内脏动脉瘤的诊断与治疗

目的　探讨内脏动脉瘤的诊断和治疗方法。方法　回顾性总结我院40 多年来收治的62 例内脏动脉瘤的临床经验。结果　本组包括肝动脉瘤15 例,胃胰十二指肠动脉瘤13 例,脾动脉瘤16 例,肾动脉瘤6 例,肠系膜上、下动脉瘤分别为5 例和1 例,腹腔干动脉瘤3 例,网膜动脉瘤3 例。本组自发性破裂大出血29 例,其中破裂入胆管14 例,上消化道10 例,腹腔及腹膜后5 例。本组术前经内脏动脉造影确诊37 例,经磁共振( MRI) 及数字减影血管造影术( DSA) 确诊各2 例,另6 例由螺旋CT 动脉造影(SCTA) 诊断。手术治疗51 例,死亡9 例,动脉栓塞治疗6 例。结论　内脏动脉瘤术前临床诊断极为困难,选择性内脏动脉造影( 包括DSA) 最具诊断价值,一旦确诊应尽早手术治疗     

三维增强核磁共振血管造影在内脏动脉瘤诊治中的应用

目的 探讨三维增强核磁共振血管造影在内脏动脉瘤诊治中的临床价值.方法 对43例内脏动脉瘤患者行三维增强MR血管造影检查,19例同期行数字减影血管造影(digital subtraction angiography,DSA).三维增强MR血管造影用屏气超快速三维梯度回波序列,图像减影后进行三维重建.结果 43例共50个内脏动脉瘤,涉及脾动脉32个(其中5例脾动脉异位起源于肠系膜上动脉),占64%;肠系膜上动脉7个(14%),腹腔动脉干5个(1例为腹腔系膜干),肾动脉4个,肝动脉2个.三维增强MR血管造影能清楚显示动脉瘤部位、大小、形态,并在立体直观显示动脉瘤及其与周围血管脏器关系方面优于DSA.43例中,行栓塞治疗15例,手术9例,保守观察19例.结论 三维增强MR血管造影能尤创、准确诊断内脏动脉瘤,所提供的三维解剖细节有助于临床治疗方案的制定,可作为内脏动脉瘤的首选检查方法.     

内脏动脉瘤诊治经验

目的　探讨内脏动脉瘤的诊断和治疗方法。方法　对 71例内脏动脉瘤的诊断和治疗进行回顾性总结。结果　 71例内脏动脉瘤中包括脾动脉瘤 2 2例 ,肝动脉瘤 16例 ,腹腔干动脉瘤 4例 ,胃、胰十二指肠动脉瘤 13例 ,肠系膜上、下动脉瘤分别为 6例和 1例 ,网膜动脉瘤 3例 ,肾动脉瘤 6例。本组自发性破裂大出血 2 9例 ,其中破裂入胆道 14例 ,上消化道 10例 ,腹腔及腹膜后 5例。术前经内脏动脉造影确诊 (包括DSA) 4 2例 ,螺旋CT血管造影 (SCTA)证实 14例 ,经核磁共振血管造影 (MRA)确诊 4例。手术治疗 5 8例 ,死亡 9例 ;动脉栓塞治疗 7例。结论　内脏动脉瘤术前临床诊断极为困难。DSA、SCTA和MRA具有诊断价值。一旦确诊 ,应尽早手术治疗。     

Evolution of the therapeutic approach of visceral artery aneurysms

INTRODUCTION: Visceral artery aneurysms are an infrequent entity. Most of them are asymptomatic, but when they present as a rupture, a high mortality is associated. MATERIAL AND METHODS: We review our experience of 18 cases between 1988 and 2006. RESULTS: 9 males and 9 females with a mean age of 66,5 years are analyzed. Aneurysms were located in splenic artery (9), hepatic artery (2), superior mesenteric artery (2), celiac trunk (3), inferior mesenteric artery (1) and gastroduodenal artery (1). Three of them were associated with abdominal aorta aneurysms. Fourteen patients were asymptomatic, three presented abdominal pain and one case presented with rupture and intraperitoneal bleeding. Surgical treatment was performed in thirteen of the patients and endovascular in five. Two cases of endovascular treatment failed and surgery was necessary. Postsurgical mortality was 0 and complications appeared in 2 patients. Mean hospital stay after surgical treatment was 11 days and 3 days after endovascular one. None of the patients presented recurrences, and one has chronic mesenteric ischemia as sequelae of surgical treatment of a superior mesenteric artery aneurysm. CONCLUSION: Visceral artery aneurysms must be treated if it is feasible, due to the potential risk of rupture. Endovascular treatment associates lower morbimortality rates and shorter hospital stay than surgical one, but nowadays many aneurysms are not suitable for this management. Endovascular treatment is a technically difficult approach, that requires a specific training and the first cases represent a learning curve.     

Surgical treatment of aneurysms of unpaired visceral branches of the abdominal aorta

Aneurysms of unpaired visceral branches of the abdominal aorta are rare diseases but they are dangerous for life. Russian Research Center of Surgery RAMS has an experience of diagnosis and surgical treatment of 23 patients with aneurysms of the celiac trunk (2), superior mesenteric artery (4), inferior mesenteric artery (1), hepatic artery (4), splenic artery (7), gastroduodenal artery (2), inferior pancreatoduodenal artery (1), multiple aneurysms of celiac trunk and superior mesenteric artery (2). 21 of 23 patients were operated. 20 patients were discharged with complete recovery. 1 (4.8%) patient died due to gastroduodenal bleeding 4 months after surgery. The results show that patients with aneurysms of unpaired visceral branches of abdominal aorta require surgical treatment.     

Successful endovascular repair of juxtarenal and suprarenal aortic aneurysms with a branched stent graft

This case report describes a new technique for repairing pararenal aortic aneurysms with a transluminally placed triple-branched stent graft with sidearms extending into the superior mesenteric artery and renal arteries. Endovascular repair with the branched stent graft was attempted in two patients with a pararenal aortic Aneurysm. Stent grafting was technically successful in both patients. Although postoperative transient renal function impairment and paralytic ileus occurred in patient 2, these complications were gradually resolved in the perioperative period. A substantial shrinkage of the aneurysm was revealed by means of computed tomographic measurements in patient 1. In both patients, complete exclusion of the aneurysm and patency of the bilateral renal arteries and the superior mesenteric artery were confirmed by means of follow-up computed tomographic images at 2 years. This minimally invasive approach for pararenal aortic aneurysms appears to be a viable therapeutic option for patients who are at high risk for open surgery.     

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??Endovascular treatment experience of aberrant splenic artery aneurysms: A study of 15 cases FANG Gang??CHEN Bin??FU Wei-guo??et al. Department of Vascular Surgery??Zhongshan Hospital??Fudan University??Shanghai 200032??China
Corresponding author??DONG Zhi-hui??E-mail: dzh926@126.com
Abstract Objective To summarize the endovascular treatment experience of aberrant splenic artery aneurysms. Methods The clinical data of 15 aberrant splenic artery aneurysms including 5 type A and 10 type B aneurysms treated by endovascular repair in Zhongshan Hospital??Fudan University from April 2007 to April 2017 was retrospectively analyzed. Results Technical success was achieved in 14 of 15 patients with angiographic documentation of aneurysmal exclusion. Endovascular treatment was abandoned after considering the high risk of coil embolization into the superior mesenteric artery and the relatively small aneurysm size in one patient. Treatment strategies of aberrant splenic artery aneurysms included coil embolization of the sac and outflow artery??with or without embolization of the inflow artery??or covered stent placement in the superior mesenteric artery. Follow-up time ranged from 2 to 117 months. No hepatic or intestinal ischemia??or death developed perioperatively or during the follow-up period. Reintervention was needed in 1 patient for persistent sac enlargement. The covered stent was found asymptomatically occluded in 1 patient at 2 years because of abundant collateral perfusion of the Riolan’s arch. Conclusion Endovascular treatment appeared to be feasible??safe??and effective in the management of aberrant splenic artery aneurysms. Furthermore??the preservation of the superior mesenteric artery??should be emphasized when optimizing aneurysmal exclusion.     

Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy

OBJECTIVE: Aneurysms involving branches of the superior mesenteric and celiac arteries are uncommon and require proper management to prevent rupture and death. This study compares surgical and endovascular treatment of these aneurysms and analyzes outcome. METHODS: Patients at the Mount Sinai Medical Center in New York who were treated for aneurysms in the branches of the celiac artery and superior mesenteric artery were identified through a search of the institution's medical records and endovascular database. Patient demographics, history, clinical presentation, aneurysm characteristics, treatments, and follow-up outcome were retrospectively recorded. Significant differences between patients treated by surgical or endovascular therapy were determined by using Student's t test and chi2 analysis. RESULTS: Between January 1, 1991, and July 1, 2005, 59 patients with 61 aneurysms were treated at a single institution. Twenty-four patients had surgical repair, and 35 underwent endovascular treatment, which included coil embolization and stent-graft therapy. Splenic (28) and hepatic (22) artery aneurysms predominated. Eighty-nine percent of splenic artery aneurysms were true aneurysms and were treated by endovascular and surgical procedures in near equal numbers (14 and 11, respectively). Pseudoaneurysms were significantly more likely to be treated by endovascular means (P < .01). The technical success rate of endovascular treatment for aneurysms was 89%, and failures were successfully treated by repeat coil embolization in all patients who presented for retreatment. Patients treated by endovascular techniques had a significantly higher incidence of malignancy than patients treated with open surgical techniques (P = .03). Furthermore, patients treated by endovascular means had a shorter in-hospital length of stay (2.4 vs 6.6 days, P < .001). CONCLUSION: Endovascular management of visceral aneurysms is an effective means of treating aneurysms involving branches of the celiac and superior mesenteric arteries and is particularly useful in patients with comorbidities, including cancer. It is associated with a decreased length of stay in the elective setting, and failure of primary treatment can often be successfully managed percutaneously.     

Massive gastrointestinal hemorrhage caused by rupture of a jejunal branch artery aneurysm

Aneurysms located in the arterial tree that directly supplies the alimentary tract account for a small percentage of all aneurysms. Jejunal branch artery aneurysms are an uncommon component of this group, and gastrointestinal hemorrhage from such an aneurysm has rarely been described. We report a case of a jejunal branch artery aneurysm appearing as sudden and massive gastrointestinal bleeding in a 28-year-old man. Diagnosis was made by selective superior mesenteric artery angiography, and the patient underwent successful segmental resection of the involved area of jejunum. The pertinent literature is reviewed.     

变异脾动脉瘤腔内治疗15例分析

目的 总结变异脾动脉瘤的腔内治疗经验。方法 回顾性分析2007年4月至2017年4月复旦大学附属中山医院血管外科收治的15例变异脾动脉瘤腔内治疗病人的临床资料,其中5例为A型变异脾动脉瘤,10例为B型变异脾动脉瘤。结果 15例病人中14例腔内治疗成功,操作结束后造影检查示瘤体不再显影;1例术中造影检查后考虑弹簧栓栓塞后移位至肠系膜上动脉风险大且病人动脉瘤直径较小,遂停止手术并随访观察。14例腔内治疗成功的病人中,1例行单纯瘤腔栓塞,5例行出瘤动脉及瘤腔栓塞,1例行入瘤动脉、瘤腔及出瘤动脉栓塞,1例行瘤腔栓塞及肠系膜上动脉覆膜支架置入,2例行出瘤动脉栓塞及肠系膜上动脉覆膜支架置入,4例行出瘤动脉、瘤腔栓塞及肠系膜上动脉覆膜支架置入。随访2～117个月,无失访或死亡病例,无肠道缺血坏死、症状性脾梗死、动脉瘤破裂等严重并发症发生。1例病人7年后再发腹痛,再次腔内治疗行瘤腔密集填塞,术后腹痛消失,密切随访。1例病人腔内治疗行出瘤动脉栓塞及肠系膜上动脉覆膜支架置入,术后第2年随访动脉造影检查示覆膜支架完全闭塞,Riolan弓显影,支架远端肠系膜上动脉灌注良好。结论 腔内治疗变异脾动脉瘤安全、有效。在腔内治疗过程中,除了对动脉瘤完成满意的血流隔绝,还应重视保护肠系膜上动脉。     

Digestive arterial bypass. Long-term clinical results

In the period between September 1966 and December 1988, 69 patients were operated, including 92 cases of restorative surgery on celiac, hepatic or superior mesenteric arteries. This is a presentation, of the detailed retrospective analysis of 12 years' experience with more homogeneously matched indications and technics. Only indirect, venous or prosthetic bypasses and reimplants are discussed; excluded are all other digestive revascularization procedures, as well as acute ischemic surgery cases. 31 patients (28 men, 3 women) of mean age 59.8 years (47-80) have undergone consecutive surgery: 11 presented with symptoms of predominantly digestive origin; 18 had a combined aortoiliac bypass operation; radiological signs of disease occurred in 46 cases. (celiac artery): 22 including 14 stenoses, 5 thrombotic cases and 3 aneurysms; superior mesenteric artery: 21 including 13 stenoses and 8 thrombotic cases; inferior mesenteric: 3 thrombotic cases). A restorative operation was carried out on 45 patients, 6 of whom had had previous surgery. 21 patients had a single artery restored: celiac (3), hepatic (9), superior mesenteric (9). Double artery surgery was performed in 12 cases. The procedures most commonly used on the hepatic and superior mesenteric arteries were indirect reimplantation and bypass surgery, respectively. Evolution showed increased numbers of anterograde constructions. No deaths were recorded in the perioperative period. Two patients had early recurrences of thrombosis at D10, which required new bypassing. During the mean retrospective period of 6.1 years, we recorded 6 cases of blindness, 8 secondary deaths, 1 single case of mesenteric infarction 18 months after a repeated restorative operation on the superior mesenteric artery; 17 patients remained symptom-free.     

A case of atherosclerotic inferior mesenteric artery aneurysm secondary to high flow state

Inferior mesenteric artery aneurysms are very rare and they are among the rarest of visceral artery aneurysms. Sometimes, the distribution of the blood flow due to chronic atherosclerotic occlusion of some arteries can establish an increased flow into a particular supplying district (high flow state). A high flow state in a stenotic inferior mesenteric artery in compensation for a mesenteric occlusive disease can produce a rare form of aneurysm. We report the case of an atherosclerotic inferior mesenteric aneurysm secondary to high flow state (association with occlusion of the celiac trunk and severe stenosis of the superior mesenteric artery), treated by open surgical approach.     

Asymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses

The prevalence of unsuspected renal artery stenosis among patients with peripheral vascular disease has been reported to be as high as 40%, but the prevalence of asymptomatic celiac and superior mesenteric artery stenoses in these patients is not known. The biplane aortograms of 205 male patients who were military veterans and had aneurysms or occlusive disease were independently reviewed, and medical records were studied to determine associated coronary disease, risk factors, and patient outcome. Fifty-six patients (27%) had a 50% or greater stenosis in the celiac or superior mesenteric artery, and seven patients (3.4%) had significant stenoses in both mesenteric arteries. Patients with celiac or superior mesenteric artery stenoses were older (p = 0.002) and had a higher prevalence of hypertension (p = 0.029) than those without significant mesenteric stenoses. Fifty of the 205 patients had significant renal artery stenoses, and 20 had advanced (greater than 75% diameter loss) renal stenoses. Ten of the 20 patients (50%) with advanced renal stenoses had a concomitant celiac artery stenosis, compared to 40 of the 185 patients (22%) who did not have advanced renal stenoses (p = 0.011). In the present study asymptomatic celiac or superior mesenteric artery stenoses were common among male veterans evaluated for peripheral vascular disease, but the prevalence of significant stenoses in both the celiac and superior mesenteric arteries was low. The prevalence of significant celiac stenosis was higher in patients with advanced (greater than 75%) renal artery stenoses who might be considered for prophylactic renal revascularization. Lateral aortography with evaluation of the celiac artery is always appropriate in these patients.     

Ruptured mycotic aneurysm: a complication of parenteral drug abuse

Mycotic aneurysms occurred in five narcotics addicts treated between 1969 and 1975. Fever, localized tenderness, swelling, loss of distal pulses, and leukocytosis were common findings. The aneurysms were located in the femoral (two patients), brachial (two), and superior mesenteric arteries (one). They occurred at the site of arterial injection in three patients. In one patient with subacute bacterial endocarditis, an aneurysm of the superior mesenteric artery developed. In one patient, the pathogenesis was uncertain. All patients had rupture of the arterial wall, with hemorrhage contained by adjacent muscle or soft tissue. Four patients were treated by ligation and debridement. One, with preexisting ischemia, required amputation below the knee. One patient underwent repair with autogenous artery. Recurrent hemorrhage necessitated ligation of the artery. In all patients, extensive sepsis and tissue necrosis precluded repair with prosthetic material. All patients survived, without evident of ischemia.     

Mesenteric vascular problems. A 26-year experience.

Mesenteric vascular problems are infrequent, but may be catastrophic. During a 26-year period, 55 private patients were treated for the following disorders: (1) 12 patients with visceral artery aneurysms, (2) 8 with celiac compression syndrome, (3) 13 with chronic mesenteric ischemia, (4) 12 with acute mesenteric ischemia, and (5) 10 with mesenteric ischemia associated with aortic reconstructions. Splenic artery aneurysms were managed by excision and splenectomy, while celiac and hepatic had excision with graft replacement. Patients with celiac compression syndrome underwent lysis of the celiac artery. Two patients had compression of both celiac and superior mesenteric artery (SMA). One patient required vascular reconstruction of both arteries for residual stenoses. Patients having chronic mesenteric ischemia were treated with bypass grafts, with one death (7.7% mortality) and good long-term results. Those with acute mesenteric ischemia were treated by SMA embolectomy, bowel resection, or both, with a mortality of 67%. When associated with aortic reconstructions, mesenteric ischemia carried a mortality of 100% if bowel infarction occurred after operation, but when prophylactic mesenteric revascularization was performed at the time of aortic surgery, prognosis was greatly improved, with only one death among six patients. An aggressive approach including prompt arteriography with early diagnosis and surgical therapy is advocated for these catastrophic acute mesenteric problems.     

Management of visceral artery aneurysms. Retrospective study of 23 cases

STUDY AIM: To evaluate symptoms and results of the treatment of aneurysms of digestive arteries. PATIENTS AND METHOD: Retrospective study of 23 patients (14 male and 9 female, mean age = 51 years) treated in two departments of academic hospital. We studied the aneurysms characteristics (location, number, size, etiology) the type of treatment, and occurrence of post-operative complications. RESULTS: The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastroepiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occurred in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed. CONCLUSION: The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contra-indication of surgery and when aneurysms are poorly accessible to surgery.     

Aneurysm of a jejunal branch of the superior mesenteric artery in a patient with Marfan's syndrome

A case of post-traumatic aneurysm of a jejunal branch of the superior mesenteric artery in a patient with Marfan's syndrome is reported. Ascending aortic involvement is well known in Marfan's syndrome but no association with visceral artery aneurysms has been previously described. The blunt abdominal trauma preceding the detection of the aneurysm may have been the precipitating cause in a predisposed patient. Because of the high risk of rupture, aneurysms of the superior mesenteric artery branches should be treated. Excision or ligation without restoring continuity are the most common surgical procedures; endovascular embolization is an alternative option especially in high risk patients.     

Visceral artery aneurysms: a single center experience

BACKGROUND: Splanchnic artery areurysm is a rare but clinically relevant disease, showing a high mortality rate in emergency surgery. Reports on splanchnic aneurysms are rare and often anecdotal. The aim of this study is to discuss data obtained from 16 patients in a single vascular surgery center. MATERIALS AND METHODS: Between January 1987 and December 2000, 16 patients underwent surgery for splanchnic artery aneurysms. In 13 patients the localization was single (in two associated with an infrarenal abdominal aortic aneurysm) and in 3 patients multiple. The arteries involved were: splenic (8), hepatic (4), celiac (3), superior mesenteric (3), ileocolic (2), and pancreatoduodenal (1). 13 patients were asymptomatic and 3 presentec with abdominal pain. All patients underwent CT scan, and abdominal aortic and selective visceral artery angiography. Before surgery, all patients underwent cerebral MR or cerebral CT scan. 13 patients underwent open vascular surgery; 3 patients (2 splenic and 1 hepatic) underwent endovascular procedure (angioembolization). Histological examination of the aneurysmal wall was obtained in 14 patients. Ultrasound examination was performed after 6 months, then yearly. 14 patients underwent abdominal CT scan during the long-term follow-up. RESULTS: Perioperative mortality was absent. 12 cases were classified as displastic, with minor or major secondary atherosclerotic changes, and in many cases severe calcications. 2 cases were classified as atherosclerotic. Cerebral MR did not show any cases of intracerebral displastric aneurismal disease. One patient was lost at follow-up after 9 years. One patient showed a recurrence at 6 years (superior mesenteric artery): the patient underwent a new surgical procedure and died 20 days after surgery for intestinal infarction. All abdominal follow-up CT scans show good results of the vascular reconstruction and escluded other new visceral or aortic aneurysms. CONCLUSIONS: Visceral artery aneurysms are an uncommon form of abdominal vascular disease showing a high postoperative mortality rate in emergencies. Surgery, and in selected cases, endovascular treatment, can successfully manage splanchnic artery aneurysms with few complications and low recurrence.     

Open staged repair of splenic and extensive superior mesenteric artery aneurysms

A 31-year-old man with a history of multiple strokes of unknown etiology presented with multiple asymptomatic visceral artery aneurysms including a 3.3-cm bilobed splenic artery aneurysm and a 3.1-cm fusiform superior mesenteric artery aneurysm. He had no family history of aneurysms, and there was no evidence of collagen disease. He underwent open splenic artery aneurysm resection without splenectomy and had an uneventful recovery. Seven months later, he had open repair of his 14.6-cm-long fusiform superior mesenteric artery aneurysm with a 15-cm-long collagen-coated polyester interposition graft with multiple visceral branch reimplantations into the graft. The postoperative course was uneventful, and computed tomography confirmed patent graft and side branches. Two years later, the patient remained free of abdominal symptoms, although he suffered another episode of a mild stroke.     

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: preliminary results

BACKGROUND: Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone. METHODS: All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure. RESULTS: Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures. CONCLUSION: This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.