Introduction vascular unit for treatment of a visceral artery

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 the latter 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.

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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, (Figure 3) 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, (Figure
1,2) which revealed a partial thrombosed aneurysm at the distant limit of the
splenic artery. The CTA confirmed 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 (partial 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. 7

 

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.9,10,11. 
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 12 whilst pregnancy is a
special etiological factor for splenic artery aneurysms rupture. 8 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, have a high rupture rate of
90% which is associated with a mortality of up to 70%. 8,13. 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 14. By reviewing 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%. 8, 15

Gastroepiploic
artery aneurysms are more common in men over women with an incidence rate of 3
to 1 and the majority is identified in people over 50 years of age 16. Among
the 22 cases of the English literature, more epidemiological data existed in 15
of them. 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. 15 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 9. 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% 15, 17.  Although the prevalence of abdominal
splanchnic aneurysms has not been clarified, in the largest series of reported
splenic aneurysms, the incidence in angiography was reported to be 0.78% 11. 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. 5, 18. Pulli et al 15 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 techniques based on wires and catheters with low perioperative morbidity.
Selective arterial angiography with embolization is applicable in some cases,
although however 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 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. 19

In
the case of the patient we treated, anatomical reasons which are that is the
elongated and tortuous celiac and 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 suggested the possibility
that another artery than the splenic had the lesion, we entered the entrance
into the lesser sac was performed 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 splenic artery maintained the arterial pulsepulsation. In this
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.