[Visceral artery aneurysms]

[Acute right-sided upper abdominal pain in a 46-year-old woman]

A 46-year-old woman presented with acute abdominal pain in the right upper quadrant. Esophagogastroduodenoscopy revealed a duodenal stenosis within the horizontal part of the duodenum. Based on the findings of abdominal computed tomography (CT), endosonography, Doppler duplex sonography and angiography, the diagnosis of an aneurysm of a branch of the inferior pancreaticoduodenal artery was established. This arterial branch was part of a collateral circulation between the superior mesenteric artery and the proper hepatic artery caused by obturation of the celiac artery. The symptomatic duodenal stenosis was the result of a local hematoma due to prior rupture of an aneurysm. After successful coiling of the afferent vessels to the aneurysm follow-up examinations showed progredient resorption of the hematoma and the patient was free of complaints.

Rare aneurysm of the hepatic artery with overlap to the gastroduodenal artery in very uncommon coincidence with occurence of hepatomesenteric trunk

BACKGROUND

Aneurysms of visceral arteries are rare, but in case of rupture, they are potentially life threatening. In addition, there is a broad spectrum of the anatomic variability for the arterial supply of the liver.

METHODS

Based on a real but very rare clinical case, including its diagnostic management and short-term course, the extraordinary coincidence of (i) an aneurysm of the gastroduodenal artery at its branching off from the hepatic artery and (ii) occurrence of hepatomesenteric trunk is described by the means of a scientific medical case report as well as an adequate and selective literature search. CASE PRESENTATION, THERAPEUTIC DECISION AND CLINICAL COURSE: A 39-year-old woman (BMI, 24 kg/m) was diagnosed (by coincidence) with an aneurysm of the proper hepatic artery (APHA) with overlap to the gastroduodenal artery in combination with an uncommon hepatomesenteric trunk using abdominal computed tomography (CT) scan (because of slight but recurrent episodes of urinary tract diseases) and, subsequently, systematic diagnostic comprising Duplex ultrasonography, magnetic resonance imaging (MRI), and conventional angiography. However, medical history was not significant for coincidence with possibly relevant chronic occlusive disease, mycotic embolization, trauma, Marfan syndrome, Klippel-Trenaunay syndrome or giant cell arteritis. Despite a moderate progression within a year to a size of actually 18 mm, we still favor watchful-waiting at this size (therapeutic [interventional] consequence, size > 20 mm) with short-term intervals for follow-up investigations using Duplex ultrasonography as the method of choice.

CONCLUSIONS

This is the first case in the accessible English-speaking literature to show this very infrequent coincidence especially indicating rare appearance of an APHA in combination with an also infrequent hepatomesenteric trunk (which potentiates the uncommon occurrence of such combination) based on the high anatomic variability of the arterial supply of the liver from the anatomic perspective.

Endovascular treatment of visceral aneurysms and pseudoaneurysms: long-term outcomes from a multicenter European study

PURPOSE

To investigate the percutaneous endovascular management of visceral aneurysms (VA) and visceral pseudoaneurysms (VPA) treated in three European interventional radiology departments.

METHODS

Patient archives from the department's databases were examined and retrospectively analyzed. Patients diagnosed between 2000 and 2010 with VA and/or VPA, confirmed by computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography and treated exclusively with percutaneous endovascular methods, were included in the study. The study's primary end points were procedural technical success, target lesion reintervention rate, and periprocedural mortality rate. Secondary end points included major and minor complications rates.

RESULTS

The medical records of 54 patients (41 male, mean age 55 ± 18.1 years) with 58 VAs or VPAs and treated with various percutaneous endovascular therapeutic modalities were analyzed. In total, 21 VAs (mean diameter 49.4 ± 21 mm, range 20-100 mm) and 37 VPAs (mean diameter 25.1 ± 14.6 mm, range 8-60 mm) were treated. Procedural technical success was achieved in 100% of the cases, while target lesion reintervention rate was 6.1% (2 of 33) and 14.2% (3 of 21) in the VPA and VA groups, respectively. Mean clinical follow-up period was 19.1 ± 21.4 months. Overall periprocedural mortality rate was 3% (1 of 33) in the VPA group and 0% (0 of 21) in the VA group.

CONCLUSION

Percutaneous endovascular treatment of VAs and VPAs is safe and effective with low morbidity and mortality. There is a small but significant reintervention rate, particularly for true aneurysms; dedicated follow-up imaging is recommended. Successful aneurysm exclusion was achieved in all cases with a second procedure.

Percutaneous treatment of a ruptured superior mesenteric artery aneurysm in a child

Splanchnic artery aneurysms are very rare in children. We report a 10-year-old girl with a large atraumatic ruptured superior mesenteric artery aneurysm that was considered inoperable. She was ultimately treated with two percutaneous US-guided thrombin injections, which led to complete occlusion of the aneurysm. The aetiology of the aneurysm remained unclear, but a family history was suggestive of a congenital connective tissue disease such as Ehlers-Danlos syndrome subtype IV.

Posttraumatic splenic artery aneurysm presenting as occult gastrointestinal bleeding

A 53-year-old man presented with a 19-month history of gastrointestinal bleeding. Repeated endoscopic investigation of the upper and lower intestine showed no source of bleeding. When the patient collapsed due to massive gastrointestinal hemorrhage he was referred to our center. Gastroscopy showed a large, bulging tumor protruding from the posterior gastric wall. The consistency of this tumor was soft and the overlying mucosa appeared smooth and intact. Endoscopic ultrasound and contrast-enhanced computerized tomography scan identified a partly thrombosized splenic artery aneurysm (SAA). Arteriography of the celiac trunk confirmed the SAA diagnosis; the SAA was subsequently occluded by coils. So far, four months after discharge, the patient is in excellent health and no further episode of gastrointestinal bleeding has occurred. SAA is a very rare cause of upper gastrointestinal bleeding, but it must be considered when no other common bleeding source can be detected.