Mesenteric Artery Aneurysm Research Articles

Ruptured visceral artery aneurysms in a patient of neurofibromatosis type 1 (NF-1) successfully treated by endovascular treatment

BackgroundNeurofibromatosis type 1 (NF-1) is an autosomal dominant disease and arteriovenous abnormalities are a well-recognized complication. There are several case reports of ruptured aneurysms; however, among them, reports of superior pancreaticoduodenal artery (PDA) and superior mesenteric artery (SMA) aneurysms are rare. We experienced the case of ruptured PDA and SMA aneurysms in a patient of neurofibromatosis type I successfully treated by endovascular treatment.Case presentationA 55-year-old woman with NF-1 came to our hospital with abdominal pain and vomiting. Enhanced abdominal computed tomography revealed a hematoma in the retroperitoneum and an aneurysm in the head of the pancreas. Angiography was performed, and a ruptured aneurysm was suspected the periphery of the PDA, and we embolized it using coils. However, on postoperative day 2, the hemoglobin level decreased, and a branch of the SMA was ruptured. She underwent embolization using coils again and discharged on postoperative day 27 without any further hemorrhage.ConclusionsTo our knowledge, this is the first successfully treated case of ruptured SMA and PDA aneurysms in a patient with NF-1.

Nonclassical Cause of Obstructive Jaundice: A Case Report of Multiple Visceral Arterial Aneurysms in a Young Patient

Multiple visceral artery aneurysms are relatively rare; the rarest are superior mesenteric artery and gastroduodenal artery aneurysms. The clinical presentation depends on the size and site of the aneurysm. We report the case of a 33-year-old man with recurrent episodes of obstructive jaundice and weight loss. Computed tomography with contrast revealed scattered hepatic arterial aneurysms with two other aneurysms along the course of the left gastro-duodenal and superior mesenteric artery. Investigations to determine the etiology were negative, but the patient had a history of smoking and substance abuse. Angiography revealed an occluded feeding artery. The patient developed multiorgan failure, leading to cardiac arrest and died. Diagnosing multiple visceral artery aneurysms needs a high index of suspicion; early diagnosis enables early intervention, which can reduce the high mortality of this condition.

P39 Physiotherapy management of long thoracic nerve injury (LTNI) post-flu vaccine in an immunocompromised patient with vasculitis: what is the best strategy?

Abstract Background We describe the case of a 12 year-old boy with polyarteritis nodosa presenting with long thoracic nerve injury (LTNI) post flu vaccination. Polyarteritis nodosa is an inflammatory vasculitis treated with immunosuppressive medication. Children with immunosuppression require seasonal flu vaccination, and LTNI is a recognised complication, rare in children, with no incidence documented. Physiotherapy plays a role in the conservative management of LTNI, however, there is debate regarding the most effective regime. Methods Case description with literature review of aetiology, treatment strategies and recommendations for effective therapeutic approach. Results Our patient was diagnosed with polyarteritis nodosa following an admission with intra-abdominal bleed, coeliac axis thrombosis and mesenteric artery aneurysm seen on angiogram. He responded well to steroids and immunosuppressive medication. Due to the risk of infection from immune suppression, he received seasonal intra-muscular influenza vaccination to the right deltoid. There were no initial complications, however, two weeks later, burning shoulder pain and sleep disturbance were reported. There was paraesthesia in the right hand although grip strength was not impaired. Of note, the patient is left hand-dominant. Examination revealed elevation of the right shoulder girdle and winging of the medial border of the scapula. Range of movement at the shoulder was full and pain-free. Palpation of the gleno-humeral joint line and deltoid were unremarkable. The clinical findings suggested long thoracic nerve denervation. Physiotherapy assessment demonstrated weakness in the serratus anterior muscle and abnormal scapula movement patterns, including decreased protraction. Nerve conduction studies reported decreased activation of the long thoracic nerve. Scapula recruitment exercises were advised, as well as posture correction. After a year, scapula-humeral rhythm and strength of the scapula muscles improved. Conclusion Causes of scapula-winging in children include osteochondromas, exostoses and sports-related injuries. Scapula-winging associated with LTNI is a recognised complication of flu vaccine but very rarely reported in under 16-year olds. Treatment of LTNI is poorly evidenced in the literature. However, physiotherapy including bracing to enhance proprioception, mobility exercises in supine to correct scapula position and strengthening of scapula muscles is reported. There is a lack of evidence to inform the most effective approach. The literature outlines that general gleno-humeral muscle strengthening is beneficial in improving shoulder function in LTNI. However, there is limited research investigating the specific role of scapula muscle strengthening in LTNI in children. The literature suggests that poor scapula function can impair the biomechanics of the shoulder and exercises that address scapula muscle control can improve movement patterns. The time to recovery from LTNI is estimated between 1-2 years and maintaining muscle bulk is our challenge, as the nerve recovers. Clinicians need to be aware of LTNI complicating flu vaccine in immuno-compromised children. We highlight the importance of physiotherapy in improving scapula biomechanics. Conflicts of Interest The authors declare no conflicts of interest.

A Challenging Case of Fibromuscular Dysplasia in a Transgender Patient: Is There a Hormonal Link?

IntroductionFibromuscular dysplasia (FMD) and superior mesenteric artery (SMA) aneurysms are rare vascular conditions. An unusual combination of both diseases is reported.Case reportA 54 year old woman presented with symptomatic SMA aneurysm. A diagnosis of FMD was made on the basis of computed tomography angiography (CTA). The patient had undergone gender reassignment surgery 10 years previously and continued to use both topical and oral hormonal therapy. The patient received open anatomical bypass through a retroperitoneal approach using great saphenous vein.ConclusionSuperior mesenteric artery aneurysms are rare and a diagnosis of FMD should be considered as part of the diagnosis process. Anatomical bypass should be considered carefully in relation to a patient's fitness as well as anatomical suitability.

Contrast-enhanced ultrasound to evaluate organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms.

To evaluate the organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms (VAAs) by contrast-enhanced ultrasound (CEUS) and colour-coded duplex sonography (CCDS). Between April 1995 to January 2016, 168 patients (78 males, 90 females; median age: 62 years) were diagnosed with VAAs at our hospital site. 60/168 patients (36%) fulfilled treatment criteria and had either open (29/60, 48%) or endovascular (31/60, 52%) aneurysm repair. Patients' characteristics and presentations were consecutively reviewed. Technical success and organ microvascularization were determined by CCDS/CEUS and correlated to computed tomography angiography (CTA) or magnetic resonance imaging (MRI). 18/60 patients (30%) presented with acute bleeding. 16/18 emergency patients (89%) were treated by endovascular means. After emergency treatment, two patients showed segmental liver malperfusion by CEUS and CTA. One small bowel resection had to be performed.42/60 patients (70%) were electively treated. 27/42 patients (64%) had open and 15/42 (36%) endovascular aneurysm repair. There were no liver or bowel infarctions after elective treatment of hepatic or mesenteric artery aneurysms (n = 13) in CCDS/CEUS and in CTA. Treatment of patients with splenic or renal artery aneurysms led to partial or complete organ loss in 42% (8/19) after operative and in 50% (5/10) after endovascular treatment (p < 0.05). The endovascular approach is the preferred therapeutic option in emergency to control bleeding. In contrast to hepatic or mesenteric procedures, patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully because of a high rate of partial or complete organ loss demonstrated by CEUS - either after open or endovascular aneurysm repair.

A Hybrid Repair of a Superior Mesenteric Artery Pseudoaneurysm Using Open Mesenteric Bypass and Endovascular Exclusion

Superior mesenteric artery (SMA) aneurysms and pseudoaneurysms are uncommonly encountered in vascular surgery practice, but they typically require repair. Historically, they have been repaired with open aneurysmorrhaphy, bypass and exclusion, or simple ligation. More recently, endovascular repair with coil embolization and stent graft exclusion have been advocated. We present a repair of an SMA pseudoaneurysm via a hybrid approach with common hepatic artery to SMA bypass, exclusion of the pseudoaneurysm with ligation of the SMA proximal to the bypass, plug occlusion of the proximal SMA, and coil embolization of the pseudoaneurysm.

Emergency Treatment of Haemorrhaging Coeliac or Mesenteric Artery Aneurysms and Pseudoaneurysms in the Era of Endovascular Management

Patients requiring emergency treatment of visceral artery aneurysms (VAAs) can be treated by endovascular or surgical techniques. Outcomes after failed attempts at endovascular control are unclear as is the present role of surgery. This study reviewed treatment and outcomes of a contemporary cohort of patients with symptomatic VAAs at a tertiary referral centre. Patients undergoing emergency treatment of a VAA of the coeliac, mesenteric arteries, or their branches were identified over a 5-year period. Patient variables, treatments, and outcomes were assessed. Forty-eight patients underwent 65 radiological and two surgical procedures. Pseuodaneuryms were present in 45 (94%) of patients. Interventional radiology procedures were the initial treatment in every patient. The initial success was 40 out of 48 (83%). Patients requiring more than one procedure were all successfully treated. Regarding initial failures, if the VAA sac could not be accessed at angiography an alternative procedure to control the VAA was required in every case. If initial endovascular treatment failed, repeating the same procedure was successful in half of the patients. Ultrasound-guided percutaneous VAA embolisation was used in four patients. The 30-day mortality was eight out of 48 (17%). There were four recorded complications including one death directly attributable to VAA treatment. Patients needing emergency treatment of a VAA could be well served by non-surgical management. When the initial attempt at control of bleeding is unsuccessful it is important to consider non-conventional means of accessing these arteries. The need for surgery, in selected centres, may exist for a small group of patients after initial failed radiological treatment only.

MODELING OF SUPERIOR MESENTERIC ARTERY ANEURYSM USING FLUID–STRUCTURE INTERACTION

The aim of this study was to model the blood flow and predict related hemodynamics characteristics in healthy superior mesenteric artery (SMA) and saccular aneurysm cases. A fluid–structure interaction (FSI) method was performed, using an arbitrary Langrangian–Eulerian mesh. The computational mesh was generated using anatomical data from available human computed tomography (CT)-images. Combining constitution and momentum equations, projection method, the discretized resultant equation were numerically solved for velocity, pressure, shear stress and vortices for healthy/aneurysmal artery. The results including velocity contours, pressure contours, shear rate values, and vortices were obtained and analyzed for three main steps including peak systole, diastole, and end of cardiac cycle. Profiles show the varying velocity and pressure for a pulsatile flow input before and after aneurysms. They also show the formation of single or multiple vortices at aneurysmal area and decrease of wall shear stress with aneurysm enlargement. Furthermore, shear rate values at the neck of aneurysms exceed throughout the entire cardiac cycle. The outcome of the computational analysis is then compared to information available on pressure, vortices and wall shear stress from some clinical findings.

Experience Using the Penumbra Ruby Coil in the Peripheral Vasculature: ACE Multicenter Study Preliminary Results

Purpose The Penumbra Ruby TM Coil system (Penumbra Inc., Alameda, California) is a new generation of larger (0.020 inch) platinum detachable coils that are designed for arterial and venous embolization in the peripheral vasculature. Recent literature has been published indicating the importance of higher packing density and its impact on occlusion stability and decreased recanalization rates. (1) The Aneurysm Coiling Efficiency (ACE) registry offers a unique opportunity to study the demographics and long-term outcomes of a multicenter cohort of patients with peripheral vasculature embolizations, reported herein. Material and Methods Between March 2012 and September 2014, data were collected at 12 centers. There were 63 cases of peripheral aneurysms/malformations or vessel sacrifices (11 splenic artery aneurysms, 9 renal artery aneurysms, 1 hepatic artery aneurysm, 2 mesenteric artery aneurysms, 7 AVMs, 6 fistulae, 3 varices, and 23 vessel sacrifices) treated with the Ruby Coils. The follow-up period was 6 months. Results The mean number of coils placed per aneurysm was 9 with mean packing density of 26% in the aneurysms/malformations cases (N = 39). Aneurysms identified at the splenic and renal arteries had volumes from 110 to 21,500 mm 3 and neck diameters ranging from 4 to 16 mm. Mean fluoroscopy time was 29 minutes. No procedural serious adverse events (SAEs) were noted. Among the cases of aneurysms with post-treatment occlusion data, 21/21 (100%) were graded as post-treatment Raymond Scale Class I occlusion. Of the 10 patients with 6-month follow up data, 10 (100%) displayed stable complete Class I occlusion with 0% recanalization. Of the peripheral vessel sacrifices, 23/23 patients (100%) were reported to have had successful coil embolization by the treating physician. The mean number of coils placed was 4 with a mean fluoroscopy time of 22 minutes. No procedural SAEs were recorded. All of the 11 patients with 6-month follow-up data displayed stable occlusion. Conclusions Using Ruby in the peripheral vasculature resulted in a high mean packing density and complete occlusion post-procedure which remained stable at 6-month follow-up. The long lengths and large volume of the coil allowed the use of fewer devices to achieve high packing densities. Due to the small cohort of cases, a larger sample size is needed to validate these data.

A rare cause of intraabdominal hematoma: rupture of mesenteric artery branch aneurysm

Superior mesenteric artery (SMA) aneurysm is the third most common splanchnic artery aneurysm. Unlike other splanchnic artery aneurysm, isolated aneurysms of the SMA branches are rare. They are usually asymptomatic and difficult to detect until they rupture and cause abdominal pain and hypovolemic shock. Thus, most cases are diagnosed after the occurrence of complications. In this report, we described a 76-year-old woman who had two saccular aneurysms in the superior mesenteric arterial branch(es). One of them was ruptured and partly thrombosed. The patient had acute renal failure secondary to massive intraabdominal hemorrhage.

Stellenwert der Sonografie im Rahmen präventiver Untersuchungen im Vergleich zur Ganzkörper-MRT – eine retrospektive Untersuchung bei 833 Patienten

The benefit of ultrasound in comparison with full-body MRI during a medical checkup in preventive health care was examined with regard to the detection of cardiovascular risk factors, metabolic syndrome, malignant tumors and further relevant findings. 833 consecutive patients (266 f/567 m, age: 19 - 93 y, mean age: 56.6 y) underwent both ultrasound (extracranial carotid arteries, thyroid, abdominal ultrasound and echocardiography) and whole-body MRI (whole-body MR angiography, head, thorax, abdomen and virtual colonoscopy). For ultrasound examinations, DEGUM level III devices were used (Siemens Acuson Antares, Siemens G60, Siemens, Erlangen). MRI examinations were performed using a 1.5 Tesla MRI device (Siemens Avanto, Siemens, Erlangen). All patients were reviewed retrospectively based on the written reports. Ultrasound was much more sensitive in detecting early atherosclerotic changes than MRI angiography. In 33 % of the patients, manifestations of atherosclerosis were found. Thoracic (3) and abdominal aortic and mesenteric artery aneurysms (3) were diagnosed by both methods. Hepatic steatosis as an important risk factor of metabolic syndrome was only found by ultrasound in 20.4 % of our patients. Malignant tumors were rare in this population (1.4 %): all abdominal tumors except one renal oncocytoma were found using both methods. MRI and ultrasound were equally sensitive with respect to the detection of small liver foci. As expected, MRI was less sensitive than ultrasound in the diagnosis of thyroid nodes. For intracranial diagnoses, malignant intrathoracic findings and colonic polyps, ultrasound is not the method of choice. For the detection of lifestyle-dependent diseases such as atherosclerosis and metabolic syndrome, ultrasound examination was more sensitive than MRI, and the same was true for the early detection of thyroid diseases. For the detection of malignant abdominal tumors, both methods were equally sensitive. Whole-body MRI can additionally detect pathological changes in the head, lungs and colon.

Case Report: Delayed Diagnosis of Mesenteric Artery Rupture

Introduction: Aneurysms of the superior mesenteric branch arteries are rare. The natural history is unknown and there is no consensus on management. We report a case of right colic artery aneurysm rupture. Report: A 70-year-old male presented with a two week history of right flank pain and syncope. On admission he was hypotensive, but responded to fluid resuscitation and was discharged after a two day observation period. He attended his family doctor with bruising in the right groin and abdominal distension. CT confirmed a 2 cm aneurysm arising from a branch of the right colic artery with a large associated haematoma and active extravasation. Discussion: Mesenteric artery aneurysms are rare and often misdiagnosed. Management options include embolisation or open surgery. The mesentery can act to tamponade in some cases resulting in a delayed diagnosis of rupture. Case Report: Delayed Diagnosis of Mesenteric Artery RuptureEJVES ExtraVol. 22Issue 6PreviewAneurysms of the superior mesenteric branch arteries are rare. The natural history is unknown and there is no consensus on management. We report a case of right colic artery aneurysm rupture. Full-Text PDF Open Access

A 6.5-cm pseudoaneurysm of the superior mesenteric artery managed by primary surgical repair

Superior mesenteric artery (SMA) aneurysms are rare but associated with significant mortality (25-40%) when complicated by rupture or thrombosis. Symptomatic SMA aneurysms, asymptomatic aneurysms of ≥2 cm size and pseudoaneurysms need intervention. We report a case of a 6.5-cm symptomatic SMA aneurysm managed by open surgical repair. At intraoperative exploration, the aneurysm was recognized to be a pseudoaneurysm with a narrow neck (1 mm defect in the native vessel) and was dealt by primary repair. Clinical presentation, the role of radiological investigations and management are discussed. Detailed preoperative assessment of the anatomical characters is essential in planning the intervention for SMA aneurysms. The required information can be obtained by selective interventional angiogram or computed tomographic angiogram with three-dimensional reconstruction. Multi-institutional prospective databases might provide better evidence regarding the timing of intervention, treatment modality, postinterventional follow-up and surveillance of patients with mesenteric aneurysms.

Giant endocarditis vegetation on a pace-maker lead

A 19 year-old man presented with a 2-month history of fever, cough and hemoptysis that were unresponsive to broad spectrum antibiotics. He had been implanted with an epicardial pace-maker at the age of 5 for complete heart block. One year before presentation, he experienced rupture of the epicardial implant following a car accident, and underwent emergency placement of an endocardial pacemaker. He also underwent orthopedic and abdominal surgery for multiple bone fractures and mesenteric artery aneurysm, with a resultant long-lasting intensive care unit stay. On admission to our hospital, computed tomography of the chest showed bilateral pulmonary inflammatory infiltrates with multiple pulmonary artery emboli. Trans-thoracic echocardiography showed a massive, mobile structure adhering to the pace-maker lead and severe pulmonary hypertension. Multiple blood cultures grew Candida albicans. The patient remained highly febrile and septic despite full dose combination antifungal treatment with caspofungin and fluconazole.

Mesenteric Autotransplantation: An Alternative Technique for Reoperation and Bypass of the Superior Mesenteric Artery

Superior mesenteric artery (SMA) aneurysms represent a minority of visceral aneurysms but may result in lethal complications if left untreated. Options for treatment include aneurysmorraphy, bypass, ligation, or embolization. Here we present a case of a man with a history of celiac graft thrombosis who presents with a recurrent symptomatic SMA aneurysm. Given his compromised celiac axis, ligation was not an option. His SMA aneurysm was repaired with a PTFE patch. However, to secure longstanding blood flow to the small bowel in the event of graft thrombosis, the distal SMA pedicle was dissected free of the ileocolic vessels and anastomosed to the aorta. Follow-up studies demonstrated an occluded PTFE patch with a patent SMA autotransplant. This case depicts a novel approach to the surgical management of complex recurrent SMA aneurysms.

Endovascular Exclusion of Superior Mesenteric Artery Pseudoaneurysms: An Alternative to Open Laparotomy in High-Risk Patients

Superior mesenteric artery (SMA) aneurysms are rare. However, patients are frequently symptomatic on presentation and require urgent repair. SMA aneurysms have the potential for severe complications, including thrombosis or rupture, resulting in acute mesenteric ischemia and death. In patients with adhesions secondary to prior abdominal surgery, traditional open exposure of the aneurysm neck via dissection at the base of the transverse colon mesentery may be technically difficult. Endovascular exclusion of visceral artery aneurysms using covered stent grafts presents a reasonable alternative to the morbidity associated with laparotomy. We report an interesting case of a patient with a large SMA aneurysm and multiple prior laparotomies treated percutaneously with a combined expanded polytetrafluoroethylene/nitinol self-expanding stent-graft allowing maintenance of end-organ perfusion and bowel viability.