Visceral artery aneurysm rupture

True aneurysms of the pancreaticoduodenal artery: successful non-operative management

BACKGROUND

True aneurysms of the pancreaticoduodenal arteries (PDA) are rare, often ruptured, and treated by operation with a high level of mortality. We review our experience since 1994 and that of the literature in the past 20 years to provide management guidelines for this uncommon clinical entity. About 100 cases of PDA aneurysms are described in the literature, most of them as case report.

METHODS

Nine patients were admitted to our institution between 1994 and 2004 for true aneurysm of the PDA. They were analyzed with regard to the clinical presentation, radiologic findings, management, and outcome.

RESULTS

Seven patients presented for sudden abdominal pain from retroperitoneal hemorrhage. In 2 patients PDA aneurysm was an incidental finding. Abdominal ultrasonography, computed tomographic scan, and visceral angiography was carried out in all cases. Aneurysms ranged from 4 to 30 mm (median, 16.5) in size. Celiac axis stenosis or occlusion was identified in 3 patients. One patient required emergent laparotomy for intra-abdominal rupture of a retro peritoneal hematoma. Therapeutic embolization was successful in all 9 patients. All except 1 are alive with no evidence of recurrence of the true PDA aneurysm with a mean follow-up of 59 months.

CONCLUSIONS

The authors recommend definitive treatment of all true aneurysms PDA because of their high risk of rupture. Ruptured PDA aneurysms suspected on CT-scan requires emergent visceral angiography and selective embolization as definitive treatment.

[Visceral artery aneurysms]

INTRODUCTION

The aim of this study was to review our experience in the diagnosis and treatment of visceral artery aneurysms.

MATERIAL AND METHOD

We performed a retrospective study through review of the medical records of patients diagnosed with visceral aneurysms from 1984 to 2003. Diagnosis, treatment and follow-up were analyzed.

RESULTS

Thirty-two aneurysms were diagnosed in 27 patients (17 men and 10 women). There were 12 aneurysms of the splanchnic artery, six of the hepatic artery, five of the celiac trunk, three gastroduodenal, one jejunal, one pancreaticoduodenal, one superior mesenteric--associated with a splanchnic, renal and celiac trunk aneurysm--, one inferior mesenteric, one cystic artery and one case of parenchymatous hepatorenal microaneurysms. Eight aneurysms were not treated. Three underwent embolization. One aneurysm was excluded with a covered endoprosthesis. Twenty aneurysms were treated surgically. Ligature or exclusion was performed in 11 patients, hepatic lobectomy in one patient, resection with revascularization in four patients, endoaneurysmorrhaphy in three patients and simple suture was performed in one hepatic artery pseudoaneurysm.

CONCLUSIONS

Current diagnostic techniques favor early and sometimes minimally invasive treatment. Splanchnic aneurysms are more difficult to diagnose and require highly varied repair techniques.

Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

Giant splenic artery aneurysms: case report and review of the literature

Although splenic artery aneurysms (SAAs) are the most common visceral aneurysms, giant SAAs >10 cm in diameter have rarely been reported. We present the case of a 67-year-old asymptomatic man who was diagnosed with a 15-cm SAA in the absence of a clear etiologic factor. The patient underwent open surgical repair. A medial visceral rotation was performed to gain good vascular control and subsequently the aneurysm was ligated from within. A systematic review was carried out, allowing us to analyze 12 cases of giant SAAs >10 cm published to date. The difference in terms of demographics, clinical presentation, and arterial location between the giant SAA group and usual SAAs may indicate a different underlying physiopathology that remains unclear at this time.

Mycotic Aneurysm of the Celiac Trunk: From Early CT Sign to Rupture

We present a case of the rapid development and rupture of a mycotic celiac trunk aneurysm. Initially on multislice computed tomography (ms-CT) there was a normal celiac trunk with minimal haziness of the surrounding fat. Only 2 weeks later the patient went into hypovolemic shock due to a ruptured celiac aneurysm. Although aneurysms of the visceral arteries are rare, they are of major clinical importance as they carry a life-threatening risk of rupture. This case illustrates the use of ms-CT in detecting and evaluating visceral aneurysms, in order to prevent emergency operation.

Is Endovascular Therapy the Preferred Treatment for All Visceral Artery Aneurysms?

Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases.

Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.

Visceral Artery Aneurysms

Visceral artery aneurysms are an uncommon form of vascular disease, yet are important to the practicing vascular surgeon because of the potential for rupture or erosion into an adjacent viscus, resulting in life-threatening hemorrhage. Many visceral artery aneurysms still present with rupture, which often results in the death of the patient. An aggressive approach to the diagnosis and management of these aneurysms is warranted. The treatment of visceral artery aneurysms has significantly evolved over the past decade. Open surgical repair has been the standard method of treatment, usually by aneurysm resection or simple ligation. Open surgical repair is durable with excellent long-term results, but is accompanied by the morbidity and mortality of a major abdominal operation. Over the past decade, catheter-based treatments with coil embolization and placement of stent grafts have emerged as promising therapies to treat visceral artery aneurysms. These have provided safe and effective short-term results and should be preferentially used in selected patients at high surgical risk.

Unexpected sudden death due to a spontaneous rupture of a gastric dissecting aneurysm: an autopsy case suggesting the importance of the double-rupture phenomenon

Gastric dissecting aneurysm is a very rare lesion with a potential risk of fatal rupture. Differentiating this from a traumatic lesion may be important in forensic casework. We report an autopsy case of sudden death due to a clinically overlooked spontaneous rupture of gastric dissecting aneurysm. A 91-year-old Japanese male visited a hospital with complaints of back pain and general fatigue, and then died at his home about 4 h later. Postmortem examination revealed massive hemoperitoneum and a subserosal hematoma originating from a vascular lesion at the lesser gastric curvature with a serosal tear. The histological findings were compatible with segmental arterial mediolysis (SAM). The pathological findings and clinical course suggested the possible 'double-rupture phenomenon' (delayed fatal rupture). This case suggested the importance of careful investigation such a vascular lesion in medico-legal practice, not only to differentiate from traumatic injury but also to investigate the process of dying.

Surgical management of peripancreatic arterial aneurysms

Peripancreatic artery aneurysms--gastroduodenal (GDA) and pancreaticoduodenal (PDA)--are highly unusual. We report 4 such aneurysms and have collated reports of true peripancreatic artery aneurysms based on an extensive review of the English literature. From this review, patient characteristics, clinical behavior, outcome and management strategies are assessed.

Treatment of multiple visceral aneurysms in a 20-year-old patient

A 20-year-old man with a history of cerebral aneurysm and a contained rupture of an intrasplenic aneurysm had a fusiform celiac and splenic artery aneurysm at presentation. This was repaired with excision of the celiac artery, aortohepatic bypass grafting, splenic artery ligation, and splenectomy.

Arterial aneurysms of the lienorenal axis during pregnancy

Rupture of an aneurysm of the renal or splenic arteries remains a rare but catastrophic complication of pregnancy with a generally dismal prognosis for both mother and fetus. Improvements in abdominal imaging for incidental conditions are unlikely to lead to earlier diagnosis of such abnormalities antenatally, hence cardiovascular collapse during pregnancy is likely to continue to be their usual presentation. Two cases are described, both of splenic artery rupture. The literature of these rare events is reviewed.

Splenic artery aneurysms: two decades experience at Mayo clinic

Although rare, splenic artery aneurysms (SAAs) have a definite risk of rupture. The optimal management of these aneurysms remains elusive. A retrospective chart review of all patients treated at our institutions with the diagnosis of SAA from January 1980 until December 1998 was undertaken. Follow-up was obtained via chart review and by direct phone contact of the patient or relative. No specific protocol was followed for management. From analysis of the patient data we concluded that although SAAs may rupture, not all intact aneurysms need intervention. Calcification does not appear to protect against rupture, although beta-blockade may be protective. Growth rates of SAA are slow and growth is infrequent. Selective management of SAAs is safe. Open ligation or transcatheter embolization should be considered for symptomatic aneurysms, for aneurysms > or = 2 cm in size, or for any SAA in women of childbearing years.

[Management of visceral artery aneurysms. Retrospective study of 23 cases]

STUDY AIM

To evaluate symptoms and results of the treatment of aneurysms of digestive arteries.

PATIENTS AND METHOD

Retrospective study of 23 patients (14 male and 9 female, mean age = 51 years) treated in two departments of academic hospital. We studied the aneurysms characteristics (location, number, size, etiology) the type of treatment, and occurrence of post-operative complications.

RESULTS

The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastroepiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occurred in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed.

CONCLUSION

The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contra-indication of surgery and when aneurysms are poorly accessible to surgery.