an open approach to the treatment of c liac artery aneurysm a case report

EJVES Extra 8, 34–36 (2004) doi: 10.1016/j.ejvsextra.2004.06.002, available online at http://www.sciencedirect.com on SHORT REPORT An Open Approach to the Treatment of Cœliac Artery Aneurysm A Case Report R Karlsson1*, P-E Thornell1, P Grahn2 and J Tjaărnstroăm1 ă lvsborgs Laănssjukhus (NA ă L), Division of Vascular Surgery, and 2Department of Radiology, Norra A Trollhaăttan, Sweden Introduction Aneurysm of the cliac artery is a rare vascular problem representing 4% of visceral aneurysms Its natural history appears to be one of expansion and rupture,1 in which case a high mortality rate is to be expected Because of this, intervention has traditionally been recommended This paper presents a case of a large cœliac artery aneurysm treated by open surgery applied to achieve a partial tangential clamping of the aorta The hepatic and splenic arteries were clamped and the sac of the aneurysm opened An externally supported mm PTFE-graft was anastomosed end-toend to the cœliac artery and the hepato-splenic junction (Fig 2) and, finally, the aneurysm sac was wrapped around the vascular graft The patient’s recovery after the procedure was slow but uneventful, and he was discharged weeks later Discussion Report The patient, a 76-year-old man, was referred to our vascular unit in October 2002 The case history revealed a thoracic aortic aneurysm (5 cm in diameter) and a cœliac artery aneurysm (3.5 cm in diameter), as diagnosed by a CT scan in 1998 A new CT scan revealed a considerable enlargement of the cœliac artery aneurysm from 3.5 to cm (Fig 1(a) and (b)) The thoracic aortic aneurysm also showed an enlargement but of lesser magnitude (from to almost cm) The cœliac artery aneurysm was given the highest priority We decided that open surgery would be the most favourable way to exclude the aneurysm The patient was operated on through a midline incision The pulsatile mass was easily identified Access was gained through the lesser sac with division of the crus of the diaphragm The suprarenal abdominal aorta was identified together with the cœliac, hepatic and splenic arteries A vascular clamp was *Corresponding author R Karlsson, Division of Vascular Surgery, ă lvsborgs Laănssjukhus (NA ă L), Trollhaăttan, Sweden Norra A Cœliac artery aneurysms are rare In the literature, we have found 179 reported cases Graham and associates have carried out the largest review of this type of aneurysm.2 Their report included 108 patients, divided into two groups The first group consisted of 60 patients from the historic era (1745 –1949) and the second group of 48 patients from the contemporary era (1950 – 1984) In the historic era, the most common etiological factor was syphilis (31%), and the cause was unknown in 52% of the cases The diagnosis was usually made post-mortem In the contemporary era, the nature of the aneurysm was unknown in 42% of the patients Luetic origin was not noted during this period The major causes were atherosclerosis (27%) and medial degeneration (17%) Aneurysm of the cœliac artery is often associated with other aneurysms, and aortic aneurysm is reported in 18– 44% of the cases.2,3 The male/female ratio has changed over time Prior to 1950 the ratio was 9:1.2 Later figures indicate a ratio of 2:1.4,5 Symptoms associated with cœliac artery aneurysms vary The most common seems to be abdominal pain 1533–3167/020034 + 03 $35.00/0 q 2004 Elsevier Ltd All rights reserved An Open Approach to the Treatment of Cœliac Artery Aneurysm A Case Report 35 Fig Shows a postoperative 3D reconstruction A, PTFE; B, splenic artery; C, hepatic artery Fig (a) The cœliac artery aneurysm is shown preoperatively in a sagittal 2D MIP-view (b) The cœliac artery aneurysm is shown in a 3D reconstruction A, cœliac artery; B, hepatic artery; C, splenic artery or discomfort Other symptoms are related to compression by the aneurysm on surrounding structures, such as the hepatic ducts, resulting in jaundice Less common symptoms are dysphagia and anorexia Some patients, however, are asymptomatic Diagnosis is established with CT or MR Angiography may be of value The increased use of CT and angiography means that more asymptomatic aneurysms are being found The question of when and how these aneurysms should be operated on has been discussed One problem has been the inability to predict the risk of rupture, and the factors that may stratify this risk have still not been identified.3 Of 179 reported cases in the literature, 94 have been surgically treated The contemporary recommendation is that all patients should be offered elective surgery with the exception of high-risk patients,5 and cases with aneurysm of below cm.3 This is based on mortality figures associated with rupture, which are reported to be in the region of 40– 100%,2,4 while mortality in elective surgery is approximately 5%.2,5 The operative approach is varied The most common technique has been resection of the aneurysm and revascularisation, either with direct anastomosis or prosthetic or saphenous vein graft Aneurysmorrhaphy has been used in selected cases Ligation with or without revascularisation is another option, which seems to be the preferred method for ruptured aneurysm Exposure can usually be obtained through a midline incision, through the lesser sac or using medial visceral rotation The endovascular treatment possibilities include coil embolization and stent grafting Coil embolization offers the possibility of treating larger aneurysms by filling the aneurysm itself or by occluding only the neck of the lesion Complications seem to be rare.6 We have found reports regarding endovascular stent grafting of cœliac artery pseudoaneurysm7 and regarding exclusion of cœliac artery aneurysm by placing a modular stent graft within the abdominal aorta at the cœliac artery orifice.8 In our search of the literature, we have found a relatively small number of EJVES Extra, 2004 R Karlsson et al 36 reports regarding stent grafting as a treatment for cœliac artery aneurysm, which indicates that this is an unusual method The development of endovascular techniques is likely to be an expanding field and one of the major advantages is the minimal invasiveness, which is especially important in poor surgical risk patients Thus, an alternative method for the treatment of our patient would have been to stent the aneurysm and to close the splenic artery using coils The management of this kind of aneurysm must be considered on an individual basis, since there are no absolute guidelines In our case, the size of the aneurysm and the rapid expansion were the grounds on which our decision to perform an open operation was based References Carr SC, Pearce WH Visceral artery aneurysms In: Geroulakos EJVES Extra, 2004 G, Cherry KJ Jr, eds Diseases of the visceral circulation London: Arnold, 2002: 130–144 Graham LM, Stanley JC, Whitehouse Jr WM et al Cœliac artery aneurysms: historic (1745– 1949) versus contemporary (1950– 1984) differences in etiology and clinical importance J Vasc Surg 1985; 2:757–764 Stone WM, Abbas MA, Gloviczki P, Fowl RJ, Cherry KJ Cœliac arterial aneurysms, a critical reappraisal of a rare entity Arch Surg 2002; 137:670– 674 Shanley CJ, Shah NL, Messina LM Common splanchnic artery aneurysms: splenic, hepatic and cœliac Ann Vasc Surg 1996; 10(3): 315 –322 Messina LM, Shanley CJ Visceral artery aneurysms Surg Clin North Am 1997; 77:425–442 Gabelmann A, Gorich J, Merkle EM Endovascular treatment of visceral artery aneurysms J Endovasc Ther 2002; 9:38–47 Bautista-Hernandez V, Gutierrez F, Capel A, Garcia-Puente J, Arill VG, Robles D, Arcas R Endovascular repair of concomitant cœliac trunk and abdominal aortic aneurysms in a patient with Behcet’s disease J Endovasc Ther 2004; 11(2):222–225 Atkins BZ, Ryan JM, Gray JL Treatment of a cœliac artery aneurysm with endovascular stent grafting—a case report Vasc Endovasc Surg 2003; 37(5):367–373 Accepted June 2004 .. .An Open Approach to the Treatment of C? ?liac Artery Aneurysm A Case Report 35 Fig Shows a postoperative 3D reconstruction A, PTFE; B, splenic artery; C, hepatic artery Fig (a) The c? ?liac artery. .. endovascular stent grafting of c? ?liac artery pseudoaneurysm7 and regarding exclusion of c? ?liac artery aneurysm by placing a modular stent graft within the abdominal aorta at the c? ?liac artery. .. 674 Shanley CJ, Shah NL, Messina LM Common splanchnic artery aneurysms: splenic, hepatic and c? ?liac Ann Vasc Surg 1996; 10(3): 315 –322 Messina LM, Shanley CJ Visceral artery aneurysms Surg Clin