Successful treatment of pseudoaneurysms of celiac and superior mesenteric arteries by combined endovascular and surgical approach

Pseudoaneurysm after pancreas resection poses serious complications, including rupture and hemorrhage. Here we report a case of delayed massive hemorrhage from celiac and superior mesenteric arteries, which was successfully treated with a combined endovascular and surgical approach. The patient was a 52-year-old man who presented with pseudoaneurysms of the celiac and superior mesenteric arteries after distal pancreatectomy. Following the detection of sentinel bleeding from the abdominal drain, emergency angiography of the celiac and superior mesenteric arteries revealed stenosis of the celiac artery and pseudoaneurysms in the superior mesenteric artery. We occluded these lesions with a platinum coil, using an interventional radiological technique combined with bypass grafting between the abdominal aorta and the SMA, using the saphenous vein. However, re-bleeding into the abdominal cavity occurred from the proximal SMA pseudoaneurysm. We inserted an endoluminal stent-graft into the abdominal aorta and completed bypass grafting between the aorta and bilateral renal arteries. The hemorrhage ceased and the postoperative course was uneventful. The patient was discharged 34 days after the treatment (149 days after the initial operation). In conclusion, this combined endovascular and surgical approach is feasible and seems appropriate for pseudoaneurysms arising from proximal sites in visceral arteries.     

The diagnosis and endovascular management of superior mesenteric artery (SMA) branch pseudoaneurysms after appendicectomy

Pseudoaneurysms arising from the visceral arteries are rare. We present 2 patients who developed pseudoaneurysms arising from branches of the superior mesenteric artery (SMA) following laparoscopic appendicectomy. Both cases were successfully treated by endovascular embolization. The diagnosis and management of SMA branch pseudoaneurysms are discussed.     

血管内介入治疗腹腔内脏动脉瘤11例经验

目的评价介入治疗腹腔内脏动脉瘤的安全性和疗效。方法用介入技术治疗腹腔内脏动脉瘤11例,包括脾动脉瘤5例,胃-十二指肠动脉瘤5例,肠系膜上动脉(SMA)瘤1例。5例以假性动脉瘤破裂出血就诊,3例表现为上腹部疼痛和搏动性包块,3例无自觉症状。10例用血管内栓塞术,1例发自SMA的动脉瘤用联合动脉内栓塞和被覆膜支架置入术治疗。结果11例均治疗成功,无并发症。5例以出血为首发症状者,术后出血立即停止。1例SMA动脉瘤术后被完全封闭,主干及分支显影正常。3例术前有症状者术后腹痛逐渐消失、包块缩小。随访4～52个月(平均25.5个月),未发生与动脉瘤相关的并发症,超声波检查无动脉瘤复发表现。结论血管内介入技术是治疗腹腔内脏动脉瘤的安全有效方法。     

重症急性胰腺炎并发假性动脉瘤大出血的处理

目的探讨重症急性胰腺炎（severe acute pancreatitis,SAP）并发假性动脉瘤大出血的诊断和处理。方法回顾性分析1990年10月至2006年10月收治的12例SAP合并假性动脉瘤出血患者的临床资料。病因：胆源性胰腺炎6例,高脂血症3例,甲状旁腺功能亢进危象1例,原因不明2例。结果CT诊断假性动脉瘤出血6例（6／9）,血管造影均诊断正确（12／12）。受累血管主要为胰腺周围血管。8例“一点法”（出血血管近端）栓塞后成功止血,2例“两点法”（动脉瘤出血血管的近端和远端）血管栓塞后成功止血。2例急诊手术缝扎止血。“一点法”栓塞止血患者中有4例4～7d后再出血,2例急诊手术止血,2例改用“两点法”成功栓塞。3例死于感染和多器官功能不全综合征,总病死率为25％。结论血管造影是SAP并发假性动脉瘤大出血的主要诊断方法,“两点法”血管栓塞止血和急诊手术是有效的治疗手段。     

Femoral non-infected anastomotic pseudoaneurysm. Clinical contribution]

The femoral region is the most common site of development of anastomotic pseudoaneurysms that represent a relatively frequent complication of reconstructive vascular surgery. Clinical examination alone generally is sufficient to diagnose these lesions because they usually appear as a pulsatile inguinal mass not accompanied by pain. Echography and angiodynography permit a better evaluation of size and blood flow. CT is useful to evaluate proximal aortic anastomosis specially in pseudoaneurysms with septic pathogenesis. Rupture or thrombosis are rare clinical presentations. Vascular reconstructive surgery is always suggested in this sort of pathology. In this paper the Authors report the clinical experience acquired from 1980 to 1990 in the General and Cardiovascular Surgery Department of the University of Milan (Head: Prof. Ugo Ruberti) is 34 cases of femoral anastomotic aseptic pseudoaneurysms, analyzing the pathogenesis of this sort of lesion, describing the surgical solutions adopted and reporting the immediate and late results.     

Popliteal entrapment syndrome caused by fibular osteochondroma

Osteochondromas are the most common tumors of bone. In adolescence, they usually present as a painless growing mass. Femoropopliteal vascular complications associated with an osteochondroma are rare, with most cases involving pseudoaneurysms. This report describes an exceptional case of a popliteal entrapment syndrome caused by a proximal fibular osteochondroma.     

Adjunctive endovascular techniques in the management of postoperative carotid artery pseudoaneurysms--useful armamentarium for vascular surgeons--three case reports

Postoperative carotid artery pseudoaneurysms are rare. The traditional treatment of choice has been operative repair, which can present a significant technical challenge owing to the reoperative neck inflammation and potential cranial nerve injuries. The authors report 3 cases of postoperative carotid pseudoaneurysms that were successfully managed by use of various adjunctive endovascular techniques. The adjunctive endovascular maneuvers included the following: 1) endoluminal balloon placement for preoperative test occlusion and intraoperative proximal control to facilitate operative dissection in the first patient with a carotid pseudoaneurysm; 2) endoluminal stent-graft placement to exclude a large expanding carotid pseudoaneurysm in the second patient; and 3) endoluminal coil placement along with balloon occlusion to achieve complete hemostasis in the third patient, who presented with a hemorrhaging carotid pseudoaneurysm. Successful outcomes were achieved in all 3 patients by use of adjunctive endovascular techniques. These cases underscore the role of adjunctive endovascular treatment as an armamentarium for vascular surgeons in the treatment of complex carotid pseudoaneurysms.     

Peroneal artery pseudoaneurysm – a case report and literature review

Background

Aneurysms of the peroneal artery are infrequent and consist mainly of pseudoaneurysms.

Case presentation

This report describes an unusual case of peroneal pseudoaneurysm developing after thromoboembolectomy with a Fogarty catheter. It was managed successfully using an endovascular technique consisting of selective catheterization and coil embolization. The coils were placed in the peroneal artery, both proximal and distal to the pseudoaneurysm.

Conclusion

Endovascular technique can be successfully used to treat pseudoaneurysms in difficult settings.     

Aortic nonanastomotic pseudoaneurysm eroding lumbar vertebra--a case report.

Nonanastomotic pseudoaneurysms are uncommon complications of prosthetic grafts, which are mostly associated with axillofemoral grafts. The case presented describes a pseudoaneurysm secondary to a previously placed end-to-side aortobifemoral bypass. Back pain developed 3 years after the original bypass and was not relieved with narcotics and muscle relaxants. The patient also complained of a 20-pound weight loss, night sweats, and frequent emesis. Approximately 1 year after the onset of back pain, left leg claudication developed. He eventually underwent magnetic resonance imaging of the lumbosacral spine, which depicted a tumorlike mass eroding the vertebral bodies of L2 and L3. Full oncologic workup was pursued preoperatively. The patient also underwent aortography, computed tomography of the abdomen and pelvis, and an inferior venacavogram to elucidate the relationships between the mass and the major vascular structures. On exploration, no malignancy was present. A hole in the native aorta approximately 2 cm above the level of the end-to-side aortic anastomosis was discovered. This was contiguous with the vertebral bodies and the left psoas muscle. The pseudoaneurysm was repaired by conversion of the proximal anastomosis to an end-to-end aorto right iliac and left femoral bypass. All of the preoperative symptoms resolved after repair of the pseudoaneurysm. Chronic aortic rupture or pseudoaneurysms are difficult to diagnose due to the unusual clinical presentations. Despite complete radiologic evaluation, preoperative diagnosis may be difficult or impossible without a high degree of suspicion. Surgical repair will depend on the cause of the pseudoaneurysm--all but infected aneurysms may be repaired in line by creating a proximal anastomosis above the level of the pseudoaneurysm. Atypical back pain in patients with previous aortic reconstructions should alert the clinician to the possibility of vascular involvement. Patients with aortic pseudoaneurysms should undergo prompt repair to avert the potential risk for rupture when the surrounding structures are no longer able to contain the pulsatile flow.     

Traumatic injury of the proximal superior mesenteric artery.

Injuries of the proximal superior mesenteric artery (SMA) are relatively uncommon, but extremely perplexing lesions. Fifteen consecutive patients with this injury, 13 injuries from gunshot wounds and two injuries from blunt trauma, have been treated. Associated lesions and massive blood loss were common, averaging 3.6 injuries and 4800 ml per patient, respectively. Methods of SMA repair include lateral arteriorrhaphy (11 patients), primary reanastomosis (3 patients), and saphenous vein grafts (1 patient). Two of three patients whose injuries included segmental loss of the SMA that required a primary end-to-end anastomosis suffered subsequent thrombosis. Second-look operations were performed in five patients with two of these requiring a further reconstructive procedure. The only late death occurred in a patient with a severe head injury and a failure of his SMA repair, which potentially could have been prevented by a second-look procedure. There were five deaths (33%), with four occurring from acute hemorrhages and one late death occurring following intestinal necrosis and sepsis. Malabsorption or other late intestinal complications did not occur. Our experience 1) supports the concept that proximal SMA lesions must be repaired, 2) suggests that primary anastomosis to repair arterial defects is associated with a high failure rate, and 3) demonstrates that the second-look operation is a useful adjunct in improving survival in these patients.     

Two-staged repair for an acute type A aortic dissection with visceral ischemia after an aortic valve replacement

There is the consensus that patients with an acute type A aortic dissection (AADA) should undergo urgent surgical treatment. However, we dared to select a two-staged repair in order to relieve the visceral ischemia first. In addition, we selected revascularization using a bypass graft without using a proximal aortic replacement or aortic fenestration, because the reason for the occlusion of the SMA was judged to be an extension of the dissection out along the proximal segment of the SMA. Consequently, we proposed that a two-staged repair of the AADA with visceral ischemia was a useful option.     

Percutaneous closure of left ventricular pseudoaneurysms after Ross procedure

Pseudoaneurysm formation is a dangerous, but uncommon, complication after the Ross procedure. We describe a patient in whom two pseudoaneurysms formed at the proximal suture line of the pulmonary autograft. These were successfully treated percutaneously, one by placement of an Amplatzer Septal Occluder (AGA Medical, Golden Valley, MN), and the other with coil embolization.     

External compression of the superior mesenteric artery by the median arcuate ligament

The median arcuate ligament can compress the proximal portion of the celiac artery causing symptoms of chronic mesenteric ischemia. This rare condition typically affects young women and often poses a diagnostic challenge. Compression of the superior mesenteric artery (SMA) in addition to the celiac artery represents an unusual variant of median arcuate ligament syndrome (MALS). We present a case of MALS resulting predominantly from external compression of the SMA. Diagnostic and therapeutic options are discussed.     

Current state and future directions of endovascular ascending and arch repairs: The motion towards an endovascular Bentall procedure

Endovascular repair of the ascending aorta and aortic arch has evolved at an astonishing pace in the past several decades. Results of endovascular arch repair in experienced centers have been improving and the technology evolving, and it has begun to challenge the current gold standard status of open surgery in some groups of patients. Hybrid strategies with adjunctive cervical debranching for distal arch lesions are being replaced by fenestrated arch repairs. Total endovascular repair for proximal aortic arch pathologies with the use of inner branches has achieved the best results; however, the main current limitations of endovascular arch repair are diameter-, length-, and angulation-related issues with the ascending aorta (proximal landing zone). Ascending aorta endovascular repair has allowed extending treatment further proximally in patients with post-surgical pseudoaneurysms of the ascending aorta or post–type A chronic aortic dissections. However, sufficient proximal landing zone is still needed in the proximal aorta for these repairs; in a significant number of patients, this is not feasible with simple proximal tubular grafts. Therefore, new technologies and techniques are being developed to deal with this limitation, including the endovascular Bentall concept, with incorporation of the aortic valve and coronary ostia. In this review, the current state and future directions of endovascular ascending and arch repairs and the motion towards an endovascular Bentall procedure are discussed.     

Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome—How I Do It

Introduction  

Superior mesenteric artery (SMA) syndrome is a well-described condition involving mechanical compression of the third part of the duodenum by the SMA and the aorta, resulting in proximal obstruction.     

Repair of Anastomotic Abdominal Aortic Pseudoaneurysm Utilizing Sequential AneuRx Aortic Cuffs in an Overlapping Configuration

Anastomotic aortic pseudoaneurysm is a known late complication following aortic repair and presents a considerable surgical challenge. We herein evaluate the endovascular alternative of using sequential AneuRx aortic cuffs to bridge the degenerative anastomotic pseudoaneurysms as a definitive treatment. Over a 3-year period, six patients with a mean age of 68.7 years (range 58-75) were identified who had proximal anastomotic aortic pseudoaneurysms secondary to previously implanted bifurcated aortic grafts (mean 15, range 12-20 years) following open surgical correction of aortoiliac occlusive disease. Five patients (83%) presented with concomitant palpable femoral anastomotic pseudoaneurysms and one patient (16%) had a pulsatile abdominal mass. All patients had computed tomographic (CT) scans confirming proximal anastomotic pseudoaneuryms without evidence of infection. The mean diameter of the pseudoaneurysms was 5.3 cm (range 4.0-7.0). Five patients were treated with endovascular methods, while one patient was not suitable for endovascular repair due to the diameter of the native aorta as seen on imaging study at the time of the procedure. AneuRx aortic extender cuffs (3.75 cm length) were deployed sequentially in five patients via a femoral approach. Devices were overlapped approximately 1.5 cm in order to achieve total exclusion of the pseudoaneurysms, and all concomitant femoral aneurysms were repaired surgically at the same time. Successful exclusion of the anastomotic pseudoaneurysm was achieved in four patients (80%) using a combination of two or three overlapping aortic cuffs. One patient had a small residual endoleak that had sealed by 1 month, evidenced by follow-up CT. The renal arteries were preserved in all patients. The average estimated blood loss and operative time were 355 ± 25 cc and 84 ± 21 min, respectively. The average length of hospital stay was 2.1 days, and there was no mortality or major morbidity. All patients underwent CT scanning surveillance at 6 and 12 months and yearly afterward. There was no evidence of late endoleak, aneurysmal expansion, or device migration during the mean follow-up of 10 months, ranging 6-27 months. Our study demonstrated that utilizing sequential AneuRx aortic cuffs applied in an overlapping configuration is an effective strategy for degenerative aortic anastomotic pseudoaneurysm from previously placed aortic grafts. Additionally, our study suggests this unique endovascular technique is an ideal alternative for creating a customized tube graft in challenging cases, particularly in high-risk patients.     

Splenic pseudoaneurysms following acute pancreatitis]

Splenic artery pseudoaneurysms are the most common of visceral artery pseudoaneurysms. Splenic pseudoaneurysms appear to have developed as a consequence of inflammatory processes adjacent to the splenic artery, particularly acute pancreatitis and chronic pancreatitis with associated pseudocysts. They are often asymptomatic and picked up on abdominal examination for ultrasound or CT scanning for other conditions. Complications include rupture with retroperitoneal hemorrhage or intraperitoneal hemorrhage. Two cases of splenic pseudoaneurysms, following acute pancreatitis, are reported between the years 1987 and 1996.     

Reoperation for pseudoaneurysm of the thoracic aorta after cardiovascular surgery

Purpose

Pseudoaneurysms of the thoracic aorta after cardiovascular surgery are rare, but life-threatening complications. We herein describe the clinical outcomes of pseudoaneurysms of the thoracic aorta arising after cardiovascular surgery.

Methods

We retrospectively reviewed 14 patients (mean age 64 years) who underwent reoperation for a pseudoaneurysm of the thoracic aorta between January 1997 and December 2010.

Results

Pseudoaneurysms of the thoracic aorta were detected incidentally during routine follow-up in 11 asymptomatic patients, whereas symptoms or signs indicating an aortic pseudoaneurysm were present in three patients. The mean intervals between repeat and previous cardiovascular surgeries and the follow-up were 167 and 62 months, respectively. The aortic pseudoaneurysms were located in the proximal and distal suture lines in six patients, and at aortotomy sites in four. These locations accounted for about 70 % of all aortic pseudoaneurysms. None of the patients died in the hospital. Postoperative complications, such as a need for permanent pacemaker implantation or groin-related issues, occurred in five patients. However, no major postoperative complications, aorta-related events or a need for reoperation developed during the follow-up period.

Conclusions

Regular follow-up, including imaging modalities and physical examinations, is mandatory to detect aortic pseudoaneurysms after cardiovascular surgery.     

A new model for intestinal ischemia in the rat

Many models of intestinal ischemia in the rat have been described yielding mortality rates of 8-80% following superior mesenteric artery (SMA) occlusion for periods of 1-85 min. These results have been difficult to reliably reproduce in our lab. Based on our theory that these inconsistent findings are secondary to individual variability in collateral circulation, we have developed a new model for intestinal ischemia with reproducible and consistent mortality. Male Sprague-Dawley rats weighting 300-400 g underwent celiotomy and evisceration. Occlusion of the superior mesenteric artery just distal to the right colic artery was achieved. Collateral arcades from the right colic artery and the jejunal arteries proximal to the site of occlusion were ligated and the bowel was returned to the abdomen for the remainder of the ischemic period. SMA occlusion alone and SMA occlusion with interruption of collateral flow were evaluated and compared for severity of ischemic injury reflected by mortality and for reproducibility of ischemia and mortality. Quantitative measurements of blood flow for each technique were made using radiolabeled microspheres, and a survival curve for SMA occlusion with collateral ligation was constructed. SMA occlusion alone in the rat is not a reliable model for mesenteric ischemia because the resulting ischemic injury is inconsistent and not reproducible. SMA occlusion with collateral ligation produced more severe and reproducible ischemia with greater mortality than did SMA occlusion alone. This technique produced mortality rates that were reproducible and were more consistently related to duration of ischemia.     

Common hepatic artery aneurysm branching from the superior mesenteric artery. Report of a case

A 58-year-old man was notified as having a mass in the head of the pancreas at medical checkup on September 26, 2000. He was admitted to our department after being diagnosed as having an aneurysm in the common hepatic artery, branching from the superior mesenteric artery (SMA), based on selective SMA angiography. From an abdominal midline incision, we were able to reach his common hepatic artery aneurysm (CHAA) by mobilizing the pancreas through the route lateral to the greater curvature of the stomach. This aneurysm arose in the common hepatic artery immediately after branching from the SMA. After proximal and distal control of the SMA and common hepatic artery, the aneurysm was incised and the distal hepatic artery was anastomosed end to side to the SMA. The patient had an uneventful postoperative course.