Visceral artery aneurysms

Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Visceral artery aneurysms (VAAs) are a rare, but serious clinical entity as rupture confers a high rate of mortality. Data regarding the prevalence, treatment, and prognosis of VAAs is largely from case series, as true randomized trials are lacking. The incidence of VAAs has risen over the decades with advances in imaging technology, availability, and utilization. Even in the presence of symptoms, the prompt diagnosis of VAAs may be challenging as symptoms are often nonspecific and varied. Although there are no definitive treatment guidelines, asymptomatic VAAs require treatment in the following scenarios: when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplant. Similar to therapeutic trends in other vascular beds, advances in endovascular devices and techniques have driven an "endovascular first" approach for the treatment of VAAs. However, although the success rates of endovascular repair are impressive, surgical intervention is still necessary in treating centers. This paper reviews the pathophysiology, clinical features, anatomic characteristics, and management strategies required for the effective diagnosis and treatment of VAAs.

Spleno-pancreatectomy En Bloc with Parcelar Gastrectomy for Splenic Artery Aneurysm - A Case Report and Literature Review

Splenic artery aneurysms are common arterial lesions which might remain asymptomatic for a long period of time. In certain cases, these lesions might encounter a significant growth and might become symptomatic. Once diagnosed, a therapeutic strategy should be taken in consideration in order to avoid the apparition of life-threatening complications such as aneurysmal rupture. This is a case report of a 45-year-old patient diagnosed with a splenic artery aneurysm who was successfully submitted to an aneurysmal resection en bloc with distal spleno-pancreatectomy and parcelar gastrectomy.

Covered stenting and transcatheter embolization of splenic artery aneurysms in diabetic patients: A review of endovascular treatment of visceral artery aneurysms in the current era

Diabetes mellitus is associated with both microvascular and macrovascular complications, which can result in visceral aneurysms as for example splenic artery aneurysms: in their management, an endovascular treatment, less invasive than surgery, is generally preferred. Endovascular treatment of splenic artery aneurysms can be based either on covered stenting (CS) or transcatheter embolization (TE). CS generally allows aneurysm exclusion with vessel preservation, while TE usually determines target artery occlusion with potential risk of distal ischemia. We performed a review of the existing literature on endovascular treatment of visceral artery aneurysms (VAAs) and psudoaneurysms (VAPAs) in the current era.

Case Report of a Large Common Hepatic Artery Aneurysm

Hepatic artery aneurysm is rare, but appropriate treatment is mandatory. We report a 50-year-old woman with an asymptomatic large hepatic artery aneurysm. The aneurysm was found as a result of abdominal computed tomography (CT) performed as a part of the screening. An open surgery was performed due to the size of the aneurysm. Aneurysmectomy was achieved, and the proper hepatic artery was anastomosed with gastroduodenal artery for adequate blood flow to the liver. Adequate hepatic circulation was confirmed postoperatively by duplex ultrasonography and CT. The patient was discharged on the 9th postoperative day.

Strategies for endovascular treatment of complicated splenic artery aneurysms

OBJECTIVE

Endovascular treatment (ET) is being increasingly used for splenic artery aneurysms (SAAs), but systematic treatment strategies have not been defined. We set out to investigate the optimal strategies for ET of complicated SAAs (CSAAs).

METHODS

CSAAs were classified into three types: type I, rupture or impending rupture; type II, at the origin of the splenic artery; and type III, having an aberrant splenic artery from the splenomesenteric trunk (type IIIA) or celiacomesenteric trunk (type IIIB). SAAs treated at our center during the last decade were reviewed, and CSAAs were selected for analysis. Patients' demographics, clinical manifestations, aneurysm characteristics, ET strategies, and outcomes were analyzed.

RESULTS

A total of 154 SAAs were identified, with 24 (15.6%) being CSAAs. Open surgery was employed in two patients, whereas 22 patients underwent ET. There were 3 patients with type I (type IIIA co-occurred in one of them), 5 with type II, and 15 with type III CSAAs. Treatment strategies included the following: immediate and thorough exclusion with embolization of the collaterals for type I; and dense embolization of the sac and outflow artery, with or without embolization of the inflow artery, or covered stent placement in the splenomesenteric trunk or celiacomesenteric, for types II and III. Technical success was achieved in 21 patients (95.5%). Mean follow-up was 33.7 ± 31.2 months (range, 1.5-117.0 months). The aneurysms remained completely thrombosed and unenlarged in 21 patients (95.5%). Reintervention was needed in one patient (4.5%) for persistent sac enlargement. The covered stent was asymptomatically occluded in one patient (11.1%). No hepatic or intestinal ischemia or death developed perioperatively or during the follow-up period.

CONCLUSIONS

With reasonable strategies toward the urgency and thoroughness needed for aneurysm exclusion as well as the anatomic challenges, ET appeared to be feasible, safe, and effective in the management of CSAAs.

Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms

Objectives Visceral arterial aneurysms may be treated using open surgery or endovascular repair, but the best approach remains controversial. This was a retrospective study aiming to compare open surgery and endovascular treatment strategies for visceral arterial aneurysms. Methods The study included all 93 patients who were admitted with visceral artery aneurysms between January 2001 and January 2011 at the Department of Vascular Surgery, Changhai Hospital, Shanghai, China. All cases underwent either open or endovascular procedures. Overall survival and adverse events were compared between the groups. Success rate, blood loss, length of surgery, and length of hospital stay were also compared. The patients were followed up at three, six, and 12 months then every year until April 2014. Results Open surgery was performed on 34 patients and endovascular procedures on 59. There were no differences in characteristics of the patients between the open surgery and endovascular groups. The perioperative complication rate was 52.9 and 13.6% in the open surgery and endovascular groups, respectively. Mean follow-up was 36.8 months (range: 11 months to 10 years). The one- and five-year survival rates were 100 and 60.6%, respectively, in the open surgery group, compared to 100 and 84.5% in the endovascular group. Multivariate analysis for factors related to overall survival showed that there was a significant relationship with the treatment approach (HR = 0.479, 95%CI: 0.278-0.825; P = 0.008) and the presence of false aneurysm (HR = 2.929, 95%CI: 1.388-6.180, P = 0.005). Conclusions Endovascular repair could be considered as an effective method for visceral artery aneurysm. Endovascular repair showed lower perioperative complication rates and better long-term survival.

Aneurysm of the Anomalous Splenic Artery Arising from Superior Mesenteric Artery Treated by Coil Embolization: A Report of Two Cases and Literature Review

BACKGROUND

Aneurysm of splenic artery (SA) which arises from the superior mesenteric artery (SMA) is a very rare condition. The aim of this study was to present our experience with 2 such patients treated by coil embolization.

METHODS

A 33-year-old man and a 61-year-old woman were incidentally identified with aneurysms of the SA which arose from the SMA. Endovascular therapy of coil embolization was chosen to treat the aneurysm.

RESULTS

Follow-up computed tomography showed no change in the location of the coils and occlusion of majority of the aneurysm sac. The 2 patients have been doing well during a 26-month and 10-month follow-up period, respectively.

CONCLUSIONS

Combined with the experience of the previous literature, we think coil embolization can be cost-effective and minimally invasive in selected cases, depending on the morphology and site of the lesion.

The presentation and management of aneurysms of the pancreaticoduodenal arcade

OBJECTIVE

Gastroduodenal artery aneurysms (GDAAs) and pancreaticoduodenal artery aneurysms (PDAAs) are uncommon lesions associated, however, with a significant risk of rupture. This study describes the clinical presentation, associated imaging findings, and operative strategies for these aneurysms.

METHODS

The records of all patients with GDAAs or PDAAs identified through an institutional database by axial imaging between 1994 and 2014 were retrospectively reviewed. Data on presenting symptoms, comorbid conditions, imaging findings, and outcomes after operative intervention were collected and examined.

RESULTS

We identified 11 GDAAs and 25 PDAAs in 35 patients. Mean size of the GDAAs was 31.1 mm (range, 10-60 mm) and mean size of the PDAAs was 19.1 mm (range, 10-48 mm). At presentation, 13 aneurysms (36%) were symptomatic and seven aneurysms (19.4%) were ruptured. Median size of ruptured aneurysms was 20 mm (range, 10-60 mm). On axial imaging, 24 aneurysms (67%) were associated with a severe stenosis or occlusion of the celiac axis origin, and 11 aneurysms (31%) were thought to be associated with compression of the celiac axis in the setting of median arcuate ligament syndrome. Twenty-four aneurysms (67%) underwent repair. Of these aneurysms, 18 (75%) were successfully managed with primary endovascular repair (coil embolization with or without celiac stent), whereas endovascular therapy failed in two (8%) and required open repair. Four aneurysms (17%) were treated with primary open repair. Overall 30-day morbidity and mortality after aneurysm repair were 29% and 4%, respectively.

CONCLUSIONS

GDAAs and PDAAs are uncommon lesions that are often associated with a celiac axis stenosis/occlusion leading to altered hemodynamics in the pancreaticoduodenal arcade. These aneurysms are prone to rupture regardless of size, and intervention is accordingly recommended for all aneurysms upon recognition. Despite the concordant celiac axis obstruction and concern for maintenance of hepatic circulation, endovascular repair of these aneurysms is generally successful and should be considered as the initial operative approach.

Vessel wall morphology is equivalent for different artery types and localizations of advanced human aneurysms

Aneurysm formation occurs most frequently as abdominal aortic aneurysm (AAA), but is also seen in other localizations like thoracic or peripheral aneurysm. While initial mechanisms for aneurysm induction remain elusive, observations from AAA samples show transmural inflammation with proteolytic imbalance and repair mechanisms triggered by the innate immune system. However, limited knowledge exists about aneurysm pathology, especially for others than AAA. We compared 42 AAA, 15 popliteal, 3 ascending aortic, five iliac, two femoral, two brachial, one visceral and two secondary aneurysms to non-aneurysmatic controls by histologic analysis, immunohistochemistry and cytokine expression. Muscular and elastic type arteries show a uniform way of aneurysm formation. All samples show similar morphology. The changes compared to controls are distinct and include matrix remodeling with smooth muscle cell phenotype switch and angiogenesis, adventitial lymphoid cell accumulation and M1 macrophage homing together with neutrophil inflammation. Inflammatory cytokines are up-regulated accordingly. Comparative analysis of different disease entities can identify characteristic pathomechanisms. The phenotype of human advanced aneurysm disease is observed for elastic and muscular type arteries, does not differ between disease localizations and might, thus, be a unique response of the vasculature to the still unknown trigger of aneurysm formation.

Celiac artery aneurysm diagnosis and repair in the postpartum female

A postpartum female presented with aching abdominal pain as well as persistently elevated blood pressure poorly controlled by medication. Computed tomography angiography was performed and identified an aneursym of the celiac artery proximal to its branching points. Due to symptomatic presentation of the patient and plans of future pregnancy, surgical repair of the aneursym was planned and performed 2 months following initial diagnosis. Celiac artery aneurysms are rare types of visceral artery aneursyms (VAAs) and comprise ~4% of all VAAs.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report

BACKGROUND

Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination.

CASE PRESENTATION

We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution.

CONCLUSIONS

GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.

Segmental arterial mediolysis with 5 splenic artery aneurysms. A rare finding of a rare disease: Case report and literature review

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The article represents SAM in SAA which is a rare finding in a rare disease and due to the paucity of sample of cases there is no standardization in the management.

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SAM should be suspected when multiple aneurysms are found in the same anatomic site.

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Angiography is important to detect adjacent involvement. CT angiography of brain should be done to rule out distal vascular disease.

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Endovascular option is the first choice but sometimes it is not feasible, in this case was excluded due to anatomical and configuration reasons.

Introduction

Splenic artery aneurysms (SAA) are uncommon findings. They are usually single and isolated; however they can be multiple; hence vasculopathy and segmental artery mediolysis may be considered.

Presentation of case

In our manuscript we present a case of a 54 year old multiparous lady who was discovered incidentally to have a diseased splenic artery containing five SSAs. The largest aneurysm was close to the takeoff of the vessel and the smallest was distal embedded in the splenic hilum. Endovascular option was technically not feasible. Therefore the patient underwent a complete splenic artery resection with splenectomy and the histopathologic examination was suggestive of segmental arterial mediolysis (SAM).

Discussion and conclusion

Multiple SAAs remains a rare finding of a rare disease. Complications can be crucial and high index of suspicion is important. Segmental arterial mediolysis can be considered in patients with several aneurysms on one anatomic site; Angiography is the gold standard diagnostic and therapeutic method. Complete splenic artery resection with splenectomy is the best treatment option for solitary vessel involvement.

Vascular imaging of the mesenteric vasculature

Imaging of the mesenteric vasculature is crucial in diagnosing vascular disease of the gastro-intestinal tract such as acute or chronic mesenteric ischemia caused by arterial stenosis, embolism or thrombosis, mesenteric vein thrombosis and mesenteric aneurysm or dissection. The reference standard for imaging of the mesenteric vasculature is digital subtraction angiography. However, modalities as duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are developing rapidly and may provide accurate imaging non-invasively. This review provides an up-to-date overview of the anatomic resolution, clinical application, emerging techniques and future perspectives of these four radiological modalities for imaging of the mesenteric vasculature.

Imaging findings and endovascular management of iatrogenic hepatic arterial injuries

Iatrogenic hepatic arterial injuries (IHAIs) include pseudoaneurysm, extravasation, arteriovenous fistula, arteriobiliary fistula, and dissection. IHAIs are usually demonstrated following percutaneous transhepatic biliary drainage, percutaneous liver biopsy, liver surgery, chemoembolization, radioembolization, and endoscopic retrograde cholangiopancreatography. The latency period between the intervention and diagnosis varies. The most common symptom is hemorrhage, and the most common lesion is pseudoaneurysm. Computed tomography angiography (CTA) is mostly performed prior to angiography, and IHAIs are demonstrated on CTA in most of the patients. Patients with IHAI are mostly treated by coils, but some patients may be treated by liquid embolic materials or stent-grafts. CTA can also be used in the follow-up period. Endovascular treatment is a safe and minimally invasive treatment option with high success rates.

Endoscopic Ultrasound as a Diagnostic Tool in a Case of Obscure Hemobilia

Hemobilia represents an uncommon cause of gastrointestinal bleeding that can present both diagnostic and therapeutic challenges. The evaluation of hemobilia typically involves cross-sectional imaging and endoscopic retrograde cholangiopancreatography (ERCP). There is limited data regarding the diagnostic utility of endoscopic ultrasound (EUS) in the evaluation of hemobilia. We present a case of a hepatic artery pseudoaneurysm as the etiology of hemobilia that was detected via EUS only. We conclude that EUS can serve as an important diagnostic tool in the evaluation of obscure hemobilia, especially in cases where imaging, ERCP, and percutaneous transhepatic cholangiography have been unsuccessful or inconclusive.

Coexisting giant splenic artery and portal vein aneurysms leading to non-cirrhotic portal hypertension: a case report

BACKGROUND

Splenic artery aneurysms are the commonest visceral and third most common abdominal artery aneurysms, having a strong association with both pregnancy and multiparity. Here we report possibly the first case of a giant splenic artery aneurysm in association with a smaller portal vein aneurysm, in a woman who had never conceived, leading to non-cirrhotic portal hypertension.

CASE PRESENTATION

A 40-year-old Pakistani Asian woman who had no evidence of liver cirrhosis presented in April 2016 for a diagnostic workup of ascites, massive splenomegaly, and pancytopenia. An abdominal ultrasound followed by computed tomography angiography showed a giant aneurysm in her splenic artery and another smaller one in her portal vein. She underwent splenectomy and excision of the splenic artery aneurysm. Surgical findings included a giant splenic artery aneurysm pressing on her portal vein and causing its aneurysmal dilatation. On her first review in July 2016, she was generally in good health, ascites had subsided, and her full blood count was normal. Her portal vein aneurysmal dilatation, which was presumed to be secondary to the pressure effect from the splenic artery aneurysm, had shrunken remarkably in size.

CONCLUSION

A giant splenic artery aneurysm can cause non-cirrhotic portal hypertension and should be treated with splenectomy and aneurysmectomy.

Repair of a splenic artery aneurysm using a novel balloon-expandable covered stent

We describe a case of endovascular exclusion of a splenic artery aneurysm. The repair utilized a novel balloon-expandable stent-graft.

Endovascular Stent Graft Repair of a Ruptured Superior Mesenteric Artery Aneurysm

A ruptured aneurysm of the superior mesenteric artery (SMA) is very rare. In recent years, there have been some reports of successful endovascular therapy of SMA aneurysms. However, endovascular stent graft repair of a ruptured SMA aneurysm has not been reported previously. We report on a 50-year-old man with a ruptured aneurysm of the proximal SMA. Using an endovascular approach, the aneurysm was initially excluded with 2 stent grafts. Two weeks following the first procedure, computed tomography angiography revealed a proximal endoleak, which was treated with another stent graft. The endovascular stent graft repair finally resulted in total exclusion of the ruptured aneurysm. Patency of the SMA was maintained and no ischemic complications occurred.

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.

Mycotic Aneurysm of the Superior Mesenteric Artery: A Delayed Complication from a Neglected Septic Embolus

Mycotic aneurysm formation in a visceral artery carries a significant risk of mortality and morbidity. The authors present a case of a symptomatic superior mesenteric artery aneurysm secondary to a septic embolus in a patient who had undergone aortic valve replacement. The patient initially presented with evidence of acute intestinal ischemia from a presumed embolic source. Although an extensive bowel resection was performed, an adequate search for the embolus was not carried out. Prompt diagnosis and removal of suspected septic emboli must be performed to avoid the formation of delayed mycotic aneurysms.

Sinister Splenic Artery Pseudoaneursym: A Rare Case of Unidentified Aetiology

Splenic Artery Pseudoaneurysms (SAP) are very rare. Giant SAPs are those which are more than 5 cm in diameter and are rarer. SAPs are usually caused by pancreatitis, trauma, surgery or other iatrogenic interventions, vasculitis, local infective or inflammatory processes. We report the successful surgical management of a giant SAP of unidentified aetiology. This case report highlights the significance that this entity may present atypically and hence, early recognition and aggressive management may be life saving.

Common and uncommon pitfalls in pancreatic imaging: it is not always cancer

Despite advances in multimodality imaging of pancreas, there is still overlap between imaging findings of several pancreatic/peripancreatic disease processes. Pancreatic and peripancreatic non-neoplastic entities may mimic primary pancreatic neoplasms on ultrasound, CT, and MRI. On the other hand, primary pancreatic cancer may be overlooked on imaging because of technical and inherent factors. The purpose of this pictorial review is to describe and illustrate pancreatic imaging pitfalls and highlight the basic radiological features for proper differential diagnosis.

A comparison of open and endovascular treatment strategies for the management of splenic artery aneurysms

Splenic artery aneurysms are rare with an incidence of less than 0.8%. Evidence to support an endovascular management strategy over open surgical repair for SAA is limited. We used the Nationwide Inpatient Sample to compare open to endovascular SAA repair by assessing postoperative outcomes, length of hospital stay, and mortality. Multivariate logistic regression analysis was done to determine predictors of postoperative complications. There were 2316 admissions with a diagnosis code for SAA [347 (14.9%) endovascular repair and 112 (4.8%) open surgery]. There was a statistically significant lower rate of cardiac (2.3% vs 6.9%, P = 0.05) and pulmonary (8.9% vs 16.1%, P = 0.05) complications for the endovascular repair group. The risk of surgical site infection was also lower (0.6% vs 5.1%, P = 0.01) in the endovascular group. Median in-hospital LOS was greater for open repairs (6 vs. 4 days, P = 0.01). There were no statistically significant differences across procedures for renal complications (8.9%, P = 0.88) or in-hospital mortality (3%, P = 0.99). Regression analysis established procedure type to be independent predictor of postoperative complications. Endovascular repair of SAA is therefore associated with a lower complication rate and less resource utilization but no difference in mortality peri-operatively. This may justify an endovascular first treatment strategy in the management of SAA.

[Multiple aneurysms splenic; surgical exclusion with conservation of the spleen]

BACKGROUND

Aneurysm of the splenic artery is diagnosed when the diameter of the splenic artery is greater than 1cm. It occupies third place among abdominal aneurysms. It is more frequent in women (4:1). It is associated with trauma, haemodynamics and local hormonal effects during pregnancy, portal hypertension (including the Caroli syndrome), arterial degeneration, atherosclerosis, and liver transplantation. It is difficult to diagnose, and it generally presents as ruptured, thus once the diagnosis is made, the surgical approach is indicated due to its high mortality.

CLINICAL CASE

Female of 66 years of age with a diagnosis of splenic artery aneurysm, with pulsing sensation at epigastric level of 8 months onset. On physical examination there is a palpable throbbing mass of 9 cm of diameter approximately, for which she was admitted. The computed tomography angiography with reconstruction showed three splenic aneurysms. Two were tied and the larger one was repaired by endo-aneurysmorrhaphy.

DISCUSSION

Visceral aneurysms are extremely rare. They are currently increasing and are the third leading cause of cardiovascular death, as morbidity/mortality is high. The surgical treatment must be done selectively according to their size. Selection of the surgical techniques depends on the anatomic location and the need for revascularisation, the aetiology and the experience of the surgeon.

CONCLUSION

A review has been presented on the advances in diagnostic, and management, concluding that the best is to preserve the spleen, and whatever the technique it must be performed by trained surgeons.

Endovascular Treatment of a Dissected Celiac Trunk Aneurysm Complicated with Consequent Pseudoaneurysm: Primary Treatment and Treatment Relapse after 5 Years

We report on an asymptomatic 56-year-old male with incidental diagnosis of celiac trunk aneurysm, diagnosed during an ultrasound scan performed to control polycystic kidney disease. The CT scan revealed a 3.8 cm saccular aneurysm of the celiac artery dissected in the superior wall with a consequent 4.3 cm pseudoaneurysm; we adopted an endovascular approach to exclude the lesion by catheterizing the celiac trunk and positioning a vascular plug in the common hepatic artery and a covered stent in the splenic artery; finally we fulfilled the aneurysm sac with Onyx. 30-day control CT scan revealed procedural success. Five years later he came back to our department for an aneurysm relapse in the common hepatic artery. We performed a second endovascular approach with a superselective catheterization of the pancreaticoduodenal arcade in order to exclude the lesion with Onyx and microcoils. Nowadays the patient is in good clinical conditions. Endovascular approach is a valuable method to treat visceral aneurysms; however, long-term imaging follow-up is essential to monitor the risk of relapse.

Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy

A hepatic artery pseudoaneurysm is a rare, but a potentially life-threatening complication after laparoscopic cholecystectomy (LC). Obstructive jaundice owing to a hepatic artery pseudoaneurysm after LC has never been reported. We report a patient with a hepatic artery pseudoaneurysm after LC who presented with tarry stools, bloody drainage and obstructive jaundice.

Primary intra-aneurysmal surgical repair of a celiomesenteric trunk aneurysm

We describe the surgical management of an asymptomatic 3-cm saccular aneurysm originating from a celiomesenteric trunk in a 45-year-old man. Surgical management was influenced by the location of the aneurysm, involving hepatic, splenic, and superior mesenteric arterial branches, by the young age of the patient, which made use of a synthetic graft less ideal, and by the lack of endovascular options.

Imaging of the porta hepatis: spectrum of disease

A wide array of pathologic conditions can arise within the porta hepatis, which encompasses the portal triad (the main portal vein, common hepatic artery, and common bile ducts), lymphatics, nerves, and connective tissue. Major vascular diseases of the portal triad include thrombosis, stenosis, and aneurysm. Portal vein thrombosis can complicate liver cirrhosis and hepatocellular carcinoma and has important therapeutic implications. Hepatic artery thrombosis and stenosis require immediate attention to reduce graft loss in liver transplant recipients. Congenital (eg, choledochal cyst) and acquired (benign and malignant) diseases of the biliary system can manifest as mass lesions in the porta hepatis. Lymphadenopathy can arise from neoplastic and nonneoplastic entities. Uncommon causes of mass lesions arise from nerves (eg, neurofibroma, neurofibrosarcoma) and connective tissue (sarcomas) and are rare. The hepatoduodenal ligament is a peritoneal reflection at the porta hepatis and is an important route for the spread of pancreatic and gastrointestinal cancers. Imaging plays a major role in diagnosis and enables appropriate management. Ultrasonography accurately demonstrates anatomic variations and pathologic conditions and is the initial modality of choice for detection of vascular and biliary lesions. Multidetector computed tomography and magnetic resonance imaging allow characterization and differentiation of various masses in the porta hepatis. Imaging-guided interventions, including embolization and stent placement, also play a key role in disease management.

Splenic artery aneurysm presenting with abdominal discomfort and weight loss

Splenic artery aneurysm (SAA) is uncommon, but it is the most frequent visceral artery aneurysm. It is more common in women, especially during pregnancy. SAA is usually asymptomatic, but abdominal pain and rupture may develop. At present, computerized tomography (CT) angiogram is the best diagnostic test but not the only. Surgical or endovascular treatment may be considered both in symptomatic or asymptomatic aneurysms greater then 2 cm in diameter. We present the case of an elderly woman with an SAA and review the literature.

[The aneurysms of digestive system arteries: three cases]

The aneurysms of digestive arteries are a rare pathological entity, with a risk of rupture associated to a high mortality rate, often asymptomatic, then they are discovered incidentally during a exam for other diagnostic purposes. We report three cases of digestive aneurysms, one of celiac trunk, one of mesenteric artery on behçet disease, and one of splenic artery, which were treated surgically with success.

MDCT of acute conditions affecting the mesenteric vasculature

Acute conditions affecting the mesenteric vessels can cause abdominal pain and result in significant morbidity and mortality if not diagnosed and treated quickly. As bowel viability depends on patency of the mesenteric vessels, prompt diagnosis is essential. Helical multidetector computed tomography (MDCT) provides a rapid, widely available, non-invasive method to promptly evaluate the mesenteric arteries, veins, and abdominopelvic viscera. Given the value of MDCT in diagnosing vascular disease, it is important the radiologist understand technical and imaging findings of mesenteric vascular injury. Therefore, successful diagnosis hinges on familiarity with MDCT angiography and the extended capabilities of volume rendering and multiplanar reformation. In this review, we illustrate and describe key MDCT findings of congenital, inflammatory, traumatic, infectious, and thromboembolic conditions affecting the mesenteric vasculature in adult patients.

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.

[Infected aneurysm of a branch of the superior mesenteric artery]

Aneurysm of the superior mesenteric artery is a rare finding. The risk of rupture is difficult to predict and manage. We report the case of a young woman who developed an aneurysm of the superior mesenteric artery in a context of bacterial endocarditis. Surgical resection without revascularization was successful.

Associated gastroduodenal artery aneurysm aortic aneurysm: the diagnostic contribution of contrast-enhanced ultrasound in correlation with computed tomography angiography

Splanchnic aneurysms are rare conditions, with localization at the level of the gastroduodenal artery being encountered in only 1.5 % of the cases. Due to the high mortality risk, early detection and optimal treatment are required. We stress the importance of ultrasonography as a primary method of detection as well as the role of contrast-enhanced ultrasound in characterization of visceral aneurysms. Due to its noninvasive nature, the examination could be used for follow-up after therapeutic procedures or in cases were a curative intervention is not possible.