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

Tja¨rnstro¨ m1 1Division of Vascular Surgery, and2Department of Radiology, Norra A¨ lvsborgs La¨nssjukhus NA¨L, Trollha¨ttan, Sweden Introduction Aneurysm of the cœliac artery is a rare

SHORT REPORT

An Open Approach to the Treatment of Cœliac Artery

Aneurysm A Case Report

R Karlsson1*, P-E Thornell1

, P Grahn2and J Tja¨rnstro¨ m1

1Division of Vascular Surgery, and2Department of Radiology, Norra A¨ lvsborgs La¨nssjukhus (NA¨L),

Trollha¨ttan, Sweden

Introduction Aneurysm of the cœliac artery is a rare vascular

problem representing 4% of visceral aneurysms Its

natural history appears to be one of expansion and

rupture,1in which case a high mortality rate is to be

expected Because of this, intervention has

tradition-ally been recommended This paper presents a case of

a large cœliac artery aneurysm treated by open

surgery

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 7 cm (Fig 1(a) and (b))

The thoracic aortic aneurysm also showed an

enlarge-ment but of lesser magnitude (from 5 to almost 6 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

abdomi-nal aorta was identified together with the cœliac,

hepatic and splenic arteries A vascular clamp was

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 8 mm PTFE-graft was anastomosed end-to-end 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 4 weeks later

Discussion 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.2,3The male/female ratio has changed over time Prior to 1950 the ratio was 9:1.2Later figures indicate a ratio of 2:1.4,5

Symptoms associated with cœliac artery aneurysms vary The most common seems to be abdominal pain

EJVES Extra 8, 34–36 (2004)

doi: 10.1016/j.ejvsextra.2004.06.002, available online at http://www.sciencedirect.com on

*Corresponding author R Karlsson, Division of Vascular Surgery,

Norra A ¨ lvsborgs La¨nssjukhus (NA¨L), Trollha¨ttan, Sweden.

or discomfort Other symptoms are related to

com-pression 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.3Of 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 2 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 Aneurysmor-rhaphy 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.6We 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.8In our search of the literature, we have found a relatively small number of

Fig 1.(a) The cœliac artery aneurysm is shown

preopera-tively 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

Fig 2.Shows a postoperative 3D reconstruction A, PTFE; B, splenic artery; C, hepatic artery

An Open Approach to the Treatment of Cœliac Artery Aneurysm A Case Report 35

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

1 Carr SC, Pearce WH Visceral artery aneurysms In: Geroulakos

G , Cherry KJ Jr, eds Diseases of the visceral circulation London: Arnold, 2002: 130–144.

2 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.

3 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.

4 Shanley CJ, Shah NL, Messina LM Common splanchnic artery aneurysms: splenic, hepatic and cœliac Ann Vasc Surg 1996; 10(3): 315–322.

5 Messina LM, Shanley CJ Visceral artery aneurysms Surg Clin North Am 1997; 77:425–442.

6 Gabelmann A, Gorich J, Merkle EM Endovascular treatment of visceral artery aneurysms J Endovasc Ther 2002; 9:38–47.

7 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.

8 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 3 June 2004

R Karlsson et al

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