A Hybrid Approach to Treatment of a Superior Mesenteric Artery Aneurysm

Abstract

Superior mesenteric artery (SMA) aneurysms represent ∼6% of mesenteric aneurysms and carry a risk of rupture. These can be repaired with open surgery or endovascular repair. We present the case of a patient who had developed aneurysmal degeneration of the SMA after dissection requiring hybrid open and endovascular repair. A 54-year-old man had presented to the emergency department with epigastric pain. He was noted to have a 7-cm-long SMA dissection with aneurysmal dilatation. He was treated nonoperatively with anticoagulation and serial imaging until his SMA aneurysm had increased to 2 cm. Preoperative imaging showed the patient had two major jejunal branches originating from the true lumen, with the remaining branches fed from the false lumen. In addition, the aneurysm degeneration extended through the SMA to just distal to the origin (Fig 1). Because of this complex anatomy, we believed a hybrid approach would be needed with a short interposition bypass, reimplantation of jejunal branches, and covered stent placement for proximal coverage. The patient underwent laparotomy with anterior exposure of the SMA. After establishing proximal and distal control, a longitudinal arteriotomy was made. The true and false lumens were noted and fenestrated. An 8-mm polytetrafluoroethylene graft was sewn in an end to end fashion. This was followed by reimplantation of the two jejunal branches as a patch. Flow was confirmed with Doppler ultrasound. Next, the polytetrafluoroethylene graft was accessed with a needle, and a sheath was placed. Angiography and intravascular ultrasound were used to confirm and delineate the anatomy. Next, we upsized to an 8F sheath and placed two 10 × 5 Viabahn stents (W.L. Gore & Associates, Flagstaff, Ariz) overlapping into the aorta and covering the proximal SMA. We postdilated with a 9-mm balloon. Completion imaging revealed good flow with exclusion of the aneurysm (Fig 2). The bowel appeared healthy at that time. The patient tolerated the procedure well and was extubated at the conclusion of the case. He required a nasogastric tube postoperatively until the return of bowel function, at which point he was allowed a regular diet. He was discharged home in sTable condition on postoperative day 6 from the hospital. A hybrid approach to complex SMA aneurysms is a feasible option for repair.Fig 2Completion angiogram at conclusion of the case.View Large Image Figure ViewerDownload Hi-res image Download (PPT)