|Year : 2020 | Volume
| Issue : 1 | Page : 88-90
Giant aneurysm of the ileocolic artery presenting as abdominal mass
Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||09-Jul-2019|
|Date of Decision||10-Jul-2019|
|Date of Acceptance||18-Jul-2019|
|Date of Web Publication||16-Mar-2020|
Dr. Raja Lahiri
Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
An aneurysm of the abdominal splanchnic artery is a relatively rare vascular disorder. Since it is characterized by nonspecific clinical manifestations, an aneurysm in this uncommon location is usually diagnosed following complications. A 55-year-old female presented with a pulsatile lump in her right iliac fossa. Contrast-enhanced computerized tomography diagnosed it as aneurysm of the superior mesenteric artery (SMA). However, on exploration, SMA was found to be free, and the aneurysm was seen to be arising from the ileocolic artery ending in the appendicular branches. Ligation followed by excision of the sac along with the cecum and appendix was done followed by ileoascending anastomosis. Isolated aneurysms of the SMA branches are rare. Most cases are diagnosed after the occurrence of complications. Due to the high risk of rupture and ligation, they can interrupt the circulation to the target organs, and therefore, surgery is indicated even in the absence of complications.
Keywords: Ileocolic artery, superior mesenteric artery, visceral artery aneurysm
|How to cite this article:|
Lahiri R. Giant aneurysm of the ileocolic artery presenting as abdominal mass. Indian J Vasc Endovasc Surg 2020;7:88-90
| Introduction|| |
An aneurysm of the abdominal splanchnic artery is a relatively rare vascular disorder. The incidence of an aneurysm in a branch of the superior mesenteric artery (SMA) is 3% of all visceral arteries. Since it is characterized by nonspecific clinical manifestations, an aneurysm in this uncommon location is usually diagnosed following complications. Giant unruptured aneurysm of the ileocolic artery is an extremely rare clinical condition.
| Case Report|| |
A 55-year-old female presented with slow-growing painless abdominal mass in her right iliac fossa for the past 3 months. On clinical examination, the lump was a nonmobile, pulsatile mass, probably retroperitoneal in origin. Preliminary ultrasonography showed the mass to be aneurysmal in origin. Contrast-enhanced computerized tomography (CECT) was done for better delineation of its origin. CECT revealed the mass to be an aneurysm of diameter 6.5 cm, arising from the SMA.
Surgery was planned, and a lower midline laparotomy was performed. On exploration, the mass was lying posterior to the ileocolic junction, causing it to protrude and with the cecum and appendix overlying its surface [Figure 1]. The origin of the SMA was dissected and traced down. The SMA was found to be free [Figure 2]. On further dissection, the aneurysm (fusiform type) was seen to be arising from the lower division of the ileocolic branch and terminating into multiple appendicular and cecal branches [Figure 3].
|Figure 2: Superior mesenteric artery and its branches dissected along with the aneurysm|
Click here to view
|Figure 3: The aneurysm arising from the ileocolic artery and terminating into the appendicular and cecal branches|
Click here to view
Owing to the location and nature of the aneurysm, it was not possible to remove the aneurysm without jeopardizing the blood supply of the ileocecal region. Hence, the origin of the aneurysm was ligated and divided, followed by the removal of the cecum and appendix along with the aneurysmal mass. An ileoascending anastomosis was done to maintain bowel continuity.
The postoperative course was uneventful, and the patient had no complications. The histopathological evaluation of the specimen revealed true aneurysm.
| Discussion|| |
Visceral artery aneurysms (VAAs) are those intra-abdominal aneurysms that affect the celiac artery, the superior and inferior mesenteric arteries, and the renal arteries and their branches. The reported incidence of VAAs is approximately 0.01%–2% on autopsy and angiographic studies 2, with over half the cases involving splenic artery aneurysms. The most common site of SMA branch aneurysm is the jejunal artery followed by the middle colic and ileal arteries. The mortality rate due to rupture varies from 25% to 70%. A true VAA (TVAA) is defined by an arterial dilatation that involves the three layers of the vascular wall (intima, media, and adventitia). It may be sacciform or fusiform. The causes of TVAA vary but are mainly atherosclerosis, fibrodysplasia, or connective tissue disorders. Treatment of true aneurysms  is indicated in the following cases:
- Clinical symptoms (pain, embolism, and rupture)
- More than 2 cm or twice the size of the artery by consensus
- Rapid increase in the diameter of the aneurysm
- Specific location (duodenopancreatic arcades)
- Pregnant women or women of childbearing age
- Project for liver transplantation or portal hypertension for splenic artery aneurysms.
VAAs can be treated by open surgery or endovascular treatment. Cochennec et al. reported 956 cases of treated VAAs, with a mean mortality rate of 1.2% in elective treatment and 15.5% in ruptured aneurysms. Surgical options include aneurysmectomy, aneurysmorrhaphy, or ligation, with or without arterial reconstruction. Simple ligation of both coeliac artery and SMA aneurysms is often possible because of the extensive collateral circulation between the celiac artery and SMAs through the pancreatic arcades. Revascularization with venous or synthetic graft or direct arterial reconstruction is deemed necessary in patients with ruptured aneurysm and bowel ischemia or preoperative signs or symptoms of intestinal ischemia.
Isolated aneurysms of the SMA branches are rare. Most cases are diagnosed after the occurrence of complications. Due to the high risk of rupture and ligation, they can interrupt the circulation to the target organs, and therefore, surgery is indicated even in the absence of complications. Early diagnosis would be useful, since the natural course can be disastrous and life-threatening without timely treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nosher JL, Chung J, Brevetti LS, Graham AM, Siegel RL. Visceral and renal artery aneurysms: A pictorial essay on endovascular therapy. Radiographics 2006;26:1687-704.
Belli AM, Markose G, Morgan R. The role of interventional radiology in the management of abdominal visceral artery aneurysms. Cardiovasc Intervent Radiol 2012;35:234-43.
Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997;77:425-42.
Pasha SF, Gloviczki P, Stanson AW, Kamath PS. Splanchnic artery aneurysms. Mayo Clin Proc 2007;82:472-9.
Chiaradia M, Novelli L, Deux JF, Tacher V, Mayer J, You K, et al.
Ruptured visceral artery aneurysms. Diagn Interv Imaging 2015;96:797-806.
Cochennec F, Riga CV, Allaire E, Cheshire NJ, Hamady M, Jenkins MP, et al.
Contemporary management of splanchnic and renal artery aneurysms: Results of endovascular compared with open surgery from two European vascular centers. Eur J Vasc Endovasc Surg 2011;42:340-6.
[Figure 1], [Figure 2], [Figure 3]