Transcatheter coil embolization of an iatrogenic superior mesenteric arteriovenous fistula: Report of a case

A 37-year-old male patient presented with abdominal pain and diarrhea. Computed tomography showed a large superior mesenteric vein aneurysm. The patient had a history of Crohn’s disease and underwent an ileocecal resection 7 years previously. A selective angiogram of the superior mesenteric artery revealed that a dilated branch of this artery fed directly into the superior mesenteric vein. The iatrogenic superior mesenteric arteriovenous fistula was successfully closed by transarterial coil embolization. Successful endovascular treatment for a superior mesenteric arteriovenous fistula has been recently reported; however, the complications of this new modality are not well understood. We herein review the current literature and discuss endovascular treatment.     

Mesenteric ischaemia after endovascular coiling of ruptured cerebral aneurysms

Summary Three patients were referred to a national neurosurgical centre following CT evidence of subarachnoid haemorrhage. The three patients, who were referred from different institutions within a seven week period, were Fisher grade 3 and WFNS Grade I at all times. Angiography showed a PCOM aneurysm in one case, a ruptured Basilar tip aneurysm and an unruptured ACOM aneurysm in another case, and an ACOM aneurysm in the third case. It was decided that the aneurysms were suitable for endovascular coiling. These patients had unremarkable intraoperative catheterizations and coiling but subsequently deteriorated post-operatively due to mesenteric ischaemia. Two patients required colectomy for mesenteric ischaemia, and the third arrested secondary to sepsis from bowel perforation. We discuss the various causes that may explain this association, and we alert the neurosurgical community for this complication which has not been reported before. Correspondence: Mahmoud Hamdy Kamel, Neurosurgery Department, 4F ward, Royal Victoria Hospital, Belfast, UK.     

Endovaskul?re Therapie der chronisch mesenterialen Isch?mie

Arteriosclerosis is the most common cause of chronic mesenteric ischemia, which is characterized by postprandial pain, unintentional weight loss and food avoidance. The use of endovascular techniques for revascularization of chronic stenoses and occlusions of the mesenteric arteries has rapidly increased over the last 10 years. The results of endovascular therapy have shown less morbidity and mortality compared to open surgical procedures, such as bypass and thrombendarterectomy. Early publications have reported higher rates of restenosis, symptomatic recurrence and reinterventions but recent case series show comparable patency rates. This article reviews visceral arterial anatomy and anomalies and endovascular techniques for the revascularization of mesenteric arteries.     

A staged,endovascular approach to treat a ruptured external iliac artery mycotic pseudoaneurysm in an intravenous drug user: A case report

IntroductionRuptured mycotic pseudoaneurysms are one of the ways IVDU patients can present in extremis. The principles of treatment include arterial ligation for haemorrhage control but can leave patients vulnerable subsequent limb ischaemia.Presentation of caseWe report a female IVDU presenting with abdominal pain and sepsis. Imaging demonstrated haemorrhage from an external iliac pseudoaneurysm. A two-staged hybrid approach with initial endografting and debridement for sepsis-control followed by delayed endograft removal and arterial reconstruction was successfully undertaken.DiscussionThe primary use of endovascular techniques to control haemorrhage in unstable patients is a useful adjunct to treat ruptured mycotic pseudoaneurysms in IVDU patients with delayed removal and arterial reconstruction.ConclusionWe have shown a successful outcome in managing a challenging patient using endovascular techniques as a bridge to definitive arterial reconstruction. This circumvents traditional approaches including primary arterial ligation, which carry a risk of limb-loss.     

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.     

Endovascular management of acute subarachnoid haemorrhage in the elderly

The objective of this study was to analyse the technical and clinical outcome in elderly patients receiving endovascular treatment for acutely ruptured intracranial aneurysms. The case notes and angiograms of 14 patients over the age of 69 years undergoing endovascular treatment for subarachnoid haemorrhage within the Interventional Neuroradiology Unit, Royal Perth Hospital over a period of 6 years were retrospectively reviewed. The degree of angiographic occlusion achieved, and periprocedural, short-term and long-term clinical outcome were retrospectively assessed. Greater than 90% occlusion was obtained in 92% of cases. 82% of patients with Hunt and Hess grade I and II had an excellent clinical outcome. We conclude that endovascular coiling is an effective means of treating acute subarachnoid haemorrhage in grade I and II elderly patients.     

Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes

BACKGROUND: Percutaneous therapy for symptomatic visceral occlusive disease is rapidly gaining popularity in many centers. This study evaluates the anatomic and functional outcomes of open and endovascular therapy for chronic mesenteric ischemia at an academic medical center. STUDY DESIGN: We performed a retrospective review of patients who underwent endovascular or open mesenteric arterial revascularization for chronic mesenteric ischemia between January 1989 and September 2003. Indications for revascularization included postprandial abdominal pain (92%) or weight loss (54%). All had atherosclerotic visceral occlusive disease with a median of 2 vessels with more than 50% stenosis or occlusion on angiography. Sixty patients (44 women, mean age 66 years) underwent 67 interventions (43 vessels bypassed, 23 vessel endarterectomies, 22 vessel angioplasty and stents). The median numbers of vessels revascularized were two in the open group and one in the endovascular group. RESULTS: Thirty-day mortality and cumulative survival at 3 years were similar (open, 15% and 62% +/- 9%; endovascular, 21% and 63%+/-14%, respectively; p=NS). Cumulative patencies at 6 months were 83%+/-7% and 68%+/-14% in the open and endovascular groups, respectively (p=NS). Major morbidity, median postoperative length of stay, and cumulative freedom from recurrent symptoms at 6 months were significantly greater in the open group (open, 46%, 23 days, and 71%+/-7%, respectively; endovascular, 19%, 1 day, and 34%+/-10%, respectively; p < 0.01). CONCLUSIONS: Endovascular revascularization is attractive because it carries equivalent patency to open revascularization. Symptomatic benefit of endovascular revascularization is not achieved, probably as a result of incomplete revascularization. Despite incomplete revascularization, endovascular therapy has equivalent survival and lower morbidity compared with open revascularization. Complete endovascular revascularization needs further evaluation to determine if it is superior to open revascularization. In the interim, endovascular therapy should be reserved for the patient unable to undergo open revascularization.     

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.     

Endovascular repair of an infrarenal abdominal aortic aneurysm with a dominant middle mesenteric artery: A case report

The middle mesenteric artery is a rare anomalous mesenteric vessel that may supply variable segments of the colon. Occlusion of this artery during endovascular aortic aneurysm repair may bear a significant risk of bowel ischemia. We report the successful interventional treatment of a patient with a 5.3 cm infrarenal abdominal aortic aneurysm, sparing a dominant middle mesenteric artery.     

Endovascular management of a ruptured thoracoabdominal aneurysm-damage control with superior mesenteric artery snorkel and thoracic stent-graft exclusion

We report a case of a large ruptured thoracoabdominal aortic aneurysm, which was stabilized with endovascular aortic exclusion and snorkel bypass of the superior mesenteric artery (SMA). An 80-year-old African American woman with multiple medical comorbidities and previous open infrarenal abdominal aortic aneurysm repair presented with a ruptured 10.7 × 7.3 cm thoracoabdominal aortic aneurysm involving the origins of the renal and mesenteric vessels. The patient underwent emergent endovascular aortic repair with placement of a covered stent into the SMA coursing parallel to the aortic endograft. This technique was initially successful in clinically stabilizing the patient; however; 3 weeks after the initial procedure, she presented with recurrent rupture necessitating proximal extension of her snorkeled SMA bypass and aortic endograft into the mid-descending thoracic aorta. The patient stabilized and was successfully discharged home.     

Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review

Mesenteric artery pseudoaneurysms are a rare and complex complication after abdominal trauma, surgery, or inflammatory disease. These lesions can be associated with compression or erosion into adjacent structures and may result in life-threatening hemorrhage. Traditional management has been open surgical ligation, aneurysm resection with interposition grafts, or resection or partial resection of the end organ involved. We present two cases of endovascular repair of complex mesenteric pseudoaneurysms. One patient presented with a recurrent pseudoaneurysm of the superior mesenteric artery and the second presented as recurrent gastrointestinal bleeding secondary to a traumatic celiac artery pseudoaneurysm-to-pancreatic duct fistula. A systematic review of the literature on endovascular management of mesenteric vascular disease and mesenteric pseudoaneurysms is included in this report to allow these cases to be put into proper perspective.     

Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemia--a case report

Acute mesenteric ischemia continues to be a highly morbid diagnosis with a high mortality rate. Percutaneous management of mesenteric ischemia is being more widely applied. Its utility is limited, though, for patients who present with an acute abdomen from ischemic bowel. The authors report a novel combination of open and endovascular techniques via a retrograde superior mesenteric artery (SMA) approach to treat acute mesenteric ischemia in the setting of an acute abdomen.     

Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease

Percutaneous interventions for symptomatic chronic mesenteric arterial atherosclerosis are rapidly gaining popularity. This study evaluates the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center. A retrospective analysis of records from patients who underwent endovascular mesenteric arterial interventions between 1984 and 2006 for chronic mesenteric ischemia was performed. Cases of acute ischemia or cases with associated bowel resection were excluded. Results were standardized to current Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using either a multivariate model for fixed variables or a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Thirty-one patients (84% female, average age 70, range 43-90, years) with 41 visceral vessel interventions were identified. Indications for intervention included weight loss >10 kg (61%) and/or postprandial pain (94%). The median SVS comorbidity score was 15 (range 10-24). All had three-vessel athero-occlusive mesenteric disease with a median of two vessels occluded on angiography. The median number of vessels revascularized was two. In all cases stenosis, and not occlusion, was treated. The 90-day mortality was 20% and the major morbidity was 6%. While primary and assisted patency rates for the interventions at 7 years were 69 +/- 8% and 72 +/- 9%, respectively (mean +/- SE, n > or = 10), cumulative freedom from recurrent symptoms was only 56 +/- 10%. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8), with a freedom from restenosis of 79 +/- 8% at 5 years. Fifty percent of these, all with recurrent symptoms, were reintervened successfully with balloon angioplasty and resolution of their symptoms. There was no significant difference between the celiac and superior mesenteric artery outcomes. The correlation of recurrent symptoms and restenosis was significant (p < 0.001). Endoluminal therapy for chronic mesenteric ischemia carries a low morbidity and mortality in a high-risk population. While anatomic patency remains high, long-term therapeutic benefit is not achieved. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.     

急性肠系膜上动脉缺血血管腔内治疗的临床经验

目的总结肠系膜上动脉缺血的血管腔内治疗治疗效果。方法 2015年5月~2016年6月,共7例患者术前采用CT血管成像检查诊断肠系膜动脉缺血,均优先采用血管腔内治疗的方式。结果一例患者因症状重,接诊时间超过24小时,腔内治疗后需要行部分小肠切除术;另有一例患者因溶栓过程出现腹膜后血肿,在保守治疗2月后,血肿明显缩小,肠系膜上动脉闭塞后侧支循环代偿,无需切除肠管;其余患者均由血管腔内治疗救治成功(71.42%),临床症状明显缓解,无患者死亡。结论及时应用血管腔内技术治疗肠系膜上动脉缺血能使患者在生存率及致残率上获益。     

Endovascular Therapy for Chronic Mesenteric Ischemia

Purpose The purpose of this article is to report on the effectiveness and durability of endovascular therapy for obstructive disease of the superior mesenteric artery and celiac trunk. Patients and methods Our retrospective study population included nine patients (five women, four men; mean age 64 years, range 34–83 years) with 15 lesions. The indication for endovascular therapy was chronic mesenteric ischemia. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency and sustained clinical benefit. Results Ten vessels were treated. The primary technical and clinical success rates were both 100% with no perioperative mortality. Major complications occurred in two patients (pseudoaneurysms). During a mean follow-up of 31 ± 18 months (range 3–60 months), thrombosis occurred in two patients at 1 and 3 months after the procedures, respectively. Thrombosis was successfully treated by catheter-directed intraarterial thrombolysis followed by percutaneous transluminal angioplasty (PTA) (n = 1) or stenting (n = 1). At 2 and 5 years, the primary patency rate was 78%, whereas survival was estimated to be 85% and 68% at 2 and 5 years, respectively. At this follow-up, all patients had obtained relief of symptoms. Conclusions Our experience suggests that endovascular treatment for chronic mesenteric arterial obstructive disease is feasible, with a low incidence of complications and acceptable midterm results. This study was presented at the 5th National Congress of the Italian Society for Vascular and Endovascular Surgery.     

Case report of multiple mesenteric mycotic aneurysms after perforated appendicitis

Introduction and importanceMycotic aneurysms are a severe and sometimes life-threatening complication of infections or sepsis. However, mycotic aneurysms of mesenteric arteries caused by a purulent peritonitis following perforated appendicitis are very rare and not previously reported. This case report contributes to the awareness and treatment of this rare complication.Case presentationWe present a case of a middle aged patient with a purulent peritonitis after perforated appendicitis. Postoperatively, recovery was not as expected. One week after laparoscopic appendectomy, CRP increased and haemoglobin levels dropped. Abdominal CT imaging revealed several mesenteric mycotic aneurysms. Because of aneurysmatic rupture, coiling of several mesenteric arteries was performed, despite the risk of bowel ischemia. After long-term antibacterial and antifungal treatment, the patient recovered completely.Clinical discussionFormation of mycotic aneurysms in mesenteric arteries is very rare and optimal treatment options are debatable. Given the high mortality of conservative therapy with antibiotics alone, treatment of mycotic aneurysms by surgery or endovascular treatment is strongly advised. In our case, it was decided to treat the aneurysms by endovascular coil embolization and to observe whether bowel ischemia would occur, because aneurysms were present in multiple mesenteric arteries.ConclusionMycotic aneurysms of several mesenteric arteries should be considered as a rare but potential complication of perforated appendicitis with purulent peritonitis. In case of rupture, successful treatment can be achieved by embolization followed by long-term antibiotics. A multidisciplinary approach including surgery, interventional radiology and microbiology is highly recommended and transfer to a tertiary referral centre should be considered.     

Clipping of distal superior cerebellar artery aneurysm with preservation of the parent vessel: a case report

A 29-year-old male presented with subarachnoid haemorrhage and a diagnosis of a ruptured distal superior cerebellar artery (SCA) aneurysm. The distal SCA harboured perforators to the brainstem; electrophysiological changes during temporary clipping proved the need for surgical clipping over endovascular occlusion. Successful clipping without distal occlusion was performed.     

Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts

Three patients with type I proximal endoleak after previous endovascular abdominal aortic aneurysm (AAA) repair were treated with fenestrated endovascular stent grafts. Six renal arteries, three superior mesenteric arteries, and one coeliac axis were targeted for incorporation by graft fenestration. The fenestration-renal ostium interface was secured with balloon-expandable stents and completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. All patients made an uncomplicated recovery. Fenestrated endovascular stent grafts can be used to salvage failed prior endovascular AAA repair in patients who are considered unsuitable for other endovascular or open surgical interventions.     

How to manage chronic mesenteric ischemia? A deliberated strategy

Abstract

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.     

肠系膜动脉瘤破裂出血的诊治分析：附8例报告

背景与目的 肠系膜动脉瘤是一种罕见的疾病,大部分患者确诊时动脉瘤已出现破裂大出血,病情危重,治疗风险大。本文回顾性分析肠系膜动脉瘤破裂患者的病例特点,探讨该疾病诊断和治疗方式的选择。方法 回顾性分析于2016年1月—2020年12月在湖南省郴州市第一人民医院血管外科收治的8例肠系膜动脉瘤破裂出血患者的临床资料和随访情况。结果 8例患者行腹部CTA或腹部增强CT明确诊断为肠系膜动脉瘤破裂出血。患者均行急诊手术治疗,其中6例行腹腔动脉造影+栓塞术;1例因腔内治疗失败后选择行开放手术;1例首选开放手术。8例患者均抢救成功,3例患者腔内治疗术后出现腹痛腹胀,药物保守治疗好转;1例患者开放手术术后出现创伤性胰腺炎,予以药物治疗治愈。所有患者住院期间均无再出血、肠缺血、肠坏死等并发症与再次手术。8例患者均随访12个月,患者正常饮食后无腹痛腹胀不适,无再次出血;复查腹部增强CT或CTA提示动脉瘤栓塞良好,血肿明显吸收。结论 临床医生要提高对肠系膜动脉瘤破裂出血疾病的认识和警惕,及时做出正确诊断。手术治疗方案可分为开放手术和腔内治疗,均安全和有效,术前应根据患者病情、瘤体位置和形态决定具体手术方案。