A Ruptured Pancreaticoduodenal Artery Aneurysm Repaired by Combined Endovascular and Open Techniques

Aneurysms of the pancreaticoduodenal arteries (PDA) are rare, accounting for <2% of all visceral aneurysms. An association with celiac artery stenosis has been reported. Many present with rupture, and a high mortality can be expected. Treatment is therefore challenging. Arterial ligation, anuerysmectomy, or bypass has been the mainstay of treatment. We recently treated a patient (who had no celiac axis) with a ruptured PDA aneurysm with combined open and endovascular techniques. A 46-year-old man was transferred to our hospital with a 1-day history of abdominal pain and syncope. On admission, an abdominal and pelvis computerized tomographic (CT) scan identified a large mesenteric hematoma, a 1.9 cm PDA aneurysm, and an occluded celiac axis. Mesenteric angiography revealed no active aneurysm leak and a stenotic superior mesenteric artery (SMA) origin. All hepatic blood flow originated from the stenotic SMA via markedly enlarged PDA collaterals. The patient was brought to the operating room, where absence of the celiac axis was confirmed. An aorto-to-proper hepatic and SMA bypass was performed using a bifurcated polyester graft. The next day, the patient was brought to the angiography suite, where the PDA aneurysm was coiled. Postprocedure CT scans confirmed thrombosis of the aneurysm. Ruptured mesenteric artery aneurysms are a challenging problem for the vascular surgeon. PDA aneurysms are rare and often occur in an unfavorable location. There appears to be an association with anatomic anomalies of the mesenteric circulation. Prompt invasive and noninvasive diagnostic studies aid in the definitive management of this often fatal problem. Combined endovascular and open techniques can be used for successful treatment.     

Endovascular Repair of a Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery and the Superior Mesenteric Artery

We present a successful endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) involving the celiac artery and the superior mesenteric artery. After the intentional occlusion of the celiac artery, an Inoue stent graft with a side arm to the superior mesenteric artery was implanted. Management of the visceral arteries in the endovascular repair of TAAA was highlighted.     

A Ruptured Pancreaticoduodenal Artery Aneurysm Associated with a Splenic Artery Aneurysm: Report of a Case

True pancreaticoduodenal artery (PDA) aneurysms are extremely rare. We report herein a case of a ruptured PDA aneurysm associated with a nonruptured splenic artery aneurysm which was successfully treated by surgery. A 55-year-old man was admitted to a local hospital complaining of sudden abdominal and back pain, and thereafter he was transferred to our university hospital. Abdominal computed tomography revealed retroperitoneal hematoma and an enhanced round spot suggesting a peripancreatic aneurysm. Emergency angiography showed a 20-mm-sized aneurysm in the inferior PDA and a 10-mm-sized aneurysm in the splenic artery. The patient underwent an emergency laparotomy with a diagnosis of a ruptured PDA aneurysm. After evacuating a large volume clot in the right retroperitoneal space and the peritoneal cavity, we detected an index finger-sized aneurysm with arterial bleeding in the right inferioposterior aspect of the pancreas. Hemostasis was obtained by oversewing the aneurysm and a ligation of the feeding arteries. A prophylactic splenectomy was performed for the nonruptured splenic artery aneurysm. This case indicates that emergency angiography is indispensable for both a definitive diagnosis and adequate surgical treatment of PDA aneurysms. Received: July 19, 2000 / Accepted: January 9, 2001     

Rupture of Mesenteric Artery Branch Aneurysm

We describe a case of ruptured mesenteric artery branch aneurysm. Since it is characterized by nonspecific clinical manifestations, aneurysm in this uncommon location is usually diagnosed following complications. Definitive diagnosis requires Doppler ultrasound followed by arteriography. The purpose of this report is to describe the pitfalls of diagnosis and define an appropriate management strategy. Unlike abdominal aortic aneurysm, isolated aneurysms of the superior mesenteric artery (SMA) branches are rare. Most cases are diagnosed after the occurrence of complications. Early diagnosis would be useful, since the natural course can be tragic without timely treatment. In this report, we describe one case of ruptured mesenteric artery branch aneurysm and review the literature for relevant data on the circumstances of discovery, methods of investigation, and appropriate management of these lesions.     

Successfully Treated Isolated Posterior Spinal Artery Aneurysm Causing Intracranial Subarachnoid Hemorrhage: Case Report

There are very few published reports of rupture of an isolated posterior spinal artery (PSA) aneurysm, and consequently the optimal therapeutic strategy is debatable. An 84-year-old man presented with sudden onset of restlessness and disorientation. Neuroradiological imaging showed an intracranial subarachnoid hemorrhage (SAH) with no visible intracranial vascular lesion. Spinal magnetic resonance imaging (MRI) detected a localized subarachnoid hematoma at Th10–11. Both contrast-enhanced spinal computed tomography and enhanced MRI and magnetic resonance angiography revealed an area of enhancement within the hematoma. Superselective angiography of the left Th12 intercostal artery demonstrated a faintly enhanced spot in the venous phase. Thirteen days after the onset of symptoms, a small fusiform aneurysm situated on the radiculopial artery was resected. The patient''s postoperative course was uneventful and he was eventually discharged in an ambulatory condition. To our knowledge, this 84-year-old man is the oldest reported case of surgical management of a ruptured isolated PSA aneurysm. This case illustrates both the validity and efficacy of this therapeutic approach.     

Impending Aneurysm Rupture after Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm

Abstract   An 81-year-old male presented with lower abdominal pain radiating to back associated with diaphoresis. He received endovascular repair of an infrarenal abdominal aortic aneurysm 21 months ago. Triple phase abdominal CT showed impending aneurysm rupture secondary to endoleak. After re-stenting and percutaneous transluminal angioplasty, he had an uneventful recovery later.     

Synchronous Colorectal Malignancy and Abdominal Aortic Aneurysm Treated With Endovascular Aneurysm Repair Followed by Laparoscopic Colectomy

Although the incidence of synchronous abdominal aortic aneurysm (AAA) and malignancies is increasing, there has been no clear consensus in the surgical treatment of such patients. The focus on surgical treatments with minimal invasiveness, such as endovascular aneurysm repair (EVAR) for AAA and laparoscopic colectomy for colorectal cancer, has increased; however, the clinical applicability of combination treatment with EVAR and laparoscopic colectomy has not been established. A 61-year-old man was diagnosed with AAA, advanced sigmoid colon cancer, and coronary artery stenosis. Because the patient also had chronic renal failure with nephrotic syndrome, among several other comorbidities, surgery was considered to be associated with high risks in this patent. Sequential treatments with percutaneous coronary intervention, EVAR, and laparoscopic colectomy were successfully performed. Staged treatment of EVAR followed by laparoscopic colectomy may be a promising strategy for high-risk patients with AAA associated with malignancy.Key words: Abdominal aortic aneurysm, Endovascular aneurysm repair, Colorectal cancer, Laparoscopic surgeryWith the aging of the general population, the prevalence of diseases associated with arterial sclerosis, such as abdominal aortic aneurysm (AAA), and that of neoplasms such as colorectal cancer (CRC), has also been increasing.¹ Therefore, the number of cases with concurrent AAA and CRC is expected to increase. However, there has been no clear consensus in the surgical treatment of such patients. The resection of CRC followed by aneurysm repair with a synthetic graft is associated with the potential risk of aneurysmal rupture during the perioperative period of the cancer operation.² Conversely, aneurysm repair prior to CRC resection may result in the delay of cancer therapy and consequent cancer progression²; there is also a possibility of aortic graft infection in the case of anastomotic leakage.¹In recent years, there has been increased focus on surgical treatments with minimal invasiveness for various diseases. In the treatment of AAA, endovascular aneurysm repair (EVAR) is a promising alternative to the conventional open graft replacement. In a large randomized study,³ EVAR was reported to achieve low operative morbidity and mortality, short hospital stay and operation time, and minimal blood loss. However, as a minimally invasive surgical procedure, the use of laparoscopic surgery for CRC is becoming more widespread. Patients who undergo laparoscopic CRC resection have significantly less blood loss and shorter hospital stays than those who undergo more invasive procedures,⁴ even though the reported oncologic outcome is equivalent to that of open surgery.⁵ Although several studies on therapy for concomitant AAA and CRC have been reported,⁶ there have only been a few reports on combination treatment with EVAR and laparoscopic colectomy.⁷ In the present report, we describe a case of synchronous AAA and sigmoid colon cancer with several other comorbidities, in which successful treatment with EVAR and laparoscopic surgery was achieved.     

Rupture of a Pancreaticoduodenal Artery Aneurysm into the Common Bile Duct Resulting in Fatal Suppurative Cholangitis: Report of a Case

A 73-year-old man with a preoperative diagnosis of cholangitis underwent a laparotomy, which revealed a necrotized gallbladder and dilated common bile duct, both filled with foul-smelling clotted blood. We could not find the cause of hemobilia at this time. On postoperative day (POD) 11, an exsanguinating hemorrhage suddenly began pouring from the T-tube, suggesting the possibility of a ruptured gastroduodenal artery branch aneurysm into the biliary system. Immediate angiography confirmed multiple aneurysms of the gastroduodenal artery. Embolization was done and there was no further bleeding from the T-tube; however, the patients condition was too critical for recovery and he died on POD 17. At autopsy, we found multiple aneurysms in the gastroduodenal artery. The posterior superior pancreaticoduodenal artery, diverging from one of the aneurysms of the gastroduodenal artery, formed another tiny aneurysm subjacent to the common bile duct wall. Rupture of this aneurysm into the biliary system caused fatal acute obstructive suppurative cholangitis.     

Percutaneous Endovascular Management of a Splenic Artery Aneurysm

Splenic artery aneurysms are extremely rare lesions. Elective repair of these aneurysms is justified only if the aneurysm’s size is greater than 2 cm and the predicted peri-operative mortality is below 0.5%. Percutaneous techniques minimise the peri-operative morbidity and mortality rates and offer a safe and effective treatment option. We report a coil-embolisation of a 5.1 cm splenic artery aneurysm and a short review of the literature concerning the endovascular treatment options.     

Rupture of Internal Iliac Artery Aneurysm into the Bladder following Aortic Aneurysm Repair

This report describes a case of ruptured internal iliac artery aneurysm into the bladder after repair of an infrarenal abdominal aortic aneurysm. Aortic repair consisted of resection of the aneurysm followed by prosthetic interposition to reestablish arterial continuity. During the postoperative period, the patient had ischemia of left colon, which was successfully treated by the Hartmann procedure. A right internal iliac artery aneurysm measuring 50 mm in diameter was demonstrated by an abdominal CT scan during the initial hospitalization but was considered stable, since ultrasonography showed no change in diameter at 3 months and 1 year. The patient was lost from follow-up until 3 years later when he was hospitalized after rupture of the right iliac artery aneurysm, then measuring 120 mm in diameter, into the bladder. Surgical repair was undertaken. The procedure involved aortobifemoral bypass with suture of the bladder defect and branches of the internal iliac artery by the endoaneurysmal route. Postoperative recovery was uneventful. Upon reexamination 1 month after discharge from the hospital, the patient was asymptomatic. This rare case confirms the gravity of internal iliac artery aneurysm and the importance of therapeutic management to prevent rupture.