Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 287-289

Endovascular management of ruptured giant aneurysm of superior mesenteric artery


Department of Vascular and Endovascular Surgery, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission28-Oct-2019
Date of Decision16-Dec-2019
Date of Acceptance20-Jan-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Ganesh Kumar Marada
Department of Vascular and Endovascular Surgery, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_87_19

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  Abstract 


Ruptured aneurysm of superior mesenteric artery (SMA) is an emergency with high mortality rates. Open surgery is most commonly preferred, but is highly morbid. Endovascular approach can be a feasible option with minimal morbidity and early recovery. We report a case of giant ruptured SMA aneurysm which was managed by endovascular intervention, not been reported in literature till date.

Keywords: Endovascular, ruptured superior mesenteric artery aneurysm, visceral artery aneurysm


How to cite this article:
Marada GK, Agarwal S, Bedi VS, Yadav A, Srivastava A. Endovascular management of ruptured giant aneurysm of superior mesenteric artery. Indian J Vasc Endovasc Surg 2020;7:287-9

How to cite this URL:
Marada GK, Agarwal S, Bedi VS, Yadav A, Srivastava A. Endovascular management of ruptured giant aneurysm of superior mesenteric artery. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 30];7:287-9. Available from: http://www.indjvascsurg.org/text.asp?2020/7/3/287/294920




  Introduction Top


Visceral artery aneurysms are usually a rare entity with worse clinical course and usually diagnosed in postmortem. The first superior mesenteric artery (SMA) repair was done by De Bakey and Cooley in 1953 in a patient with mycotic SMA aneurysm (SMAA).[1]


  Case Report Top


Endovascular management has been reported previously for ruptured SMAAs of size 2–3 cm till date.[2] We report a case of giant ruptured SMAA of size 11 cm, managed by endovascular technique. Our patient is a 58-year-old male who presented to the emergency department with complaints of acute pain abdomen for 2 days. He is a known hypertensive, nonsmoker with no history of diabetes mellitus, coronary artery disease, previous surgeries, or blunt trauma to the abdomen. There is a negative family history for aneurysm and genetic disorders, intra-abdominal inflammation, or infection suggestive of the etiology being degenerative (atherosclerosis).

The patient's blood pressure was 100/60 mm of Hg with tachycardia. On examination, a very large, tender pulsatile mass of approximately 13 cm × 10 cm was felt in the epigastric region with mild abdominal distension and sluggish bowel sounds with no guarding or rigidity. Blood investigations showed very low hemoglobin (7.6 g/dl) and borderline serum creatinine (1.3 mg/dl).

Computed tomography (CT) angiography images showed giant, calcified, partially thrombosed aneurysm of SMA of size 11.2 cm × 10 cm × 10 cm with minimal leak with hemoperitoneum and fusiform dilatation of infrarenal abdominal aorta with dimensions of 4.1 cm × 4.2 cm as seen in [Figure 1] and [Figure 2]. There were no further jejunal branches arising from SMA and celiac artery had stenosis; inferior mesenteric artery (IMA) was not visualized.
Figure 1: Computed tomography angiography (Sagittal view): Superior mesenteric artery aneurysm with celiac artery compression

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Figure 2: Three-dimensional reconstruction computed tomography angiography

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A hybrid procedure was planned and left brachial artery cutdown was done; 6-Fr sheath introduced and later on 8-Fr long sheath was exchanged. Contrast shot revealed severe compression of the celiac artery and large partially thrombosed aneurysm of SMA [Figure 3] with minimal leak and no further branches from SMA. IMA origin was not visualized with reformation seen distally through collaterals.
Figure 3: Digital subtraction angiography image: Superior mesenteric artery aneurysm

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Fluoroscopic-guided repair of aneurysm was done in proximal SMA using 16 mm × 12 mm Amplatzer vascular Plug II [Figure 4]. Postdeployment of the plug, SMA aneurysmal sac was not visualized and no leak was seen. Celiac artery showed severe compression [Figure 5] and the only visceral artery which was supply abdominal viscera. Hence, celiac artery stenting was done using 8 mm × 29 mm stent (Omnilink Elite; Abbott Vascular). Poststenting, good contrast runoff was noted in the celiac artery across the stent with plug in SMA [Figure 6].
Figure 4: Deployed superior mesenteric artery plug

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Figure 5: DSA image: Superior mesenteric artery plug with celiac artery stenosis

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Figure 6: DSA image: Superior mesenteric artery plug with patent celiac artery stent

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Postprocedure, the patient's symptoms gradually resolved and hemoglobin improved, but he continued to have mild abdominal distension; hence, repeat CT angiography was done which showed patent celiac artery stent, occluded SMA, and normal enhancement of bowel wall. His distension resolved gradually and was started on diet, which he tolerated well and discharged on day 4.


  Discussion Top


The incidence of SMAA is around 6% of all visceral artery aneurysms (VAAs) and involves the first 5 cm of the artery. It usually occurs in the fifth decade of life with no gender predisposition.[3] The most common etiology of SMAAs is mycotic[4] accounting to 60%, and other conditions associated with true SMAA are atherosclerosis, connective tissue disease, and polyarteritis nodosa. Our patient did not have a history of infection or connective tissue disorders, suggesting the causative pathology being atherosclerosis.

SMAAs are associated with a significant rate of rupture with high mortality rate and mostly diagnosed postmortem. Early intervention was advocated previously due to high risk of rupture and high mortality regardless of size or symptoms,[5] but recent data show evidence which suggests that small (<2.5 cm) aneurysms, especially in patients at poor surgical risk, can be safely monitored conservatively.[6]

Surgery is commonly practiced which includes aneurysmectomy, arterial reconstruction, and rarely simple ligation. Endovascular approach is usually preferred in elective cases which includes stenting and coil embolization of SMAAs.[7]

Endovascular management of ruptured VAAs has been reported as a feasible option, but should be used selectively.[8] Endovascular therapies provide a shorter hospital stay, the use of local/conscious sedation, lower cost, and faster recovery.

Our patient also had concomitant celiac artery compression for which he underwent celiac artery stenting along with deployment of plug in SMA. For a giant ruptured SMAA with no distal reformation and nonvisualized IMA, in which tissue planes can be obscure, there is high risk of injury to the celiac artery, and being the only named arterial supply to abdominal viscera, endovascular approach was preferred.


  Conclusion Top


In a patient with symptoms of acute pain abdomen with a pulsatile mass, the diagnosis of ruptured VAA should be suspected. A correct and timely evaluation for the ruptured aneurysm with aggressive management can reduce the risk of imminent mortality. With evolving techniques and emerging technologies, endovascular approach can be a feasible and preferred option when compared to open surgery in selective cases of ruptured SMAA.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
De Bakey ME, Cooley DA. Successful resection of mycotic aneurysm of superior mesenteric artery; case report and review of literature. Am Surg 1953;19:202-12.  Back to cited text no. 1
    
2.
Kwon OC, Han YH, Kwak BS. Spontaneous rupture of a superior mesenteric artery aneurysm. Dig Liver Dis 2017;49:716.  Back to cited text no. 2
    
3.
Stanley JC. Mesenteric arterial occlusive and aneurysmal disease. Cardiol Clin 2002;20:611-22, vii.  Back to cited text no. 3
    
4.
Kopatsis A, D'Anna JA, Sithian N, Sabido F. Superior mesenteric artery aneurysm: 45 years later. Am Surg 1998;64:263-6.  Back to cited text no. 4
    
5.
Lorelli DR, Cambria RA, Seabrook GR, Towne JB. Diagnosis and management of aneurysms involving the superior mesenteric artery and its branches-a report of four cases. Vasc Endovascular Surg 2003;37:59-66.  Back to cited text no. 5
    
6.
Stone WM, Abbas M, Cherry KJ, Fowl RJ, Gloviczki P. Superior mesenteric artery aneurysms: Is presence an indication for intervention? J Vasc Surg 2002;36:234-7.  Back to cited text no. 6
    
7.
Saltzberg SS, Maldonado TS, Lamparello PJ, Cayne NS, Nalbandian MM, Rosen RJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg 2005;19:507-15.  Back to cited text no. 7
    
8.
Liu CF, Kung CT, Liu BM, Ng SH, Huang CC, Ko SF. Splenic artery aneurysms encountered in the ED: 10 years' experience. Am J Emerg Med 2007;25:430-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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