Superior Mesenteric Artery Aneurysm Research Articles

Presentation and Management of a Rare and Fatal Disease: Saccular Superior Mesenteric Artery Aneurysms

Presentation and Management of a Rare and Fatal Disease: Saccular Superior Mesenteric Artery Aneurysms

PC174. Presentation and Management of a Rare and Fatal Disease: Saccular Superior Mesenteric Artery Aneurysms

Superior mesenteric artery aneurysm (SMAA) is a fatal degeneration of the visceral arteries. Although a rarely encountered entity, it requires timely management because of the high mortality rate associated with rupture, particularly when the aneurysm is saccular in nature. As such, urgent treatment is generally indicated. We present five cases of SMAA that were managed operatively. This study was a retrospective case series completed at a single, large academic institution from January 2016 to January 2019. We describe the presentation, operative management, postoperative outcomes, and follow-up from a series of five patients with SMAA. Five patients (80% female) with true SMAA were identified and diagnosed by computed tomography angiography. All cases involved saccular aneurysms. Three presented emergently with severe abdominal pain, one of whom was to have ruptured SMAA. Two elective cases were incidentally identified on imaging. Two cases were mycotic in etiology, secondary to intravenous drug abuse and infective endocarditis. The remainder were cryptogenic. There were no patients with history of atherosclerosis or elastin or collagen disorders. All of the SMAAs involved branches or branch points of the superior mesenteric artery (SMA). The largest SMAA was 3.2 cm in a proximal SMA branch point. All cases were treated with open surgical resection of the SMAA. Interposition reversed saphenous vein graft was used for reconstruction in a single case involving the main SMA trunk. None of the cases required bowel resection for ischemia. The operative mortality was 20% and related to ruptured SMAA. SMAAs are particularly prone to rupture, at which point intraoperative mortality can reach up to 30%. Accordingly, many authors suggest repairing SMAAs even in asymptomatic patients. Earlier studies supported revascularization, but this has more recently shifted to ligation alone because of the dense collateralization network. In addition, bowel should be closely examined for ischemic changes whenever the integrity is in question. The presenting and management features in our case series are supportive of this literature, with the exception that our population of patients was predominantly female. Future studies will continue to determine factors associated with rupture and poor outcomes, along with the optimizing surgical approach.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Visceral artery anomalies in patients with Alagille syndrome.

Intracranial and pulmonary vascular anomalies are well-known complications and causes of mortality in AGS; however, visceral artery anomalies are less commonly recognized. Herein, we present a retrospective analysis of our experience with pediatric LDLT that focuses on the current problems with and treatments for visceral artery anomalies in AGS after LDLT. Between May 2001 and December 2017, 294 LDLTs were performed for 285 pediatric recipients. Of these, 13 LDLTs (4.4%) for 12 AGS patients were performed. We classified the visceral artery anomalies into aneurysms and stenosis. The overall incidence of visceral aneurysm was 2 of 12 recipients (16.7%) and included a SMA aneurysm in one patient and an IPDA aneurysm with a subsequent SPA aneurysm in one patient; the ages of the diagnosis of visceral aneurysm were 16.3, 21.1, and 21.7y, respectively. An endovascular treatment was performed for a progressive IPDA saccular aneurysm (12.0×14.5×15.0mm). The overall incidence of visceral artery stenosis was 7 of 12 recipients (58.3%) and the median age at the diagnosis of visceral artery stenosis was 15.5y (range 1.7-22.9y). All 3 AGS patients with RA stenosis suffered from renal dysfunction (eGFR of 51, 78, and 51mL/min/1.73m2 ). The morbidity of visceral artery anomalies is not negligible. The performance of periodic imaging examinations is necessary, even for infants, because it is difficult to detect visceral vascular anomalies in the infant stage.

Clinical Profile and the Management of Mycotic Superior Mesenteric Artery (SMA) Aneurysm in Infective Endocarditis: A Potential Tsunami

Clinical Profile and the Management of Mycotic Superior Mesenteric Artery (SMA) Aneurysm in Infective Endocarditis: A Potential Tsunami

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

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.

Endoscopic Extraction of a Migrated Coil From the Duodenum 9 Years After Superior Mesenteric Artery (SMA) Aneurysm Embolization

Although visceral artery aneurysms and pseudo-aneurysms are relatively rare entities, they carry a life threatening risk of rupture. Therefore, elective treatment is warranted to reduce this risk, and trans-catheter arterial embolization has recently emerged as a safe and effective modality. Immediate complications of this procedure include hematoma at the entry site, occlusion of an incorrect vessel, and inadvertent aneurysm rupture. Herein, we report an unusual case of late coil migration into the gastrointestinal tract that was successfully removed endoscopically. A 30 year old gentleman with a past medical history of Gardner's syndrome status post total proctocolectomy with an ileal-J-pouch-anal anastomosis was diagnosed with an extensive abdominal desmoid tumor. This was complicated by recurrent intra-abdominal abscesses, which subsequently resulted in the formation of a 2.5 cm diameter mid-SMA aneurysm. This was successfully treated with trans-catheter arterial coil embolization. The patient later on developed gastric polyposis, requiring interval screening esophagogastroduodenoscopies (EGD). During a routine EGD, 9 years after his SMA aneurysm coil embolization, a free floating coil was discovered in the duodenum. The patient was completely asymptomatic, and an EGD 5 months prior revealed no such abnormality. The duodenal wall was inspected and showed no ulceration, erosion or fistulous tract. The coil was removed from the duodenum with raptor forceps and placed into the stomach, which was then retrieved using a roth net. There were no complications during or after the procedure. CT angiogram demonstrated continued occlusion of the SMA. He was followed for 1 year after coil removal without complication. Coil migration into the gastrointestinal lumen is extremely rare, and to our knowledge, this is the second case reported of a migrated coil that had been removed endoscopically. Migration is associated with ulcers, fatal hemorrhage, or can be asymptomatic as in our case. The exact mechanism of asymptomatic coil migration is not clearly defined, and has only been speculated. Although no treatment strategy has been established in managing these migrated coils, endoscopy proves to be a safe and suitable option.1863_A Figure 1. Migrated Coil in the Duodenum1863_B Figure 2. Extraction of Coil using Roth Net

Concurrent presentation of an intraductal tubulopapillary neoplasm and intraductal papillary mucinous neoplasm in the branch duct of the pancreas, with a superior mesenteric artery aneurysm: a case report

BackgroundSince the concept of intraductal tubulopapillary neoplasm (ITPN) was introduced in the current World Health Organization classification of tumors, the number of reports of ITPN occurrence has increased gradually. However, ITPN is usually located in the main pancreatic duct, with few reports of a branch duct ITPN. As a result, imaging protocols for the diagnosis of a branch duct ITPN have not been established.Case presentationWe report a case of a concurrent presentation of a branch duct ITPN and intraductal papillary mucinous neoplasm (IPMN) in the head of the pancreas, with a superior mesenteric artery (SMA) aneurysm. Initially, the cystic masses in the pancreatic head were diagnosed as branch duct IPMNs, with treatment consisting of a pylorus-preserving pancreaticoduodenectomy, in combination with an aneurysmectomy performed for treatment of the SMA aneurysm. Pathological examination confirmed these cysts were a combination of branch-type ITPN and IPMN. The patient recovered from the treatment without complication, with no evidence of recurrence over a period of 34 months post-surgery.ConclusionThis case report of a synchronous presentation of an ITPN and IPMN indicates the difficulty in differentiating these two types of neoplasms in the branch duct of the pancreatic head.

Liver perfusion dependent on superior mesenteric artery aneurysm

Liver perfusion dependent on superior mesenteric artery aneurysm

Endovascular management of inflammatory superior mesenteric artery aneurysm: A case report and review of literature

Superior mesenteric artery aneurysm (SMAA) is a rare clinical entity which can present with a wide spectrum of symptoms. It is associated with a high risk of rupture, morbidity, and mortality. Variable clinical manifestations often lead to misdiagnosis and improper therapies with high mortality ranging from 8.5% to 25%. We present a case of a 60-year-old male patient who presented with abdominal pain and a palpable pulsatile mass in the right hypochondriac and epigastric regions. He was diagnosed to have a large SMAA which was treated successfully with stent grafts.

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.

Hybrid Retrograde Endovascular Repair of a Rapidly Expanding Chronic SMA Dissection

A 59-year-old man with a 7-cm superior mesenteric artery (SMA) aneurysm had expanded 2 cm in the past 4 months. He presented 7 years after being lost to follow-up in the early postoperative period after thoracic endovascular aortic repair for type B dissection with dilated chronic aortic and aortic branch dissections: a 12-cm type 3 thoracoabdominal aortic aneurysm, a 59-cm SMA aneurysm, and 4-cm common and internal iliac artery aneurysms. As the patient underwent and recovered from a staged, multimodal, thoracoabdominal aortic and iliac artery repair, the SMA aneurysmal dilation rapidly progressed. Given the previous thoracoabdominal aortic surgery as well as an inflamed, large, residual aortic aneurysm sac and inflamed surrounding tissue, including the large SMA aneurysm itself, a hybrid retrograde endovascular repair was used. This consisted of laparotomy, and SMA true lumen branch exploration with open and retrograde placement of endografts from the SMA thoracoabdominal branch graft repair to the true lumen of the native SMA, followed by patch angioplasty and SMA false lumen embolization. The patient recovered well and was discharged to home after a 1-week hospital admission. Resultant, extensive, aneurysmal dilations may be safely repaired in a multistage, multimodal fashion to use the advantages of a variety of approaches—endovascular, open, and hybrid—while modifying technical challenges and overall risk.

Visceral artery aneurysms: an institutional review

Methods: It is a retrospective review of prospectively kept data of patients treated for visceral artery aneurysms in Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center from 1997 to 2009.Results: Fifteen patients were diagnosed with 16 visceral artery aneurysms. These consisted of 7 splenic (in 6 patients), 4 hepatic, 2 superior mesenteric, 1 gastroduodenal, and 1 renal artery aneurysms. There were 14 symptomatic patients including 4 who presented with rupture. Commonest presenting symptom was pain abdomen (14/15), followed by gastrointestinal bleed (6/15) and mass abdomen (5/15). The diagnosis was made with the help of CECT of abdomen in 13 patients, which was confirmed by conventional angiography in three patients. In two patients with obscure GI bleeding, diagnosis was clinched by conventional angiogram. Eight patients were treated only surgically, with three mortality. Transcatheter embolization alone was used in 5 patients. Two patients were treated with combination of surgical and endovascular therapy. One patient with superior mesenteric artery aneurysm in whom nothing could be done during laparotomy died six months later. Average follow up duration was one year.Conclusion: Splenic artery remains the most commonly afflicted vessel among the visceral artery aneurysms. The VAAs can be treated surgically or with endovascular means with fair success, although the best mode of treatment needs to be individualized.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 3-6

The Management of Superior Mesenteric Artery Aneurysm: Experience with 16 Cases in a Single Center

Superior mesenteric artery aneurysm (SMAA) represents a rare but potentially fatal condition. This study aimed to present the individual management protocol of SMAA in our center and to discuss a potential preliminary treatment algorithm. SMAA patients treated in our center between January 2007 and December 2014 were retrospectively reviewed on January2015. Sixteen patients with SMAA were identified, including 1 female and 15 males, with a mean age of 48.9±12.9years. Three patients (3/16, 18.8%) were treated by multiple overlapping bare stents and one (1/16, 6.3%) initially by a single bare stent. Two cases (2/16, 12.5%) were treated by a covered stent implantation, but one of those suffered from SMAA rupture 7days later, whereas the other had inner-stent thrombosis one month after discharge and died from multiple organ-dysfunction syndrome. Nine patients (9/16, 56.2%) received conservative therapy, one of who received multiple overlapping bare stents implantations for persistent abdominal pain. One patient underwent open surgery. There were 2 major complications, with no death during hospitalization and 1 death during follow-up. SMAA treatment needs to be individually prescribed, based on clinical manifestation, anatomy, and etiology. Multiple overlapping bare stents are safe and effective in selective patients with SMAA, and covered stents should be used with caution to avoid covering proximal branches; open surgery should be reserved for patients with suspected intestinal necrosis.

Spontaneous rupture of a superior mesenteric artery aneurysm

Spontaneous rupture of a superior mesenteric artery aneurysm

Localized Aortic Root Dissection with a Superior Mesenteric Artery Aneurysm.

In this study, the case of a 46-year-old female patient with localized aortic root dissection and a superior mesenteric artery (SMA) aneurysm is described. Computed tomographic angiography could not clearly delineate an intimal flap in the aortic root, but it detected SMA aneurysm, which implied the presence of a vulnerability of the aortic wall. Finally, transesophageal echocardiography (TEE) evidently showed the intimal flap localized in the aortic root. The present case suggests that TEE is of paramount importance for detecting localized aortic root dissection. In addition, a coexisting vascular lesion may be a clue to diagnose another vascular lesion.

Ligature and Removal of Mesenteric Artery Aneurysm Associated to Resection of the Terminal Ileum in Patient with Endocarditis and Negative Blood Cultures

The term mycotic aneurysm involves an infection of secondary aneurysmal wall to bacterial endocarditis. The 63% of mycotic aneurysms of the superior mesenteric artery are due to embolism from a septic endocarditis. Although most of these aneurysms is diagnosed, due to the increase in diagnostic methods, even a quarter of the superior mesenteric artery aneurysms present with rupture, intestinal ischemia and hemodynamic instability by increasing the mortality and morbidity of this disease. We report the case of a patient came to our attention for abdominal pain, suffering from bacterial endocarditis, with diagnosis of the thrombosed superior mesenteric artery aneurysm.

Embolization of Superior Mesenteric Artery Aneurysm with Celiac Trunk Artery Occlusion-A Case Report

Superior Mesenteric Artery Aneurym (SMAA) are a rare clinical finding with nonexistent or non-specific symptoms in most cases. The final event of SMAA is the rupture and its incidence is questionable. We present a case of a 61 year-old female with an accidental finding of giant SMAA.

Endovascular treatment of coexistent superior mesenteric artery aneurysm and celiac artery aneurysm

Endovascular treatment of coexistent superior mesenteric artery aneurysm and celiac artery aneurysm

Endovascular Stent Graft Repair of a Ruptured Superior Mesenteric Artery Aneurysm

A ruptured aneurysm of the superior mesenteric artery (SMA) is very rare. In recent years, there have been some reports of successful endovascular therapy of SMA aneurysms. However, endovascular stent graft repair of a ruptured SMA aneurysm has not been reported previously. We report on a 50-year-old man with a ruptured aneurysm of the proximal SMA. Using an endovascular approach, the aneurysm was initially excluded with 2 stent grafts. Two weeks following the first procedure, computed tomography angiography revealed a proximal endoleak, which was treated with another stent graft. The endovascular stent graft repair finally resulted in total exclusion of the ruptured aneurysm. Patency of the SMA was maintained and no ischemic complications occurred.

Collateral flow-related superior mesenteric artery aneurysm in chronic juxtarenal aortic occlusion

Collateral flow-related superior mesenteric artery aneurysm in chronic juxtarenal aortic occlusion