Rapid Formation and Hybrid Treatment of a Large Superior Mesenteric Artery Aneurysm

Abstract

BACKGROUND Superior mesenteric artery (SMA) aneurysms account for about 5.5% of all visceral aneurysms, and are most commonly secondary to infectious causes or dissection. They tend to expand and rupture. Here, we present our successful diagnosis and treatment of a 41-year-old man with asymptomatic coeliac trunk stenosis, in whom the large aneurysm of the branch of the SMA developed in a very short time after conservative treatment of plastron appendicitis. CASE REPORT A 41-year-old man was diagnosed with plastron appendicitis during abdomen ultrasound (US) examination. Following 2 weeks of conservative treatment with intravenous antibiotic therapy, complete resolution of symptoms was obtained and confirmed in the computed tomography (CT) scan, and no other pathologies were diagnosed. Three weeks later, during the US examination, a 33-mm aneurysm of the branch of the SMA was diagnosed. The patient was admitted to the Vascular Surgery Department, where a critical stenosis of the coeliac trunk secondary to the compression by median arcuate ligament and a 33-mm true visceral aneurysm of one of the branches of the SMA were diagnosed. Successful treatment of the aneurysm was performed. Surgical decompression of the coeliac trunk and subsequent elective endovascular embolization of the SMA aneurysm with angioplasty of the coeliac trunk were performed. The postoperative period was uneventful and the patient was released from the hospital and remains asymptomatic. CONCLUSIONS Visceral artery aneurysm can form very quickly. In some of the aneurysms, a combination of open surgical and endovascular methods should be performed.

Figure 1.

Plastron appendicitis. A thickened hypoechogenic appendix measuring 1.16×1.59 cm, surrounded by a 3.68×3.92×5.7 cm plastron. (A) Transverse plane. (B) Longitudinal plane.

Figure 2.

(A) Anechoic, rounded mass in the upper abdomen measuring 3.14×3.24×3.75 cm localized about 5 cm inferiorly to the corpus of the pancreas. (B) Color Doppler imaging confirming the presence of the blood flow in the lesion – visceral aneurysm of the SMA.

Figure 3.

(A) CT demonstrating celiac trunk narrowing with typical hook sign (red arrow), aneurysm (white arrow) and large collateral vessel (yellow arrows) connecting celiac trunk and SMA, originating from the aneurysm and constituting for major blood supply to the liver. (B) Volume-rendering reformation.

Figure 4.

Decompressed celiac trunk (on the white vascular loop) and 2 large arteries branching from the celiac trunk: the common hepatic artery and the splenic artery. Aneurysm is not exposed.

Figure 5.

(A) Arteriography made from SMA showing aneurysm and implanted stent in the celiac trunk: good patency and restored blood flow through celiac trunk with collateral artery connecting the 2 vessels. (B) Fully embolized aneurysm with patent visceral arterial bed.

Figure 6.

Algorithm of the treatment of the unruptured Peripancreatic Arteries Aneurysm Coexisting with Celiac Artery Lesion. According to: Antoniak R, Grabowska-Derlatka L, Maciąg R, Ostrowski T, Nawrot I, Gałązka Z, Nazarewski S, Rowiński O. Treatment algorithm of peripancreatic arteries aneurysm coexisting with coeliac artery lesion: Single institution experience. Biomed Res Int. 2018; 2018: 5745271.