Superior Mesenteric Artery Aneurysm in a Multi Aneurysmal Disorder Associated with a Distal Arteriovenous Fistula

Abstract

IntroductionA superior mesenteric artery aneurysm (SMAA) is arare and most often isolated event that has variouscauses. This is, as far as we know, the first reportedcase of an SMAA, treated surgically by resection andreplacement, and associated with a distal arteriove-nous fistula responsible for arterial enlargement andmultiple arterial aneurysms.Case ReportA 60-year-old man with no specific cardiovascular riskfactors (coronary symptoms, valve disorder, or cardiacmedication) or past medical or surgical history wasadmitted to the cardiology unit with severe heartfailure, acute dyspnea and peripheral edema. Trans-thoracic echocardiography revealed right ventriculardilatation (70 mm in diastole) with functional tricus-pid regurgitation. The cardiac failure was treated andthe patient rapidly recovered. Whilst in hospital, alarge distal arteriovenous fistula was found in the leftankle. The patient reported that when he was 9 yearsold the left ankle was injured in a bicycle accident andbled profusely. The wound was compressed to stop thebleeding and the skin was directly sutured. The distalarteriovenous fistula related to the injury remainedundiagnosed at the time and developed over the next50 years. In a patient with no history of valve disordersor heart disease the arteriovenous fistula was pre-sumed responsible for a case of heart failure whichresponded rapidly to appropriate medication.Following successful cardiac management thepatient was transferred to the vascular surgery unitfor investigation and treatment of the distal arteriove-nous fistula. Angiography showed a distal arteriove-nous fistula between the left posterior tibial artery andvein. The distal arterial tree was normal. The angio-gram also showed arteriomegaly involving the entireleft arterial network with a popliteal aneurysmmeasuring 35 mm in diameter, and a dilated super-ficial femoral artery which measured 17 mm proxi-mally and 24 mm in the adductor hiatus (Fig. 1).Arteriomegaly was associated with multiple aneur-ysm formation including an aneurysm of the leftcommon iliac artery (35 mm), an abdominal aorticaneurysm (55 mm) and an aneurysm of the right renalartery (20 mm). Before managing the aneurysms wedecided to treat the arteriovenous fistula with doubleembolization (arterial and venous) under local anes-thetic. First, the posterior tibial artery adjacent to thearteriovenous fistula was embolized using three Cookcoils (MREY EMBOLIZATION COIL