Visceral artery aneurysms

Treatment strategy for splenic artery aneurysms and novel classification based on imaging

OBJECTIVE

The incidence of splenic artery aneurysms (SAAs) has increased with advances in imaging techniques, necessitating a comprehensive classification to guide treatment strategies. This study aims to propose a novel classification system for SAAs based on aneurysm characteristics and to review treatment outcomes at our center.

METHODS

This retrospective study included 113 patients with SAAs admitted to Peking Union Medical College Hospital from January 2019 to December 2023, assessed using computed tomography angiography or digital subtraction angiography. A new classification system was devised based on the aneurysm location, morphology, integrity, and parent artery anatomy. Treatment strategies were determined based on these characteristics, with interventions ranging from endovascular therapy to laparoscopic and open surgery. Patients were followed up after the intervention to assess mortality, complications, reinterventions, and aneurysm-related outcomes.

RESULTS

The study cohort of 113 patients with 127 SAAs had a predominance of female patients (63.7%) and a mean age of 52.7 years. The SAAs were classified into five types, with type I being the most common. The intervention techniques varied across types, with sac embolization, covered stent implantation, and artery embolization being the most frequently used. The overall technical success rate was 94.7%, with perioperative complication and reintervention rates of 25.0% and 0.9%, respectively, and no deaths within 30 days after the intervention. The median follow-up duration was 21 months, with overall complications rate of 3.5% and no aneurysm-related complications or deaths.

CONCLUSIONS

The proposed classification system effectively guides the selection of treatment strategies for SAAs, incorporating key anatomical and morphological features. This system facilitated high technical success and low complication rates, underscoring the importance of tailored techniques in managing SAAs.

Hybrid approach to intrapancreatic inferior pancreaticoduodenal aneurysm repair

Pancreaticoduodenal artery aneurysms (PDAAs) are an extremely rare visceral artery aneurysm subtype, usually managed by endovascular techniques. We report the case of a 57-year-old man with an intrapancreatic, inferior PDAA abutting the superior mesenteric artery (SMA). This location, in relation to the SMA, risks SMA thrombosis using an endovascular-only approach. Our approach consisted of open exploration and ligation of the inferior PDAA junction at the SMA, followed by endovascular coil embolization of the aneurysm. This case serves as a reminder that although many vascular diseases can be treated with less invasive endovascular strategies, open surgery can sometimes be the safer alternative.

Deep learning algorithm applied to plain CT images to identify superior mesenteric artery abnormalities

OBJECTIVES

Atypical presentations, lack of biomarkers, and low sensitivity of plain CT can delay the diagnosis of superior mesenteric artery (SMA) abnormalities, resulting in poor clinical outcomes. Our study aims to develop a deep learning (DL) model for detecting SMA abnormalities in plain CT and evaluate its performance in comparison with a clinical model and radiologist assessment.

MATERIALS AND METHODS

A total of 1048 patients comprised the internal (474 patients with SMA abnormalities, 474 controls) and external testing (50 patients with SMA abnormalities, 50 controls) cohorts. The internal cohort was divided into the training cohort (n = 776), validation cohort (n = 86), and internal testing cohort (n = 86). A total of 5 You Only Look Once version 8 (YOLOv8)-based DL submodels were developed, and the performance of the optimal submodel was compared with that of a clinical model and of experienced radiologists.

RESULTS

Of the submodels, YOLOv8x had the best performance. The area under the curve (AUC) of the YOLOv8x submodel was higher than that of the clinical model (internal test set: 0.990 vs 0.878, P =.002; external test set: 0.967 vs 0.912, P =.140) and that of all radiologists (P <.001). The YOLOv8x submodel, when compared with radiologist assessment, demonstrated higher sensitivity (internal test set: 100.0 % vs 70.7 %, P =.002; external test set: 96.0 % vs 68.8 %, P <.001) and specificity (internal test set: 90.7 % vs 66.0 %, P =.025; external test set: = 88.0 % vs 66.0 %, P <.001).

CONCLUSION

Using plain CT images, YOLOv8x was able to efficiently identify cases of SMA abnormalities. This could potentially improve early diagnosis accuracy and thus improve clinical outcomes.

Fenestrated endovascular aortic repair of a superior mesenteric artery aneurysm using carbon dioxide angiography and intravascular ultrasound

Superior mesenteric artery aneurysms are rare; however, current guidelines suggest they all require repair due to the high rupture and mortality rates, and endovascular repair is an effective management strategy. Iodinated contrast traditionally used in endovascular repair can cause significant complications, including severe allergic reactions and contrast-induced nephropathy in patients with chronic renal disease. Therefore, other imaging methods should be used during endovascular procedures to reduce these risks. We describe a unique and innovative approach using carbon dioxide angiography and intravascular ultrasound during fenestrated endovascular repair of an uncommon superior mesenteric artery aneurysm in a patient with severe contrast allergies.

Robotic resection for splenic artery aneurysm associated with neurofibromatosis type 1: a case report

BACKGROUND

Neurofibromatosis type 1 is an autosomal-dominant disease characterized by café-au-lait spots and neurofibromas, as well as various other symptoms in the bones, eyes, and nervous system. Due to its connection with vascular fragility, neurofibromatosis type 1 has been reported to be associated with vascular lesions, such as aneurysms. However, there have been few reports of abdominal visceral aneurysms associated with neurofibromatosis type 1. Furthermore, there have been no reports of robotic treatment of aneurysms associated with neurofibromatosis type 1. In this report, we describe the case of a patient with neurofibromatosis type 1 with a splenic artery aneurysm who was successfully treated with robotic surgery.

CASE PRESENTATION

This report describes a 41-year-old Asian woman with a history of neurofibromatosis type 1 who was referred to our hospital for evaluation of a 28 mm splenic artery aneurysm observed on abdominal ultrasound. The aneurysm was in the splenic hilum, and transcatheter arterial embolization was attempted; however, this was difficult due to the tortuosity of the splenic artery. Thus, we suggested minimally invasive robotic surgery for treatment and resection of the splenic artery aneurysm with preservation of the spleen. The postoperative course was uneventful, and the patient was discharged on the eighth day after surgery. At 1 year of follow-up, the patient was doing well, with no evidence of recurrence.

CONCLUSION

We encountered a rare case of splenic artery aneurysm in a patient with neurofibromatosis type 1 who was successfully treated with robotic surgery. There is no consensus on treatment modalities for neurofibromatosis-related aneurysms, and endovascular treatment is considered safe and effective; however, surgery remains an important treatment modality. Especially in patients with stable hemodynamic status, robotic surgery may be considered as definitive treatment. To our knowledge, this is the first successfully treated case of a splenic artery aneurysm in a patient with neurofibromatosis type 1.

Ruptured Mycotic Aneurysm of the Superior Mesenteric Artery: A Case Report

An infected (mycotic) aneurysm of the visceral arteries is an uncommon entity, which may arise from a secondary infection of a preexisting aneurysm or be due to degeneration from a primary infection. Mycotic aneurysms require prompt recognition and definitive treatment; otherwise, there can be devastating morbidity and mortality. We present the case of a 51-year-old female with HIV and Crohn's disease who presented with subacute abdominal pain, nausea, and vomiting and was found to have an ultimately fatal mycotic aneurysm of the superior mesenteric artery. In addition, we discuss the characteristic imaging features of mycotic aneurysms on computed tomography and magnetic resonance imaging.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Clinical Characteristics and Management of Peripancreatic Arterial Aneurysms: A 20-year Experience

Pancreaticoduodenal and gastroduodenal artery aneurysms (PDAAs and GDAAs) are rare visceral aneurysms. Considering the rupture risk regardless of size, treatment should be provided promptly. We reviewed the characteristics and management of peripancreatic aneurysms in a retrospective, single-center review of consecutive patients with PDAAs and GDAAs between 2000 and 2022. Demographics, clinical characteristics, radiologic features, treatment, and outcomes were recorded. Nineteen PDAAs and seven GDAAs were identified in 24 patients. The median sizes of the PDAAs and GDAAs were 21 mm (range: 8-50 mm) and 14 mm (range: 11-32 mm), respectively. There were 4 ruptured cases (15.4%). Ten aneurysms (38.5%) had concomitant visceral aneurysms, and 16 (61.6%) were associated with celiac pathology. Aneurysms were managed using endovascular in 12 (46.2%), surgical in 4 (15.4%), and combined methods in 3 (11.5%) cases; 7 patients (26.9%) were lost to follow-up or refused treatments. During a median 13.8-month follow-up (range: 1-147.6), two complications (7.7%) occurred including pancreatitis and coil migration into the superior mesenteric artery after embolization within 30 days. After 30 days, aorto-common hepatic artery bypass graft stenosis was identified in one PDAA. Depending on the characteristics of peripancreatic aneurysms, endovascular, surgical, and hybrid approaches might all be practical treatment options.

Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk

Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.

Women of Childbearing Age Have Higher Mortality Rates Following Inpatient Interventions for Splenic Artery Aneurysms

BACKGROUND

Splenic artery aneurysms (SAAs) are the most common type of splanchnic aneurysms. Current guidelines recommend repair of SAAs in women of childbearing age because maternal mortality is high. The purpose of this study was to evaluate treatment modalities and outcomes following inpatient SAA repair in women.

METHODS

The National Inpatient Sample database from 2012 to 2018 was queried. Patients with SAAs were identified using International Classification of Diseases (ICD) 9 and 10 codes. Childbearing age was defined as 14-49 years. The primary outcome was in-hospital mortality.

RESULTS

A total of 561 patients were admitted with a diagnosis of SAA between the years of 2012 and 2018. There were 267 (47.6%) female patients and of these 103 (38.6%) were of childbearing age. The overall in-hospital mortality rate was 2.7% (n = 15). There were no differences in rates of elective admissions or type of repair (open versus endovascular) between women of childbearing age and the remainder of the cohort. However, women of childbearing age were significantly more likely to undergo a splenectomy compared to the remainder of the cohort (32.0% vs. 21.4%, P = 0.028). Women of childbearing age had higher rates of in-hospital mortality compared to the remainder of the cohort (5.8% vs. 2.0%, P = 0.040). Subset analysis of the women of childbearing age revealed that those undergoing a splenectomy versus no splenectomy (14.8% vs. 2.6%, P = 0.039) and those treated in the nonelective versus elective setting (10.5% vs. 0%, P = 0.032) had higher rates of in-hospital mortality. There was 1 patient with an ICD code associated with pregnancy and they survived.

CONCLUSIONS

Women of childbearing age had higher in-hospital mortality following inpatient interventions for SAAs with all of the deaths occurring in the nonelective setting. These data support the pursuit of aggressive elective treatment of SAAs in women of childbearing age.

Splenic artery aneurysm with extrahepatic portal venous obstruction: A case report

Introduction and importance

Case presentation

Discussion

Conclusion

•

SAA with EHPVO is especially common during pregnancy.

•

Albeit rare, due to its high risk of fatality, it is extremely important for clinicians to diagnose and manage it well.

•

Surgery is the best modality of treatment for SAA with EHPVO with hypersplenism.

A unique proposed etiology for inferior mesenteric artery aneurysm: A case report

The etiology of large artery aneurysms has long been established as secondary to atherosclerotic disease and degenerative changes in the vessel walls. Less common, are aneurysms of the visceral arteries; the splanchnic and renal arteries. Rarer yet, are inferior mesenteric artery aneurysms, accounting for approximately 1% of visceral artery aneurysms. While causes range from inflammatory to congenital disease, a proposed etiology of proximal, solitary inferior mesenteric artery aneurysms, is correlated to the “jet disorder phenomenon,” first described in a 1990 case report by Sugrue, and Hederman. This paradigm states that aneurysm formation may occur secondary to celiac and superior mesenteric artery occlusion, causing increased, and turbulent arterial flow distally. We present a case that demonstrates a small inferior mesenteric artery aneurysm without findings of celiac or superior mesenteric artery stenosis or occlusion. This patient did, however, have a large thrombosed common hepatic artery aneurysm which may serve as an alternate cause of jet disorder phenomenon. The findings in this case offers support for focused screening of proximal arterial vasculature when an inferior mesenteric artery aneurysm is encountered.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

Open Repair of Large Hepatic Artery Pseudoaneurysm Without Collateral Circulation: A Case Report

Hepatic artery pseudoaneurysm is a rare arterial disease. This case report describes a patient with hepatic artery pseudoaneurysm who presented with recurrent epigastric pain over a 4-month period. Computed tomography angiography (CTA) showed aneurysmal enlargement of the hepatic artery measuring 55 mm × 46 mm. The angiographic information is as follows: (1) the common hepatic artery originated from the superior mesenteric artery; (2) the proper hepatic artery originated from the common hepatic artery; (3) the proper hepatic aneurysmal disease had no collateral circulation. After careful consideration, the patient underwent an open surgical repair (OSR). The patient recovered well without any associated complications. The 1-year follow-up of patients did not reveal any relevant complications. The treatment choice, puzzles, and reflections of this case are all discussed in this article.

Spontaneous rupturing of splenic artery aneurysm: Another reason for fatal syncope and shock (Case report and literature review)

Splenic artery aneurysm (SAA) is a rare condition; however, it is one of the most common intra-abdominal aneurysm. In the emergency department (ED), due to an uncommon cause of shock and syncope in SAA, it poses great diagnostic challenge for emergency physicians. Here we reported a case of spontaneous rupturing of SAA. A 47-year-old man presented to the ED for syncope and shock. As he had unstable hemodynamic, we gave him fluid resuscitation and point-of-care ultrasound (POCUS), free intraperitoneal fluid was identified on ultrasound, then hemorrhagic ascites was identified by a diagnostic abdominal paracentesis. The rare but life-threatening diagnosis of spontaneous rupturing of SAA was confirmed by contrast-enhanced Computed Tomography and surgery. Spontaneous SAA rupturing is a rare fatal condition which needs immediate diagnosis and management to achieve a favorable outcome. Though there are no risk factors, emergency physicians should consider SAA in the differential diagnosis of sudden collapse. Also, as an emergency physician, it is very important to be a master of first aid skills such as POCUS and treat patients according to the process.

Aneurysms of the superior mesenteric artery and its branches

OBJECTIVE

Aneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6-15% of all visceral artery aneurysms. We present our 30-year experience with management of aneurysms of the SMA and its branches at a high-volume referral center.

METHODS

A retrospective review of all patients diagnosed with an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. Clinical presentation, etiology, aneurysm shape and size, treatment modalities and outcomes were analyzed. Growth rate of aneurysms was estimated using linear regression.

RESULTS

131 patients with 144 aneurysms were reviewed. Patients were primarily male (64%) with a median age of 60. There were 57 fusiform, 30 saccular and 57 dissection-associated aneurysms. 41 patients had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). 35 patients (27%) were symptomatic at presentation. 111 aneurysms had multiple computed tomography angiograms (CTA) with a median follow-up of 43.6 months (IQR 10.6-87.2 months). Only 18 aneurysms (16%) had an estimated growth rate of ≥1.0 mm per year. Initial aneurysm size was significantly associated with growth rate for fusiform aneurysms (OR 1.13 [95% CI 1.0-1.3], P = 0.02) but not saccular (OR 0.91 [95% CI 0.76-1.1], P = 1.1) or dissection-associated aneurysms (OR 1.2 [95% CI 0.91-1.5], P = 0.20). Acute abdominal pain (OR 5.9 [95% CI 1.6-22]; P = 0.01) and chronic abdominal pain (OR 3.7 [95% CI 1.1-13]; P = 0.04) were associated with aneurysm growth. There were only two ruptures, both of whom had diagnoses of fibromuscular dysplasia and systemic lupus erythematosus, respectively, whom presented as rupture with no prior imaging. 46 patients (34%) underwent operative repair with an average aneurysm size of 24.0 ± 8.6 mm, including 36 open revascularizations and 8 endovascular procedures. There was one perioperative death and nine patients had perioperative complications (25%). There were 91 aneurysms <20 mm with an average size of 13.4 ± 3.1 mm followed over a median of 120.8 months (IQR 30.5-232.2 months), and there were no ruptures within this cohort during the follow-up period.

CONCLUSION

This study represents one of the largest series on aneurysms of the SMA and its branches. Aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms have a higher risk of growth. Aneurysms <20 mm of degenerative etiology may be safely monitored without treatment.

A Large Series of True Pancreaticoduodenal Artery Aneurysms

INTRODUCTION

True pancreaticoduodenal artery aneurysms (PDAA) are rare and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health-system from 2004-2019 with true PDAA, with a focus on risk factors, interventions, and patient outcomes.

METHODS

Patients were identified by querying a single health-system PACS database for radiographic reports noting a PDAA. Retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests.

RESULTS

A total of 59 true PDAA were identified. Forty aneurysms (68%) were intact (iPDAA) and 19 (32%) were ruptured (rPDAA) at presentation. Mean size of ruptured PDAA was 16.4 mm (median size 14.0 mm; range 10 - 42 mm) and mean size of intact PDAA was 19.4 mm (median size 17.5mm; range 8 - 88 mm), this difference was not statistically significant (P = 0.95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%, P=0.017), and less likely to have aneurysmal wall calcifications (6% vs 53%, P=0.002). Thirty-seven patients underwent intervention (63%); with eight (22%) undergoing concomitant hepatic revascularization (2 stents and 6 bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAA experienced an aneurysm related mortality of 10.5% while those with iPDAA experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. Ruptured PDAA showed a trend towards increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%, P=0.13).

CONCLUSIONS

These findings support previous reports that the rupture risk of PDAA is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both intact and ruptured PDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Hemosuccus Pancreaticus: A Comprehensive Review of Presentation Patterns, Diagnostic Approaches, Therapeutic Strategies, and Clinical Outcomes

Hemosuccus pancreaticus is a rare but potentially torrential and life-threatening cause of acute upper gastrointestinal bleeding. It is described as an intermittent hemorrhage from the major duodenal papilla via the main pancreatic duct. Peripancreatic pseudoaneurysm following chronic pancreatitis is a common underlying etiology. However, gastroduodenal artery pseudoaneurysm-related hemosuccus pancreaticus remains exceedingly rare in the etiological spectrum of upper gastrointestinal bleeding. We hereby delineate a rare case of hemosuccus pancreaticus associated with gastroduodenal artery pseudoaneurysm in a patient who initially presented with abdominal pain and hematochezia. He was successfully managed with coil embolization without recurrence or sequelae. Furthermore, we conducted a search of the MEDLINE (PubMed and Ovid) database for relevant studies on hemosuccus pancreaticus published between inception and September 15, 2021. The available clinical evidence on causes, presentation patterns, diagnosis, and management was analyzed and summarized. This article highlights the rarity, the intermittent nature of hemorrhage, and the lack of a standardized diagnostic approach for this elusive disease. Clinicians should remain cognizant of hemosuccus pancreaticus, especially in patients presenting with symptoms and signs of intermittent gastrointestinal bleeding and abdominal pain. Prompt diagnosis carries paramount importance in saving patients from repeat hospital admissions and disease-associated morbidity and mortality. Conventional angiography with coil embolization may constitute an effective treatment strategy.

Evolving Diagnostic and Therapeutic Options for Visceral Artery Aneurysms

BACKGROUND

Visceral artery aneurysms (VAAs) are associated with a very high mortality rate when ruptured and may present as a surgical emergency. Due to their rarity and varying pathophysiology, literature concerning the optimal management of VAAs is limited. This review evaluates the evolving management options for VAAs with a focus on open and endovascular repair.

METHODS

A combination of databases including OVID, PubMed and Medline were used to perform a literature search. Search terms employed include 'visceral artery aneurysms', 'angiography', '3D-volumetric rendering', 'management', 'open repair' and 'endovascular repair', amongst others.

RESULTS

3D modelling in conjunction with existing diagnostic techniques, such as computed tomography and angiography, may improve diagnostic sensitivity. The literature surrounding operative management of VAAs highlights the effectiveness of endovascular repair for anatomically suitable aneurysms. Advances in endovascular technologies may expand the type and number of aneurysms amenable to catheter-based treatment approaches. For aneurysms not amenable to endovascular treatment, or those with an emergency indication, open repair remains an appropriate management choice.

CONCLUSION

Although rare, VAAs pose a high mortality risk, especially when ruptured. Practical limitations that restrict current operative approaches may be overcome by recent developments including novel neurointerventional techniques that have been applied in VAA management.

The endovascular management of a 3.5-cm gastroduodenal artery aneurysm presenting with gastritis and recurrent pancreatitis

Visceral artery aneurysms (VAAs) are a rare entity. Within this subset of aneurysms, gastroduodenal artery (GDA) aneurysms represent an even more rare occurrence. We present a case report of treating GDA aneurysm on semi-elective basis followed by literature review of the clinical presentation and mainstream treatment modalities. GO is a 65-year-old male, with 6-month history of recurrent epigastric pain. He was found to have acute pancreatitis and an adjacent 3.5-cm GDA aneurysm. After conservative treatment of pancreatitis, the aneurysm was treated with coil embolization of the sac and GDA. Most VAAs are asymptomatic; GDA aneurysms tend to present clinically with epigastric pain or pancreatitis. In addition, together with pancreaticoduodenal aneurysms, GDA aneurysms warrant immediate intervention once diagnosed. Open surgical options for VAAs include aneurysm resection with or without revascularization (i.e., bypass), aneurysm ligation, or end-organ resection (i.e., splenectomy). Endovascular repair involves coil embolization with or without stent placement. While endovascular modality continues to be the first choice for stable elective VAA patients, modality of treatment for ruptured VAA or unstable patients will vary according to the patient's overall status, operator's experience, and institute capacity.

Mycotic (Infected) Pseudoaneurysm, a Diagnostic Challenge - Case Series

Mycotic pseudoaneurysm (or infected pseudoaneurysm) is an infectious arteritis, leading to the destruction of the arterial wall with the formation of a blind, saccular outpouching contiguous with the arterial lumen. Delayed management or non-management of mycotic pseudoaneurysms is associated with high morbidity and mortality due to complications such as arterial rupture, hemorrhage, and fulminant sepsis. Earlier diagnosis of mycotic pseudoaneurysm is essential for time management. Multidetector computed tomography (MDCT) is a widely used imaging modality for detecting the mycotic pseudoaneurysm, its characterization, and vascular mapping. MDCT findings of mycotic pseudoaneurysm are blind, saccular outpouching of an artery with irregular arterial wall, perivascular soft-tissue mass, or edema. Uncommon results of MDCT include arterial lumen thrombosis, arterial wall calcification, and perivascular gas. Management of mycotic pseudoaneurysm includes endovascular stenting with graft repair, endovascular embolization, open surgery, medical therapy (intravenous antibiotics), or a combination of these. We report three cases of mycotic pseudoaneurysm affecting aortic isthmus, a segmental branch of the pulmonary artery, and the internal mammary artery. All cases posed a diagnostic challenge, which only on subsequent imaging revealed to be a mycotic pseudoaneurysm.

[Embolization of splenic artery aneurysms: Treatment of choice. About a case and review of the literature]

Splenic artery aneurysms constitute 60% of digestive artery aneurysms. They are often discovered incidentally and by imaging. Currently, endovascular treatment is considered the first-line treatment, as it is less invasive with less morbidity and mortality than surgery. An aggressive approach in their management is certainly justified because the overall mortality of ruptured splenic aneurysms is 25%. False splenic aneurysms have a greater potential for rupture than true aneurysms because they grow faster. Endovascular treatment is generally indicated for aneurysms larger than 2cm or with an increase in size of more than 0.5cm/year. Embolization is rarely associated with an infarction of the spleen due to the good supply of short gastric vessels. Embolization is performed using different materials including coils, which can be used alone or with other embolic agents. Post-embolization syndrome can be seen with persistent pain, fever and other systemic symptoms. Endovascular treatment compared to open surgery is associated with better quality of life and appears to be the most cost-effective strategy. Endovascular treatment and especially coil embolization are starting to be the standard treatment. Surgical and laparoscopic treatment are reserved for ruptured aneurysms which are burdened with significant mortality, especially in pregnant women. We report the case of a 66-year-old female patient in whom a splenic artery aneurysm was discovered incidentally during an ultrasound for an ovarian cyst.

Laparoscopic Resection of a Splenic Artery Aneurysm with Vascular Reconstruction During Pregnancy

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

Dual endovascular repair (coils and stent) of a true aneurysm of the gastroduodenal artery

We report a case of an asymptomatic gastroduodenal artery aneurysm diagnosed in a 39 year-old woman. An abdominal ultrasound study showed an aneurysmal dilatation of the gastroduodenal artery with 2 x 2 cm diameter. To confirm this finding, she then underwent a computed tomography scan of the abdomen and pelvis that showed a saccular aneurysm of the gastroduodenal artery. A dual endovascular approach was used to exclude the aneurysm by stent-assisted coil embolization. Complete exclusion of the aneurysm sac was confirmed on final angiography. She was discharged from the hospital on postoperative day 1.

Vascular Remodeling and Immune Cell Infiltration in Splenic Artery Aneurysms

Rupture of splenic artery aneurysms (SAAs) is associated with a high mortality rate. The aim of this study was to identify the features of SAAs. Tissue sections from SAAs were compared to nonaneurysmal splenic arteries using various stains. The presence of intraluminal thrombus (ILT), vascular smooth muscle cells (VSMCs), cluster of differentiation (CD)-68+ phagocytes, myeloperoxidase+ neutrophils, CD3+, and CD20+ adaptive immune cells were studied using immunofluorescence microscopy. Analysis of SAAs revealed the presence of atherosclerotic lesions, calcifications, and ILT. Splenic artery aneurysms were characterized by a profound vascular remodeling with a dramatic loss of VSMCs, elastin degradation, adventitial fibrosis associated with enhanced apoptosis, and increased matrix metalloproteinase 9 expression. We observed an infiltration of immune cells comprising macrophages, neutrophils, T, and B cells. The T and B cells were found in the adventitial layer of SAAs, but their organization into tertiary lymphoid organs was halted. We failed to detect germinal centers even in the most organized T/B cell follicles and these lymphoid clusters lacked lymphoid stromal cells. This detailed histopathological characterization of the vascular remodeling during SAA showed that lymphoid neogenesis was incomplete, suggesting that critical mediators of their development must be missing.

[Embolization of a pseudoaneurysm of the inferior gastroduodenal artery]

Aneurysms and pseudoaneurysms of visceral arteries are relatively rare clinical entities and their pathogenesis has not yet been fully understood. Aneurysmal rupture appears to be a complication leading to life-threatening internal haemorrhage and is a cause of high mortality. However, advances in endovascular surgery techniques have extended the capabilities of treating aneurysms, allowing microemboli to be delivered even to the hard-to-reach portions of the vascular bed with complicated anatomy. Presented in the article is a clinical case report regarding embolization of a false aneurysm of the inferior gastrointestinal artery, separated by a microcoil, and demonstrating possibilities of endovascular superselective embolization of the target vessel.

High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know

The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ^©RSNA, 2019.

Coil embolization of a ruptured gastroduodenal artery pseudoaneurysm presenting with hemosuccus pancreaticus

Hemosuccus pancreaticus is a rare form of upper gastrointestinal bleeding that accounts for roughly 1 in 1500 cases. It is characterized by hemorrhage from the ampulla of Vater secondary to rupture of a peripancreatic pseudoaneurysm or visceral artery pseudoaneurysm. Among the visceral artery pseudoaneurysms, gastroduodenal artery pseudoaneurysms are among the rarest. In this case report, we describe a successful coil embolization of a large ruptured gastroduodenal pseudoaneurysm in a patient with massive gastrointestinal bleeding.

Hybrid management approach for superior mesenteric artery and branch aneurysms

Visceral artery aneurysms are rare, with a 25% rupture risk and an associated 70% mortality. A 55-year-old woman with progressive epigastric pain was found to have multiple large superior mesenteric artery (SMA), branch, and gastroduodenal artery aneurysms along with an occluded celiac artery trunk with hepatic flow dependent on the aneurysm branch. Management included antegrade aortohepatic artery bypass with gastroduodenal artery ligation, followed by SMA stenting and aneurysm coiling. This case is novel, given the diffuse pattern and rarity of SMA and branch aneurysms. This hybrid surgical management highlights innovative strategies to minimize morbidity without compromising definitive treatment of complex visceral artery aneurysms.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

Replaced right hepatic artery pseudoaneurysm managed with coil embolisation

A 20-year-old male patient presented to our emergency surgery department with blunt trauma to the abdomen and in a state of shock. The patient was resuscitated and a Contrast-Enhanced Computed Tomography (CECT) was done which showed a grade 2 liver injury involving segment VIII. The patient was managed conservatively and discharged after 8 days. The patient again presented after 3 weeks with severe anaemia, fever and melena. An upper gastrointestinal endoscopy revealed bile mixed with blood at the ampulla of Vater, consistent with haemobilia. CT angiography showed grade 2 injury of the liver with large haematoma in segment VIII. A large right subcapsular collection, a saccular area consistent with pseudoaneurysm of the replaced right hepatic artery arising from the superior mesenteric artery, was seen. A replaced left hepatic artery arising from the left gastric artery was also observed. The patient underwent right hepatic artery coil embolisation, with postprocedure digital subtraction scan showing no extravasation of contrast. The patient recovered well in the follow-up.

Hemobilia from a right hepatic artery pseudoaneurysm due to chronic cholecystitis

Splanchnic pseudoaneurysms are rare causes of hemobilia. Specifically, hepatic artery pseudoaneurysms from infectious or inflammatory etiology are even more rare. In this article, we describe our encounter with a 72-year-old female presenting with obstructive jaundice and acute blood loss anemia. Upper endoscopy indicated hemobilia and endoscopic retrograde cholangiopancreatography was completed with stent in place. Post endoscopic retrograde cholangiopancreatography, computed tomography angiogram indicated a right hepatic artery pseudoaneurysm which was the cause of her hemobilia. The patient was ultimately treated with selective coil embolization and interval cholecystectomy.

A hybrid procedure for middle colic artery aneurysm complicated by chronic juxtarenal segmental aortic occlusion

Here we describe a hybrid procedure, that is, a combination of open isolation and coil embolization, to treat a saccular middle colic artery aneurysm deep behind the pancreas. The middle colic artery provided the collateral blood flow necessary to bypass a chronic segmental aortic occlusion. For preservation of the collateral vessels, we surgically excluded and bypassed the aneurysm and then performed endovascular embolization of the pancreaticoduodenal arteries flowing into the aneurysm, resulting in complete isolation of the aneurysm without jeopardizing blood flow. This hybrid procedure for visceral artery aneurysms can be effective when the collateral vessels need to be preserved.

Splenic Artery Aneurysm (SAA) Rupture in Pregnancy: A Case Report of a Rare but Life-Threatening Obstetrical Complication

This is the case of a 38 year-old Lebanese woman G2P1, history of previous cesarean section, presenting at 30+5 weeks of gestation with acute left-sided flank pain and a two-day history of chills and dysuria. In light of the clinical presentation, the patient was initially diagnosed with pyelonephritis and managed accordingly; however, her clinical status deteriorated with worsening hypotension and lethargy despite resuscitative measures and a normal abdominal ultrasound. Failure to revive the patient eventually led to a cardiac arrest for which a peri-mortem cesarean section was performed at bedside. Upon abdominal entry, an actively-bleeding ruptured splenic artery aneurysm (SAA) was identified, for which massive transfusion protocol was activated, and the patient was transferred to the operating room. The patient had a complicated postoperative course, the fetus was stillborn, and she was discharged home after 6 months of hospital stay. In view of the high mortality and morbidity associated with ruptured SAA in pregnancy, early recognition and prompt intervention are crucial for maternal and fetal benefit.

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.

Cesarean section following idiopathic rupture of renal artery aneurysm leading to fetal dysfunction

BACKGROUND

Renal artery aneurysms (RAAs) in pregnancy are uncommon, with most found after rupturing. The risk of RAA rupture increases during pregnancy and delivery.

CASE PRESENTATION

A 29-year-old woman at 36 weeks and 5 days of gestation presented with severe back and abdominal pain. No fetal movements were identified. Cesarean section (C/S) was performed due to severe fetal bradycardia. No signs of placental abruption or abnormalities of the placenta were apparent intraoperatively, but gross hematoma was identified intraoperatively in the left retroperitoneal space. To evaluate persistent hypotension and retroperitoneal hematoma, contrast-enhanced computed tomography was performed and revealed ruptured RAA in the left kidney. Transcatheter arterial embolization (TAE) was performed.

CONCLUSIONS

This case report describes fetal dysfunction caused by RAA rupture and controlled by TAE.

Visceral Artery Aneurysms: Decision Making and Treatment Options in the New Era of Minimally Invasive and Endovascular Surgery

The abdominal viscera blood supply is derived from anterior branches of the abdominal aorta. Visceral artery aneurysms (VAAs) include aneurysms of the following arteries and their branches: the celiac artery, the hepatic artery, the splenic artery, the superior mesenteric artery, the inferior mesenteric artery, the pancreaticoduodenal artery, and the gastroduodenal artery. Overall VAAs comprise < 2% of all types of arterial aneurysms. Asymptomatic VAAs are now being encountered more frequently due to the widespread use of advanced diagnostic abdominal imaging. The incidental finding of a VAA frequently leaves clinicians with a dilemma as to the best course of management. The focus of this review is on current treatment options and management guidelines for both symptomatic and asymptomatic VAAs.

Percutaneous Embolization of an Inferior Mesenteric Artery Aneurysm in a Patient With Type IV Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) refers to a group of genetic disorders involving the connective tissues. Type IV EDS impairs type III collagen that is responsible for vessel integrity. Patients with type IV EDS are susceptible to vascular and visceral complications, including aortic aneurysms, pseudoaneurysms, dissections, and spontaneous rupture of internal organs. Treating aneurysms with open surgery versus endovascular techniques each carry a unique risk-to-benefit ratio that must be applied to each individual carefully. We present a patient with type IV EDS who presented with a rapidly growing inferior mesenteric artery aneurysm. The patient was treated with a percutaneous endovascular technique using coils and n-butyl-cyanoacrylate glue.

Mycotic Superior Mesenteric Artery Aneurysm: Case Report and Literature Review

Superior mesenteric artery (SMA) aneurysm is the third most common splanchnic artery aneurysm. A 73-year-old woman presented with a minimally symptomatic SMA aneurysm, which was resected by laparoscopic surgical technique. The patient recovered quickly and remained well after 8 months of follow-up. This case report and literature review presents a rare mycotic aneurysm that developed in the SMA. Laparoscopic surgery can be a useful technique for the treatment of mycotic SMA aneurysms.

Warfarin Overdose Associated Inferior Mesentery Artery Aneurysm Rupture Mimicking Spontaneous Bowel Hematoma

Inferior mesentery artery (IMA) aneurysm rupture is easily overlooked in patients with abdominal pain due to its uncommon occurrence. It may result in catastrophic consequence once misdiagnosed as spontaneous bowel hematoma in patients with anticoagulant overdose and intra-abdominal hematoma, as treatment strategy for both diseases varies differently. We present a case of a 70-year-old male who came to our emergency department with the chief complaint of abdominal pain over periumbilical area, eventually diagnosed as anticoagulant overdose associated IMA aneurysm rupture without occlusion of superior mesentery artery (SMA) and celiac artery (CA). This case report alerts us to consider the rare other source of bleeding, for instance ruptured inferior mesentery aneurysm, while encountering such an extraordinary large intra-abdominal hematoma in patients on anticoagulant.