Hybrid Management Approach for Superior Mesenteric Artery and Branch Aneurysms
Christopher Jacobs, Javairiah Fatima
University of Florida, Gainesville, FL
INTRODUCTION: Visceral artery aneurysms (VAAs) are defined as aneurysmal dilation >1.5x the diameter of the celiac, SMA, IMA and their branches. Overall incidence is exceeding low at 0.01-0.2% with superior mesenteric artery (SMA) and branch aneurysms comprising only 5% of VAAs. Patients are typically asymptomatic, diagnosed incidentally on imaging; however, some patients are symptomatic with nonspecific symptoms of abdominal pain. The risk of rupture from a VAA is about 25% with a mortality of 70%. Indications for repair due to the high risk of rupture are: symptomatic VAAs, VAAs >2 cm, expansion of >0.5 cm/year, females of child bearing age or those that are pregnant.
METHODS: A 55-year-old healthy female presented with a 1-week history of crampy epigastric pain with emesis and decreased appetite. CTA revealed one large 3.5 cm SMA branch aneurysm and two smaller GDA aneurysms (Figure 1). The proximal celiac trunk was occluded with the primary blood supply to the proper hepatic artery via retrograde GDA flow. Initial approach was via an upper midline incision where the GDA and common hepatic arteries were identified and ligated. A supraceliac aorta to hepatic artery bypass was performed with a 14 mm x 7 mm rifampin-soaked Dacron graft with an end to side anastomosis to the hepatic artery. The next day, selective catheterization of the SMA was performed and a micro-catheter and wire system was used to selectively catheterize the SMA to the origin of the GDA where multiple coils from 8-12 mm were used to coil embolize the two GDA aneurysms, followed by coil embolization of the larger SMA branch aneurysm with a 6 mm iCAST stent deployed in the SMA and post-dilated to 8 mm without aneurysm filling on completion angiogram.
RESULTS: She recovered, tolerated a regular diet and was discharged home on postoperative day five on antiplatelet therapy. One-month postoperative CTA was notable for a patent aorta to hepatic artery bypass with complete thrombosis of the aneurysms. She fully recovered without any sequelae one year postoperatively.
CONCLUSIONS: This case is unique as SMA and SMA branch aneurysms are rare, the pattern of multiple visceral aneurysms as seen in this patient is even less common and she had no risk factors for this. As the rate of rupture and subsequent rate of mortality from a rupture is high, most patients with VAAs with a diameter of 2 cm, rapid growth or ominous morphology should be treated. Interestingly, this patient presented not only with multiple aneurysms, she also had the additional dilemma of an occluded celiac trunk with hepatic flow dependent on the aneurysm branch. This likely was the reason for aneurysmal degeneration of the GDA as a compensatory mechanism. The hybrid management of aorto-hepatic bypass followed by coil embolization and stent placement in this case are an innovative and unique approach for complex visceral aneurysms while maintaining perfusion to the liver and foregut.
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