Treatment of a Celiac Trunk Aneurysm Close to the Hepato-splenic Bifurcation by Using Hepatic Stent-graft Implantation and Splenic Artery Embolization

Endovascular Oriented Classification and Treatment of Celiac Trunk Aneurysms: 10 Years Experience

OBJECTIVE

To propose an endovascular-oriented classification of celiac trunk aneurysms (CTa) and discuss single center results of this rare pathology.

METHODS

Data of all patients admitted to our institution for CTa from 2011 to 2021 were prospectively collected. Of them, those who underwent endovascular treatment were retrospectively analyzed. All preoperative CT scans were reviewed and CTa were classified in 4 different configurations based on progressive distal landing zone. We excluded from the classification all cases with median arcuate ligament syndrome (MALS), patients with coexistent aortic dilation or no endovascular proximal neck. Preoperative demographics, intraoperative data and post-operative complications were recorded. All-cause late mortality and complications were identified through a review of office charts and telephone assessment.

RESULTS

During the study period 19 patients were referred to our Institution for CTa. Ten patients underwent endovascular treatment (ET). In 6 cases a watchful waiting strategy was adopted, 2 (10.5 %) patients refused ET and one patient without suitable proximal landing zone (< 10 mm) was not proposed to open surgical repair for surgical contraindication but is followed by strict instrumental and clinical evaluation. Six (60%) patients presented type 2 CTa; all of them underwent ET requiring positioning of covered stent-graft and SA embolization. Three (30%) patients presented type 3 CTa; all of them underwent ET with covered stent-graft deployment over the GDA with preliminary embolization. One (10%) patient presented type 4 CTa that was treated by means of covered stent-graft deployment along the right hepatic artery with left hepatic artery embolization. Overall, no major complications and perioperative mortality was observed.

CONCLUSION

Celiac trunk aneurysms are rare, and no classifications have still been presented. Stent-graft exclusion provides excellent short-term outcome with no significant morbidity and mortality rate when technically feasible.

Quadrifurcation Variants of the Celiac Trunk

BACKGROUND

The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate.

METHODS

The CT quadrifurcations were documented on 112 computed tomography angiograms.

RESULTS

Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P = 0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA + right hepatic artery+GDA pattern, type 2 had an HGT + right inferior phrenic artery + CHA + SA pattern, type 3 had a gastrophrenic trunk + left inferior phrenic artery+CHA + SA pattern, type 4 showed an left gastric artery + CHA + SA + left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one.

CONCLUSIONS

Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Ligation of symptomatic celiac artery aneurysm without vascular reconstruction: Utilizing the natural collateral circulation of the celiac axis: A case report

INTRODUCTION

Celiac artery aneurysm is very rare visceral artery aneurysm. Symptomatic and ≥ 2.5 cm sized aneurysm requires treatment. Excision and revascularization is the most commonly employed procedure.

CASE PRESENTATION

We report a case of ligation and excision of celiac artery aneurysm extending onto the splenic and hepatic arteries without vascular reconstruction. The patient was a 52 year old lady who was evaluated for abdominal pain and was found to have a celiac artery aneurysm involving the hepatic and splenic arteries. She was evaluated with computerized tomography and digital subtraction angiography of the abdominal vessels. These confirmed good natural collaterals from the branches of superior mesenteric artery supplying the liver, stomach and spleen. We performed ligation and excision of the aneurysm and ligation and division of hepatic, splenic and left gastric arteries as the aneurysm was extending on to these vessels, without any vascular reconstruction, utilizing the natural collaterals from the superior mesenteric artery.

DISCUSSION

Ligation of celiac artery aneurysm without revascularization is often done in emergency situations. Excision and revascularization is the treatment of choice to ensure adequate blood supply to liver, spleen and stomach. We could utilize the natural collateral circulation of celiac artery from superior mesenteric artery avoiding a complex procedure of revascularization.

CONCLUSION

We present this because of the rarity of the disease as well as rarity of the technique of not performing vascular reconstruction. We emphasize on the pre-operative and operative evaluation of collateral circulation with conventional angiography and intraoperative Doppler respectively.

Endovascular treatment with stenting of celiac artery aneurysms

This study aimed to detail the clinical outcomes of patients suffering from celiac arterial aneurysm (CAA) that underwent treatment via stent occlusion.This is a single-center, retrospective study. A total of 8 consecutive CAA patients were treated via stent occlusion from March 2014 to September 2018 at our hospital. Follow-up computed tomography was conducted after stenting at 1, 3, 6, and 12-month time points and every year thereafter. Both short- and long-term outcomes were assessed.In total, 8 stents were inserted into these 8 patients, with 2 being uncovered and 6 being covered stents. In 2 patients, stents were positioned in the celiac artery, while in the remaining 6 patients they were placed in the celiac and common hepatic arteries. The median operative duration was 66 minutes. No patients exhibited procedure-associated complications, and the median follow-up duration was 39 months (range: 18-72). Abdominal contrast-enhanced CT analyses of these patients exhibited stent and distal artery patency in 100% of patients, together with CAA obliteration. Visceral necrosis did not occur in any patients over the follow-up period.Stent occlusion can be safely and effectively used to treat CAA patients.

Endovascular stent repair of celiac arterial aneurysm

The aim of this study was to evaluate the safety and clinical effectiveness of endovascular stent repair of celiac arterial aneurysm (CAA).From January 2015 to December 2018, 11 patients (7 males, 4 females with a mean age of 52.2 ± 7.9 years) underwent endovascular stent repair of CAA in our center. A covered stent was used to occlude the CAA neck. Follow-up was performed 2 weeks and 1, 3, 6, and 12 months following surgery and yearly thereafter. Rates of technical success, treatment-related complications, and long-term outcome were analyzed.Each patient was placed with 1 stent for repair of CAA. Stent was placed in the celiac and common hepatic arteries for 10 patients and was placed in the celiac artery for 1 patient. The duration of the procedure ranged from 50 to 75 minutes (mean 63.2 ± 7.2 minutes). The rate of technical success of the endovascular stent repair was 100%. No patient experienced CAA rupture or instant endoleak during or after stent insertion. Abdominal pain was relieved progressively after stent insertion. All patients were followed-up for 6 to 48 months (mean 22.4 ± 10.8 months). All patients were alive during the follow-up. No endoleaks were experienced during follow-up with 100% stent patency rate. No patient suffered splenic, hepatic, or bowel infarction during follow-up.Endovascular stent repair is a safe, simple, and effective treatment for patients with CAA.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Endovascular Repair of Concomitant Celiac and Splenic Artery Aneurysms Using a Combination of Coil Embolization and Aortic Cuff Stent Graft

Large celiac artery aneurysms are associated with a high rupture and mortality risk. Traditionally, open surgical repair has been the mainstay of treatment. Endovascular alternatives have been increasingly described, ranging from coil embolization to exclusion with covered stent grafts. Certain features such as a short wide neck, small vessel diameters, and severe vessel tortuosity can limit these two options. We describe a 75-year-old man with a splenic and celiac trunk aneurysm that was treated using a combination of coil embolization to occlude the outflow artery and aneurysm sac, followed by an aortic stent graft cuff to block the inflow. This resulted in successful exclusion of the splenic and celiac artery aneurysms while preserving flow to both the spleen and liver through collateral pathways.

Laparoscopic ligation of celiac trunk and splenic artery aneurysms with function preservation

Celiac trunk aneurysms (CTAs) are rare and usually asymptomatic. Although most of these aneurysms can be treated with percutaneous embolization, some uncommon locations of the aneurysm may make this approach impossible. We report a patient with a celiac trunk aneurysm (CTA) and a proximal splenic artery aneurysm (SAA). Due to the size and location of these two aneurysms, after multidisciplinary discussion, endovascular management was considered inappropriate and they were treated by laparoscopic ligation of the two aneurysms and revascularization. This procedure offers good postoperative recovery with good preservation of the visceral function. Some collateral vessels in the viscera were obvious on postoperative day 7.

Endovascular Repair of Celiac Artery Aneurysm with the Use of Stent Grafts

PURPOSE

To determine the feasibility, safety, and long-term outcome of stent-graft insertion for endovascular repair of celiac artery aneurysm (CAA).

MATERIALS AND METHODS

From January 2010 to April 2015, 10 patients (three men and seven women; mean age, 51.6 y ± 12.1; age range, 39-81 y) with CAAs underwent endovascular repair via stent-graft insertion in a single center. During treatment, the stent graft was placed at the celiac and common hepatic arteries. Standard follow-up protocol included abdominal CT angiography and clinical examinations at 1, 3, 6, and 12 months and annually thereafter. Follow-up was performed every 2-3 months via telephone for the duration of the follow-up period to confirm patients' general condition. Data on patient characteristics, technical success, procedure-related complications, and follow-up were collected and analyzed retrospectively.

RESULTS

CAA was successfully sealed by the stent graft in all patients. The common hepatic artery was patent after stent insertion in all patients, and no procedure-related complication occurred. All patients were followed up for 1-64 months (mean, 19.3 mo ± 18.9). Abdominal CT angiography demonstrated no endoleak, stent obstruction, or splenic infarction during follow-up. All patients experienced CAA shrinkage with formation of thrombi or increase in the quantity of thrombi in the CAA sac.

CONCLUSIONS

Stent-graft insertion is a safe and effective method for endovascular repair of CAA.

Endovascular treatment of aneurysm of splenic artery arising from splenomesentric trunk using stent graft

We report a rare case of aneurysm of splenic artery arising anomalously from the superior mesenteric artery (SMA). The aneurysm was treated successfully by coil embolization of the splenic artery distal to aneurysm and then deploying a stent graft in the SMA. A combination of stent graft and coil embolization for the treatment of aberrant splenic artery aneurysm has been reported only once. We describe the imaging findings and the endovascular procedure in this patient.

A new flow control technique using diluted epinephrine in the N-butyl-2-cyanoacrylate embolization of visceral artery pseudoaneurysms secondary to chronic pancreatitis

Although n-butyl-2-cyanoacrylate (NBCA) has been used as an effective liquid embolization material, its indication for pseudoaneurysms has seemingly been limited because of the technical difficulties of using NBCA, such as reflux to the parent artery and causing significant infarction. Thus, considerable skill in using NBCA or a device to control blood flow during its polymerization is required to achieve embolization without severe complications. We report our new technique for controlling blood flow using diluted epinephrine in transcatheter arterial NBCA embolization of five pseudoaneurysms in four cases secondary to hemosuccus pancreaticus.

Modified stent-supported coil embolization for treatment of a splenic artery pseudoaneurysm

A patient presented 2 weeks after distal pancreatectomy and splenectomy with increased bloody output from his surgical drain. Catheter angiography found an enlarging splenic artery stump pseudoaneurysm. During the procedure, there was concern that nontarget embolization may occur, given the short splenic artery remnant. Pseudoaneurysm thrombosis was subsequently achieved using a variation of stent-supported coil embolization. At 3-month follow-up, the patient had no recurrent bleeding from the surgical site. Although this technique has been described in the treatment of neurovascular and renal artery aneurysms, it is applicable to, and readily adapted for, use in visceral arterial procedures.

Endovascular Treatment of Pseudoaneurysm of the Common Hepatic Artery with Intra-aneurysmal Glue (N-Butyl 2-Cyanoacrylate) Embolization

A 40-year-old man, a chronic alcoholic, presented with acute epigastric pain. Selective celiac arteriography showed a pseudoaneurysm arising from the common hepatic artery. We hereby describe a technical innovation where complete pseudoaneurysm exclusion was seen after intra-aneurysmal N-butyl 2-cyanoacrylate (glue) injection with preservation of antegrade hepatic arterial flow and conclude that intra-aneurysmal liquid injection may have potential as a therapeutic option to reconstruct a defective vessel wall and thereby maintain the antegrade flow.