Abstract endoluminal treatment was ruled out, due to anticipated

Abstract

 

While
the aneurysm of the splenic artery represents the third more common abdominal
arterial aneurysm being next to the aortic and iliac aneurysms, the aneurysm of
the gastroepiploic artery is extremely rare occurring at a frequency of 3 – 4% of
all visceral arteries; only 22 cases have been reported in the English
literature.  We present the case of 65-year-old
woman with an asymptomatic visceral artery aneurysm which was an incidental
ultrasonography finding. Magnetic resonance imaging showed an arterial aneurysm
close to the peripheral splenic artery with intense tortuosity of the celiac
and splenic artery; thus endoluminal treatment was ruled out, due to
anticipated anatomic obstacles which would increase the risk for complications.
An abdominal computed tomography angiography confirmed the existence of   an
arterial aneurysm with a diameter of 2,3 cm near the splenic hilus.   The
patient underwent an elective open surgery through a chevron incision where the
complicated celiac artery anatomy and the aneurysm of the left gastroepiploic
artery was revealed. The aneurysm was resected with intact the splenic artery
and the patient left the hospital on the 4th postoperative day
without any complication. Historically, most of aneurysms of the gastroepiploic
aneurysms have been observed in men in the 6th decade of their life,
and   after rupture. In modern times early
incidental diagnosis is frequent due to the spread of imaging studies. Due to
the advanced current imaging armamentarium diagnostic approach and preoperative
planning is of paramount importance in order to avoid complications. In the
present case, diagnostic invasive intrarterial digital angiography was rejected
as the intention to treat through the tortuous celiac artery was out of the
question, following the findings of the already performed magnetic resonance
imaging study.   

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Keywords

 

Left
gastroepiploic artery, Visceral artery aneurysm, Aneurysm

 

 

 

 

 

 

 

 

 

 

Introduction

 

Aneurysms
of visceral arteries are rare vascular lesions, occurring at a frequency of 0,1
– 2% among all arterial aneurysms 1,2. Whilst splenic artery aneurysms
represent the majority (60%) of splanchnic aneurysms, gastroepiploic
arterial aneurysms (GEA) are more rare, occurring at a frequency of 3 – 4% of
all visceral arteries aneurysms 3,4,5. The left gastroepiploic artery (LGEA)
is the largest branch of the splenic artery and is anastomosed with the right
gastroepiploic artery (RGEA), which usually originates from the gastroduodenal
artery. Both branches run along the large curvature of the stomach supplying
both surfaces of it -through ascending branches-, and the greater omentum
-through descending branches.

We
present herein, a case of a woman with a left gastroepiploic aneurysm,
initially misinterpreted as splenic artery aneurysm. In addition, aetiology, clinical
manifestations and course, therapeutic challenges for the treatment of
gastroepiploic artery aneurysm, and a brief review of the literature are discussed.

 

Case report

 

A
65-year-old woman was referred to our vascular unit   for
treatment of a visceral artery aneurysm, which was a random finding in
follow-up ultrasound scanning, after left total mastectomy, lymphadenctomy and
chemotherapy, due to breast cancer. The patient had no history of traumatic
injury, hypertension or smoking. She was asymptomatic and during clinical
examination, the abdomen was soft without epigastric tenderness; no mass was noticed.
The hemoglobin (Hb) on admission was 12,5 g/dl and all other investigations
including ECG, chest X-rays and biochemistry were within normal limits.

Upper
abdomen ultrasound study had showed a hypoechoic deformation of about 2 cm in
diameter in the left abdomen, above the left kidney, with the suspicion of an
adrenal mass.

A
Magnetic Resonance Imaging (MRI) was performed, revealing a mass of 2.1 x 2.3
cm in diameter, between the left adrenal gland and the spleen, in contact with
the splenic artery and although not totally clarified, the aneurysm of the
splenic artery was also added to the differential diagnosis.

A Computed Tomography Angiography (CTA) followed,
which revealed a partial thrombosed aneurysm at the distant limit of the
splenic artery. The CTA showed a long and tortuous anatomy of celiac artery
trunk with intense curvature and an approximate length of 2,5 x 2,3 cm compared to the 1.25 cm of normal length. 6

The
patient underwent elective operation under general anaesthesia. A left
subcostal (Chevron) incision   was
performed followed by entrance in the lesser omental bursa.  The aneurysm has been exposed and the origin
artery was identified as the left gastroepiploic. The artery was ligated on
either side of the aneurysm and it was excised. 
Postoperative hemoglobin was found to be 10,8 g/dL; no blood transfusion
was needed. The patient was discharged on the 4th postoperative day
after an uncomplicated course of hospitalization. Histology of the resected artery
confirmed the diagnosis of a true arterial aneurysm.

 

Discussion

 

Ten
separate institutional reviews identified in the literature reported a total of
over of 3000 splanchnic aneurysm cases (1-10). According to these reviews, the
predominant locations were splenic (35%), hepatic (23%), superior mesenteric (19%),
pancreaticoduodenal/gastric (8.6%), celiac (7.6%) and renal (7%) arteries. Gastroepiploic
artery aneurysms accounted for only 3.5% (7) of the cases. gibb

 

Many
factors have been incriminated as causes of splanchnic artery aneurysms with
main the atheroscerotic disease 1,8. Other etiological factors include
arteriosclerosis, trauma, local inflammation such as pancreatitis or
anastomotic leakage, medial dysplasia or agenesis, mycotic embolism, congenial
vascular anomaly, infection, medial necrosis, trauma, pregnancy, portal
hypertension, biliary disease, pancreatitis, and connective tissue disease and
segmental arterial mediolysis.Ikeda, Boriori, Stanley 15.  Splenic artery aneurysms are likely the most
common, because of their association with pancreatitis; an increased incidence
has been reported in patients with dominant polycystic kidney disease Nagaba whilst
pregnancy is a special etiological factor for splenic artery aneurysms rupture.
In particular for the LGEA aneurysms, specific relating etiologic factors
are not mentioned to the English literature and we cannot suggest any known
relating factor to the LGEA aneurysm of the parient we managed.

Splanchnic
arterial aneurysms, besides their rare incidence they have a high rupture rate
of 90% which is associated with a mortality of up to 70%. Stanley, Chandran.
The mortality rate depends not only on the characteristics of the aneurysm like
the origin artery, the size, the different clinical behavior between the true
and the pseudoaneurysms, but also on the fact of whether is possible for the
bleeding site to be revealed during laparotomy Kleinsasser. By the analysis
of the recorded cases we notice that among the 17 cases of GEAAs with
accessible data, 15 of them ruptured, so the rupture rate is 88%.

Gastroepiploic
artery aneurysms are more common in men over women with an incidence rate
of  3 to 1 and the majority are
identified in people over 6th decade of life (over 50 years of age) Stanley2.
Among the 22 cases of the English literature, more epidemiological data existed
in 15 of them. The ratio among men and women was 2,2 with 11 cases (68,8%) of
male and 5 cases (31,2%) of female patients. The mean age of patients was 57,3 years.
The statistical analysis showed that females had an 8-years difference in
diagnosis 64 years among women versus 56,4 among men .

 

Clinical
manifestations of gastrointestinal arterial aneurysms (GAA) are not associated
with any special symptoms and they vary from asymptomatic to epigastric tenderness.
Pulli There is lack of studies, comparing this heterogeneity to clinical manifestations,
but this may be related to the size of the aneurismal lesion, and reduced
stomach blood flow during the normal process of digestion.  As a result, many of them are often diagnosed
incidentally or on an emergency basis after rupture Ikeda. The LGEAA of the
patient we present here was also an incidental finding, following a standard
ultrasonoraphy abdominal study.

 

The
widespread use of noninvasive imaging studies like the ultrasonography and the
computed tomography has made early diagnosis more frequent. This reflects to
the therapeutic approach as an early asymptomatic diagnosis permits an elective
surgery with an operative mortality of 0-3% contrary to an emergency procedure
in which the mortality rate is 50-70% caselli, Pulli. Al though the
prevalence of abdominal splanchnic aneurysms has not been clarified, in the largest
series of reported splenic aneurysms, the incidence on angiography was reported
to be 0.78% Stanley et al. 1986. Patients often have more than one visceral
artery aneurysm and full vascular assessment is recommended in these cases. Intarterial
digital substraction angiography (IADSA) is an invasive but valuable tool  either for diagnostic or for therapeutic
intervention. Due to the anatomic obstacles and in particular the tortuous
celiac and splenic artery and the distal location of the aneurysm we excluded
the IADSA with the presumption that the endovascular approach would be
technically difficult and risky. Thus for the preoperative planning, CTA was
used.

 

Many
endovascular and percutaneous transabdominal techniques have been described
concerning the treatment of splanchnic arterial aneurysms. An important point
is when to intervene. The indication for intervention is related to concerns
over the risk of rupture due to the high associated mortality upon this
complication.  Since most visceral
aneurysms rupture, elective resection is advocated; pseudoaneurysms are more
likely to rupture than true aneurysms. 13,14. Pulli et al pulli suggest
that asymptomatic visceral artery aneurysms greater than 2 cm and symptomatic
ones regardless of size should be treated. 
Aneurysms of the splenic artery are the most commonly encountered and
least likely to rupture, except during pregnancy. Aneurysms of other visceral
arteries, like the LGEA are less common and as a result less well-studied, with
a result of a limited experience in their treatment. Due to this high rate of
rupture and subsequent mortality, all patients diagnosed with GEAA should be
treated immediately. The surgical technique depends on the location of the
artery, the surgeon’s experience, the patient’s general health status and the
urgency of intervention. Minimally invasive techniques constitute a modern
therapeutic solution with several limitations.   

 

Visceral
artery aneurysm and pseudoaneurysms can be successfully treated intravascular
with low perioperative morbidity. Selective arterial angiography with
embolization is applicable in some cases, although surgical intervention
remains the usual management. A contraindication to intravascular or
interventricular interference is inappropriate and prohibitive anatomy.
However, urgent correction of these lesions continues to be associated with
increased mortality rates. Aneurysm exclusion can also be achieved by coil
plating and the selective use of N-butyl-2-cyanoacrylate.

Laparotomy
offers is the ability to reconstruct or use a graft in general, where the
collateral circulation is poor or non-existent. Prospective surgical candidates
for intervention are patients with symptomatic aneurysm, aneurysms in pregnant
women and as stated before asymptomatic aneurysms larger than 2 cm. Some
authors also reported successful laparoscopic resection of GEAs.

In
the case of the patient we treated, anatomical reasons which are the elongated
and tortuous splenic artery, and logistics, led us to reject the endovascular
option.  A multi-specialist medical
meeting consisted of a vascular surgeon, general surgeon and interventional
radiologist was held and after the situation was explained to the patient, the
surgical approach was decided.  As the
preoperative parclinical studies had confirmed the distal location of the aneurysm
and the possibility that another artery than the splenic had the lesion, we
entered the lesser sac between the greater curvature of the stomach and the
transverse colon.  During the operation
short gastric arteries were preserved and the splenic artery was identified
till the spleen hilus; we found that an arterial distal branch identified as
the left GEA had the lesion. Before removing the diseased arterial part with
the aneurysm, a temporal proximal and distal cross-clamping confirmed no
interference with the splenic artery supply, thus we ligated the pre- and
post-aneurismal artery with crossing polypropylene 4.0 and resected the
aneurysm.  The spleen showed no color
change and the spenic artery maintained the arterial pulse.  In the intraoperative setting, it was clear
that an endovascular approach could be unsuccessful and potentially dangerous.

 

Conclusion

 

Proper
imaging studies have assisted in identifying an incidental initial abdominal
mass, as a visceral artery aneurysm with a diameter greater than 2cm; an
aneurysm of the left GEA was the intraoperative apocalypse. The information
from the MRI and the detailed CTA prevented us of an attempt of an endovascular
approach which could be at least problematic. Open surgery in a fit patient
remains the best therapeutic option for LGEAAs

 

Declaration of Conflicting Interests

 

The
authors declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.

 

Funding

 

The
authors received no financial support for the research, authorship, and/or
publication of this article.

 

 

Table 1.
Cases of Left Gastroepiploic Artery Aneyrusms in English literature.

 

Figure 1.
Computed tomography scan with intravenous contrast demonstrating a Left
Gastroepiploic Artery Aneurysm. Note the tortuous anatomy of splenic artery.

 

Figure 2.
Three-dimensional reconstruction of arterial-phase computed tomography imaging.
The 12th rib was removed from the image.

 

Figure 3. Abdominal MRI scan showing the LGEA aneurysm.