Mini-Laparotomy for Superior Mesenteric Artery Aneurysm Due to Takayasu's Arteritis

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Successful conservative treatment of an isolated inflammatory superior mesenteric artery aneurysm

Inflammatory superior mesenteric artery aneurysm is an extremely rare but life-threatening condition that can result in fatal rupture. Early surgery has been emphasized to prevent aneurysm rupture. We present a case that was successfully managed with conservative treatment. The patient was treated with intravenous methylprednisolone pulse therapy followed by oral prednisolone. Steroid therapy should be considered for unruptured inflammatory superior mesenteric artery aneurysms before surgery.

Experience of managing superior mesenteric artery aneurysm and its midterm follow-up results with 18 cases

OBJECTIVES

To characterize the clinical features, treatment, and prognosis of superior mesenteric artery aneurysms and provide evidence for clinical decision-making.

METHODS

We retrospectively reviewed the diagnosis and treatment of 18 cases of superior mesenteric artery aneurysm admitted to our center from 2003 to 2020, including demographic data, risk factors, clinical manifestations, diagnosis, treatment strategies, and follow-up results.

RESULTS

The average age of the patients was 49.1 years, and males accounted 83.3%. The development of the disease was associated with infection, hypertension, pancreatitis, and trauma, but no significant associations with atherosclerosis were noted by our results. Nine patients were diagnosed with true aneurysm, seven patients with pseudoaneurysm, and two patients with dissecting aneurysm. Rupture of aneurysm occurred in three patients (16.7%), and one of them died before surgery. The surgery success rate was 94.1%, and open surgery was performed on nine patients, endovascular surgery on three patients, and conservative treatment on three patients. The follow-up rate was 77.8% (14/18), and the average follow-up time was 48.2 months. The mortality and reintervention rate during follow-up was 0. The two-year patency rate of artificial vessels and covered stents was 50%.

CONCLUSION

The clinical manifestations and features of superior mesenteric artery aneurysms vary between patients. Careful evaluation of vascular anatomy and personalized treatment strategy are critical in the management of superior mesenteric artery aneurysms. Midterm follow-up results of superior mesenteric artery aneurysms are satisfactory.

Surgical Treatment of True Superior Mesenteric Artery Aneurysms

BACKGROUND

Superior mesenteric artery aneurysms (SMAAs) are a rare clinical problem that can be associated with significant morbidity and mortality. The optimal surgical approach for both mycotic and degenerative SMAAs remains poorly defined. The study was designed to review our institutional experience and develop a treatment algorithm.

METHODS

A single-institution, retrospective review was performed to document presentation, treatment, and outcomes of patients undergoing surgical repair of SMAAs from 2003 to 2020. The primary end-point was 30-day mortality, and secondary end-points included complications, patency, freedom from reinfection, freedom from reintervention, and survival.

RESULTS

Eighteen patients (mean age: 46 ± 16 yrs; 50% male; mean diameter 2.4 ± 2.0 cm) underwent treatment of mycotic (50%) or degenerative (50%) SMAAs. Abdominal pain (66%) was the most common presenting symptom, and the diagnosis was confirmed with CT arteriography. Endocarditis secondary to intravenous drug abuse was responsible for most (88%) of the mycotic SMAAs, with a majority (66%) having positive cultures and Streptococcus being the most common organism. The majority (61%) of patients underwent urgent or emergent repair with aneurysmectomy and interposition saphenous vein bypass being the most common treatment of mycotic SMAAs while aneurysmectomy and prosthetic bypass were used most frequently for degenerative aneurysms. The operative mortality rate was 6% with a major complication rate of 17% (n = 3 patients: respiratory failure/reintubation-1, pulmonary embolism-1, necrotizing pancreatitis/graft disruption and death-1). The single death occurred in a patient with a degenerative aneurysm that developed postoperative pancreatitis and multiple organ dysfunction. The mean clinical follow-up time was 25 ± 48 (95% CI 1-48) months. The estimated primary patency, freedom from reinfection, and freedom from reintervention were 93 ± 7 %, 94 ± 5%, and 94 ± 5%, respectively, at 1 year. The overall mean survival was 55 ± 51 (95% CI 30-80) months with an estimated survival at 3 years of 77 ± 10%.

CONCLUSIONS

SMAAs associated with both degenerative and mycotic etiologies can be treated using a variety of surgical approaches with acceptable morbidity and mortality. Mycotic SMAAs should likely be repaired, regardless of size, while the indications for asymptomatic, degenerative aneurysms remain to be defined by further natural history studies.

Presentation and Management of Rare Saccular Superior Mesenteric Artery Trunk and Branch Aneurysms

Superior mesenteric artery (SMA) aneurysm is caused by degeneration of the visceral arteries. Although a rarely encountered entity, it requires timely management owing to the high mortality rate associated with rupture, particularly when the aneurysm is saccular in nature. As such, urgent treatment is generally indicated. We present five cases of SMA aneurysm arising from the main trunk or branches of the SMA.

Visceral artery aneurysms: review on indications and current treatment strategies

Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.

Esophageal Artery Pseudoaneurysm and Takayasu Arteritis in a Patient with Autosomal Dominant Polycystic Kidney Disease

A 47-year-old female previously diagnosed with ADPKD visited the hospital due to sudden pain in her upper abdomen and back. Esophagogastroduodenoscopy, contrast-enhanced abdominal computed tomography (CT), and CT angiography identified an esophageal artery pseudoaneurysm and hematoma in the esophagus. Urgent angiography and embolization were performed. After the procedure, CT angiography and positron emission tomography were performed due to differences in blood pressure between the arms. The patient was also found to have Takayasu arteritis and subsequently received outpatient follow-up care. The possible mechanisms that cause vascular abnormalities in ADPKD patients include damaged vascular integrity due to abnormal polycystin expression caused by PKD mutations and connective tissue abnormalities. Further research is needed to confirm these mechanisms, and ADPKD patients should be assessed for vascular abnormalities.

Reversal of Acute Mesenteric Ischemia by Salvation of the Meandering Mesenteric Artery with Stenting of the Left Internal Iliac Artery

The presence of the meandering mesenteric artery, which is a nonconstant tortuous arterial component unifying the peripheral intestinal circulation, is evidence of chronic occlusive disease of the main intestinal arteries. This collateral intestinal arterial pathway, when present, must be preserved in any abdominal intervention, as it is often the only remaining arterial supply of the intestine; its ligation can be accompanied by intestinal ischemia. We present herein, the case of a 42-year-old man, heavy smoker, who had chronic mesenteric ischemia without particular clinical manifestations till the hospitalization for acute myocardial infarction for which he underwent balloon angioplasty and stenting of the left circumflex coronary artery. Three days later, he experienced acute-on-chronic intestinal ischemia with crescendo clinical manifestations; intra-arterial angiography revealed the presence of a meandering mesenteric artery in a milieu of celiac, superior and inferior mesenteric, and right internal iliac artery occlusion accompanied by a tight stenosis of the left internal iliac artery. Successful stenting of the orifice of the left internal iliac artery was followed by a well-defined dilatation of the meandering artery, revascularization of the peripheral branches of the inferior-through the superior hemorrhoidal artery-and superior mesenteric arteries and complete resolution of the acute mesenteric ischemia. Thus, time was gained for the patient in order to have, if needed, a future elective open revascularization of the mesenteric artery, when the perioperative risk of mortality from the recent myocardial infarction and the coronary angioplasty and stenting will be minimal.