under the diagnosis of ruptured pancreaticoduodenal artery aneurysm. Follow-up computed tomography performed 2 weeks later showed rapid enlargement of a gastric artery aneurysm, and she underwent an additional embolization. Atherosclerotic, inflammatory or hereditary causes were excluded, and the patient was clinically diagnosed with segmental arterial mediolysis accompanied by multiple SAAs, one of which showed acute remodeling after endovascular treatment.

Surgical treatment of visceral artery aneurysms: A 25-year experience

OBJECTIVE

The aim of this study was to analyze our 25-year experience with surgical treatment of visceral artery aneurysms (VAAs), with particular attention paid to early and long-term results.

MATERIALS AND METHODS

From January 1982 to September 2007, 55 patients (32 males, 58%, and 23 females, 42%) underwent surgical treatment of 59 VAAs. Only one patient was treated with an endovascular procedure. Mean patient age was 59.3 years (range, 36-78 years). The site of aneurysmal disease was splenic artery in 30 (50.8%) cases, renal artery in nine (15.2%) cases, common hepatic artery in seven (11.9%) cases, pancreaticoduodenal artery in four (6.8%) cases, celiac trunk in three (5.1%) cases, superior mesenteric artery in two (3.4%) cases, and gastroduodenal, inferior mesenteric, middle colic and right gastroepiploic in one (1.7%) case for each artery. Two (3.6%) patients had multiple VAAs. In five (9.1%) patients, an abdominal aortic aneurysm coexisted. Early results in terms of mortality and major complications were assessed. Follow-up consisted of clinical and ultrasound examinations at 1 and 12 months, and yearly thereafter. Long-term results in terms of survival and aneurysm-related complications were analyzed.

RESULTS

In all but two cases, elective intervention in asymptomatic patients was performed. Two (3.6%) patients had a ruptured aneurysm (one pancreaticoduodenal artery and one middle colic artery). The one perioperative death was due to an acute pancreatitis in a patient operated on for a giant inflammatory splenic artery aneurysm, yielding a perioperative mortality rate of 1.8%. Two major complications (retroperitoneal hematoma and acute pancreatitis) were recorded. Mean duration of follow-up was 82.1 months (range, 0-324 months). Estimated 10-year survival rate was 79.5%. During follow-up two aneurysm-related complications occurred, with an estimated 10-year, aneurysm-related, complication-free survival rate of 75.2%.

CONCLUSION

In the era of minimally invasive therapeutic approaches, elective open surgical treatment of visceral artery aneurysms is safe and effective, and offers satisfactory early and long-term results.

Rupture of the spleen or splenic vessels (splenic emergency syndrome) in late pregnancy: a report of two autopsy cases

Emergencies of splenic origin in pregnancy involving rupture of the splenic artery or hemorrhage are rare events that can present suddenly and unexpectedly. We report two cases of young women, both in the third trimester of gestation, who suffered sudden malaise while at home and were admitted to the ER. On arrival, both were in severe hemorrhagic shock due to gross hemoperitoneum and they died in the operating theatre during emergency surgery. To better clarify the causes and sequence of these mortalities, forensic autopsy was requested in each case. In the first (a 26-year-old primigravida in the 40th week of pregnancy), cadaveric section demonstrated the rupture of an aneurysm of the splenic artery. In the second (a 28-year-old multipara in the 33rd week of pregnancy), the clinical and anatomopathological data suggested splenic hemorrhage. In both cases histology showed a fibrodysplasia of the arterial wall involving the splenic artery in one case and the hilar branches in the other. In agreement with the data in literature, in such cases particular importance must be attributed to examination of the arterial wall. In pregnancy a synergic effect between hemodynamic and endocrine factors can cause degeneration of the arteries resulting in dramatic hemorrhage. From the forensic pathologist's viewpoint, these cases underline the importance of histopathological study of the splenic artery in the interpretation of the pathogenesis of splenic vessel rupture or hemorrhage.

Multiple giant superior mesenteric artery branch aneurysms

Mesenteric arterial branch aneurysms are rare. Giant, multiple, mesenteric branch artery aneurysms are even more uncommon, and only a few reports exist in the literature. We describe a 73-year-old asymptomatic female found to have an abdominal bruit and subsequently diagnosed with multiple mesenteric branch artery aneurysms by computed tomography and angiography. In addition, the patient was found to have celiac artery occlusion at its origin. Risk factors include hypertension, hyperlipidemia, grandmultiparity, and tobacco dependence. She was treated successfully with open surgery including ligation of multiple branch aneurysms and vein bypass reconstruction to preserve hepatic and mesenteric artery flow. Our purpose is to review this uncommon entity in terms of diagnosis, etiology, treatment options, and literature review.

Pseudovasculitis and corticosteroid therapy

Pseudovasculitis, vasculitis-like syndromes, vasculitis look-alikes, or mimics of vasculitis represent a heterogeneous collection of disorders that are capable of simulating vasculitis. Inappropriate diagnosis leads to delay or absence of proper management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. We report the case of fibromuscular dysplasia suspected to be a polyarteritis nodosa. The progression of the lesions visualized by the ultrasonographic study and computed tomography (CT) scan after 10 days of treatment led to an emergency laparotomy. The possible deleterious role of steroids given to treat the suspected vasculitis is discussed.

Trente-huit cas de lésions dysplasiques de l’artère mésentérique supérieure

Dysplasia of the renal and cervical arteries are well known, but dysplasia of the superior mesenteric artery (SMA) is less frequent and has specific presentation. There have been few reports on the different types of presentations. We report a series of 38 cases and present the characteristic features together with a comparison with data in the literature. These non-atheromatous non-inflammatory lesions of the arterial wall occurred either in a context of fibromuscular disease which cause is unknown (30/38 patients) or in patients with genetic disease such as neurofibromatosis (3/38) or Ehlers-Danlos disease (5/38). The fibromuscular disease presented three aspects with specific characteristics. a) stenosing lesions found predominantly in women with a different morphology than in the other localization (usually associated): irregular diffuse stenosis discovered in patients with hypertension, or ischemic digestive symptoms (6/14 patients). b) Aneurysms, also found predominantly in women, but less frequently associated with other dysplasias. These aneurysms were generally sacciform. Unlike data in the literature, our series only included rupture in 1/8 cases. The aneurysm was discovered during the exploration of abdominal pain or hypertension. c) The third type of fibromuscular disease concerned dissections which were observed in the male population, (except one case of segmental dysplasia), and presented with signs of digestive ischemia in the other seven patients, four in an emergency context requiring immediate treatment. Two genetic diseases were observed. a) Neurofibromatosis led to dysplasia analogous to fibromuscular disease, but with abnormal nerve formations in the wall. For the three cases observed, one involved only the visceral arteries and the two others thoraco-abdominal coarctation. b) We had five patients with Ehlers-Danlos syndrome, with dysplasia of the superior mesenteric artery. For three there was a fusiform dilatation and in one small aneurysms along the arterial trunk, which only required surveillance. There was only one aneurysm which required treatment by resection and venous graft. In these young patients, revascularization was generally achieved with autologous material and the prognosis was favorable. Embolization was successful in treating the sacciform aneurysm in one patient. In conclusion, dysplasia of the superior mesenteric artery has a specific presentation which must be recognized to enable diagnosis of this not uncommon condition in young subjects (even children) who often present with an acute abdomen requiring urgent treatment.

Two-Graft Repair of Very Proximal Superior Mesenteric Artery Aneurysms: A Technical Note

Visceral artery aneurysms are found in only 0.2% of the general population. Among these, aneurysms of the superior mesenteric artery (SMA) are very unusual and account for only 5.5 % to 8 %. Risk of rupture or embolization is the impetus for their definitive treatment and this should be performed in acceptable candidates. These aneurysms are typically located distal to the origin of the SMA and this situation lends itself to interposition grafting as a means of both aneurysm repair and reestablishment of prograde SMA blood flow. However, SMA origin aneurysms that arise directly from the abdominal aorta add a degree of complexity because the vascular reconstruction must include the diseased visceral aorta as well as the SMA. In this article we report successful operative treatment of large aneurysms at the origin of the superior mesenteric artery using a two-graft technique in two elderly patients.

Fibromuscular dysplasia

The most common clinical manifestations of fibromuscular dysplasia (FMD) are hypertension due to renal artery involvement and transient ischemic attack or stroke due to carotid or vertebral artery involvement. Patients with renal artery FMD and hypertension should undergo primary angioplasty with the goal of curing the hypertension. If the blood pressure fails to normalize following angioplasty, the physician should institute antihypertensive medications according to the recommendations of the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure VII. In patients with cerebrovascular FMD, antiplatelet agents represent the cornerstone of therapy. Percutaneous angioplasty has emerged as the preferred treatment for symptomatic cerebrovascular FMD.