Efficacy and safety of transcatheter arterial embolization of omental artery aneurysm: A single-center experience

BACKGROUND

Omental artery aneurysm (OAA) is an extremely rare visceral artery aneurysm. Ruptured OAAs are associated with a high mortality rate. Transcatheter arterial embolization (TAE) has been used to treat OAA in recent years. However, the risk of omental ischemia due to TAE remains unclear. Therefore, this study aimed to investigate the efficacy and safety of TAE of OAA as a first-line treatment.

METHODS

Fifteen patients with true aneurysms or pseudoaneurysms who underwent OAA-TAE between 1 April 2010 and 31 December 2022 were included in this study. The technical and clinical outcomes, the incidence of omental infarction after TAE as a major complication, OAA-TAE techniques, radiological findings on computed tomography angiography and angiogram, and patient characteristics were evaluated.

RESULTS

Fifteen patients (nine men, six women; age, 69.8 ± 18.59 years) underwent TAE of OAAs (mean aneurysm size of 9.30 ± 6.10 mm) located in the right gastroepiploic (n = 9), left gastroepiploic (n = 1), and epiploic (n = 5) arteries. All patients with ruptured (n = 6) and unruptured (n = 9) OAA successfully underwent TAEs using coils, n-butyl-2-cyanoacrylate, or gelatin sponges. Hepatic artery thrombosis and coil migration were observed during the procedure; however, these adverse events were manageable. Transfusion of red blood cell units (4.66 ± 1.63 units) was required only in cases with ruptured OAAs after TAE. Additional surgery or TAE due to rupture or rerupture of OAA and omental infarction was not required during the postoperative and follow-up periods.

CONCLUSION

The OAA-TAE can effectively treat ruptured and unruptured OAAs, and the risk of omental infarction after OAA-TAE may not be high.

Spontaneous Rupture of a Right Gonadal Artery Aneurysm: A Case Report

Gonadal artery aneurysm is a rare condition characterized by nonspecific presentation, typically manifesting as flank pain and formation of a retroperitoneal hematoma on imaging studies. Failure to recognize and treat this condition promptly can have serious consequences, as the presence of an aneurysm may lead to severe bleeding. Notably, most reported cases of gonadal artery aneurysms are not trauma-induced but rather spontaneous. In this case report, we describe the case of a previously healthy woman in her late 30s who presented to the emergency department with initial symptoms of flank pain and elevated white blood cell count. Subsequent imaging via computed tomography of the abdomen and pelvis revealed a significant hematoma surrounding the right kidney, indicative of a substantial hemorrhagic event. Angioembolization followed by endograft placement was performed on the patient, and she was expected to make a full recovery.

Endovascular Stent Graft Placement and Coil Embolization for Splenic Artery Aneurysm with an Anatomical Variant

A 62-year-old woman with abdominal pain was diagnosed with a splenic artery aneurysm (SAA) and an anatomical variant in the splenic artery (SA) arising from the superior mesenteric artery (SMA) as its first branch. To treat the SAA, the draining artery and a small branch of the SAA were embolized, and then small-diameter stent grafts were deployed from SMA orifice, covering the aberrant origin of the SA and preserving the second branch of SMA. Intraoperative angiography confirmed successful exclusion of the SAA without endoleak or arterial dissection. The stent graft was patent and the aneurysm had shrunk 3.5 years after the operation.

A Case of Jejunal Artery Aneurysm Successfully Treated with Endovascular Embolization

Jejunal artery aneurysms are extremely rare; only 58 cases have been reported up to 2022. The high rupture rate necessitates a curative treatment. Only four cases of true jejunal artery aneurysms treated with endovascular embolization were reported. We report a case of a 75-year-old man with a true jejunal artery aneurysm who was successfully treated with endovascular embolization. The aneurysm was located in the third jejunal branch. The proximal and distal distance to the superior mesenteric artery and the first bifurcation of the third jejunal branch, respectively, were too short to perform isolation. First, we performed packing in the aneurysm, followed by secondary parent artery embolization. Finally, we achieved total occlusion of the aneurysm and its parent artery with preserved distal intestinal blood flow.

Coil embolization of asymptomatic left gastric artery aneurysm: Case report and literature review

Patients with visceral artery aneurysms are rare, and the reported incidence of left gastric aneurysm (LGA) is only 4%. At present, although there is little knowledge about such disease, it is generally believed that appropriate treatment should be planned to prevent some dangerous aneurysms from rupturing. We introduced a case of 83-year-old patient with LGA who underwent endovascular aneurysm repair. The 6-month follow-up computed tomography angiography showed complete thrombosis in the aneurysm lumen. In addition, to insight the management strategy on LGAs deeply, a literature review concerning this entity published in recent 35 years was performed.

Disappearing multiple visceral aneurysms in Vascular Ehlers-Danlos syndrome

OBJECTIVE

To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS).

METHODS

We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms.

RESULTS

Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.

Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography

Splenic artery aneurysm (SAAs) rupture is associated with a high mortality rate. Regular surveillance with imaging before and after intervention is crucial to guide best evidence treatment. The following study aimed to determine the efficacy of color Doppler ultrasound imaging (DUS) compared to digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) as a follow-up modality after selective coil embolization of true SAAs. We analyzed data from 20 patients, 15 females (48.1 ± 16.1 years) undergoing selective SAA coil embolization using detachable fibered embolization coils. Imaging using DUS, MRA, and DSA was performed 3 months after the initial embolization or the consequent re-embolization procedure. Primary clinical success, defined as Class I aneurysm occlusion, on 3-month follow-up was seen in 16 (80.0%) patients. DUS had a sensitivity of 94.4% and a specificity of 42.9% when compared to DSA and 92.3% and 30%, respectively, when compared to MRA in identifying Class I aneurysm occlusion. The positive predictive value (PPV) of DUS in identifying the need for re-embolization was 75.0%, while the NPV of DUS in these terms was 90.5%. DUS showed a high sensitivity in detecting aneurysm occlusion and clinical success, simultaneously exhibiting poor specificity. Still, with caution, this follow-up modality could be used for monitoring select low-risk patients after selective embolization of SAAs. DUS could provide a higher cost-to-benefit ratio, enabling more systematic post-procedural follow-up, as it is far more commonly used compared to MRA and non-invasive compared to DSA.

Gastrointestinal bleeding caused by rupture of a posterior inferior pancreaticoduodenal artery pseudoaneurysm: A case report

BACKGROUND

Gastrointestinal bleeding caused by a ruptured pancreatic pseudoaneurysm is rare, and a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery is especially rare. A 68-year-old man was hospitalized after presenting intermittent black stools and dyspnea accompanied by severe anemia. Angiographic examination revealed that Pseudoaneurysm of the posterior inferior pancreaticoduodenal artery.

METHODS

Angiography was performed and revealed a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery. Subsequently, a blood transfusion and endovascular embolization were performed.

RESULTS

The patient's gastrointestinal bleeding stopped, and the hemoglobin level remained stable. During 1 year of follow-up, the patient remained in a generally good condition.

CONCLUSION

posterior inferior pancreaticoduodenal artery pseudoaneurysmIt is rare and difficult to diagnose, gastrointestinal bleeding is a serious complication, vascular interventional embolization is effective.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Patient-specific modeling of hemodynamic characteristics associated with the formation of visceral artery aneurysms at uncommon locations

Objective

Hemodynamic characteristics play critical roles in aneurysm initiation and growth. This study aims to explore the effect of common hemodynamic parameters on the formation of visceral artery aneurysms (VAAs), especially those from the pancreaticoduodenal arteries or other uncommon locations, using real patients' models.

Methods

Three-dimension vessel models of 14 VAAs from 13 patients were selected and constructed from computed tomography angiography (CTA) images. Aneurysms were manually removed to perform computational fluid dynamics (CFD) simulations of the models before aneurysm formation. Flow field characteristics were obtained and compared at the aneurysm forming and para-aneurysm areas. Aneurysm forming models were categorized into high-wall-shear stress (WSS) and low-WSS groups according to WSS value at aneurysm forming versus para-aneurysm areas.

Results

Computational fluid dynamics analysis revealed that the high WSS group had significantly higher WSSmax (P = 0.038), higher time average WSS (TAWSS) (P = 0.011), higher WSS gradient (WSSG) (p = 0.036), as well as lower oscillatory shear index (OSI) (P = 0.022) compared to the low WSS group. Significant higher WSSmax (P = 0.003), TAWSS (P = 0.003), WSSG (P = 0.041) and lower OSI (P = 0.021) was observed at the aneurysm forming site compared to both upstream and downstream areas.

Conclusion

Both local increase and decrease of WSS and WSS gradient were observed for the visceral artery aneurysm forming area. Computational fluid dynamics analysis could shed light on the pathogenesis of visceral artery aneurysms at uncommon vessel locations.

Differentiation of multiple visceral artery aneurysm rupture from major bleeding after coronary artery bypass grafting

BACKGROUND

Visceral artery aneurysm is a very rare disease, but it is clinically important because of the high risk of rupture involved. These ruptures must be differentiated from those that occur during hospitalization after extra-abdominal surgery.

METHODS

During hospitalization after off-pump coronary artery bypass grafting, a 77-year-old woman developed hypovolemic symptoms and had decreased hemoglobin. There was no obvious bleeding, but while screening for possible complications after cardiac surgery, abdominal computed tomographic angiography showed multiple visceral artery aneurysms of the gastroduodenal and pancreaticoduodenal arteries along with hemoperitoneum.

RESULTS

The patient underwent coil embolization of the visceral artery aneurysm and was discharged without any complications.

CONCLUSIONS

In patients with coronary artery disease with risk factors for atherosclerosis, if anemia occurs without apparent bleeding after surgery, visceral artery aneurysm should be considered as a differential diagnosis.

Combined endovascular and surgical treatment of a giant celiac artery aneurysm with consequent gastric outlet obstruction: a case report and literature review

BACKGROUND

Visceral artery aneurysms (VAA) are rare with an incidence of up to 0.2% and mortality of up to 40%. Aneurysms larger than 5 cm are referred to as giant visceral artery aneurysms (GVAA). We present a case of a celiac artery aneurysm of 14 cm which required endovascular and surgical management. A review of the literature with focus on treatment is also provided.

CASE PRESENTATION

In this case report, a 76-year-old male presented with postprandial nausea and vomitus. An ultrasound and computed tomography scan showed an aneurysm of the celiac artery of approximately 14 cm. Initial treatment was conducted with coiling. Despite this treatment, patient presented again with the same complaints, most likely due to gastric outlet syndrome caused by the aneurysm sac. Partial open removal of the aneurysm sac was performed with release of the duodenum. Due to recurring dysphagia and postprandial nausea, a gastroenterostomy was created, which was later supplemented with a Roux-en-Y anastomosis due to gastroparesis. Patient recovered uneventful after the Roux-en-Y and was discharged from the hospital.

CONCLUSION

Giant visceral artery aneurysms sometimes need multimodal treatment. We showed that an endovascular first approach of a giant visceral artery aneurysm is not only technically feasible, but it also facilitates subsequent open surgery due to limiting blood loss and reducing the need for extensive mobilisation of the viscera to gain arterial control.

Concomitantly discovered visceral artery aneurysms do rarely grow during cancer therapy

Visceral artery aneurysms (VAA) are a rare entity of arterial aneurysms with the imminent threat of rupture. The impact of cancer and chemotherapy on the growth of VAAs is unknown. A retrospective dual center cohort study of patients with concomitant VAA and different types of cancer was conducted and the impact of various chemotherapeutic agents on VAA growth was studied by sequential CT analysis. For comparison, a non-cancer all comer cohort with VAAs and no cancer was studied to compare different growth rates. The primary endpoint was aneurysm progress or regression >1.75 mm. Chi-square test, Fisher's exact test and Mann-Whitney test was used for statistical comparison. In the 17-year-period from January 2003 to March 2020, 59 patients with 30 splenic artery aneurysms, 14 celiac trunk aneurysms, 11 renal artery aneurysms and 4 other VAA and additional malignancy were identified. 20% of patients suffered from prostate cancer, the rest were heterogeneous. The most prevalent chemotherapies were alkylating agents (23%), antimetabolites (14%) and mitose inhibitors (10%). Eight patients had relevant growth of their VAA and one patient showed diameter regression (average growth rate 0.1 ± 0.5 mm/year). Twenty-nine patients with 14 splenic, 11 RAAs (seven right) and 4 celiac trunk aneurysms were available in the non-cancer comparison cohort (average growth rate 0.5 ± 0.9 mm/year, p = 0.058). However, the growth rate of patients receiving operative treatment for relevant VAA growth was significantly higher (p = 0.004). VAAs grow rarely, and rather slow. Cancer and/or chemotherapy do not significantly influence the annual growth rate. Additional control examinations seem unnecessary.

Spontaneous thrombosis of a giant common hepatic artery aneurysm-A case report

Splachnic aneurysms (hepatic artery aneurysms) are a rare entity ranging from atypical symptoms to devastating rupture.

Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience

OBJECTIVES

Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years.

METHODS

We retrospectively reviewed our prospectively maintained registry between January 1, 1992 - March 30, 2020.

RESULTS

We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity.

CONCLUSION

Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.

Life-threatening Upper Gastrointestinal Bleeding Due to Ruptured Gastroduodenal Artery Aneurysm in a Child

Gastroduodenal artery (GDA) aneurysm is a rare cause of massive life-threatening upper gastrointestinal (UGI) bleeding in children. Prompt resuscitation with fluids, administration of large amount of blood products (massive transfusion), prompt diagnostic evaluation using computed tomography (CT) angiography or digital subtraction angiography (DSA), and therapeutic endovascular or catheter-based interventions are life-saving. In cases with failed endovascular interventions, open surgical approach to ligate aneurysm is required. We report a 10-year-male with life-threatening UGI bleed due to ruptured GDA aneurysm possibly secondary to sepsis requiring resuscitation, massive transfusion, CT angiography and DSA, endovascular intervention, and ultimately surgical management with good outcome.

Natural History of Unruptured Visceral Artery Aneurysms Due to Segmental Arterial Mediolysis and Efficacy of Transcatheter Arterial Embolization: A Retrospective Multiinstitutional Study in Japan

OBJECTIVE. The purpose of this study was to clarify the natural history of unruptured visceral artery aneurysms due to segmental arterial mediolysis and the efficacy of transcatheter arterial embolization. MATERIALS AND METHODS. Patients with a pathologic or clinical diagnosis of visceral artery aneurysms due to segmental arterial mediolysis between 2005 and 2015 were enrolled. For patients with clinical diagnoses, images were collected and assessed by central radiologic review. To clarify the natural history of unruptured aneurysms, the morphologic changes were assessed. The efficacy and safety of transcatheter arterial embolization for aneurysms due to segmental arterial mediolysis were evaluated. RESULTS. Forty-five patients with 123 aneurysms due to segmental arterial mediolysis were enrolled. Among the 123 aneurysms, 70 unruptured aneurysms were evaluated for natural history. Forty-five of the 70 (64%) aneurysms had no change in morphology. Among the other 25 aneurysms, nine (13% of the 70) were reduced in size, 13 (19%) disappeared, and three (4%) were newly found at follow-up. Aneurysms of the middle colic artery were ruptured in 10 of 11 (91%) cases. Transcatheter arterial embolization was performed on 45 aneurysms and was successful in all cases but caused slight arterial injury in three cases (6.7%). CONCLUSION. At initial diagnosis, unruptured aneurysms due to segmental arterial mediolysis are likely to be stable or to resolve, but the risk of rupture of aneurysms of the middle colic artery appears high. Transcatheter arterial embolization is a useful treatment, but careful manipulation is necessary.

Successful Repair of Superior Mesenteric Artery Aneurysm with Reconstruction of Branches

Superior mesenteric artery aneurysms (SMAAs) are rare and potentially life-threatening. Whether surgical or endovascular repair is performed, mesenteric ischemic complication is the greatest concern. A 56-year-old gentleman with SMAA underwent surgical resection with reconstruction of the superior mesenteric artery (SMA) and its branches using the great saphenous vein with several techniques, including island reconstruction of the branches, staged segmental cross-clamping, and an external shunt, to reduce the mesenteric ischemia time. The postoperative course was uneventful with no signs of mesenteric ischemia. A computed tomography scan showed that all grafts to the SMA and its branches were patent.

A Case of Segmental Arterial Mediolysis: Hemoperitoneum with Hemorrhagic Shock due to Rupture of a Visceral Artery Aneurysm Following Subarachnoid Hemorrhage

Objective

Segmental arterial mediolysis (SAM) is a non-inflammatory and non-atherosclerotic vascular disease characterized by segmental medial defect/necrosis of muscular arteries as a result of mediolysis. SAM affects the visceral and intracranial arteries, and causes arterial dissection and aneurysm. We report a case of aneurysmal subarachnoid hemorrhage (SAH) followed by hemoperitoneum due to a ruptured visceral artery aneurysm.

Case Presentation

A 54-year-old man developed SAH from a ruptured anterior communicating artery aneurysm, which was clipped on the same day. Thereafter, he was treated to prevent cerebral vasospasm. Six days after onset, he developed acute anemia and his blood pressure decreased, suggesting hemorrhagic shock. Hemoperitoneum was detected on computed tomography and abdominal angiography was performed. Irregular and stenotic arterial findings, and an unusual aneurysm with contrast stasis were found in a branch vessel from the right gastroepiploic artery. SAM was diagnosed based on the clinical course and angiographic characteristics. Endovascular treatment consisted of embolization of the visceral artery aneurysm with liquid embolic material. after embolization, the vital signs stabilized and he recovered from shock. Acute treatment for SAH was continued. Although the patient did not develop vasospasm-related sequelae, he was transferred to the rehabilitation hospital 7 weeks after onset and his modified Rankin Scale score at 3 months after onset was 2.

Conclusion

Visceral artery aneurysm associated with SAM should be considered as the cause of hemoperitoneum with hemorrhagic shock during the acute phase of SAH.

Naturally shrunk visceral artery aneurysms by stenting for the superior mesenteric artery occlusion

A 77-year-old woman who had experienced postprandial abdominal pain for four years was admitted to our institution presenting sudden and severe abdominal pain. Contrast-enhanced computed tomography (CECT) demonstrated complete short-segmented occlusion in the orifice of the superior mesenteric artery (SMA), and saccular aneurysms in the right hepatic artery and the anterior superior pancreaticoduodenal artery. She was diagnosed with abdominal angina due to occlusion of the SMA. The SMA was recanalized by stenting, and a CECT scan confirmed naturally shrunk aneurysms after eight months. The patency of the SMA was maintained at five years after endovascular treatment.

Hepatic Artery Aneurysm in the Setting of Acute Pancreatitis and Giant Cell Arteritis

Visceral artery aneurysms are rare with an incidence of 0.1%-0.2%. Of these, 20% are hepatic artery aneurysms (HAAs). Despite the potential of remaining asymptomatic for long periods of time, the risk of rupture for HAAs is 20%-80%. Treatment includes operative management with open or endovascular techniques. HAA in the setting of pancreatitis has been reported in two prior cases outside of the United States. However, there have been no cases describing the association of HAA and giant cell arteritis (GCA). We present a rare case of an 80-year-old male with a history of GCA who was found to have developed HAA following an episode of acute pancreatitis that was repaired surgically with an open technique. To our knowledge, the association between HAA with acute pancreatitis and GCA has not been reported before.

Video-robotic aneurysmectomy for splenic artery aneurysm: case report and literature review

We herein report the case of a symptomatic splenic artery aneurysm (SAA) diagnosed in a 65-year-old woman. Endoluminal exclusion was considered as first option, but the potential risk of postoperative splenic infarction, postsplenectomy thrombocytosis and immunodeficiency in an otherwise healthy patient raised the possibility to carry out a surgical procedure of vascular reconstruction using the robotic device Da Vinci^® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). We performed the resection of the aneurysm and the continuity of the splenic artery was restored by end-to-end anastomosis.

Massive Hemorrhage From Multiple Hepatic Artery Aneurysms

A 66-year-old man, with an abnormal porta hepatis, consistent with tumor or inflammation, developed massive bleeding from one of numerous hepatic artery aneurysms, and coil embolization achieved control of bleeding. He died of subsequent multisystem organ failure, and the most likely diagnosis was either polyarteritis nodosa or segmental arterial mediolysis. Although the dual hepatic blood supply allows a degree of arterial embolization, this case demonstrates the risks associated with large territory hepatic arterial embolization in the presence of hemodynamic instability. We discuss the management issues related to massive hepatic bleeding when no surgical approach is possible.

Gastroduodenal Artery Aneurysm: A Case Report and Concise Review of Literature

Gastroduodenal artery (GDA) aneurysm is a rare but potentially fatal vascular disease, with chronic pancreatitis being reported as the commonest aetiological factor. Its main complication is rupture, which is not uncommon and carries high risk of mortality. Clinical suspicion and advanced imaging tools should be employed in a timely fashion to make a diagnosis before this ominous event. We report a case of successfully treated GDA aneurysm who presented with minor bleeding episodes before suffering a major bleed and briefly discuss this pathology in light of the existing literature.

Splenic artery aneurysm of the hepatosplenomesenteric trunk

We herein report the case of a splenic artery aneurysm with a hepatosplenomesenteric trunk that presented in a pregnant woman. Catheter embolization was not performed due to the wide neck of the aneurysm and its close location to the trunk indicates a high risk of mesenteric trunk thrombosis. We instead performed surgical resection of the aneurysm after successful delivery of the infant by Caesarian section. The splenic artery was reconstructed by side-to-end anastomosis with the common hepatic artery.

[Not Available]

Visceral artery aneurysms (VAA) and pseudoaneurysms (VAPA) can be life-threatening conditions with high incidence of rupture and hemorrhage. Greater availability and increased use of advanced imaging technology has led to the increased incidental detection of asymptomatic visceral aneurysms. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic pseudoaneurysms. Due to this, both VAA and VAPA have become an increasingly frequent diagnosis confronting the vascular surgeon. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular occlusive and aneurysmal disease. All VAA and VAPA can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting, particularly in patients who are poor surgical candidates due to their comorbidities or who present a hostile abdomen. However, in the emergent setting it may carry a higher morbidity and mortality. We review the literature about open and endovascular approach for the treatment of VAA and VAPA both in the elective and emergent setting.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.

Long-term outcomes of coil packing for visceral aneurysms: correlation between packing density and incidence of coil compaction or recanalization

PURPOSE

To evaluate the correlation between packing density and the incidence of coil compaction or recanalization of visceral artery aneurysms (VAAs) after coil packing.

MATERIALS AND METHODS

Between July 2004 and April 2012, coil packing was performed for 46 true visceral aneurysms (16 splenic, 11 pancreaticoduodenal, eight renal, six hepatic, three superior mesenteric, one right gastric, and one gastroepiploic) in 42 patients. The size and volume of the aneurysm, packing density, and the incidences of compaction and recanalization were evaluated retrospectively.

RESULTS

The mean follow-up period was 37 months ± 8 (range, 11-80 mo). The mean packing density was 19% ± 8 (range, 5%-42%), mean aneurysm size was 19 mm ± 8 (range, 5-40 mm), and mean volume was 4,108 mm(3) ± 5,435 (range, 72-26,235 mm(3)). Compaction and recanalization occurred in two (4%) and 12 aneurysms (26%), respectively. The mean packing density was significantly lower in aneurysms with compaction or recanalization than in unaffected aneurysms (12% vs 22%; P = .00014). There was a significant difference in mean packing density between small (< 20 mm; 22%) and large (≥ 20 mm) aneurysms (15%; P = .0045). The mean size and volume were significantly larger for coil-compacted or recanalized aneurysms than for unaffected aneurysms (P < .05). In aneurysms with a packing density of at least 24%, no compaction or recanalization occurred.

CONCLUSIONS

Coil compaction or recanalization after coil packing for VAAs more often occurs after insufficient embolization with low packing density and in patients with large aneurysms.

Pancreaticoduodenal artery pseudoaneurysm caused by segmental arterial mediolysis: a case report of surgical treatment

A 64-year-old woman underwent surgical resection of a posterior inferior pancreaticoduodenal arterial aneurysm in the subacute phase of acute aortic dissection (AAD). Concomitantly, a distal pancreatectomy was also required. The aneurysm was approximately 20 mm in diameter. Surgical resection of the aneurysm was performed because endovascular treatment was considered to be technically difficult due to dissecting lesions that had remained at the abdominal aorta. Histopathological findings suggested this aneurysm to be a pseudoaneurysm, which had arisen as a result of segmental arterial mediolysis. Approximately 1 year after surgery, no recurrence of the aneurysms was detected.

Inferior mesenteric artery aneurysm: case report and literature review

An inferior mesenteric artery (IMA) aneurysm is the rarest among visceral artery aneurysms. A 69-year-old man was referred to our hospital with an asymptomatic IMA aneurysm associated with occlusion of the superior mesenteric artery (SMA) and celiac artery (CA). After revascularization of the SMA with an 8-mm expanded polytetrafluoroethylene (ePTFE) graft, the aneurysm was resected, and the IMA was reconstructed. The "jet disorder" phenomenon has been thought to cause an IMA aneurysm in the case of CA and SMA obstruction. We consider it better to revascularize not only an IMA but also an SMA or CA for preventing that phenomenon.