Journal of Vascular Surgery
Volume 29, Issue 6 , Pages 1162-1163, June 1999

Superior mesenteric artery syndrome as a result of enlarged abdominal aortic aneurysm☆☆☆

Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College. Wakayama, Japan

Received 15 October 1998; accepted 16 December 1998.

Article Outline

 

Superior mesenteric artery (SMA) syndrome is a rare entity of a disease in which the third part of the duodenum is compressed by the overlying SMA.1 Patients are seen with repeated vomiting and a sense of fullness in the upper abdomen. Reportedly, there are many causes that can decrease the vascular angle between the SMA and the aorta, which would result in the obstruction of the duodenum. The anatomic mechanisms of this syndrome have remained controversial. We experienced a case of abdominal aortic aneurysm presented with SMA syndrome and treated it successfully with a graft replacement of the aneurysm.

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CASE REPORT 

A 71-year-old man was seen at our hospital with severe abdominal pain and nausea after meals. He had undergone a partial gastrectomy with end-to-end gastroduodenostomy 20 years previously. The symptoms had occurred repeatedly for a few months. The symptoms always had disappeared soon after massive vomiting. The physical examination results revealed a pulsatile mass at the abdomen. The bowel sounds were almost normal. Computed tomographic imaging results revealed an abdominal aortic aneurysm (7 cm in maximal diameter) that involved the bilateral iliac artery. The stomach and the duodenum were dilated, and the third part of the duodenum was sandwiched between the SMA and the abdominal aortic aneurysm (Fig. 1), a typical condition of the SMA syndrome.2 Barium duodenogram results revealed dilatation of the duodenum and barium retention within the duodenum (Fig. 2).

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  • Fig. 1. 

    Preoperative enhanced computed tomographic imaging showing large abdominal aortic aneurysm and dilated proximal duodenum. The third part of duodenum was sandwiched between superior mesenteric artery and abdominal aortic aneurysm. An, Aneurysm; SMA, superior mesenteric artery.

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  • Fig. 2. 

    Preoperative barium duodenographic results revealed dilatation of duodenum and barium retention within duodenum. Note string-like structure that compressed the duodenum ( arrows).

Surgery was performed through median laparotomy. The proximal jejunum was adhered in part to the retroperitoneum over aneurysm and was released. The aneurysm was replaced with the inclusion method with an aortobiliac knitted Dacron graft. The aneurysmal wall was resected in large part, and the graft was tightly covered with the rest of the wall so that the angle between the aneurysmal wall and the SMA became wide open. The postoperative course was uneventful, and the patient did not have any more nausea and vomiting. The barium duodenogram test results revealed no obstruction (Fig. 3), and the computed tomographic results showed a wide space between the SMA and the aortic wall, implying the release of compression (Fig. 4).
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  • Fig. 3. 

    Postoperative enhanced computed tomographic results. A wide space between superior mesenteric artery and aortic wall was observed, showing release of compression of the third part of the duodenum. SMA, Superior mesenteric artery.

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DISCUSSION 

The SMA syndrome occurs with various causes.3 Only seven cases of SMA syndrome in conjunction with abdominal aneurysm have been reported at this time.4, 5 Edwards and Katzen4 reported this syndrome combined with dissecting abdominal aortic aneurysm. During the operation, they noticed chronic fibrosis around the aneurysm in the area surrounding the transverse portion of the duodenum, which could have caused the obstruction. In contrast, our case was infrarenal aneurysm, and, apparently, there was no lesion around the portion near the SMA. Assumably, the symptoms in this case developed with the extent of the dilatation of the aneurysm together with the adhesion of the proximal jejunum, which might have pulled the SMA downwards and backwards and reduced the space between the SMA and the aneurysm. The adhesion was assumed to be caused by the previous gastrectomy, although we were unable to obtain the details of the operation. An aneurysm with a diameter as large as 7 cm is not rare, and patients are never seen with repeated vomiting. We strongly speculate that the adhesion of the jejunum is associated with the cause of SMA syndrome in this case. The operation was performed in a routine manner for the abdominal aortic aneurysm. To free space around the duodenum, a graft was tightly wrapped with the remnants of the aneurysmal wall, and it was strong enough to remove the symptoms after the operation. This syndrome is rarely seen in patients with abdominal aortic aneurysm, but surgeons must recognize these symptoms as a part of the aneurysmal origin, and the operation should be considered immediately as the first choice of treatment.

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References 

  1. von Rokitanski C. Lehrbuch der pathologischen anatomie. In: 3rd ed. Vienna: Braunmüller & Seidel; 1861;p. 187
  2. Santer R, Young C, Rossi T, Riddlesberger MM. Computed tomography in superior mesenteric artery syndrome. Pediatr Radiol. 1991;21:154–155
  3. Ahmed AR, Taylor I. Superior mesenteric artery syndrome. Postgrad Med J. 1997;73:776–778
  4. Edwards KC, Katzen BT. Superior mesenteric artery syndrome due to large dissecting abdominal aortic aneurysm. Am J Gastroenterol. 1984;79:72–74
  5. Lamont PM, Clarke PJ, Collin J. Duodenal obstruction after abdominal aortic aneurysm repair. Eur J Vasc Surg. 1992;6:107–110

☆ Reprint requests: Dr Hiroyoshi Komai, Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College, 27, 7-bancho, Wakayama, Japan 640-8156.

☆☆ 24/4/96865

PII: S0741-5214(99)70255-7

Journal of Vascular Surgery
Volume 29, Issue 6 , Pages 1162-1163, June 1999

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