Pseudoaneurysm of Superior Mesentery Artery Branch After Renal Extracorporeal Shock Wave Lithotripsy: Case Report and Review

Crohn's Disease and Jejunal Artery Aneurysms: A Report of the First Case and a Review of the Literature

Background and Objectives: Jejunal artery (JA) and ileal artery (IA) aneurysms constitute less than 3% of all visceral artery aneurysms (VAAs), carrying a risk of rupture as high as 30%, and a mortality of 20%. Though many etiologies have been reported in the literature, no mention exists on a causal association between these aneurysms and inflammatory bowel diseases (IBD). We present the first case of a JA aneurysm related to Crohn's Disease (CD) together with a review of the literature. Materials and Methods: A 74-year-old male presenting with CD intestinal relapse and an incidental finding at the computed tomography enterography (CTE) of a 53 × 47 × 25mm apparently intact JA pseudoaneurysm, arising from the first and second jejunal branches, underwent coil embolization followed by small bowel resection, with an uneventful outcome. We also included the review of literature on JA and IA aneurysms, analyzing all reports published in PubMed and Scopus from 1943 to July 2022. Results: 60 manuscripts with 103 cases of JA and IA aneurysms in 100 patients were identified. Among cases with available data, 34 (33.0%) presented acutely with rupture, 45 (43.7%) were described as non-ruptured. 83 (80.6%), and 14 (13.6%) were JA and IA aneurysms, respectively, having a median size of 15 (range:3.5-52) mm. Atherosclerosis (16.5%), infections (10.7%), and vasculitides/connective tissue disorders (9.7%) represented the main causes mentioned. Mean age was 53.6 (±19.2) years, male patients being 59.4%. One third of patients (32.4%) were asymptomatic. Overall, treatment was indicated in 63% of patients, with surgery and endovascular procedures performed in 61.9% and 38.1% cases, respectively. The technical success rate of endovascular treatment (EVT) was 95.8%. The mortality rate was 11.8%, being higher (21.2%) in the rupture group. Conclusions: The prompt treatment accomplished in our case granted a successful outcome. JA and IA aneurysms should be included among local complications of IBD. Considering their high potential for rupture, regardless of size, a low threshold for endovascular or surgical treatment should be applied.

Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm

Visceral artery pseudoaneurysms are rare but potentially life-threatening. Among visceral artery pseudoaneurysm (VAPA), the superior mesenteric artery (SMA) pseudoaneurysm is the rarest type. VAPAs are usually related with infection, inflammatory disease, trauma, or arises as a postoperative complication. Early diagnosis and endovascular or surgical intervention are key in lowering the risk of intestinal infarction and death due to potentially fatal hemorrhage. A 49-year-old man presented with cough, shortness of breath, weight loss, and an incidental finding of spontaneous SMA pseudoaneurysm with localized bleed on CT angiography. An urgent endovascular embolization was performed of the pseudoaneurysm, with an adequate outcome and recovery. SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and related morbidity and mortality. Direct oral anticoagulants like apixaban (Eliquis) have also been reported to cause pseudoaneurysm formation by slow and constant bleeding, which may have contributed here as a cause of pseudoaneurysm along with infective endocarditis, which was diagnosed later after endovascular embolization. The treatment can be either an endovascular, endoscopic, or open surgical approach. 

Pseudoaneurysm of external iliac artery after extracorporeal shock wave lithotripsy revealing Behçet disease

Extracorporeal shock wave lithotripsy (ESWL) can lead to rare but severe arterial complications. The causal relationship of ESWL with arterial pseudoaneurysm formation in a patient with Behçet disease is discussed. A 35-year-old man presented with acute recrudescence of right flank pain caused by ureteral lithiasis immediately after having undergone a last session of ESWL. Abdominal examination revealed a painful pulsatile mass in the right iliac region. Contrast-enhanced computed tomography identified a pseudoaneurysm of the right external iliac artery in a patient with a medical history of Behçet disease. The pseudoaneurysm was treated endovascularly, including the use of a covered stent with intensive immunosuppressive therapy. We obtained successful exclusion of the pseudoaneurysm. This case highlights that arterial pseudoaneurysm may occur after ESWL in patients with Behçet disease. Strict follow-up after ESWL sessions is necessary.

Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report

Background

Visceral arterial pseudoaneurysms (VAPAs) are rare vascular entities with serious consequences. Traditionally, they are associated with trauma, infection, and inflammatory disease, or they can arise as a post-operative complication.

Report

An 87 year old man presented with abdominal pain and was found to have a spontaneous VAPA on a computed tomography angiogram. Serial imaging 4 months previously had demonstrated no aneurysm. Between scans, warfarin was changed to apixaban for aortic valve replacement, but he had no other changes to any other medications. He required urgent endovascular coiling of the pseudoaneurysm, with satisfactory recovery and outcome.

Discussion

VAPAs are extremely rare, with splenic artery VAPAs the most commonly reported. Regardless, fewer than 250 cases of splenic artery pseudoaneurysm have been reported. Superior mesenteric artery (SMA) pseudoaneurysms are the rarest type of VAPAs. Early identification and urgent treatment are warranted because of the associated high mortality risk, with a 50% risk of rupture in any given VAPA. Treatment options range from open operation to endoscopic and endovascular procedures. Apixaban has been proposed to contribute to pseudoaneurysm formation by slow and continuous bleeding that results in the formation of the pseudoaneurysm.

Conclusions

Spontaneous VAPAs are extremely rare and this is the first time a VAPA has been associated with the novel oral anticoagulant "apixaban". Urgent management of any VAPAs is important because of the high risk of rupture and potential life threatening haemorrhage.

Mechanisms of primary blast-induced traumatic brain injury: insights from shock-wave research

Traumatic brain injury caused by explosive or blast events is traditionally divided into four phases: primary, secondary, tertiary, and quaternary blast injury. These phases of blast-induced traumatic brain injury (bTBI) are biomechanically distinct and can be modeled in both in vivo and in vitro systems. The primary bTBI injury phase represents the response of brain tissue to the initial blast wave. Among the four phases of bTBI, there is a remarkable paucity of information about the cause of primary bTBI. On the other hand, 30 years of research on the medical application of shockwaves (SW) has given us insight into the mechanisms of tissue and cellular damage in bTBI, including both air-mediated and underwater SW sources. From a basic physics perspective, the typical blast wave consists of a lead SW followed by supersonic flow. The resultant tissue injury includes several features observed in bTBI, such as hemorrhage, edema, pseudoaneurysm formation, vasoconstriction, and induction of apoptosis. These are well-described pathological findings within the SW literature. Acoustic impedance mismatch, penetration of tissue by shock/bubble interaction, geometry of the skull, shear stress, tensile stress, and subsequent cavitation formation, are all important factors in determining the extent of SW-induced tissue and cellular injury. Herein we describe the requirements for the adequate experimental set-up when investigating blast-induced tissue and cellular injury; review SW physics, research, and the importance of engineering validation (visualization/pressure measurement/numerical simulation); and, based upon our findings of SW-induced injury, discuss the potential underlying mechanisms of primary bTBI.

Tratamento endovascular de pseudoaneurisma de artéria mesentérica superior: relato de caso

O pseudoaneurisma de artéria mesentérica superior é uma doença rara, porém com alta taxa de ruptura e mortalidade. Sua etiologia geralmente é infecciosa e comumente o diagnóstico é feito por meio de achado nos exames de imagem. Historicamente, seu tratamento de eleição tem sido o reparo cirúrgico aberto; entretanto, é associado a inúmeras complicações e dificuldades técnicas. Relatamos um caso de pseudoaneurisma de artéria mesentérica superior em um paciente portador de abscesso hepático no qual, após resolução do processo infeccioso, foi empregado, com sucesso, um tratamento minimamente invasivo endovascular, com implante de micromolas e stent não-recoberto.

Renal pseudoaneurysm following laser lithotripsy: endovascular treatment of a rare complication

Hemorrhagic complications of renal transplantation can be life threatening and require prompt and timely intervention. This brief report describes the exceedingly rare formation of an extrarenal pseudoaneurysm of a transplant renal artery following laser lithotripsy for nephrolithiasis in a teenage male. The pseudoaneurysm ruptured into the renal collecting system. Transarterial coil embolization of the wide-neck saccular pseudoaneurysm of the extraparenchymal renal artery with the assistance of a 'safety microguidewire' was successfully performed and the allograft was preserved.

[Embolization of a renal artery aneurysm. Effect of an ESWL?]

The development of a peripheral aneurysm of the renal artery as a result of an ESWL is a rarely described complication. We discuss in the presented case the diagnosis and successful endovascular treatment of a complicated aneurysm of a renal segment artery with complete preservation of the renal parenchyma.