Solved on SIR Connect
By R. Torrance Andrews, MD, FSIR, Jackson Bennett, MD, Mithil B. Pandhi, DO, and Sudhen B. Desai, MD, FSIR
Feedback on unusual pattern of mesenteric aneurysms
Original post, lightly edited for flow:
bit.ly/3DKhM1O
The patient is a 56-year-old woman whose only past medical history is migraines— for which she uses nonsteroidals—and a duodenal ulcer diagnosed without EGD 20 years ago. She presented with acute onset of severe RUQ pain that bores into her back. CT showed a cluster of aneurysms in the GDA distribution with “some regional fluid and stranding that could reflect mild leakage, bleeding, and impending rupture, inflammation/infection.” The patient underwent angiogram that showed a markedly dilated pancreaticoduodenal/GDA arcade artery with four aneurysms in series along the artery, measuring between 2 and 4 cm. The celiac origin is occluded and celiac flow is reconstituted by the aneurysmal artery and a collateral that was acting like an arc of Buehler. The feeders were embolized, which successfully occluded the aneurysms.
I’ve seen this pattern many times in the splenic artery, but never here, so I’m not sure how to explain it. There are no other aneurysms and no findings of FMD or vasculitis. The patient is too old and has the wrong phenotype for the usual collagen vascular disorders like Marfan and Ehlers-Danlos syndromes. She has no history of sepsis or bacteremia episodes that may have caused mycotic aneurysms. EGD during the current event did show an active duodenal ulcer in the third portion.
Has anyone seen this pattern in this location? Should I just assume these are related to ulcers? Any other thoughts?
Author background and current practice preferences for treatment of mesenteric aneurysms?
Author name and contact information R. Torrance Andrews, MD, FSIR Swedish Medical Center, First Hill Campus, Seattle
I have spent 26 years in full-time IR practice, with the first 12 years academic and more recently private practice. I usually treat mesenteric aneurysms > 2 cm with either coil embolization or endograft exclusion, depending on the anatomy. I use endografts to preserve flow if the lesion in question is either fusiform along the main channel or eccentric but with a large enough neck that I can’t pack it with coils and be confident they won’t prolapse into the main artery. I embolize the feeding artery with coils if I don’t mind sacrificing it. The challenge with endografts is that they are unwieldy
and difficult to maneuver around a lot of turns.
How often have you encountered unusual patterns of mesenteric aneurysms such as this case? This was the first time I had seen aneurysms in the pancreaticoduodenal arcade, which is unusual because of their large size and multiplicity.
What is your preferred IR approach in treating patients with mesenteric aneurysms in a pancreaticoduodenal or GDA distribution? Given the relatively small size of the normal pancreaticoduodenal arteries and the vigorous collateral supply in the area, I would normally just coil the feeding arteries. However, this case was unusual because the pancreaticoduodenal arcadewas also supplying flow to branches of the occluded celiac trunk, and careless embolization might have infarcted the spleen and reduced hepatic perfusion as well. The trunk vessels were
too tortuous for endograft exclusion. Fortunately, we were able to identify and isolate a large collateral channel that was not involved in the cluster of aneurysms and that vessel was felt to be an adequate alternative collateral.
What was the outcome for this patient on follow-up? The aneurysmal segment was embolized successfully and without complication. At follow-up approximately 5 years later, the large cluster of aneurysms in the pancreaticoduodenal arcade remain occluded and no new aneurysms in that distribution or other adjacent distributions have been identified. In other words, this does not appear to have been a collagen vascular disorder, vasculitis, or other chronic or relapsing condition. The parallel channel—perhaps an uninvolved pancreaticoduodenal branch or an arc of Bueuhler—continues to supply the celiac distribution, so the patient has not had any ischemic complications of the liver, stomach, or spleen.
Which specific methods or techniques do you find useful in treating these aneurysms? The patient needed some mechanism for maintaining perfusion to the celiac trunk after embolization or excision of the aneurysms. The question was whether to do this by endovascular means, surgically or by some combination of both. I think any of these would have been viable options. Had there not been an adequate collateral vessel and had revascularization of the celiac been required, I would have attempted this by endovascular approach. Had that failed, it might have been necessary for surgical revascularization.
What specifically prompted you to reach out regarding this case/topic? I was concerned that I might be missing something, specifically that the patient
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