Endovascular Repair of Concomitant Celiac Trunk and Abdominal Aortic Aneurysms in a Patient With Behçet's Disease

Prophylactic prosthetic wrapping for vascular anastomosis in patients with Behçet's aortic aneurysms: an experience from a resource-challenged setting

BACKGROUND

The objectives of the current study were to evaluate our technical and clinical results of surgical treatment of infrarenal Behçet's abdominal aortic aneurysm (AAA). In addition to the prosthetic wrapping of the constructed anastomosis as a prophylactic measure for patients with vasculo-Behçet's disease, together with the administration of per- and postoperative immunosuppressive therapy.

METHODS

A single-center retrospective case series included 16 patients with vasculo-Behçet's AAA who treated with open surgical repair, between January 2005 and December 2013. The administration of immunosuppressive treatment was done preoperatively to achieve complete remission of the disease activity before starting the surgical repair. Patients' data were retrieved and analyzed emphasizing the diagnostic procedures, the used surgical techniques, and suitable graft selection, as well as, graft-related complications. The patients were followed up for one month to a maximum of 72 months. The median follow-up period was 24.83±9.4 months.

RESULTS

This study included 16 patients, 10 (63%) males, and 6 (37%) females, with the median age of (30.50 years, range: 21-37 years). Moreover, all patients were anticoagulated and discharged on warfarin and aspirin therapy. All surgical procedures were done on an elective basis except for only one emergency laparotomy, which was performed for a life-threatening ruptured aneurysm. The vascular anastomoses were performed using either interposition tube graft (for isolated AAA), or Y-shaped graft (for concomitant aorto-iliac aneurysms). Furthermore, prophylactic prosthetic wrapping was applied encircling the graft to the host artery. In addition, all patients received systemic immunosuppressive therapy post-surgical intervention to prevent anastomotic site complications. Technical success was obtained in 100% of cases. Moreover, the patients were followed up for a period of 12-72 months. Two anastomotic pseudoaneurysms were developed postoperatively. More interesting is that both were infected (one low-virulent that was conservatively treated and one overt that was surgically repaired). Furthermore, there was no aneurysm-related mortality.

CONCLUSIONS

Prophylactic prosthetic wrapping of vascular anastomosis in patients with Behçet's AAA in resource-challenged settings, where the proximal anastomoses were all end-to-end with wrapping, is an affordable, simple, reliable, and feasible technique, and commonly associated with a lower incidence of anastomotic site false aneurysms and different complications related to the implanted graft, where endovascular procedures might not be applicable. Moreover, the proper preoperative medical preparation for controlling the activity of Behçet's disease, with the administration of immunosuppressive agents, followed by immediate postoperative therapy, may have a good impact on the operative technical success and the prevention of the development of serious postoperative complications; especially anastomotic pseudoaneurysms (which may be complicated by fatal hemorrhage), as well as other graft-related complications.

Coeliac artery dissection as a rare manifestation of Behcet's disease

Behcet's disease is a multisystemic vasculitis. Arterial involvement in the form of acute dissection is rare. A 42-year-old Lebanese man with Behcet's disease presented with severe abdominal pain. On exam, blood pressure was 162/104 mm Hg, and he exhibited epigastric tenderness. CT angiogram demonstrated an acute dissection of the coeliac artery trunk, common hepatic artery and proper hepatic arteries, with asymmetric thickening of the proximal left subclavian artery and circumferential thickening of the abdominal infrarenal aorta suggestive of vasculitis. Treatment included intravenous clevidipine, nitroprusside and methylprednisolone, which transitioned to oral metoprolol, amlodipine and prednisone. He responded well. Arterial dissections have been described with Behcet's. We report a coeliac artery aneurysm in association with a flare of Behcet's disease. Arterial wall inflammation combined with the sheering forces of hypertension likely predisposes to arterial dissection.

Rupture of celiac trunk aneurysm in patient with Behçet Disease

We report a case of a ruptured aneurysm of the celiac trunk in a 32-year-old, male patient with Behçet Disease (BD). Aneurysm resection was performed and the patient is well during a follow up of 32 months. To our knowledge, this is the first reported case of a ruptured celiac trunk aneurysm successfully treated in a patient with BD. RESUMO Relatamos o caso de um aneurisma roto do tronco celíaco em um paciente de 32 anos, do sexo masculino, portador de Doença de Behçet (DB). A ressecção do aneurisma foi realizada e o paciente está bem, com acompanhamento de 32 meses. Até onde sabemos, este é o primeiro caso relatado de um aneurisma do tronco celíaco roto tratado com sucesso em um paciente com DB.

Spontaneous Intra-Abdominal Hemorrhage Due to Rupture of Jejunal Artery Aneurysm in Behcet Disease: Case Report and Literature Review

Rupture of jejunal artery aneurysm is a very rare event resulting in life-threatening hemorrhage in Behcet disease (BD). We report a case of ruptured jejunal artery aneurysm in a 35-year-old patient with BD. The patient had a 1-year history of intermittent abdominal pain caused by superior mesenteric artery aneurysm with thrombosis. Anticoagulation treatment showed a good response. Past surgical history included stenting for aortic pseudoaneurysm. On admission, the patient underwent an urgent operation due to sudden hemorrhagic shock. Resection was performed for jejunal artery aneurysm and partial ischemia of intestine. The patient was diagnosed with BD, based on a history of recurrent oral and skin lesions over the past 6 years. Treatment with anti-inflammatory medications showed a good response during the 8-month follow-up.An increased awareness of BD and its vascular complications is essential. Aneurysms in BD involving jejunal artery are rare, neglected and require proper management to prevent rupture and death. To our knowledge, this is the first reported case of jejunal artery aneurysm caused by BD.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Recurrent aortic aneurysms in Behçet disease

The following is a case of a 22-year-old male with recurrent thoracic aneurysms with several constitutional symptoms, including gastrointestinal discomfort, irritable bowel syndrome, lactose intolerance, and a 2-week history of severe lower back pain. The patient underwent an initial thoracoabdominal repair of a visceral aneurysm followed by endovascular repair of a recurrent thoracic pseudoaneurysm. The etiology of the visceral aneurysm was initially hypothesized to be mycotic; however, further information revealed signs and symptoms consistent with the diagnostic criteria for Behçet disease (BD). We suggest that BD be considered in younger patients who present with an aortic aneurysm. Although open repair is the traditional approach for arterial lesions in BD, the role for endovascular intervention should be considered as it represents a surgical repair with a significant reduction in morbidity.

Celiac artery aneurysm repair in Behcet disease complicated by recurrent thoracoabdominal aortic aneurysms

Behçet's disease is a chronic, relapsing multisystemic inflammatory disorder characterized by recurrent orogenital aphthous ulcers, uveitis, and skin lesions. Vascular involvement occurs in up to 38% of these patients. Herein, we report a 19-year-old male who initially presented with an isolated celiac artery aneurysm that was treated with open surgical repair. The patient was subsequently diagnosed with Behçet's disease after the development of oral aphthous ulcers and multiple recurrent postoperative deep venous thromboses and thoracoabdominal arterial aneurysms. Ultimately, a hybrid approach was undertaken. This is the fifth celiac artery aneurysm ever reported in this patient group and the first to present with an isolated celiac artery aneurysm as the initial manifestation of Behçet's disease.

Massive gastrointestinal bleeding due to the rupture of arterial aneurysm in Behçet's disease: case report and literature review

Massive gastrointestinal bleeding is a very rare manifestation of gastrointestinal Behçet's disease, mainly from the gastrointestinal mucosal lesions. We report herein the case of a 50-year-old man with intestinal Behçet's disease who suffered massive hemorrhage from ruptured arterial aneurysm. Colonoscopy demonstrated large amount of fresh blood in the entire colon, but we were not able to localize bleeding focus anywhere in the colon. Angiography was performed and it revealed that a small aneurysm on the right ileocolic artery with apparent extravasation of contrast material. A guiding catheter was inserted to a right ileocolic artery and superselective arterial embolization using microcoils was successful. Following this procedure, the gastrointestinal bleeding gradually subsided and completely stopped within a few days. He is now treating with prednisolone and sulfasalazine without recurrent bleeding until now.

Traitements actuels et perspectives thérapeutiques dans la maladie de Behçet

Behçet disease is a multisystem inflammatory disorder, the cause of which remains unclear. Vasculitis is its predominant histopathological feature. It remains a source of significant morbidity in affected patients, many of whom become blind. Treatment of its various manifestations remains controversial today because of the paucity of randomized controlled trials and the absence of standardized outcome measures for this disease. The preferred treatment modalities combine different drugs, including topical therapies as well as systemic corticosteroids, NSAIDs, colchicine, and immunosuppressive and cytotoxic agents. The principal objectives are always relief of symptoms, control of inflammatory eye disease, suppression of systemic inflammation and vasculitis and prevention of recurrences and thus of irreversible damage. Although the prognosis of various manifestations of Behçet disease has improved, many patients still have refractory disease that requires treatment with combinations of various immunosuppressants, cytotoxic agents, and corticosteroids, which may lead to serious infections or secondary malignancy. Recent improvements in our understanding of the pathogenic mechanisms of Behçet disease, especially its molecular basis, have led to a new generation of potential treatments with improved side-effect profiles and more specific immune targeting. These include new immunosuppressants, biologic medicines, tolerizing agents and immunoablation techniques. Until randomized controlled studies with these agents are conducted, however, no final judgment about their usefulness is possible.

[Aneurysm of the coeliac trunk. A case report]

Aneurysm of the coeliac artery is a rare vascular problem. The most serious clinical complication of coeliac artery aneurysm is rupture. Because of this, surgery is traditionally recommended. This paper presents a case of a coeliac artery aneurysm treated by open surgery.

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

We present a case of a 73-year-old man in whom a celiac trunk aneurysm close to the hepato-splenic bifurcation was discovered and treated by using celiac-hepatic stent-grafts implantation and splenic artery embolization.

Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm

A 72-year-old man was admitted because of progressive right upper-abdominal distension and pain as well as concurrent remittent fever for 5 months. He had undergone a radical gastrectomy and catheter intubation in the common hepatic artery for chemotherapy 12 months before admission. The diagnosis of giant infected hepatic-celiac artery pseudoaneurysm was established. Coils embolotherapy was given in another hospital, but it failed. After admission, a computed tomographic aortogram showed a mass 10.3 x 8.5 x 8.1 cm in size in the right upper abdomen that originated from the common hepatic artery and the celiac artery. A celiac-super mesenteric artery (SMA) double catheter simultaneous digital subtraction angiography (DSA) further revealed that the entrance of the aneurysm opened directly from the abdominal aorta, the distance between the orifice of SMA and celiac axis was only 0.5 cm, and the diameter of the celiac trunk had been aneurysmally enlarged to 2.0 cm. A blood culture was positive for Bacillus pyocyaneus. After detailed discussion and preparation, a stent-graft complex was negotiated through the left femoral artery and deployed successfully into the abdominal aorta to seal the orifice of celiac trunk under the dynamic supervision of DSA. Completion angiography revealed that the hepatic-celiac pseudoaneurysm was completely excluded from aortic flow by the endoluminal stent-graft complex, while the SMA and renal arteries remained perfectly patent. The patient recovered uneventfully and was discharged without any residual symptoms. At a 5-year follow-up, the patient remained asymptomatic and was leading a normal life.

Major vessel involvement in Beh??et disease

PURPOSE OF REVIEW

Large vessel vasculitis occurs in a subgroup of patients with Behçet disease at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and the need for aggressive treatment are essential for optimal care of these patients. The authors review the clinical spectrum and management of large vessel problems in Behçet disease, highlighting contributions over the past year.

RECENT FINDINGS

Vasculo-Behçet patients are at risk for multiple vessel-related complications including thromboses, stenoses, occlusions, and aneurysms. A number of factors may contribute to thrombosis in individual cases, but the primary reason for clot seems to reside in the inflammatory process in the arterial wall, still incompletely understood. An appreciation for the challenges in the perioperative period requires the joint efforts of physicians and surgeons, and fuels the study of alternate, less invasive procedures for Behçet patients.

SUMMARY

Because of earlier recognition, aggressive medical treatment, and novel surgical procedures, the morbidity and mortality of large vessel vasculitis in Behçet disease are beginning to change. In the absence of controlled treatment studies, reports of clinical experience remain an important source of information for clinicians. Identification of patients at risk for vascular complications remains a priority.