Introduction vascular unit for treatment of a visceral artery

Introduction Aneurysmsof visceral arteries are rare vascular lesions, occurring at a frequency of 0,1- 2% among all arterial aneurysms 1,2. Whilst splenic artery aneurysmsrepresent the majority (60%) of splanchnic aneurysms,gastroepiploic arterial aneurysms (GEA) are more rare, occurring at afrequency of 3-4% of all visceral arteries aneurysms 3,4,5. The leftgastroepiploic artery (LGEA) is the largest branch of the splenic artery and isanastomosed with the right gastroepiploic artery (RGEA), which usuallyoriginates the latter from the gastroduodenal artery. Both branches run alongthe large curvature of the stomach supplying both surfaces of it -throughascending branches-, and the greater omentum -through descending branches. Wepresent herein, a case of a woman with a left gastroepiploic aneurysm,initially misinterpreted as splenic artery aneurysm.

In addition, aetiology, clinicalmanifestations and course, therapeutic challenges for the treatment ofgastroepiploic artery aneurysm, and a brief review of the literature arediscussed. Case report A65-year-old woman was referred to our vascular unit for treatment of a visceralartery aneurysm, which was a random finding in follow-up ultrasound scanning,after left total mastectomy, lymphadenctomy and chemotherapy, due to breastcancer. The patient had no history of traumatic injury, hypertension orsmoking. She was asymptomatic and during clinical examination, the abdomen wassoft without epigastric tenderness; no mass was noticed. The hemoglobin (Hb) onadmission was 12,5 g/dl and all other investigations including ECG, chestX-rays and biochemistry were within normal limits.Upperabdomen ultrasound study had showed a hypoechoic deformation of about 2 cm indiameter in the left abdomen, above the left kidney, with the suspicion of anadrenal mass.AMagnetic Resonance Imaging (MRI) was performed, (Figure 3) revealing a mass of2.

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1 x 2.3 cm in diameter, between the left adrenal gland and the spleen, incontact with the splenic artery and although not totally clarified, theaneurysm of the splenic artery was also added to the differential diagnosis. A Computed Tomography Angiography (CTA) followed, (Figure1,2) which revealed a partial thrombosed aneurysm at the distant limit of thesplenic artery. The CTA confirmed a long and tortuous anatomy of celiac arterytrunk with intense curvature and an approximate length of 2,5 x 2,3 cm compared to the 1.25 cm of normal length.

6Thepatient underwent elective operation under general anaesthesia. A leftsubcostal (partial Chevron) incision  was performed, followed by entrance in the lesser omental bursa. The aneurysmhas been exposed and the origin artery was identified as the leftgastroepiploic. The artery was ligated on either side of the aneurysm and itwas excised.  Postoperative hemoglobinwas found to be 10,8 g/dL; no blood transfusion was needed. The patient wasdischarged on the 4th postoperative day after an uncomplicatedcourse of hospitalization. Histology of the resected artery confirmed thediagnosis of a true arterial aneurysm.

 Discussion Tenseparate institutional reviews identified in the literature reported a total ofover of 3000 splanchnic aneurysm cases (1-10). According to these reviews, thepredominant locations were splenic (35%), hepatic (23%), superior mesenteric (19%), pancreaticoduodenal/gastric(8.6%), celiac (7.6%) and renal (7%) arteries. Gastroepiploic artery aneurysmsaccounted for only 3.

5% (7) of the cases. 7 Manyfactors have been incriminated as causes of splanchnic artery aneurysms withmain the atheroscerotic disease 1,8. Other etiological factors includearteriosclerosis, trauma, local inflammation such as pancreatitis oranastomotic leakage, medial dysplasia or agenesis, mycotic embolism, congenialvascular anomaly, infection, medial necrosis, trauma, pregnancy, portalhypertension, biliary disease, pancreatitis, and connective tissue disease andsegmental arterial mediolysis.9,10,11. Splenic artery aneurysms are likely the most common, because of theirassociation with pancreatitis; an increased incidence has been reported inpatients with dominant polycystic kidney disease 12 whilst pregnancy is aspecial etiological factor for splenic artery aneurysms rupture. 8 Inparticular for the LGEA aneurysms, specific relating etiologic factors are notmentioned to the English literature and we cannot suggest any known relatingfactor to the LGEA aneurysm of the parient we managed.Splanchnicarterial aneurysms, besides their rare incidence, have a high rupture rate of90% which is associated with a mortality of up to 70%.

8,13. The mortalityrate depends not only on the characteristics of the aneurysm like the originartery, the size, the different clinical behavior between the true and thepseudoaneurysms, but also on the fact of whether is possible for the bleedingsite to be revealed during laparotomy 14. By reviewing the recorded cases wenotice that among the 17 cases of GEAAs with accessible data, 15 of themruptured, so the rupture rate is 88%. 8, 15Gastroepiploicartery aneurysms are more common in men over women with an incidence rate of 3to 1 and the majority is identified in people over 50 years of age 16.

Amongthe 22 cases of the English literature, more epidemiological data existed in 15of them. Among the 22 cases of the English literature, more epidemiologicaldata existed in 15 of them. The ratio among men and women was 2,2 with 11 cases(68,8%) of male and 5 cases (31,2%) of female patients. The mean age ofpatients was 57,3 years. The statistical analysis showed that females had an8-years difference in diagnosis 64 years among women versus 56,4 among men . Clinicalmanifestations of gastrointestinal arterial aneurysms (GAA) are not associatedwith any special symptoms and they vary from asymptomatic to epigastrictenderness. 15 There is lack of studies, comparing this heterogeneity to clinicalmanifestations, but this may be related to the size of the aneurismal lesion,and reduced stomach blood flow during the normal process of digestion.

  As a result, many of them are often diagnosedincidentally or on an emergency basis after rupture 9. The LGEAA of thepatient we present here was also an incidental finding, following a standardultrasonoraphy abdominal study. Thewidespread use of noninvasive imaging studies like the ultrasonography and thecomputed tomography has made early diagnosis more frequent. This reflects tothe therapeutic approach as an early asymptomatic diagnosis permits an electivesurgery with an operative mortality of 0-3% contrary to an emergency procedurein which the mortality rate is 50-70% 15, 17.

 Although the prevalence of abdominalsplanchnic aneurysms has not been clarified, in the largest series of reportedsplenic aneurysms, the incidence in angiography was reported to be 0.78% 11. Patientsoften have more than one visceral artery aneurysm and full vascular assessmentis recommended in these cases. Intarterial digital substraction angiography(IADSA) is an invasive but valuable tool either for diagnostic or fortherapeutic intervention. Due to the anatomic obstacles and in particular thetortuous celiac and splenic artery and the distal location of the aneurysm weexcluded the IADSA with the presumption that the endovascular approach would betechnically difficult and risky. Thus for the preoperative planning, CTA wasused.  Manyendovascular and percutaneous transabdominal techniques have been describedconcerning the treatment of splanchnic arterial aneurysms.

An important pointis when to intervene. The indication for intervention is related to concernsover the risk of rupture due to the high associated mortality upon thiscomplication.  Since most visceralaneurysms rupture, elective resection is advocated; pseudoaneurysms are morelikely to rupture than true aneurysms. 5, 18. Pulli et al 15 suggest that asymptomaticvisceral artery aneurysms greater than 2 cm and symptomatic ones regardless ofsize should be treated.  Aneurysms of thesplenic artery are the most commonly encountered and least likely to rupture,except during pregnancy.

Aneurysms of other visceral arteries, like the LGEAare less common and as a result less well-studied, with a result of a limitedexperience in their treatment. Due to this high rate of rupture and subsequentmortality, all patients diagnosed with GEAA should be treated immediately. Thesurgical technique depends on the location of the artery, the surgeon’sexperience, the patient’s general health status and the urgency ofintervention.

Minimally invasive techniques constitute a modern therapeuticsolution with several limitations.   Visceralartery aneurysm and pseudoaneurysms can be successfully treated intravascularwith techniques based on wires and catheters with low perioperative morbidity.Selective arterial angiography with embolization is applicable in some cases,although however surgical intervention remains the usual management. Acontraindication to intravascular or interventricular interference isinappropriate and prohibitive anatomy. However, urgent correction of theselesions continues to be associated with increased mortality rates. Aneurysmexclusion can also be achieved by coil plating and the selective use ofN-butyl-2-cyanoacrylate.Laparotomyoffers the ability to reconstruct or use a graft in general, where thecollateral circulation is poor or non-existent. Prospective surgical candidatesfor intervention are patients with symptomatic aneurysm, aneurysms in pregnantwomen and as stated before asymptomatic aneurysms larger than 2 cm.

Someauthors also reported successful laparoscopic resection of GEAs. 19 Inthe case of the patient we treated, anatomical reasons which are that is theelongated and tortuous celiac and splenic artery, and logistics, led us toreject the endovascular option.  Amulti-specialist medical meeting consisted of a vascular surgeon, generalsurgeon and interventional radiologist was held and after the situation wasexplained to the patient, the surgical approach was decided.  As the preoperative parclinical studies hadconfirmed the distal location of the aneurysm, and suggested the possibilitythat another artery than the splenic had the lesion, we entered the entranceinto the lesser sac was performed between the greater curvature of the stomachand the transverse colon.  During theoperation short gastric arteries were preserved and the splenic artery wasidentified till the spleen hilus; we found that an arterial distal branchidentified as the left GEA had the lesion. Before removing the diseasedarterial part with the aneurysm, a temporal proximal and distal cross-clampingconfirmed no interference with the splenic artery supply, thus we ligated thepre- and post-aneurismal artery with crossing polypropylene 4.0 and resectedthe aneurysm.  The spleen showed no colorchange and the splenic artery maintained the arterial pulsepulsation.

In thisintraoperative setting, it was clear that an endovascular approach could beunsuccessful and potentially dangerous.   Conclusion Properimaging studies have assisted in identifying an incidental initial abdominalmass, as a visceral artery aneurysm with a diameter greater than 2cm; ananeurysm of the left GEA was the intraoperative apocalypse. The informationfrom the MRI and the detailed CTA prevented us of an attempt of an endovascularapproach which could be at least problematic. Open surgery in a fit patientremains the best therapeutic option for LGEAAs. Declaration of Conflicting Interests Theauthors declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article. Funding Theauthors received no financial support for the research, authorship, and/orpublication of this article.