Symptomatic splanchnic artery dissection：imaging diagnosis and interventional treatment / 介入放射学杂志

Objective To summarize the experience in the diagnosis and treatment of symptomatic splanchnic artery dissection. Methods A total of 21 patients with symptomatic splanchnic artery dissection, who were admitted to the Affiliated First Hospital of China Medical University during the period from June 2006 to March 2014, were included in this study. Combined with the literature, the clinical data, including the diagnosis and treatment, were analyzed. Results Contrast-enhanced abdominal CT and CT angiography revealed superior mesenteric artery dissection in 15 cases, celiac artery dissection in 5 cases and splenic artery dissection in one case. Conservative therapy was employed in 5 patients; among them one was complicated with hepatic artery thrombosis. Of the 16 patients who received endovascular stent placement, additional intestinal resection was performed in 2 and transcatheter thrombolysis treatment in other 2. No procedure-related severe complications occurred in perioperative period. All the patients were followed up for 2-74 months (mean of 19.1 months). In patients who received endovascular stent placement, the abdominal pain and the bloody stool were relieved or disappeared, and no abdominal pain recurred. CT angiography showed that in-stent blood flow was fluent, the stent was in good position, and neither stenosis nor thrombosis was observed. One patient with superior mesenteric artery dissection died of stroke three months after the treatment. Conclusion It is very important to make early diagnosis and to adopt early treatment for symptomatic splanchnic artery dissection. CT angiography can confirm the diagnosis in most cases, but attention should be paid to some atypical manifestations. For the treatment of splanchnic artery dissection, endovascular stent placement is mini-invasive, safe and reliable.

Clinical Experience of Symptomatic Spontaneous Isolated Splanchnic Artery Dissection / 대한혈관외과학회지

PURPOSE: Symptomatic spontaneous isolated splanchnic artery dissection (SSISAD) is a rare disease entity. The treatment guideline for SSISAD has not been established. Isolated dissection of splanchnic artery can be clinically asymptomatic or symptomatic. Symptomatic dissection is more important because it can indicate ischemia of abdominal organ. METHODS: A retrospective study was conducted on 15 consecutive patients (mean age, 47.0 years; male, 87%) with SSISAD from January 2006 to July 2013. Each patient had acute onset abdominal pain and was diagnosed with SSISAD by abdominal-pelvic computed tomography. RESULTS: Median follow-up duration was 14.5+/-27.7 months (range, 1 to 79 months). Splanchnic arterial dissection involved celiac artery in three patients and superior mesentery artery in 12 patients. Conservative management (including bowel rest, hypertension medication, anticoagulation, and prophylactic antibiotics) was done in 14 patients. Endovascular treatment with stent insertion was performed in one patient. We experienced favorable clinical outcomes with SSISAD, even though one case needed endovascular treatment. CONCLUSION: Conservative management and selective revascularization could be a treatment option in patients with SSISAD.

Diagnosis and Management of Superior Mesenteric Artery Aneurysms: 5 cases

PURPOSE: Superior mesenteric artery (SMA) aneurysms are rare but have a definite rupture risk. We reviewed our experience with 5 patients to try to determine how to manage SMA aneurysms. METHOD: A retrospective review was undertaken of the medical records of 5 patients with SMA aneurysms diagnosed and treated at Seoul National University Hospital (SNUH) over the past 12 years. Clinical presentation, diagnosis, aneurysm characteristics, management and outcome were reviewed. RESULT: The 5 patients with SMA aneurysms, 4 males and 1 female, had a mean age of 52.2 years (range: 38~66). One patient had ruptured at presentation. Four associated aneurysms were present in two patients. The etiologies were variable. The first was a systemic disorder, fibromuscular dysplasia associated with SMA aneurysm, the second and third were mycotic SMA aneurysms resulting from septic aortic and mitral valves, and the fourth and fifth were dissecting SMA aneurysms. Four patients presented with abdominal pain, the other with left calf tightness caused by an aneurysm of the left popliteal artery. All five patients underwent surgery. One patient died after three operations due to massive gastrointestinal bleeding. CONCLUSION: Aneurysms of the superior mesenteric artery (SMA) are rare, constituting 5.5% of splanchnic artery aneurysms(1). Nevertheless, such aneurysms have a definite rupture risk, irrespective of size, and may be difficult to manage even in the elective situation. Thus, SMA aneurysms must be treated promptly at diagnosis to minimize morbidity and mortality. All SMA aneurysms should be repaired in patients at good operative risk. And interventions such as endovascular embolization or endoluminal stent grafting provide additional therapeutic options to those at poor operative risk.

A Case of Hemoperitoneum due to Splanchnic Artery (Left gastric artery) Aneurysmal Rupture / 대한내과학회지

Splanchnic artery aneurysms, previously thought to be rare, are being diagnosed with incresed frequency because of development of noninvasive imaging techniques. The pathogenesis of visceral aneurysms is varied and may be secondary to arteriosclerosis (30%), trauma (25%), inflammation (11%), gestational alteration, surgery, infection, medial necrosis, collagen vascular disease, arteritis, and congenital anomalies. Clinical manifestation of visceral artery aneurysms is vague and not specific. The diagnosis and treatment for them are difficult. Preoperative arteriography may be helpful in emergency situation to detect the aneurysm and visualize multiple aneurysms. Surgical ligation, resection and/or reconstructive surgery are first choice of treatment for them. Otherwise, transarterial embolization has also been reported for them recently. We report a case of hemoperitoneum due to left gastric artery aneurysmal rupture and a rare complication of splanchnic artery aneurysm "Double rupture". The patient was treated successfully with simple ligation of the ruptured vessel.

Clinical Experiences of the Splanchnic Artery Aneurysms

Aneurysm of the splanchnic arteries are an uncommon form of vascular disease that have a significant potential for rupture or erosion into an adjacent viscera, resulting in life-threatening hemorrhage. Nearly 22% of these aneurysms present as surgical emergencies, including 8.5% that result in death. The major splanchnic vessels affected, in descending order of frequency, include the splenic(60%), hepatic(20%), superior mesenteric, celiac, gastric and gastroepiploic, jejunal-ileal-colic, pancreaticoduodenal and pancreatic, gastroduodenal arteries. Although in most instances these aneurysms are asymptomatic, their propensity for catastrophic exsanguinating rupture has long been recognized. Surgical and nonsurgical intervention has paralleled advances in angiography and vascular surgical technique. Currently, the increased use of percutaneous catheter-based therapy in the management of that disease. We report our experiences with surgical intervention and transcatheter arterial embolization(TAE) in 7 patients with splanchnic artery aneurysms. These consisted of 2 splenic, 3 hepatic, and 2 gastroduodenal artery aneurysms. Two splenic artery aneurysm patients were treated surgically with ligation of the proximal and distal aneurysm and splenectomy; one died of a ruptured splenic artery aneurysm before surgery was initiated and another was no further treatment. Other 5 patients were treated by TAE; no complications and no further treatments during follow-up. TAE is a safe and highly successful technique for the effective identification and treatment of splanchnic artery aneurysm.

Iatrogenic Pseudoaneurysm of Splanchnic Artery after Hepato-Biliary-Pancreatic Surgery

Extensive hepato-biliary-pancreatic (H-B-P) surgery is still associated with a high postoperative morbidity and mortality than other intraabdominal organ operation. Especially, iatrogenic pseudoaneurysm of splanchnic artery after major H-B-P surgery, although not frequent, can be a devastating and often leads to fatal hemorrhage due to aneurysm rupture. In a series of 300 patients who underwent major hepato-biliary-pancreatic surgery between 1989 and 1995, 6 patients with iatrogenic pseudoaneurysm were reviewed retrospectively. There were 1 hepatic artery pseudoaneurysm after hepatopancreaticoduodenectomy and portal vein resection for Klatskin tumor, 1 proper hepatic artery pseudoaneurysm after extended right hepatectomy and bile duct resection for Klatskin tumor, 1 superior mesenteric artery and common hepatic artery pseudoaneurysm after pancreatoduodenectomy for periampullary cancer, 1 hepatic artery pseudoaneurysm after pancreatoduodenectomy for periampullary cancer,1 pseudoaneurysm of anastomotic site between hepatic artery and splenic artery after type II regional total pancreatectomy for periampullary cancer, and 1 pseudoaneurysm of iliac artery conduit for hepatic artery reconstruction after orthotopic liver transplantation. Five of these 6 pseudoaneurysms were resulted from aggressive radical surgery including skeletonization of hepatoduodenal ligament. Pseudoaneurysm should be highly suspected when continued leukocytosis, fever and gastrointestinal bleeding such as hematemesis or melena are shown. Celiac angiogram should be considered for the early detection of pseudoaneurysm. Angiographic embolization might be considered as a primary treatment, however, if it is not successful, early surgical intervention might be an another life-saving option.