Surgical treatment of abdominal aortic aneurysms located close to the visceral arteries: Report of three cases

The standard surgical treatment for abdominal aortic aneurysms (AAA) is in situ replacement of the infrarenal aorta, which is associated with a low mortality rate. On the other hand, thoracoabdominal aortic aneurysms (TAA) remain a formidable challenge and the complications that can occur may be severe including neurologic dysfunction and renal failure. We report herein three cases of patients with AAA located very close to the visceral arteries, for which in situ replacement of the infrarenal aorta was not feasible due to severe inflammation and adhesion. Therefore, aortic stump closure and in situ bypass grafting was performed to avoid reconstruction of the visceral arteries. No major complications or operation-related deaths occurred. Thus, while in situ replacement is usually recommended over bypass grafting for patients whose aneurysms are located very close to the visceral arteries, aortic stump closure and in situ bypass grafting should be considered as a more effective surgical option.     

Spontaneous dissecting aneurysm of the main trunk of the superior mesenteric artery: Report of a case

A 47-year-old man with a sudden onset of abdominal pain was diagnosed as having an aneurysm of the main trunk of the superior mesenteric artery (SMA), which induced ischemic colitis of the transverse colon probably because of a transient decrease in the SMA blood flow. The patient was successfully treated by resection of the aneurysm and an end-to-side anastomosis of the SMA to the aorta. A histological examination revealed a spontaneous dissecting aneurysm of the SMA.     

An isolated dissecting: aneurysm of the superior mesenteric artery: report of a case

We report herein the case of a 56-year-old man found to have an isolated dissecting aneurysm of the superior mesenteric artery (SMA) after he presented with a 3-day history of postprandial epigastralgia of sudden onset. An echogram showed marked dilatation of the SMA and a high level of peripheral echoes in a linear fashion within its lumen. A thin-section contrast enhanced computed tomography revealed a thin flap, separating two distinct well-enhanced lumina. Angiography confirmed the presence of a localized dissecting aneurysm of the SMA. The patient was treated conservatively and has since been followed up as an outpatient. Following the presentation of this case, the problems regarding the diagnosis and management of this rare disease are discussed based on a review of the literature.     

Ruptured superior mesenteric artery aneurysm occurring in association with a heterotopic pancreas: Report of a case

Aneurysmal disease of the visceral arteries is found in only about 0.2% of the population, and the celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. We present herein the case of a 71-year-old woman who suffered rupture of a SMA aneurysm. Histological examination of the periarterial tissues which existed next to the aneurysm revealed a heterotopic pancreas. To the best of our knowledge, no other case of an SMA branch aneurysm presenting in association with a heterotopic pancreas has ever been described in either the Japanese or English literature. This is the first report to indicate that a heterotopic pancreas is a likely incidental factor predisposing to visceral aneurysms.     

Giant true aneurysm of superficial femoral artery in patient with multiple atherosclerotic aneurysms: A case report

True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms.We report the case of a 84-year-old patient presenting a giant degenerative ruptured aneurysm of the superficial femoral artery. The patient underwent successful aneurysm resection and bypass grafting, with a satisfying long-term follow-up and patency of the graft. The patient was also operated one year before, for a ruptured aneurysm of the abdominal aorta.This case report is rare, because we described a case of patient with multiple atherosclerotic aneurysms, who present, for the second time, a life threating ruptured aneurysm. In this report, we see extreme and rapid evolution of SFA Aneurysm before being symptomatic.Degenerative aneurysms of the lower extremity most commonly involve the popliteal artery, while they are rarely detected in the femoral region (Leon et al., 2008). In this region, aneurysms most frequently involve the common femoral artery (CFA), whereas true aneurysms of the superficial femoral artery (SFA) represent only 15% to 25% of femoral arterial aneurysms [1], [2], [3], [4], [5].Degenerative aneurysms of the SFA display peculiar characteristics (in terms of clinical onset, diagnostic timing, and clinical behavior) so that they differ from other peripheral aneurysms. Because the relative rarity of this location, our case report can be useful to participate to increase the number of reported cases, and define the therapeutic approach for this rare location.     

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.     

Portal vein calcification: A clinical review of the last 50 years and report of a case associated with dysplasminogenemia

We report herein a case of a 68-year-old Japanese woman in whom calcification of the portal vein was recognized by plain abdominal X-ray radiograph and computed tomography (CT) scan when she presented with repeated thrombosis of the portal system. Following emergency small bowel resection for intestinal necrosis caused by superior mesenteric vein thrombosis, hematological studies revealed the association of dysplasminogenemia. A review of 21 cases of portal vein calcification reported between 1940 and 1990 revealed the average age to be 53.7±10.2 years and the male/female ratio 17:4. Although the majority of cases suffered from portal hypertension (81%), only 38% had any evidence of liver cirrhosis, while 52% had normal liver function, being comparable to idiopathic portal hypertension. The calcified lesions were located in the portal vein in 100% of cases, the splenic vein in 62%, the superior mesenteric vein in 33%, and the inferior mesenteric vein in 0%. The precise etiology of the calcification was not elucidated in any of the reviewed cases. The patient reported herein is the first reported case of portal vein calcification due to repeated thrombosis of the portal system caused by dysplasminogenemia, which could be accounted as a cause of idiopathic portal hypertension.     

A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm,with associated bronchial artery aneurysms: Report of a case

A 57-year-old woman who went into shock following an acute left hemothorax was operated on after stabilization under the diagnosis of a ruptured aortic aneurysm. A left fifth intercostal thoracotomy was done which revealed approximately 500 ml of bloody effusion in the extrapleural space and 2,000 g of clotted blood in the pleural cavity. While the aneurysm was initially thought to have originated in the isthmic or descending aorta, intraoperative findings revealed a swollen hematomatous thymus adherent to the aorta. A ruptured thymic branch aneurysm, 3 cm in diameter, was subsequently found in the resected hematomatous thymus. Histological examination also revealed several small aneurysms in the tortured bronchial arteries. Postoperative angiography showed a saccular aneurysm, 1.5 cm in diameter, and several smaller aneurysms in the bronchial artery of the left lung. The aneurysm was successfully treated by a transcatheter arterial embolization, and the patient has had no further symptoms since then. To our knowledge, there has been no other case of a ruptured thymic artery aneurysm reported in the literature, and only a few cases of bronchial artery aneurysms have been documented.     

Complete avulsion of the papilla of Vater and gastroduodenal artery due to blunt abdominal trauma: Report of a case

A case of traumatic avulsion of the papilla of Vater and gastroduodenal artery successfully treated by pancreaticoduodenectomy is presented herein. The mechanism of this rare injury appeared to be a shearing force applied to the common bile duct and gastroduodenal artery. Thus, when the liver is driven cephalad by compression of the abdomen and by the deceleration force, the common bile duct and gastroduodenal artery are avulsed from the fixed duodenum and pancreas. The mechanism of this rare injury is postulated on the basis of operative and histological findings. Our case is thought to be the first of traumatic avulsion of the papilla of Vater and gastroduodenal artery to be reported in Japan.     

A case report of communication of the coronary sinus with both atria associated with persistent left fuperior vena cava

A 16-year-old Japanese girl with a persistent left superior vena cava draining into the coronary sinus was surgically treated. Both coronary sinus and left superior vena cava were totally unroofed in the posterior wall of the left atrium, but the routes were recognized as a deep ditch. Both preoperative diagnosis and the ensuing successful correction were performed only after the third cardiac catheterization and the third operation, respectively. The importance of preperative diagnosis and the surgical procedures to correct this anomaly were discussed.     

Syringomatous adenoma of the nipple with microcalcifications on mammography: A case report

Syringomatous adenoma of the nipple (SAN) is a rare benign lesion which often presents as a subareolar mass with associated nipple shape changes including pruritus, crusting, and discharge It is thought that syringomatous tumors arise from eccrine glands of the nipple and areola. Due to its locally infiltrative growth pattern the main differential is with low-grade adenosquamous carcinoma which requires more aggressive surgical treatment. Syringomatous adenoma of the nipple can recur, and therefore complete local excision is recommended. We present a case of a syringomatous adenoma of the nipple diagnosed after nearly 5 years of observation with microcalcifications noted on mammography.     

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: a case report and review of the literature

BACKGROUND

Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction.

CASE DESCRIPTION

A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2.

CONCLUSION

This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.     

Ligation of symptomatic celiac artery aneurysm without vascular reconstruction: Utilizing the natural collateral circulation of the celiac axis: A case report

IntroductionCeliac artery aneurysm is very rare visceral artery aneurysm. Symptomatic and ≥ 2.5 cm sized aneurysm requires treatment. Excision and revascularization is the most commonly employed procedure.Case presentationWe report a case of ligation and excision of celiac artery aneurysm extending onto the splenic and hepatic arteries without vascular reconstruction. The patient was a 52 year old lady who was evaluated for abdominal pain and was found to have a celiac artery aneurysm involving the hepatic and splenic arteries. She was evaluated with computerized tomography and digital subtraction angiography of the abdominal vessels. These confirmed good natural collaterals from the branches of superior mesenteric artery supplying the liver, stomach and spleen. We performed ligation and excision of the aneurysm and ligation and division of hepatic, splenic and left gastric arteries as the aneurysm was extending on to these vessels, without any vascular reconstruction, utilizing the natural collaterals from the superior mesenteric artery.DiscussionLigation of celiac artery aneurysm without revascularization is often done in emergency situations. Excision and revascularization is the treatment of choice to ensure adequate blood supply to liver, spleen and stomach. We could utilize the natural collateral circulation of celiac artery from superior mesenteric artery avoiding a complex procedure of revascularization.ConclusionWe present this because of the rarity of the disease as well as rarity of the technique of not performing vascular reconstruction. We emphasize on the pre-operative and operative evaluation of collateral circulation with conventional angiography and intraoperative Doppler respectively.     

Multiple aneurysms of the distal posterior inferior cerebellar artery with recurrent hemorrhage undetectable on preoperative neuroradiological findings: case report

We report a rare case of multiple aneurysms of the distal posterior inferior cerebellar artery (PICA) associated with recurrent hemorrhage undetectable on preoperative neuroradiological findings. A 68-year-old woman was admitted to our hospital in April, 2003 because of a sudden onset of headache, back neck pain and nausea. CT scan at the time of admission showed a hematoma in the 4th & 3rd ventricles, and a mild subarachnoid hemorrhage (SAH) in the basal, right ambient & quadrigeminal cisterns. She had had a similar history of previous intraventricular hemorrhage and SAH in October, 2001. Three-dimensional CT angiograms and left vertebral angiograms performed at that time revealed an irregular vascular lesion at the tonsillomedullary segment (TMS) of the left PICA. However, the final diagnosis was unclear. Left vertebral angiograms at the time of the 2003 admission revealed an irregular vascular lesion in the same region more clearly and the size of aneurysmal dilatations had increased considerably. So, preoperative diagnosis of an irregular vascular lesion at the TMS of the left PICA (distal PICA aneurysm was not ruled out) was based on the above neuroradiological findings. The patient was surgically treated through the suboccipital approach. The TMS of the left PICA had made a difficulty loop formation was observed. Five distinct aneurysma were found on the TMS of the left PICA. To prevent bleeding, the ruptured aneurysm & three unruptured aneurysms were clipped and the residual unruptured one was wrapped with Bemsheets. Postoperative left vertebral angiograms demonstrated neither clipped aneurysms nor occlusive findings at the TMS of the PICA. The patency of the PICA was preserved. The postoperative course was uneventful and the patient was discharged without new neurological deficits. There has been no rebleeding during the one year since surgery. The 23 reported cases of multiple aneurysms of the distal PICA including our case were reviewed and their neuroradiological and clinical features are discussed.     

Hepatoblastoma of the adult with pericardial metastasis: A case report

BackgroundHepatoblastoma is the most frequent liver tumor in children, but very rare in the adult and associated with an unfavorable prognosis. The diagnosis is always postoperative or post mortem and biopsy is not useful. Surgery is the only accepted treatment.Case presentationOur patient underwent surgery in the suspect of liver metastasis from a previous gastric cancer. Surgery consisted in left lobectomy with partial diaphragm resection and partial pericardiectomy for a pericardial lesion, found after the opening of the thorax. The diaphragm defect was corrected with a biological mesh.ResultsThe histopathological examination indicated hepatoblastoma of the adult with pericardial metastases. The patient was asymptomatic and without recurrence after 21 months of follow up.ConclusionThe hepatoblastoma of the adult is related to a poor prognosis with median survival time less than 5 months. Surgery is the only curative treatment, but in many cases tumor resection requires complex operations. Vascular and thoracic expertise could be useful in the management of hepatoblastoma.     

Bilateral femoral hernia in a male cadaver with vascular variations: case report and review of the literature

Femoral hernia, which is a less common occurrence than inguinal hernia, is not congenital in most cases and is uncommon in young males. It is considered to be more common in females than in males due to an enlarged femoral ring in the former. A case of bilateral femoral hernia in a 64-year-old male cadaver is described within the framework of an anatomical approach. On the right side, the protrusion of the viscus appeared as a small intestine coil, whereas on the left side the protruded viscus appeared as a pelvic colon’s appendix appiplocae. On both sides, the protruded viscus was located in front of an aberrant obturator artery, which oriented from the external iliac artery and not from the internal iliac artery as should be the case. The puberal branch of the inferior epigastric artery was absent. The cadaver’s medical history and his skin examination excluded an abdominal surgery. In the literature, case reports of bilateral femoral hernia appear only seldom, especially those of male patients who had not undergone inguinal hernia repair surgery. In femoral hernias more often than in other types of hernia, the protruded viscus is strangulated and undergoes a tissue necrosis. Morbidity and mortality for complicated femoral hernia is high. Knowledge of vascular variation such as presented by the cadaver under study is extremely useful to the surgeon because any iatrogenic injury of the aberrant obturator artery during a laparoscopic repair may result in dangerous hemorrhage.