TOI 6. Heart in Abdomen: Challenge to Deal With Pseudoaneurysm of Superior Mesenteric Artery With Tetralogy of Fallot

Abstract

A 28-year-old man underwent total correction of tetralogy of Fallot in 2003. He was diagnosed with infective endocarditis 2 months before and received treatment in a cardiac unit. After discharge, he developed periumbilical pain associated with early satiety and decreased appetite. On examination of this thinly built patient, a pulsatile mass (0 × 10 cm) was palpable in the periumbilical region, more on the left side. Echocardiography showed a secundum-type atrial septal defect measuring 17 mm (left to right shunt), residual perimembranous ventricular septal defect (bidirectional shunt), severe mitral regurgitation with eccentric jet, tricuspid regurgitation (moderate), and pulmonary regurgitation (mild). Computed tomography angiography of the abdomen showed leakage of contrast material from the superior mesenteric artery (SMA) into an aneurysmal sac (6.8 × 7 cm) that occupied almost half the capacity of the peritoneum/abdominal cavity. Digital subtraction angiography showed distal SMA aneurysm with high flow; coil embolization could not be done because of the chance of gut ischemia and persistent pressure symptoms afterward; therefore, the open surgical approach was decided on. On opening of the peritoneal cavity, a beating heart wrapped in mesentery with surrounding inflammation was encountered. Proximal SMA control was taken just near to the aneurysm; the sac was opened and the hematoma evacuated, and the SMA was ligated inside the aneurysmal sac. Dusky proximal bowel found intraoperatively improved after evacuation of hematoma and ligation of the SMA aneurysmal branch, suggestive of impaired circulation from pressure of the sac. No revascularization was required. SMA pseudoaneurysm is rarely encountered in vascular practice. An aneurysmal sac of such size with distorted anatomy is a challenge to deal with, especially in a patient with such comorbidities.