Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: A report of two cases and a literature review
Article Outline
Mesenteric artery pseudoaneurysms are a rare and complex complication after abdominal trauma, surgery, or inflammatory disease. These lesions can be associated with compression or erosion into adjacent structures and may result in life-threatening hemorrhage. Traditional management has been open surgical ligation, aneurysm resection with interposition grafts, or resection or partial resection of the end organ involved. We present two cases of endovascular repair of complex mesenteric pseudoaneurysms. One patient presented with a recurrent pseudoaneurysm of the superior mesenteric artery and the second presented as recurrent gastrointestinal bleeding secondary to a traumatic celiac artery pseudoaneurysm-to-pancreatic duct fistula. A systematic review of the literature on endovascular management of mesenteric vascular disease and mesenteric pseudoaneurysms is included in this report to allow these cases to be put into proper perspective.
Mesenteric artery pseudoaneurysm is a rare but complex complication after abdominal trauma, mesenteric revascularization, or inflammatory disease. These lesions can result in compression or erosion of adjacent structures or life-threatening hemorrhage. Traditional management has been operative repair with an interposition graft or arterial ligation and, if needed, resection or partial resection of the end organ involved.1 Advances in technology have led to endovascular approaches to these lesions. Reports have emerged describing thrombin injection, embolization, or stent graft exclusion, or a combination, in both individual cases and small retrospective series. We present two patients with mesenteric artery pseudoaneurysm and their subsequent endovascular management as well as a review of the English literature illustrating an evolution of the management of mesenteric pseudoaneurysm.
Case reports
Patient 1
A 79-year-old woman presented with acute worsening of chronic abdominal pain and a large, tender, pulsatile mass in her upper abdomen. Her medical history included aortoiliac disease, chronic mesenteric ischemia, and renal artery stenosis. Prior vascular reconstructions included aortobifemoral and superior mesenteric artery (SMA) bypasses and left renal angioplasty and stenting.
Seven months before admission, the patient underwent operative repair of a symptomatic SMA pseudoaneurysm with a polytetrafluoroethylene (PTFE) interposition graft. Her recovery and subsequent 7 months were uneventful until 3 days before admission, when she developed rapidly progressive abdominal discomfort, food intolerance, tachycardia, and a fall in her hematocrit.
An initial abdominal computed tomography (CT) scan revealed a recurrent SMA pseudoaneurysm (Fig 1). The patient was not septic and did not have radiologic or clinical evidence to suggest infection as a cause for the recurrent pseudoaneurysm. We therefore believed arterial wall degeneration at the site of distal anastomosis was the likely cause.
Fig 1.
The initial abdominal computed tomography scan shows a pseudoaneurysm (arrow) of the superior mesenteric artery (SMA) that recurred in a 79-year-old woman 7 months after a previous open SMA pseudoaneurysm repair.
An arteriogram demonstrated the SMA bypass graft and a pseudoaneurysm at the distal anastomosis (Fig 2, A). The SMA was cannulated, and multiple attempts to pass a 6-mm Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) into the SMA were unsuccessful owing to stent inflexibility and the femoral approach. The left brachial artery was then cannulated; however, the stent graft could not be properly positioned owing to the SMA stenosis and inadequate catheter length.
Fig 2.
A, A preintervention arteriogram of the superior mesenteric artery (SMA) shows the pseudoaneurysm. B, A postintervention arteriogram demonstrates successful exclusion of pseudoaneurysm by stent grafts.
It was thought that obliteration of the pseudoaneurysm cavity would temporize the patient’s condition until a more appropriately sized and flexible stent graft could be obtained. Access into the pseudoaneurysm cavity was obtained with a microcatheter system. The pseudoaneurysm was then obliterated with coil embolization and thrombin injection. A completion arteriogram showed minimal contrast in the inferior portion of the pseudoaneurysm (Fig 2, B).
The patient was transferred to the surgical intensive care unit for monitoring, with plans to obtain approval and consent for the off-label use of a Jomed stent graft (Jomed International AB, Helsingborg, Sweden). Interestingly, the patient’s symptoms had resolved and her aneurysm was no longer pulsatile or tender.
Two days later two 5-mm × 26-mm Jomed stent grafts were successfully deployed, excluding the pseudoaneurysm (Fig 2, C). The patient subsequently developed a symptomatic right common femoral artery pseudoaneurysm that required operative repair, and she also underwent thrombectomy and repair of a thrombosed left brachial artery.
She was discharged on oral antibiotic therapy 7 days after the stent graft procedure, tolerating a regular diet and without abdominal pain. A follow-up CT scan 1 month later showed a patent graft and no pseudoaneurysm (Fig 3). The patient remained asymptomatic for 7 months after the procedure, at which time she died of myocardial infarction.
Fig 3.
An abdominal computed tomography scan at 1 month after the interventions shows a patent superior mesenteric artery and excluded pseudoaneurysm (arrows).
Patient 2
A 32-year-old man presented with recurrent gastrointestinal (GI) bleeding 7 months after a gunshot wound to his abdomen. During the exploratory laparotomy at the time of his injury, a retroperitoneal hematoma in the area of the pancreas was observed and sutures were placed to control bleeding. His recovery was complicated by a pancreatic leak that was successfully treated with bowel rest and hyperalimentation.
During the next 6 months, he was hospitalized on four occasions for GI bleeding requiring blood transfusions. Results of esophagogastroduodenoscopy, colonoscopy, and small bowel follow-through were negative on each hospitalization. On his fifth hospitalization for the same problem, he underwent a bleeding scan, which was negative. A CT scan of the abdomen and pelvis demonstrated what appeared to be a pseudoaneurysm of the celiac artery (Fig 4), which was confirmed arteriographically.
Fig 4.
An abdominal computed tomography scan with contrast shows a pseudoaneurysm of the celiac artery (arrows) in a 32-year-old man who sustained a gunshot wound of the abdomen 6 months earlier. The patient presented with recurrent gastrointestinal bleeding.
The patient had no symptoms or signs of sepsis and no radiologic findings suggesting an infected pseudoaneurysm. The pseudoaneurysm had a wide neck and appeared to arise from the anterior portion of the celiac artery at its junction with the common hepatic artery, measuring 11 × 13 mm. Injection of the celiac artery demonstrated the source of the GI bleeding was a communication of the pseudoaneurysm with the pancreatic duct resulting in hemosuccus pancreaticus (Fig 5).
Fig 5.
Selective arteriogram of the celiac artery reveals a pseudoaneurysm and arteriopancreatic duct fistula (arrows).
Operative repair was expected to be associated with significant morbidity, so an endovascular approach was planned. The goal was to exclude the pseudoaneurysm while maintaining hepatic perfusion. Using a bilateral common femoral artery approach, the celiac artery and SMA were cannulated. The celiac catheter was then advanced into the proximal splenic artery and left gastric artery and embolized with 5-mm and 2-mm coils, respectively, to prevent backflow into the pseudoaneurysm. The common hepatic artery was then cannulated and an 8-mm × 40-mm Fluency stent (Bard Peripheral Vascular, Tempe, Ariz) was placed in the hepatic artery just proximal to the gastroduodenal artery and extended into the celiac trunk. A completion arteriogram showed exclusion of the pseudoaneurysm and obliteration of the arteriopancreatic fistula (Fig 6).
Fig 6.
A selective arteriogram of the celiac artery after coil embolization of the left gastric artery and splenic artery and covered stent graft of celiac trunk to common hepatic artery shows that the arteriopancreatic duct fistula has been obliterated.
The patient did well and was discharged 3 days later tolerating a full diet. During the next year of follow-up, the patient had no further GI bleeding. A mesenteric arterial duplex ultrasound examination 18 months after the procedure demonstrated a patent celiac stent and hepatic artery.
Discussion
Opinions differ about management of aneurysms and pseudoaneurysms of the visceral arteries. Interestingly, some authors do not differentiate between true and false aneurysms. Traditionally, mesenteric artery aneurysms and pseudoaneurysms have been managed with open surgical repair. Repair of asymptomatic true aneurysms and pseudoaneurysms has been advised because of the high likelihood of rupture and resultant death. In one of the larger reports, 22% of patients with visceral artery aneurysms presented as emergencies resulting in 9% mortality.2 A recent report indicates a more pessimistic presentation and outcome, with 42% of visceral artery aneurysm patients presenting with rupture resulting in 25% mortality.3
During the last two decades, there has been a shift in the management of these lesions. In the mid-1980s, case reports and small series reported successful treatment of mesenteric artery aneurysms and pseudoaneurysms with embolization. Technical success was 56% to 100%, with complication rates of 0% to 50% (Table I).3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 In fact, embolization alone was used to treat two-thirds of the aneurysms and pseudoaneurysms found in our literature review. Unfortunately, follow-up was poor and recanalization and patency rates were sporadically recorded.
Table I. Literature review: embolization experience
| Year published | Author | Embol (n) | Tech success % (n) | Conv | Comp % (n) | Mort % (n) | F/U (months) |
|---|---|---|---|---|---|---|---|
| 1987 | Mandel4 | 19 | 79 (15) | N/A | N/A | 0 | N/A |
| 1987 | Baker5 | 8 | 100(8) | 3 | 13(1) | 0 | N/A |
| 1992 | Salam6 | 16 | 81(13) | 0 | 8(1) | 0 | 8m |
| 1993 | Repasky7 | 1 | 100(1) | 0 | 0 | 0 | N/A |
| 1996 | Stambo8 | 8 | 88(7) | 1 | 0 | 0 | 21 |
| 1998 | Reber9 | 5 | 100(5) | 0 | 40(2) | 0 | 35 |
| 1999 | Hama10 | 1 | 100(1) | 0 | 0 | 0 | 10 |
| 1999 | de Perrot11 | 3 | 100(3) | 0 | 0 | 33(1) | N/A |
| 2000 | Carr12 | 6 | 67(4) | 2 | 50(3) | 11(1) | N/A |
| 2000 | Carrmeci13 | 9 | 56(5) | 4 | 0 | 0 | N/A |
| 2001 | Hossain14 | 8 | 100(8) | 0 | 0 | 0 | N/A |
| 2001 | Carr S3 | 4 | 100(4) | 0 | 25(1) | 0 | N/A |
| 2001 | Kasirajan15 | 12 | 75(9) | 0 | 0 | 0 | 46 |
| 2002 | Gabelmann16 | 25 | 92(23) | 1 | 50(12) | 4(1) | 49 |
| 2002 | Pilleul17 | 18 | 78(14) | N/A | N/A | N/A | 0.4 |
| 2002 | Parildar18 | 22 | 95(21) | 1 | 0 | 5(1) | 12 |
| 2003 | Flati19 | 1 | 100(1) | 0 | 0 | 0 | 11 |
| 2003 | Tessier20 | 2 | 100(2) | 0 | 0 | 0 | N/A |
| 2004 | Deshmukh21 | 30 | 97(29) | 0 | 7(2) | 3(1) | N/A |
| 2004 | Sessa22 | 13 | 100(13) | 0 | 15(2) | 0 | N/A |
| 2005 | Lau23 | 14 | 100(14) | 0 | 50(7) | 14(2) | N/A |
| 2005 | Saltzberg24 | 15 | 94(14) | 1 | 22(3) | 0 | N/A |
| Total | — | 240 | 89(214) | 6(13) | 17(34) | 3(7) | 22 |
In the late 1990s, reports of exclusion with stent grafts began to appear (Table II).24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 All reported cases were technical successes with no deaths and only one complication. A variety of stent grafts have been used; however, most were Jomed stent grafts, as used in our first patient. Follow-up was short-term and inconsistent.
Table II. Literature review: stent graft experience
| Year | Author | Stents (N) | Complications (%) | Death (%) | Type | F/U (mos) | Clinical patency |
|---|---|---|---|---|---|---|---|
| 1998 | McGraw25 | 1 | 0 | 0 | Self-made | 12 | Y |
| 2000 | Nyman26 | 1 | 0 | 0 | Wallgraft | 12 | NA |
| 2000 | Paci27 | 1 | 0 | 0 | Unknown | 3 | Y |
| 2001 | Tan28 | 1 | 0 | 0 | Jostent | 9 | Y |
| 2001 | Yoon29 | 1 | 0 | 0 | Jostent × 1 | 3 | Y |
| 2002 | Venturini30 | 1 | 0 | 0 | Jostent | 12 | Y |
| 2002 | Roček31 | 1 | 0 | 0 | Jostent | 30 | NA |
| 2002 | Cowan32 | 1 | 0 | 0 | Jostent | 60 | NA |
| 2002 | Larson33 | 2 | 0 | 0 | Symbiot | 13 | NA |
| 2002 | Arepally34 | 1 | 0 | 0 | Jostent × 3 | 4 | Y |
| 2002 | Brountzos35 | 1 | 100 | 0 | Hemobahn Wallstent | 1 | Y |
| 2003 | Appel36 | 1 | 0 | 0 | Jostent & Wallgraft | 6 | NA |
| 2003 | Takahashi37 | 1 | 0 | 0 | Gianturco Z | 10 | Y |
| 2004 | Ogino38 | 1 | 0 | 0 | Passager stent | 24 | Y |
| 2004 | Seriki39 | 1 | 0 | 0 | Jostent | NA | NA |
| 2004 | Gandini40 | 1 | 0 | 0 | Jostent | 7 | Y |
| 2005 | Qu41 | 1 | 0 | 0 | Talent | 60 | Y |
| 2005 | Saltzberg24 | 3 | 0 | 0 | Viabahn | NA | NA |
| Total | 21 | 1(5) | 0 | — | 17 (avg) | — |
Recently, reports of mesenteric pseudoaneurysms and true aneurysms are focusing on endovascular management. For pseudoaneurysms, the approach using embolization and thrombin injection to obliterate the pseudoaneurysm, followed by endoluminal stent grafting for optimal revascularization, is developing a therapeutic foothold (Table III).3, 13, 14, 15, 21, 22, 23, 24 The mortality rate of endovascular treatment is less than either open repair or medical management. The success of the endovascular approach has led some to endorse it as an alternative therapy for true mesenteric artery aneurysms, even in the presence of rupture.3, 13, 14, 15, 21, 22, 23, 24 We recognize that successful reports represent a bias in that technical failures and complications are rarely published.
Table III. Literature review: contemporary management of visceral artery aneurysms
| Year | Author | Study dates | N | VAA (n) | Open % (n) | Comp % (n) | Mort % (n) | Endo % (n) | Comp % (n) | Mort % | Med⁎ (n) | Comp % | Mort (N) | F/U (mos) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2000 | Carmecci13 | 1980-1998 | 31 | 34 | 74(25) | 0 | 3(1) | 26(9) | 0 | 0 | — | — | — | NA |
| 2001 | Kasirajan15 | 1988-1998 | 9 | 12 | 22(2) | 0 | 0 | 61 | 0 | 0 | 11%(1) | 0 | 0 | 46 |
| 2001 | Carr S3 | 1990-2000 | 26 | 34 | 50(15) | 38(5) | 13(2) | 15(4) | 0 | 25%(1) | 27%(7) | 0 | 14%(1) | 15 |
| 2001 | Hossain14 | 1983-1998 | 30 | 30 | 63(19) | 21(4) | 11(2) | 27(8) | 25(2) | 0 | 10%(3) | 0 | 0 | NA |
| 2003 | Tessier21 | 1980-1998 | 10 | 10 | 70(7) | NR | 0 | 20(2) | NA | 0 | NR | NR | NA | 46 |
| 2004 | Sessa22 | 1975-2002 | 34 | 42 | 69(29) | 28(8) | 10(3) | 31(13) | 23(5) | 0 | NA | NA | NA | NA |
| 2005 | Saltzberg24 | 1990-2003 | 65 | 65 | 14(9) | 11% | 11 | 28(18) | 20(4) | 0 | 58%(35) | 0 | 0 | 21 |
| Total | 205 | 227 | 51(106) | 17(18) | 8(9) | 29(60) | 15(9) | 0.2%(1) | 22%(46) | 0 | 2%(1) | 32 |
⁎Medical treatment (nonoperative/no endovascular procedure). |
Principles for endovascular management have been refined during the last two decades, contributing to the safe management of these patients. Sound management principles include the obliteration and exclusion of the aneurysm or pseudoaneurysm with maintenance of distal perfusion and obliteration of side branches. Magnetic resonance imaging or CT establishes the diagnosis and a management strategy can be planned. Selective arteriography reveals the details necessary for precise management. Identifying collateral and major branches, sizing vessels, and maintaining guidewire access are important principles.
Early in the evolution of endovascular procedures, embolization alone gained therapeutic favor. This is accomplished with coils, gel foam, thrombin, or a combination of these. The drawback of embolization alone is potential recanalization and recurrence of the pseudoaneurysm. The gastroduodenal artery has been reported to be the most common focal source of visceral artery aneurysm rupture and is usually amenable to arterial embolization. The most effective technique of arterial embolization is occlusion of the artery distal and proximal to the aneurysm.3
When occlusion of the vessel is not possible, direct embolization of the pseudoaneurysm, as was done in our first case, is recommended, assuming the pseudoaneurysm does not have a short, wide neck, which increases the risk of inadvertent vessel thrombosis or embolization. In these situations, stent grafts appear to be the preferred endovascular approach, thereby excluding the pseudoaneurysm and preserving distal perfusion. Unfortunately, the options for stent grafts are limited and the smaller diameter of these vessels is problematic. Drawbacks associated with stent grafts are the diameter of the target vessel, the difficult trackability, and the need for large access sheaths. Although covered stent grafts are available for cardiac angioplasty rescue, these are often not readily available in peripheral endovascular units.
Long-term follow-up of endovascular interventions for mesenteric artery aneurysms and pseudoaneurysms is not available. A prudent course of follow-up should include clinical evaluation combined with some form of imaging modality, including ultrasonography, CT, magnetic resonance angiography, and duplex subtraction angiography. It seems reasonable that timing of follow-up imaging be similar to that used for aortic endograft repair, generally at 1 month, 6 months, and annually thereafter, assuming normal findings.
Conclusion
We report two cases of endovascular management of complicated mesenteric pseudoaneurysms, with one presenting as recurrent gastrointestinal hemorrhage from a celiac artery to pancreatic duct fistula. The good early results of these complicated patients, avoiding serious morbidity, supports an initial endovascular approach for these patients. Combining embolization, where appropriate, with stent graft revascularization will likely maximize success. Long-term follow-up is important to assess the proper role of endovascular management in these patients.
References
- . Splanchnic artery aneurysms. In: Rutherford RB editors. Vascular Surgery. 6th ed.. Philadelphia: W.B. Saunders; 2005;p. 1565–1581
- . Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg. 1986;3:836–840
- . Visceral artery aneurysm rupture. J Vasc Surg. 2001;33:806–811
- . Nonoperative management of peripancreatic arterial aneurysms (A 10-year experience). Ann Surg. 1987;205:126–128
- . Splanchnic artery aneurysms and pseudoaneurysms: transcatheter embolization. Radiology. 1987;163:135–139
- . Nonoperative management of visceral aneurysms and pseudoaneurysms. Am J Surg. 1992;164:215–219
- . Transcatheter embolization of a superior mesenteric artery pseudoaneurysm and arteriovenous fistula. J Vasc Interv Radiol. 1993;4:241–244
- . Arteriographic embolization of visceral artery pseudoaneurysms. Ann Vasc Surg. 1996;10:476–480
- . Superselective microcoil embolization: treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg. 1998;186:325–330
- Transcatheter embolization of a superior mesenteric artery pseudoaneurysm (A case report). Acta Radiol. 1999;40:649–651
- . Management of bleeding pseudoaneurysms in patients with pancreatitis. Br J Surg. 1999;86:29–32
- . Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis. J Vasc Surg. 2000;32:722–730
- . Visceral artery aneurysms as seen in a community hospital. Am J Surg. 2000;179:486–489
- . Visceral artery aneurysms: experience in a tertiary-care center. Am Surg. 2001;67:432–437
- . Endovascular management of visceral artery aneurysm. J Endovasc Ther. 2001;8:150–155
- . Endovascular treatment of visceral artery aneurysms. J Endovasc Ther. 2002;9:38–47
- . Transcatheter embolization of splanchnic aneurysms/pseudoaneurysms: early imaging allows detection of incomplete procedure. J Comput Assist Tomogr. 2002;26:107–112
- . Embolization of visceral pseudoaneurysms with platinum coils and N-butyl cyanoacrylate. Abdom Imaging. 2003;28:36–40
- . Successful embolization of a bleeding pseudoaneurysm of the celiac tripod. Am J Surg. 2003;185:565–566
- Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg. 2003;38:969–974
- . Transcatheter embolization as primary treatment for visceral pseudoaneurysms in pancreatitis: clinical outcome and imaging follow up. Indian J Gastroenterol. 2004;23:56–58
- . Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg. 2004;18:695–703
- Transcatheter embolisation of visceral pseudoaneurysms--technical difficulties and modification of embolisation technique. Eur J Vasc Endovasc Surg. 2005;30:133–136
- Is endovascular therapy the preferred treatment for all visceral artery aneurysms?. Ann Vasc Surg. 2005;19:507–515
- . Autogenous vein-covered stent for the endovascular management of a superior mesenteric artery pseudoaneurysm. J Vasc Interv Radiol. 1998;9:779–782
- . Multiple pancreaticoduodenal aneurysms: treatment with superior mesenteric artery stent-graft placement and distal embolization. J Vasc Interv Radiol. 2000;11:1201–1205
- . Pseudoaneurysm of the common hepatic artery: treatment with a stent-graft. Cardiovasc Intervent Radiol. 2000;23:472–474
- . Pseudoaneurysm of the superior mesenteric artery after pancreas transplantation treated by endovascular stenting. Transplantation. 2001;72:336–338
- . Stent-graft repair of a splenic artery aneurysm. Cardiovasc Intervent Radiol. 2001;24:200–203
- Hemorrhage from a right hepatic artery pseudoaneurysm: endovascular treatment with a coronary stent-graft. J Endovasc Ther. 2002;9:221–224
- . Percutaneous treatment of a superior mesenteric artery pseudoaneurysm using a stent-graft. AJR Am J Roentgenol. 2002;178:1459–1461
- Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent. J Vasc Surg. 2002;35:805–807
- . Stent graft repair of visceral artery aneurysms. J Vasc Surg. 2002;36:1260–1263
- . Treatment of splenic artery aneurysm with use of a stent-graft. J Vasc Interv Radiol. 2002;13:631–633
- . Pancreatitis-associated splenic artery pseudoaneurysm: endovascular treatment with self-expandable stent-grafts. Cardiovasc Intervent Radiol. 2003;26:88–91
- . Percutaneous stent-graft treatment of superior mesenteric and internal iliac artery pseudoaneurysms. J Vasc Interv Radiol. 2003;14:917–922
- Stent graft treatment for abdominal pseudoaneurysm near the celiac artery. J Thorac Cardiovasc Surg. 2003;126:600–602
- . Superior mesenteric artery stent-graft placement in a patient with pseudoaneurysm developing from a pancreatic pseudocyst. Cardiovasc Intervent Radiol. 2004;27:68–70
- . Endovascular stent graft: treatment of pseudoaneurysm of the superior mesenteric artery. Cardiovasc Intervent Radiol. 2004;27:271–273
- Endovascular treatment of a giant superior mesenteric artery pseudoaneurysm using a nitinol stent-graft. Cardiovasc Intervent Radiol. 2005;28:102–106
- . Endoaortic stent grafting of a giant infected hepatic-celiac pseudoaneurysm. J Vasc Surg. 2005;42:159–162
Competition of interest: none.
PII: S0741-5214(06)01637-5
doi:10.1016/j.jvs.2006.09.010
© 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
