Aneurysm of the coeliac artery

A case of coeliac artery aneurysm associated with multiple splanchnic artery aneurysms is reported. This abnormality involved the gastroepiploic and hepatic arteries. The coeliac artery was ligated at laparotomy and the liver revascularized by direct anastomosis of the common hepatic artery to the aorta. Arteriography on the fifth postoperative day showed a satisfactory result. The surgical problems associated with aneurysms of the coeliac artery are reviewed. Copyright © 1996 The International Society for Cardiovascular Surgery.     

A case of ruptured and unruptured developing cerebral aneurysms at the bilateral M2 bifurcations five years after surgery for ruptured aneurysm at the end of the azygos anterior cerebral artery

A 36-year-old woman with 4 cerebral aneurysms at unusual sites including bilateral M2 bifurcation aneurysms is reported. She had been in good health in the previous 5 years since the treatment for a ruptured aneurysm at the end of the azygos anterior cerebral artery when she was 31 years old. Five years later, she became comatose with a huge hematoma in the right temporal lobe due to the rupture of the aneurysm at the right M2 bifurcation, which had been very small 5 years ago. She underwent an emergent clipping operation, and then she became alert with motor weakness extremities of on her left-side. Postoperative angiograms revealed a de novo aneurysm at the left M2 bifurcation and an aneurysm at the origin of the lenticulostriate artery, which has remained unchanged for 5 years. An aneurysm at the M2 bifurcation is rare, especially when it is situated bilaterally at the mirror sites. To detect de novo aneurysms, postoperative angiographical follow-up should be considered in patients with multiple aneurysms and in young patients.     

Aneurysmectomy and revascularization of a large hepatic artery aneurysm

Aneurysms of the hepatic artery are rare, but are associated with significant mortality because of their lack of symptoms at presentation and risk of rupture. We report a case of an enlarging 4-cm hepatic artery aneurysm involving the proximal common hepatic artery to the bifurcation of the right and left hepatic arteries which was found incidentally on ultrasound examination. Endovascular treatment with a stent was considered, but because of the location of the aneurysm as well as the presence of significant thrombosis involving the right and left hepatic arteries, aneurysmectomy and revascularization using saphenous vein was performed. Doppler ultrasound measurements demonstrated good flow through the graft postoperatively and at 1-month follow-up. Although a variety of endovascular techniques exist to treat hepatic artery aneurysms, our results indicate that open excision and revascularization may be required and can have a good outcome.     

Etiological factors and surgical treatment of pericallosal aneurysm

In spite of the belief that pericallosal bifurcation is the predilectional site for aneurysm, only a few reports have so far been available. Since 1963 nine cases of such aneurysms have been encountered at the Yamaguchi University Hospital. All aneurysms located on so-called pericallosal bifurcation at the genu of the corpus callosum. Seven aneurysms were saccular and two were fusiform. Multiple aneurysms were found in one case, while another case had a combined arteriovenous malformation at the periphery of the aneurysm. In one case, the internal carotid artery on the opposite side was occluded. Seven of the 9 patients were treated surgically. Ligation of the afferent artery was performed in the case with combined arteriovenous anomaly. Direct attack to the aneurysm was safely done in the remaining 6 cases through interhemispheric approach, neck clipping in 3 cases and adhesive coating in 3. Postoperative results were excellent in all cases but one, in which postoperative meningitis developed. In view of the disastrous outcome of pericallosal aneurysm when left alone, we believe that the direct surgical attack is the treatment of choice. Fortunately, an aneurysm at this site can be handled easier and safer than deep seated aneurysms in connection with Willis's circle, since it can be approached by interhemispheric route.     

Aneurysms of the visceral arteries: report of 5 cases

Visceral artery aneurysms are uncommon and usually result from atherosclerosis, periarteritis nodosa and fibromuscular dysplasia. Hepatic artery aneurysms were detected in two patient, splenic artery aneurysms in three. In four patients rupture occurred. In the two patients with hepatic artery aneurysm hemobilia from arterial rupture into the common bile duct and intraperitoneal bleeding in lesser sac was assessed. Ruptured aneurysms of the splenic artery with free intraperitoneal bleeding occurred in two patients, one patient had an asymptomatic splenic artery aneurysm. In four patients the diagnosis was made by contrast-TC and/or celiac and mesenteric angiography. In four patients excision of the aneurysm was successfully performed. One patient with ruptured hepatic artery aneurysm and in which resection and revascularization was made died.     

Surgical management of hepatic artery aneurysm: a case report

Hepatic artery aneurysms are uncommon and account for 20% of splanchnic artery aneurysms. The real incidence is unknown, but it is estimated to be 0.4% or less. Therapeutic procedures can be performed either surgically or as endovascular treatment. We report a case of a 77-year old man who was referred to our institute for an asymptomatic atherosclerotic hepatic artery aneurysm, measuring 4.5 cm in diameter, without evidence of dissection or rupture, involving the common and the proper hepatic artery. Resection of the aneurysm was performed, and the gastroduodenal artery was ligated. Reconstruction consisted in placement of an end-to-end prosthetic graft between the origin of the common hepatic artery and the distal third of the proper hepatic artery. An intraoperative arteriogram revealed a complete interruption of flow in the left hepatic artery. Intraoperatively, dissection of the left hepatic artery was revealed. Therefore the left hepatic artery was ligated and a new end-to-end prosthetic graft was performed between the origin of the common hepatic artery and the right hepatic artery. The postoperative course was complicated by respiratory failure requiring ventilator-assisted breathing. The patient was subsequently weaned from the ventilator and was discharged to our ward 4 days after surgery. No long-term hepatic or pancreatic complications were detected.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Aneurysms of the hepatic arteries

Seven patients with an aneurysm of the hepatic artery were investigated and operated on between 1976 and 1987. Five patients presented at the time of rupture and in three of those the aneurysm communicated with the biliary tree causing hemobilia. The aneurysm was located in the right hepatic artery in four patients; in the common hepatic artery in two patients, and in the left hepatic artery in one patient. Excision of the aneurysm was performed in five cases, but in two cases a liver resection had to be carried out. Five of the seven patients survived, including both patients who had elective surgery. It is concluded that hepatic artery aneurysms have a high tendency to rupture and therefore an elective operation should be performed in all patients with diagnosed aneurysm of the hepatic artery.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

Management of isolated common iliac artery aneurysms

Purpose: Since isolated common iliac artery aneurysms are rare and there is no consensus regarding some aspects of their management, we reviewed our recorded experience with common iliac artery aneurysms from 1977 through 1993. Methods: We were able to identify 25 patients having a total of 33 common iliac artery aneurysms on the basis of information maintained by our medical records staff, old surgical logs and a departmental registry that was implemented in 1989. Follow-up data were collected from outpatient charts and by telephone contact. New imaging studies were obtained for 14 patients who either underwent common iliac artery aneurysm repair without aortic replacement (aortic ultrasound scans, n = 7) or had no surgical treatment whatsoever (computerized tomography of the abdomen and pelvis, n = 7). Results: All 25 patients were men (mean age, 71 years). Eighteen patients (72%) had elective (n = 14) or urgent (n = 4) operations to repair common iliac artery aneurysms with mean diameters of 3.8 cm and 5.8 cm, respectively. There was one postoperative death (5.5%) in conjunction with complementary renal revascularization in a patient with preoperative renal insufficiency. During a mean follow-up period of 50 months, two (29%) of the seven patients who had not received bifurcation grafts at the time of their common iliac artery aneurysm procedures had developed infrarenal aortic aneurysms. Seven (28%) of the original 25 patients were observed without intervention for common iliac artery aneurysms measuring 2–2.5 cm in diameter. No common iliac artery aneurysm enlargement or new aortic aneurysms have been documented in any of these patients at a mean follow-up interval of 57 months. Conclusions: In our limited experience, the risk for spontaneous rupture appears to be concentrated among common iliac artery aneurysms exceeding 5 cm in diameter, while those that are less than 3 cm in diameter may fail even to enlarge under observation. Therefore, common iliac artery aneurysms measuring ≥3 cm in size probably warrant surgical treatment, at which time simultaneous aortic replacement also should be a serious consideration.     

Retroperitoneal bleeding due to a ruptured aneurysm of the middle colic artery

In a 51-year-old man the middle colic artery ruptured. The patient had abdominal pain for several days, and then suddenly, a considerable intraperitoneal bleeding occurred. The aneurysm was extirpated and in the postoperative angiogram, numerous aneurysms were detected in the colic artery. Splanchnic artery aneurysm mainly occurs in renal artery, splenic artery and hepatic artery, but rarely in the mesenteric artery. The pathogenesis of mesenteric artery aneurysms is usually mycotic false aneurysm from prior aortic endoarteritis. In the present case, the etiology of the aneurysm was not confirmed.     

Nonoperative management of visceral aneurysms and pseudoaneurysms.

During the period from 1975 to 1991, 41 patients with 60 visceral artery aneurysms were treated at the Affiliated Hospitals of Emory University. The total included 13 patients in whom 16 aneurysms were treated primarily by transarterial embolization. There were seven hepatic artery aneurysms, three splenic artery aneurysms, three gastroduodenal artery aneurysms, two left gastric artery aneurysms, and one right gastroepiploic artery aneurysm. Average age of these patients was 50 years; there were eight males and five females. Seven patients presented with gastrointestinal bleeding, and two patients presented with abdominal pain. In four patients, the aneurysm was an incidental finding. Etiology of the true or false aneurysms consisted of pancreatitis in two patients, trauma in three patients, connective tissue disease in one, and was unknown in the remainder. Embolization was performed in seven cases with Gianturco coils and Gelfoam, with coils alone in four, with Gelfoam alone in four, and with detachable balloons in one instance. Complete occlusion was achieved initially in 13 cases. Recanalization occurred in two patients over a mean follow-up period of 8.6 months, requiring re-embolization in one patient, whereas the other patient was managed expectantly. In three cases, embolization was unsuccessful: two cases required surgical correction, and one case was managed expectantly. Only one complication was related to the embolization procedure, which was a common hepatic arterial dissection that proceeded to the formation of a false aneurysm. Embolization as the primary treatment modality for visceral artery aneurysms should be considered in patients with the following diagnoses: pseudoaneurysms associated with pancreatitis, intrahepatic aneurysms, most splenic artery aneurysms, and gastric, gastroduodenal, and gastroepiploic aneurysms. The procedure has a low risk and may obviate a difficult surgical procedure, but it does not preclude surgical intervention should the need arise.     

Intracranial aneurysm and vasculopathy after surgery and radiation therapy for craniopharyngioma: case report

OBJECTIVE AND IMPORTANCE: This case report illustrates the possible occurrence of intracranial aneurysms after surgery and radiation-induced vasculopathy. CLINICAL PRESENTATION: An internal carotid bifurcation aneurysm was diagnosed in a 19-year-old woman in a routine follow-up examination by magnetic resonance imaging 5 years after subtotal removal of a giant cystic craniopharyngioma treated by postoperative external radiotherapy. The presence of the aneurysm was confirmed by angiography. INTERVENTION: It was decided to treat the aneurysm by embolization with Guglielmi detachable coiling. However, at the beginning of the procedure, a few weeks after the diagnosis, a dramatic reduction in the carotid artery blood flow was observed, along with signs of thrombosis inside the aneurysm. In light of these findings, the procedure was aborted. Four months later, another angiographic examination confirmed the exclusion of the aneurysm and compensatory flow through the external carotid artery. CONCLUSION: During the assessment of patients who have undergone postoperative radiotherapy, the potential for the development of aneurysms and radiation-induced vasculopathy exists and should be kept in mind. Considering the potential for spontaneous thrombosis of these aneurysms, cautious judgment is recommended before making a decision to treat them.     

True giant common hepatic artery aneurysm associated with obstructive jaundice: a case report

The appropriate treatment for extrahepatic hepatic artery aneurysms remains controversial, with arguments for and against embolization. We describe a case of a giant true aneurysm of the common hepatic artery associated with obstructive jaundice of nonhemobilia origin. The patient, a 49-year-old previously healthy man, presented with upper midepigastric pain, jaundice, and low-grade fever. The diagnosis of the aneurysm was mainly based on computed tomography scan findings. The aneurysm was successfully embolized using wire coils, and the patient was operated on for acute abdomen. Necrotizing acalculus cholecystitis was found, and cholecystectomy followed by aneurysmectomy without hepatic artery reconstruction was performed. The jaundice subsided spontaneously, and the patient was discharged in good condition. Giant common hepatic artery aneurysms can be managed by either surgery or embolization. In the absence of liver ischemia there is no need for common hepatic artery reconstruction unless a bilioenteric bypass has to be performed to resolve the issue of jaundice. If the latter is required, reconstruction of the hepatic artery might be justifiable to maximize the blood supply to the bile duct.     

Double aneurysms at distal basilar artery: report of nine cases

OBJECTIVE: Double aneurysms at the basilar bifurcation and the basilar artery-superior cerebellar artery (BA-SCA) junction have not been well investigated previously. We analyzed nine patients with double basilar aneurysms to evaluate their radiological characteristics and suitable treatment. METHODS: Between 1978 and 1999, the incidence of double aneurysms was 5.3% in our 169 consecutive surgical cases of distal BA aneurysms. Seven (77.8%) of the nine patients with double aneurysms had associated aneurysms in the anterior circulation. Open surgery was performed in eight patients and coil embolization in one. The patients' radiological findings, choice of treatment, and surgical results were analyzed retrospectively. RESULTS: The size of the basilar bifurcation aneurysms ranged from 2 to 8 mm (mean, 4.4+/-2.0 mm), and the size of the BA-SCA aneurysms ranged from 2 to 12 mm (mean, 5.6+/-3.6 mm). Diagnosis of double basilar aneurysms was difficult when the basilar trunk had twisted or when size differences between the two aneurysms were apparent. The angle between the posterior cerebral artery and SCA appeared to be wider on the same side as the BA-SCA aneurysms (101+/-42 degrees) than on the opposite side (26+/-24 degrees). The P1 segment of the posterior cerebral artery originated in an upright direction from the basilar bifurcation between the two basilar aneurysms in seven patients. The pterional approach was used in eight patients; 14 basilar aneurysms were successfully clipped and 2 were wrapped. Nonstraight clips with short blades were used frequently. Coil embolization of double aneurysms was required twice in one patient because the initial angiogram was misinterpreted as a single aneurysm and its bleb. CONCLUSION: Measurement of the posterior cerebral artery-SCA angle is a simple method to estimate the presence of BA-SCA aneurysms and to differentiate double aneurysms from a bilocular aneurysm at the basilar bifurcation. The pterional approach is suitable for clipping double basilar aneurysms because anterior circulation aneurysms often coexist, and the upstanding P1 segment is an obstacle in the subtemporal approach to the basilar bifurcation aneurysm. Nonstraight clips with short blades are convenient to avoid conflicting clips in the narrow surgical space.     

Hemobilia from ruptured hepatic artery aneurysm. Report of a case and review of the literature.

Hepatic artery aneurysm is a rare vascular disease associated with high mortality caused by massive hemorrhage or by complications following surgical treatment. Over the past twenty-five years it has been managed surgically with increasing success. Eighty reported cases of hepatic artery aneurysms ruptured into the biliary tree were reviewed and the etiology, clinical signs, diagnosis, and treatment of such an aneurysm are discussed. A personal case with an aneurysm of the right hepatic artery ruptured into the common hepatic duct is reported. The diagnosis was made before surgery by arteriography and the aneurysm was successfully managed by ligation of the right hepatic artery both proximal and distal to the aneurysm, closure of the communication between the common hepatic duct and the aneurysm, and choledochal drainage. Hemobilia secondary to hepatic artery aneurysm must be considered in thedifferential diagnosis of unexplained gastrointestinal hemorrhage.     

Systemic multiple aneurysms of the extracranial internal carotid artery, intracranial vertebral artery, and visceral arteries: case report.

A rare case of systemic multiple aneurysms located in the extracranial internal carotid artery, intracranial vertebral artery, and intraperitonial arteries is described. A 56-year-old woman was referred to our hospital with suspected rupture of an aneurysm of the right extracranial internal carotid artery. Digital subtraction angiography demonstrated a giant aneurysm in the right extracranial internal carotid artery and an aneurysm of fusiform type of the left intracranial vertebral artery. The extracranial carotid artery aneurysm was successfully resected, with end-to-end anastomosis of the internal carotid artery, preserving the cranial nerves. Five days later, an aneurysm of the left hepatic artery ruptured unexpectedly and was treated with emergency surgery. Other aneurysms in the liver and spleen were identified on postoperative celiac angiography. The patient subsequently underwent an operation for a left intracranial vertebral artery aneurysm by proximal clipping.     

Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils.

In a multicenter study, 120 patients with intracranial aneurysms presenting a high surgical risk were treated using electrolytically detachable coils and electrothrombosis via an endovascular approach. The results of treatment in patients with posterior fossa aneurysms (42 patients with 43 aneurysms) are presented. The most frequent clinical presentation was subarachnoid hemorrhage (24 cases). The clinical follow-up periods ranged from 1 week to 18 months. Complete aneurysm occlusion was obtained in 13 of 16 aneurysms with a small neck and in four of 26 wide-necked aneurysms. A 70% to 98% thrombosis of the aneurysm was achieved in 22 of 26 aneurysms with a wide neck and in three of 16 small-necked aneurysms. One aneurysm could not be treated due to a technical complication. Two cases required postprocedural surgical clipping of a residual aneurysm. One patient (originally in Hunt and Hess Grade V) experienced procedural rupture of the aneurysm requiring an emergency parent artery occlusion. He eventually died 5 days later. Another patient (originally in Grade IV) had coil migration and posterior cerebral artery territory ischemia. A third patient developed a permanent neurological deficit (hemianopsia) after complete occlusion of a wide-necked basilar bifurcation aneurysm. One patient, harboring an inoperable giant basilar bifurcation aneurysm, died from aneurysm bleeding 18 months after partial occlusion. Overall morbidity and mortality rates related to treatment were 4.8% (two cases) and 2.4% (one case), respectively (2.6% and 0% if considering only patients in Hunt and Hess Grades I, II, and III). It is suggested that this technique is a viable alternative in the management of patients with posterior fossa aneurysms associated with high surgical risk. Longer angiographic and clinical follow-up study is necessary to determine the long-term efficacy of this recently developed endovascular occlusion technique. Close postoperative angiographic and clinical monitoring of patients with wide-necked subtotally occluded aneurysms is mandatory to check for potential aneurysmal recanalization, regrowth, and rupture.     

Unilateral supraorbital keyhole approach in patients with middle cerebral artery (M1-M2 segment) symmetrical aneurysms.

A left middle cerebral artery aneurysm at the bifurcation (M1-M2 segment) and a right smaller aneurysm, symmetrical to the previous one were diagnosed in a 69-year-old female after angiographic examination for subarachnoid hemorrhage. The preoperative radiological study did not enable us to identify the bleeding aneurysm so a left supraorbital keyhole approach was performed to operate on the bigger aneurysm. In the same surgical session, using the same way of approach, we decided to attack also the right aneurysm which then revealed itself as being responsible for bleeding. The postoperative angiograms confirmed the complete exclusion of both aneurysms and the patient was discharged after good recovery. Although there are remarkable controversies about the surgical strategies for multiple aneurysms, our experience gives us the opportunity to emphasize the supraorbital keyhole approach and to reconsider the "timing" of multiple/bilateral aneurysms.     

De novo formation and rupture of an azygos pericallosal artery aneurysm. Case report

An azygos pericallosal artery (APCA) aneurysm is a rare anomaly that is closely associated with saccular aneurysms. This is the earliest report to document de novo formation and rupture of an aneurysm at the bifurcation of an unpaired pericallosal trunk. The authors report the case of a woman who presented at the age of 52 years with subarachnoid hemorrhage (SAH) from the rupture of a newly formed APCA bifurcation aneurysm, 7 years after she had undergone surgery to clip a ruptured anterior cerebral artery aneurysm. De novo formation of aneurysms after SAH rarely occurs and certain risk factors like multiple and familial aneurysms, arterial hypertension, or smoking have been postulated. Late follow-up examination with angiography to detect de novo aneurysms should be considered in patients with this vascular anomaly after SAH.