Visceral artery aneurysm rupture

Management of true visceral artery aneurysms in 31 cases

INTRODUCTION

True visceral artery aneurysms (VAA) should be treated under elective conditions in dependency on maximum diameter. In this respect, the traditional accepted threshold is 2cm, whereas VAA sizing less than 2cm should conservatively be observed without invasive treatment. The aim of this study was to review differences in the treatment outcome over three decades.

MATERIAL AND METHODS

This was a retrospective review of all treated VAAs at one institution from 1985 to 2015. Patients demographics, aneurysm characteristics, management and outcome were recorded with special regard to differences in the course of time.

RESULTS

Thirty-one true VAA in 29 patients (74% female) were repaired (5 ruptured, 26 intact). Mean diameter was 30.27±11mm for intact and 38.0±8.5mm for ruptured VAA (rVAA) (P=NS). Most patients were asymptomatic (67.8% asymptomatic, 16.1% symptomatic without rupture and 16.1% with rupture). There was a vice-versa situation in chosen treatment techniques between the first (1985-2000) and the second (2001-2015) time period [first period: 75% open repair (OR) and 25% endovascular repair (ER); second period: 27% OR and 73% ER; P=0.009]. OR included aneurysm ligation and resection with (end-to-end-anastomosis, graft interposition or without blood flow reconstruction), while ER was exclusively coil embolization with sacrifice of all parent afferent and efferent arteries. Immediate technical success was 81% for all procedures. There was a trend toward higher technical success rate of VAA being treated in second time period, but we found no significant differences (69% in the first, 93% in the second; P=0.101). Conversion to OR due to technical failures was necessary after 3 endovascular repairs (20%). The overall 30-day-mortality rate decreases in the course of time (25% in the first and 0% in the second period; P=0.038). Furthermore, there was a lower 30-day mortaliy rate after ER of all VAA (elective and urgent repair) (20% after OR, 0% after ER; P=0.038). There was no decrease in 30-day mortality rate of rVAA (100% in the first and 20% in the second period; P=NS).

CONCLUSION

In the fact of medical progress and a growing number of endovascular procedures, this study presents a decrease in mortality rate after elective aneurysm repair over three decades. This might become an argument to reduce the 2-cm threshold in highly selected individuals.

Multiple Visceral Artery Aneurysms: An Uncommon Manifestation of Antineutrophil Cytoplasmic Antibody Vasculitis

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis mainly affect small vessels. They are an exceptional etiology of visceral artery aneurysms, which are themselves unusual and potentially serious vascular disease. We report the case of a patient followed for vasculitis associated with ANCA with kidney disease who presented with symptomatic aneurysm of the inferior mesenteric artery and aneurysm of the superior mesenteric artery.

Genuine splenic artery aneurysm rupture treated by N-butyl cyanoacrylate and metallic coils under resuscitative endovascular balloon occlusion of the aorta

Case

A 66 year-old woman who presented with sudden lower abdominal pain was transferred to our emergency room. Vital signs were stable on arrival at the hospital, but immediately became unstable. Systolic/diastolic blood pressure and heart rate were 66/33 mmHg and 70 b.p.m., respectively. Computed tomography scanning showed splenic artery aneurysm rupture and extravasation. The patient was treated non-operatively and definitively by endovascular therapy comprising resuscitative endovascular occlusion of the aorta for hemodynamic control, N-butyl cyanoacrylate, and metallic coils as an embolization material.

Outcome

On admission day 3, she was enrolled in another department and admission day 54, she was discharged.

Conclusion

Although resuscitative endovascular occlusion of the aorta and N-butyl cyanoacrylate is known to be effective, the use of resuscitative endovascular occlusion of the aorta with transcatheter arterial embolization and N-butyl cyanoacrylate for non-traumatic bleeding has not previously been reported. By combining and adapting these devices, their applications in endovascular management may be increased.

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.

Successfully treated life-threatening upper gastrointestinal bleeding from fistula between gastroduodenal artery pseudoaneurysm and duodenum

Case

An 85-year-old man was admitted to the hospital, underwent laparotomy, and was diagnosed with diffuse peritonitis due to perforation of gastric ulcer. Omental patch repair was carried out. After surgery, he suddenly vomited blood and manifested hypovolemic shock. An emergency upper gastrointestinal endoscopy was carried out immediately. However, the bleeding source was not visible. Dynamic-enhanced abdominal computed tomography showed a pseudoaneurysm of the gastroduodenal artery-communicating duodenal lumen with extravasation. Next, the patient underwent angiography for embolization. However, selective arterial embolization was not successful.

Outcome

Finally, duodenotomy was carried out. The fistula between the pseudoaneurysm and duodenal lumen was directly ligated. An aneurysm could be clearly identified by previous findings.

Conclusions

Gastroduodenal artery aneurysms are very uncommon but possibly lethal if they rupture. This life-threatening condition requires rapid diagnosis and treatment. Minimally invasive treatment is the preferred therapy for gastroduodenal artery aneurysm; however, acute care surgery should be considered without hesitation when conditions are critical.

Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients

PURPOSE

The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm.

METHODS

Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms.

RESULTS

False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P<0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible.

CONCLUSIONS

Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.

Left gastric artery aneurysm rupture: a rare cause of retroperitoneal bleeding: a case report

INTRODUCTION

Visceral artery aneurysms are very rare. Patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on ultrasound, MRI or abdominal computed tomography. Among these, splenic artery aneurysms are the most common ones accounting for 60% of all splanchnic aneurysms and gastric and gastroepiploic aneurysms account for only about 4%.

CASE PRESENTATION

We present a 61-year-old Caucasian male previously fit and well, presenting with sudden onset epigastric pain due to retroperitoneal haemorrhage secondary to ruptured left gastric artery aneurysm. Apart from a tender epigastrium, there were no other obvious signs elicited on abdominal examination. He had persistent tachycardia and haemoglobin drop from 10 g/dl to 6.7 g/dl. He underwent a contrast computed tomography which identified the ruptured left gastric artery. The aneurysm was controlled successfully with coil embolisation of the left gastric artery. At three-month follow-up, there was no evidence of the aneurysm.

CONCLUSION

Clinical presentations that do not correlate with examination finding should prompt immediate extensive investigation. The aid of contrast computed tomography and minimally invasive radiological interventional is the key to a fruitful outcome for this very rare entity.

Left gastric artery aneurysm in Marfan syndrome: a unique case

A 78-year-old man presented with abdominal pain, high International Normalised Ratio and rapidly falling haemoglobin. He had a background of Marfan syndrome and was on warfarin following mechanical aortic valve replacement. Abdominal CT imaging showed haemoperitoneum with a leaking aneurysm of the left gastric artery measuring 10 mm in diameter. The decision whether to reverse his anticoagulation provided a difficult clinical scenario given the risk of thrombosis associated with the mechanical aortic valve. The patient went on to have a successful percutaneous embolisation of the aneurysm using a metallic coil and Onyx. Left gastric artery aneurysms are rare and have a reported mortality of up to 70%. This is the first case of gastric artery aneurysm described in a patient with Marfan syndrome.

Endovascular coil embolization for a giant anomalous splenic artery aneurysm

Splenic arteries arising from superior mesenteric arteries, also known as splenomesenteric trunks, are uncommon entities. Aneurysms in relation to these variant splenic arteries are even rarer. Open surgery, laparoscopic technique, or endovascular management could be chosen. We report a patient with an anomalous splenic arteries aneurysm that was excluded with coil embolization in a minimally invasive endovascular way. A follow-up contrast-enhanced computed tomography angiogram performed 1 year after the procedure showed total exclusion of the aneurysm sac, patency of the superior mesenteric artery, and the patient was in good condition.

Multiple visceral artery aneurysms

A 63-year-old woman patient was presented with 3 visceral artery aneurysms, which were identified accidentally at nuclear magnetic resonance imaging carried out because of small mass in the left adrenal gland, which was suspected by ultrasound. Computed tomography (CT) examination was indicated and showed fusiform aneurysm on splenic artery, saccular aneurysm of right renal artery, and saccular aneurysm of left segmental renal artery. Also, she experienced hypertension, cardiomyopathy, thyroid gland strum with normal hormone levels, osteoporosis, and rheumatoid arthritis. The patient was treated by open conventional surgery followed by end-to-end anastomosis reconstructions firstly of the right renal and then splenic artery. In 5 days, the patient was released from hospital in good condition. Control CT examination in 9 months did not show enlargement of remaining aneurysm. Histopathology confirmed just typical aneurysm degeneration based on atherosclerosis.

Cost-effectiveness of endovascular repair, open repair, and conservative management of splenic artery aneurysms

OBJECTIVE

Open repair (OPEN) and conservative management (CONS) have been the treatments of choice for splenic artery aneurysms (SAAs) for many years. Endovascular repair (EV) has been increasingly used with good short-term results. In this study, we evaluated the cost-effectiveness of OPEN, EV, and CONS for the treatment of SAAs.

METHODS

A decision analysis model was developed using TreeAge Pro 2013 software (TreeAge Inc, Williamstown, Mass) to evaluate the cost-effectiveness of the different treatments for SAAs. A hypothetical cohort of 10,000 55-year-old female patients with SAAs was assessed in the reference-case analysis. Perioperative mortality, disease-specific mortality rates, complications, rupture risks, and reinterventions were retrieved from a recent and extensive meta-analysis. Costs were analyzed with the 2014 Medicare database. The willingness to pay was set to $60,000/quality-adjusted life years (QALYs). Outcomes evaluated were QALYs, costs from the health care perspective, and the incremental cost-effectiveness ratio (ICER). Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to include the uncertainty around the variables. A flowchart for clinical decision-making was developed.

RESULTS

For a 55-year-old female patient with a SAA, EV has the highest QALYs (11.32; 95% credibility interval [CI], 9.52-13.17), followed by OPEN (10.48; 95% CI, 8.75-12.25) and CONS (10.39; 95% CI, 8.96-11.87). The difference in effect for 55-year-old female patients between EV and OPEN is 0.84 QALY (95% CI, 0.42-1.34), comparable with 10 months in perfect health. EV is more effective and less costly than OPEN and more effective and more expensive compared with CONS, with an ICER of $17,154/QALY. Moreover, OPEN, with an ICER of $223,166/QALY, is not cost-effective compared with CONS. In elderly individuals (age >78 years), the ICER of EV vs CONS is $60,503/QALY and increases further with age, making EV no longer cost-effective. Very elderly patients (age >93 years) have higher QALYs and lower costs when treated with CONS. The EV group has the highest number of expected reinterventions, followed by CONS and OPEN, and the number of expected reinterventions decreases with age.

CONCLUSIONS

EV is the most cost-effective treatment for most patient groups with SAAs, independent of the sex and risk profile of the patient. EV is superior to OPEN, being both cost-saving and more effective in all age groups. Elderly patients should be considered for CONS, based on the high costs in relation to the very small gain in health when treated with EV. The very elderly should be treated with CONS.

Endovascular salvage for contained rupture of gastroduodenal artery aneurysm presented with obstructive jaundice

Gastroduodenal artery (GDA) aneurysms are rare but lethal conditions when ruptures develop. Most common clinical presentation are gastrointestinal hemorrhage and abdominal pain. Obstructive jaundice is unusual. Computed tomography and angiography are useful tools for diagnosis and treatment plan. Any GDA aneurysm should be considered for definitive treatment. Recently, endovascular intervention has gained popularity for its safety and efficacy. Here, we described a patient of GDA pseudoaneurysm presented with generalized jaundice and was treated successfully with endovascular intervention.

Visceral artery aneurysms: Incidence, management, and outcome analysis in a tertiary care center over one decade

Objectives

To evaluate the incidence, management, and outcome of visceral artery aneurysms (VAA) over one decade.

Methods

233 patients with 253 VAA were analyzed according to location, diameter, aneurysm type, aetiology, rupture, management, and outcome.

Results

VAA were localized at the splenic artery, coeliac trunk, renal artery, hepatic artery, superior mesenteric artery, and other locations. The aetiology was degenerative, iatrogenic after medical procedures, connective tissue disease, and others. The rate of rupture was much higher in pseudoaneurysms than true aneurysms (76.3 % vs.3.1 %). Fifty-nine VAA were treated by intervention (n = 45) or surgery (n = 14). Interventions included embolization with coils or glue, covered stents, or combinations of these. Thirty-five cases with ruptured VAA were treated on an emergency basis. There was no difference in size between ruptured and non-ruptured VAA. After interventional treatment, the 30-day mortality was 6.7 % in ruptured VAA compared to no mortality in non-ruptured cases. Follow-up included CT and/or MRI after a mean period of 18.0 ± 26.8 months. The current status of the patient was obtained by a structured telephone survey.

Conclusions

Pseudoaneurysms of visceral arteries have a high risk for rupture. Aneurysm size seems to be no reliable predictor for rupture. Interventional treatment is safe and effective for management of VAA.

Key Points

• Diagnosis of visceral artery aneurysms is increasing due to CT and MRI.

• Diameter of visceral arterial aneurysms is no reliable predictor for rupture.

• False aneurysms/pseudoaneurysms and symptomatic cases need emergency treatment.

• Interventional treatment is safe and effective.

Open repair, endovascular repair, and conservative management of true splenic artery aneurysms

OBJECTIVE

True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs.

METHODS

A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions.

RESULTS

Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P = .04).

CONCLUSIONS

EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.

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.

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.

Hepatic artery aneurysm developing after Billroth's operation

In this report we review the unusual case of a patient with a common hepatic artery aneurysm presenting 30 years after a Billroth's II resection. A 65-year-old man with epigastric pain and 10 kg of weight loss in the previous 6 months was referred to our clinic. Computed tomography revealed the presence of an aneurysm of the common hepatic artery (HAA) of 35 mm. This HAA was surgically excluded by aneurysmectomy and prosthetic bypass. Intraoperatively we observed extensive peritoneal adhesions and connective tissue formation in the region of the hepatoduodenal and hepatogastric ligaments, and the outer wall of the HAA was tightly affixed to the root of the transverse mesocolon by connective adhesions. Retraction of the adhesions slowly brought about a continued stretching and thinning of the arterial wall likely caused the HAA.

Celiacobihepatic venous bypass for liver revascularization in a patient with intrahepatic contained rupture of a common hepatic artery aneurysm

Visceral artery aneurysms are rare, often incidental findings due to unspecific or no symptoms. We report a unique case of a 54-year-old patient with a contained rupture of a common hepatic artery aneurysm, without panarteritis nodosa or immunoglobulin G4 association, into the right liver hilum, that led to shock, cholestasis, and liver function impairment. Aneurysm resection and cholecystectomy, followed by revascularization with a great saphenous vein celiacobihepatic bypass and Roux-en-Y hepaticojejunostomy were performed. The patient was discharged 13 days later. Liver function was normal, and the revascularization patency was confirmed at follow-up at 3 and 12 months.

Unusual upper gastrointestinal bleeding: Ruptured superior mesenteric artery aneurysm in rheumatoid arthritis

This case report describes an unusual case of upper gastrointestinal (UGI) bleeding caused by a ruptured superior mesenteric artery (SMA) aneurysm in the duodenum in a patient with rheumatoid arthritis. The patient presented with UGI bleeding and hemorrhagic shock. Emergency UGI endoscopy could not identify the source of the bleeding because of excessive blood clots under the second portion of the duodenum. An SMA aneurysm with active contrast extravasation was diagnosed by computed tomography. The aneurysm, together with the fourth portion of the duodenum and the proximal portion of the jejunum, was surgically resected, and the SMA was skeletonized. On postoperative day 15, the patient was discharged from hospital under satisfactory conditions. Rheumatoid arthritis has been known to cause a wide spectrum of manifestations, and an SMA aneurysm is an unusual extra-articular manifestation. An SMA aneurysm rupture presenting as upper gastrointestinal bleeding is a rare complication with a high mortality rate. The clinician must be alert to this potential issue to achieve rapid diagnostic confirmation, and immediate surgical or radiological intervention.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.

Total endovascular solution for complex visceral aneurysms

Visceral aneurysms are rare in the general population (<2%), and the most serious complication is represented by aneurysm rupture. The use of stent grafts to exclude visceral aneurysms is described in several reports but is reserved for patients with favorable anatomy. We report here on a hepatic artery pseudoaneurysm in a liver transplant patient and a patient with an aneurysmal vein graft degeneration of a renal bypass, both with no suitable proximal neck for standard stent grafting. Both patients were successfully treated with a custom-made aortic endograft with a single fenestration for the hepatic or renal artery, together with a visceral covered stent. Although initial results are promising, long-term follow-up is required to assess durability.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.

Pancreaticoduodenal artery aneurysm involving papilla of vater successfully treated with endovascular approach despite intraoperative rupture

An 81-year-old woman presented with dizziness and nasal bleeding. Gastrointestinal fiberscopy (GIF) showed a pulsatile aneurysm in the duodenum, and that the orifice of the papilla of Vater was involved. Three-dimensional computed tomography imaging showed an unruptured aneurysm in the pancreatic duodenal arcade. The patient underwent an emergent endovascular embolization of the donor arteries using coils and gelatin sponge particles. She was discharged without any complications. This case was extremely rare because of the anatomic location of the unruptured pancreaticoduodenal artery aneurysm and the fact that it involved the papilla of Vater, was detected with GIF, and was successfully treated endovascularly.

Hepatic artery pseudoaneurysms: a single-center experience

BACKGROUND

The management of hepatic artery aneurysms has evolved largely because of changes in etiology and presentation, and advances in endovascular therapy. Although many case reports have been published on the condition, few have been from developing countries and few have compared patient outcomes after angioembolization and surgery.

PATIENTS AND METHODS

This study retrospectively analyzed patients admitted with hepatic artery pseudoaneurysms between 1999 and 2011. The patients were divided into those who presented before 2007 (surgery group) and after 2007 (embolization group), and their demographic characteristics, presentation, and investigations; the technical and clinical success of treatment; and in-hospital mortality were studied.

RESULTS

A total of 29 patients were studied, 17 of whom men, with a median age of 42 years. Of these 29 patients, 8 underwent surgery and 21 had embolization (24 total procedures). No mortality was seen in the surgery group, and their hospital stay was longer and transfusion requirement higher than those in the embolization group, in whom technical success was achieved in all procedures and clinical success in 19 of 24 (79%). Clinical failure and complications were seen when common hepatic artery aneurysms were embolized. Three patients (14%) died in the embolization group from ischemic hepatitis and bowel gangrene, coagulopathy, and a leak from a previous pancreaticojejunal anastomosis.

CONCLUSIONS

Both surgery and angioembolization are equally effective for hepatic artery pseudoaneurysms, but the latter has the advantages of more rapid bleeding control, shorter hospital stay, and lower transfusion requirement.

Pancreaticoduodenal artery pseudoaneurysm caused by segmental arterial mediolysis: a case report of surgical treatment

A 64-year-old woman underwent surgical resection of a posterior inferior pancreaticoduodenal arterial aneurysm in the subacute phase of acute aortic dissection (AAD). Concomitantly, a distal pancreatectomy was also required. The aneurysm was approximately 20 mm in diameter. Surgical resection of the aneurysm was performed because endovascular treatment was considered to be technically difficult due to dissecting lesions that had remained at the abdominal aorta. Histopathological findings suggested this aneurysm to be a pseudoaneurysm, which had arisen as a result of segmental arterial mediolysis. Approximately 1 year after surgery, no recurrence of the aneurysms was detected.

Unenhanced magnetic resonance angiography with time-spatial labeling inversion pulse for evaluating visceral artery aneurysms after endosaccular packing with detachable coils: preliminary results

The aim of this brief report is to compare unenhanced magnetic resonance (MR) angiography with time-spatial labeling inversion pulse (Time-SLIP) with conventional digital subtraction angiography (DSA) in assessing degree of saccular visceral artery aneurysm (VAA) occlusion after endosaccular packing with detachable coils. Eight patients with VAAs (five renal and three splenic artery aneurysms) were enrolled in this study. VAA occlusion rates based on Time-SLIP MR angiography were complete occlusion in four patients, neck remnants in three patients, and body filling in one patient. These findings corresponded with the DSA findings.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.

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.

Aneurysm-osteoarthritis syndrome with visceral and iliac artery aneurysms

OBJECTIVE

Aneurysms-osteoarthritis syndrome (AOS), caused by SMAD3 mutations, is a recently described autosomal-dominant syndrome characterized by arterial aneurysms, tortuosity, and aortic dissections in combination with osteoarthritis. Our objective was to evaluate the AOS-related vascular consequences in the visceral and iliac arteries and raise awareness for this aggressive syndrome among vascular specialists.

METHODS

All AOS patients were monitored regularly according to our clinical AOS protocol. The study included those with one or more visceral aneurysms or tortuosity, or both. Clinical and surgical data were obtained from record abstraction.

RESULTS

The study included 17 AOS patients (47% men) aged 47±13 years. A total of 73 aneurysms were encountered, of which 46 were located in the abdomen. The common iliac artery was most commonly affected (37%), followed by the superior mesenteric artery (15%), celiac trunk (11%), and splenic artery (9%). Rapid aneurysm growth≤1 year was found in three arteries (gastric, hepatic, and vertebral artery). Furthermore, arterial tortuosity was noted in 94% of patients. Four patients underwent six elective (endo) vascular interventions for aneurysms in the iliac, hepatic, gastric, or splenic artery, without major perioperative or postoperative complications.

CONCLUSIONS

AOS predisposes patients to widespread visceral and iliac artery aneurysms and extreme arterial tortuosity. Early elective aneurysm repair should be considered because the risk of aneurysm rupture is estimated to be very high and elective (endo) vascular interventions were not complicated by fragility of arterial tissue. Given the aggressive behavior of AOS, it is of utmost importance that vascular specialists are aware of this new syndrome.

Coil embolization of a gastroduodenal artery pseudoaneurysm secondary to cholangitis: technical aspects and review of the literature

A 72-year-old woman with end-stage renal disease was admitted with right upper quadrant pain, hypotension, an elevated bilirubin, and leukocytosis. A computed tomography scan showed a dilated common bile duct and an associated 4.5 cm gastroduodenal artery pseudoaneurysm. The pseudoaneurysm was coil embolized successfully while maintaining dual access from the brachial and femoral arteries using the "body floss" technique. Subsequently, the patient underwent endoscopic treatment for her obstructive jaundice. We report on the technical aspects of this case and review the literature.

Visceral artery aneurysms

Visceral artery aneurysms (VAAs) are a rare condition, in case of a rupture they have a high mortality rate up to 70%. Visceral artery aneurysms are seen more often these days with the more widespread use of computed tomography and angiography. There are various options for treating VAAs; open surgical repair, endovascular treatment, and laparoscopic surgery. We report 5 cases of visceral aneurysms, all treated differently--ligation, aneurysmectomy (with splenectomy), emergency and elective coil embolization, and conservatively. We will further give a review of the literature on etiology, diagnosis, and treatment options.