The role of emergency presentation and revascularization in aneurysms of the peripancreatic arteries secondary to celiac trunk or superior mesenteric artery occlusion

Abstract

Objective: The goal of this study was to analyze our 10-year experience in the treatment of aneurysms of the collateral circulation secondary to steno-occlusions of the celiac trunk (CT) or superior mesenteric artery (SMA).Methods: In the last 10 years, 32 celiac-mesenteric aneurysms were detected (25 true aneurysms and seven pseudoaneurysms) in 25 patients with steno-occlusion of the CT or SMA. All cases were diagnosed and treated at our center, with either surgical or endovascular approach. As open surgery, we performed aneurysmectomy and revascularization; as endovascular treatment we performed both the embolization (or graft exclusion) of the aneurysm sac, and embolization of afferent and efferent arteries.Results: Sixteen patients (64%) underwent endovascular treatment, accounting for 66% of aneurysms (21/32). Six patients (24%) and seven associated aneurysms (22%) underwent open surgery. Three asymptomatic patients (12%), representing a total of four aneurysms (12%), were not treated. For endovascular procedures, the technical success rate was 90%, with a 56% clinical success rate. For open surgery, clinical and technical success were achieved in five patients (83%) and six procedures (86%), respectively. Sixty-eight percent of patients (17/25) were treated in an emergency setting, using either endovascular (88%) or open (12%) approaches. Although technical success was achieved in more than 85% of these procedures for both approaches, clinical success was reached less frequently among patients with an acute presentation (P ¼ .041). Regardless of the type of treatment, CT or SMA revascularization during the first procedure did not show an increased rate of clinical success (P ¼ .531). However, we reported four cases of visceral ischemia after an endovascular approach without revascularization, with three open surgical corrections required. The mean follow-up was 41 months (range, 0-136 months).Conclusions: Neither of the approaches described qualifies as a standard optimal choice. We suggest a tailored therapeutic approach based on the clinical condition at the time of diagnosis and specific vascular anatomy.

Symptomatic pancreaticoduodenal artery aneurysm with coeliac artery occlusion repaired by ligation of aneurysm and creation of neocoeliac trunk

“…The Society for Vascular Surgery has published guidelines for management of visceral arterial aneurysms and they have advised to treat all aneurysms arising from pancreaticoduodenal arcade irrespective of symptoms due to high risk of rupture. In the presence of coeliac artery occlusion, ligation or embolization of an aneurysm might had fatal outcome in the form of hepatic ischaemia and even mortality, further not addressing the occlusion can lead to recurrences 9,10 . Endovascular embolization of aneurysm has been successfully reported, but in view of occlusion of coeliac trunk due to median arcuate ligament syndrome, ligation of aneurysm with hepatic artery revascularization was preferred as published by Bonardelli et al 10 …”

Aneurisma de artéria pancreatoduodenal inferior: tratamento endovascular

“…Aneurysms of the visceral arteries (VAA) are rare, with an incidence of 0.02% in the general population. [1][2][3] Aneurysms of the pancreaticoduodenal artery (PDAA) are the least frequent type, accounting for just 2% of all VAA, 4 and inferior pancreaticoduodenal artery aneurysms (iPDAA) are the least often described subtype. [1][2][3] Use of angiotomography has increased the number of PDAA diagnoses, as a result of incidental findings.…”

“…[1][2][3] Aneurysms of the pancreaticoduodenal artery (PDAA) are the least frequent type, accounting for just 2% of all VAA, 4 and inferior pancreaticoduodenal artery aneurysms (iPDAA) are the least often described subtype. [1][2][3] Use of angiotomography has increased the number of PDAA diagnoses, as a result of incidental findings. [1][2][3] Nonetheless, the majority of PDAA are still discovered and treated in emergency situations, with increased risk of complications such as hemoperitoneum and hypovolemic shock, with rates of aneurysm rupture in the literature in the range of 45-53%.…”

“…[1][2][3] Use of angiotomography has increased the number of PDAA diagnoses, as a result of incidental findings. [1][2][3] Nonetheless, the majority of PDAA are still discovered and treated in emergency situations, with increased risk of complications such as hemoperitoneum and hypovolemic shock, with rates of aneurysm rupture in the literature in the range of 45-53%. [3][4][5] These aneurysms are supplied by collateral vessels with hyperdynamic flow and are often associated with occlusive stenosis of the celiac trunk (CT) and superior mesenteric artery (SMA).…”

“…[1][2][3] Nonetheless, the majority of PDAA are still discovered and treated in emergency situations, with increased risk of complications such as hemoperitoneum and hypovolemic shock, with rates of aneurysm rupture in the literature in the range of 45-53%. [3][4][5] These aneurysms are supplied by collateral vessels with hyperdynamic flow and are often associated with occlusive stenosis of the celiac trunk (CT) and superior mesenteric artery (SMA). 3,4 Endovascular treatment is the preferred method, except in cases of suspected visceral ischemia, in patients with hostile vascular anatomy, or if prior endovascular treatment has failed.…”