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Aneurysm of the Gastroduodenal Artery Associated With Stenosis of the Superior Mesenteric Artery
Case Reports
Aneurysm of the Gastroduodenal Artery Associated With Stenosis of the Superior Mesenteric Artery Pierre Gouny, MD, Sumio FukuL MD, Armand Aymard, MD, Benoit Decaix, MD, Herve Moty, MD, Jean-Jacques Merland, MD, and Oscar Nussaume, MD, Paris, France
A 68-year-old patient was hospitalized after the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. This patient had severe heart failure, which led to acute pulmonary edema and inoperable triple-vessel coronary disease. In the first of two procedures the superior mesenteric artery was dilated; 48 hours later the gastroduodenal artery aneurysm was embolized with minicoils and acryl glue. Immediate and follow-up arteriograms at 10 months showed that results were satisfactory. Transluminal treatment of both lesions is an alternative to surgical treatment, especially in high-risk patients. (Ann Vasc Surg 1994;8:281-284.)
An a n e u r y s m in a n artery bridging two o t h e r arteries, one of w h i c h is occluded or stenotic, is m o s t often the c o n s e q u e n c e of a local high-flow state. The vascularity of the territory ordinarily supplied by the stenotic or occluded artery is t h e r e b y e n s u r e d by increased flow in the collateral ( a n a s t o m o t i c ) artery. This is responsible for turbulences, w h i c h can in t u m provoke aneurysmal dilation of the arterial w a l l ) The m o s t freq u e n t l y reported association of this type w i t h i n the a b d o m e n is anemrysm of the g a s t r o d u o d e n a l artery w i t h stenosis of the celiac axis. 2 In the only previously reported case of a n e u r y s m of the gast r o d u o d e n a l artery associated w i t h stenosis of the superior m e s e n t e r i c artery (SMA), the patient was treated via a two-step surgical procedure. 3 In the first operation the a n e u r y s m , w h i c h h a d ruptured, was treated u r g e n t l y by suture ligation. A few weeks later the stenotic SMA was r e c o n s t r u c t e d
From the Service de Chirurgie Vasculaire et Thoracique, H6pital Rothschild, and Service de Neuroradiologie, H~pital Lariboisidre, Paris, France. Reprint requests: O. Nussaume, MD, Service de Chirurgie Vasculaire et Thoracique, H6pital Rothschild, 33 Boulevard de Picpus, 75012 Paris, France.
by transposition of the splenic artery. To the best of our k n o w l e d g e complete endovascular treatm e n t of a n a n e u r y s m of the g a s t r o d u o d e n a l artery associated w i t h stenosis of the SMA has never b e e n reported.
CASE R E P O R T A 68-year-old man was admitted to the hospital in November 1991 for circulatory problems of the left fourth toe. Aortography led to the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the SMA. Although this patient had a 20 pack-year smoking habit, he did not have a history of alcohol abuse, pancreatitis, or abdominal surgical operations. In 1968 he had a myocardial infarction. Since that date he has experienced noninvalidating angina and ischemic heart failure, which led to acute pulmonary edema in November 1991. Cardiac catheterization in 1990 showed severe triple-vessel coronary disease. The patient's general and cardiac status precluded coronary bypass or angioplasty. No abdominal pain or loss of weight was noted. Examination of the abdomen did not reveal any bruit or mass. Aortograms showed a 3 cm aneurysm of the gastroduodenal artery immediately proximal to the origin of the superior duodenopancreatic artery (Fig. 1) and a postostial stenosis of the SMA (Fig. 2). Pulsed abdominal Duplex 281
282
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Annals of vascular Surgery
Fig. 3. Plain film showing embolization of the aneurysm of the gastroduodenal artery via selective catheterization using mmicoils.
Fig. 1. Aortogram of aneurysm of the gastroduodenal artery immediately proximal to the superior pancreaticoduodenal artery.
Fig. 2. Selective arteriogram of postostial stenosis of the SMA.
Fig. 4. Aortogram 10 months after the double translumihal procedure showing the absence of restenosis of the S/VIA. The minicoils are visible in the aneurysm of the gastroduodenal artery, which is not opacified.
Vol. 8, No. 3 1994
scanning showed that the stenosis was hemodynamically equivalent to a short occlusion with well-pulsed reinjection from the distal end. Turbulent flow was found in the gastroduodenal aneurysm. Since this patient was considered at high risk for surgery, we elected to pursue percutaneous transcatheter treatment. Two successive procedures were performed. The first procedure took place on December 4, 1991. intraoperative films showed a 2 cm long, very tight, irregular, postostial, centered stenosis of the SMA that was responsible for a considerable upstream circulatory delay. The SMA and all of its branches were opacified by the gastroduodenal artery. The stenosis was dilated with a 5 F angioplasty catheter using a 2 cm • 6 m m balloon. Follow-up arteriograms showed that the residual stenosis was < 30%. Visualization of the comm o n hepatic artery now showed that the gastroduodehal artery was still dilated; the circulating flow was slow and the SMA was no longer injected via the gastroduodenal artery. The aneurysm was embolized 48 hours later with minicoils and acryl glue (Fig. 3). Follow-up arteriograms showed that the aneurysmal sac was almost completely excluded and that the initial segments of the gastroduodenal and the right gastroepiploic arteries were patent. The patient did not experience any abdominal symptoms and serum amylase remained stable during and after the procedure: The patient was discharged on day 5. Arteriograms obtained 10 months later showed that the gastroduodenal artery remained embolized. The caliber of the SMA was satisfactory (Fig. 4). One month after transvascular treatment of the intestinal arteries a popliteal to peroneal artery bypass was performed under regional anesthesia and resulted in healing of the fourth toe.
DISCUSSION A h i g h - f l o w state in a collateral artery b e t w e e n t w o intestinal arteries, o n e of w h i c h is occluded or stenotic, c a n c a u s e a n e u r y s m a l f o r m a t i o n . Pressure m e a s u r e m e n t s in the n e c k of the a n e u r y s m before a n d after r e c o n s t r u c t i o n c a n c o n f i r m this. S p o n t a n e o u s t h r o m b o s i s of the a n e u r y s m of the g a s t r o d u o d e n a l artery can also be c o n f i r m e d r o e n t g e n o g r a p h i c a l l y after isolated r e c o n s t r u c t i o n of the celiac axis. 4'5 Our o b s e r v a t i o n is similar to t h a t of Q u a n d a l l e et al. x w h o reported a p a n c r e atic arcade a n e u r y s m a s s o c i a t e d w i t h stenosis of the celiac axis. Before dilatation the SMA a n d its b r a n c h e s w e r e opacified t h r o u g h the gast r o d u o d e n a l artery. Once t r a n s l u m i n a l angiop l a s t y h a d b e e n p e r f o r m e d , the SMA could be visualized directly a n d flow t h r o u g h the gast r o d u o d e n a l artery w a s n o t e d to be slow. Thus the g a s t r o d u o d e n a l artery w a s the collateral artery s u p p l y i n g the stenotic SMA. O t h e r possible
Aneurysm of gastroduodenaI artery with stenosis of SMA 283
causes of isolated a n e u r y s m of the g a s t r o d u o d e nal artery are chronic pancreatitis, w h i c h w a s e l i m i n a t e d in our case, a n d a t h e r o m a . An a n e u r y s m in a n intestinal artery m u s t be treated b e c a u s e of the risk of rupture, 6'7 especially w h e n the d i a m e t e r is large (3 c m in our patient). Surgical t r e a t m e n t of g a s t r o d u o d e n a l artery ane u r y s m consists of exclusion b y ligation of the arteries p r o x i m a l a n d distal to the a n e u r y s m w i t h or w i t h o u t excision of the a n e u r y s m . The topogr a p h y of the a n e u r y s m a n d size of the artery m a y occasionally m a k e it m o r e difficult to reestablish vascular continuity. Vascular reconstruction, however, is n o t m a n d a t o r y b e c a u s e of the m u l tiple a n a s t o m o t i c p a t h w a y s s u r r o u n d i n g the d u o d e n u m a n d pancreas. W h e n the a n e u r y s m is c o n t a i n e d w i t h i n the pancreatic p a r e n c h y m a , p a n c r e a t o d u o d e n e c t o m y m a y be the only w a y to control the a n e u r y s m , z6"8 T r a n s l u m i n a l embolization consists of i n t r o d u c i n g a c a t h e t e r into the artery a n d injecting coils or glue i n t o the a n e u r y s m . 9'1~ C a u t i o n m u s t be exercised, however, as r u p t u r e of the a n e u r y s m h a s b e e n reported in three cases b e c a u s e of excessive pressure e m ployed to inject the glue. n I n six p a t i e n t s w i t h a n e u r y s m due to chronic pancreatitis u n d e r g o i n g e m b o l i z a t i o n a n d followed for 10 years, no a n e u r y s m a l r u p t u r e or c o m p l i c a t i o n distal to the t h r o m b o s e d a n e u r y s m w a s r e p o r t e d ) 2_ Surgical r e c o n s t r u c t i o n of the SMA c a n be a c c o m p l i s h e d either b y direct r e i m p l a n t a t i o n , anterograde or r e t r o g r a d e bypass, or t r a n s a o r t i c enda r t e r e c t o m y . The rate of successful surgical reconstruction of the SMA is 80% at a m e a n follow-up of 4 to 8 years. ~3~6 P e r c u t a n e o u s t r a n s l u m i n a l a n g i o p l a s t y of the SMA is possible only w h e n the stenosis is located distal to the o s t i u m a n d w h e n the guidewire passes t h r o u g h the stenosis. This t e c h n i q u e is associated w i t h a 48% success rate at 1 year. ~7 Isolated stenosis of a n intestinal artery requires r e c o n s t r u c t i o n only w h e n associated w i t h i n t e s t i n a l a n g i n a or, in our case, w h e n associated w i t h a n o t h e r lesion. Isolated reconstruction of the stenosis w i t h o u t treating the a n e u r y s m does n o t theoretically preclude rupture; on the o t h e r h a n d , t w o cases of s p o n t a n e o u s t h r o m bosis of small a n e u r y s m s h a v e b e e n r e p o r t e d after isolated t r e a t m e n t of stenosis of the celiac axis. 4"~ Moreover, isolated ligation of the a n e u r y s m can lead to i s c h e m i a in the territory of the stenotic artery. Q u a n d a l l e et al., 2 in a survey of the literature, f o u n d 23 cases of stenosis or occlusion of the celiac axis associated w i t h a n e u r y s m of a pancrea t i c o d u o d e n a l artery. Six of these p a t i e n t s did n o t u n d e r g o elective t r e a t m e n t a n d 17 u n d e r w e n t
284
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resection or ligation of the aneurysm, three by pancreaticoduodenectomy. Reconstruction of the celiac artery territory was achieved in six cases only (35%). Two of these cases, however, involved isolated division of the arcuate ligament. The tolerance to ischemia was evaluated by observing the intestinal organs during the operation. This type of evaluation does not allow us to predict the ultimate outcome i n the case of isolated cure of aneurysm. The territory distal to the stenosis remains at risk because the direct collateral circulation has been suppressed. New collaterals can develop, making a new aneurysm possible. CONCLUSION In our opinion the association of an aneurysm of the gastroduodenal artery with stenosis of the SMA requires a two-step treatment approach. In our patient a transvascular procedure was performed at 48-hour intervals. Repeated puncture of the artery increased the risk of hemorrhage, but the small caliber of the material used (5 F) helped decrease the trauma to the vessels. When the aneurysm is treated first, intestinal ischemia may not be diagnosed immediately, as in the case of open surgery. Reconstruction of the stenosis must be the first step w h e n transvascular treatment is planned. The frequency of restenosis after transluminal angioplasty is higher than after surgical revascularization. Special attention must be paid to the surveillance of these patients by pulsed Doppler or follow-up arteriograms. In patients at high risk t h e transluminal method avoids the cardiac and pulmonary complications of laparotomy.
REFERENCES 1. Sutton D, Lawton G. Celiac stenosis or occlusion with aneurysm of the collateral supply. Clin Radiol 1973;24:49-53. 2. Quandalle P, Chambon JP, Marache P, et al. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis: Report of two cases and review of the literature, Ann Vasc Surg 1990;4:540-545. 3. Billon JF, Gouillat C, Brudon JR, et al. Traltement chirurgical des an~vrysmes des art~res digestives: Apropos de 23 cas. Lyon Clair 1989;85:367-371. 4. Proud G, Chamberlain J. Aneurysm formation on the small pancreatic arteries in association with coeliac axis compres7 sion. Ann R Col] Surg Engl 1978;60:294-297. 5. Mora JD, Obst D. Celiac axis artery stenosis with aneurysmal calcification of the collateral supply. Aust Radiol 1976;20: 252-258. 6. Spanos PK, Kloppedal EA, Murray CA. Aneurysms of the gastroduodenal and pancreaticoduodenal arteries. Am J Surg 1974;127:345-348. 7. Melli~re D, Becquemin JP, Kassab M, et al. An6vrysmes des art~res digestives: Quelles indications? J Mal Vasc 1989;14: 206 -212. 8. Stanley JC, Zelenock GB. Splanchnic artery aneurysm. In Rutherford R, ed. Vascular Surgery. Philadelphia: WB Saunders, 1984, pp 969-983. 9. Baker KS, Tisnado J, Cho StL et al. Splanchnic artery aneurysms and pseudoaneurysms: Transcatheter embolization. Radiology 1987;163:135-139. 10. Thakker RV, Gajjar B, Wilkins RA, et al. Embolization of gastroduodenal artery aneurysm caused by chronic pancreatitis. Gut 1983;24:1094-1098. 11. Lina JR, Jaques E Mandell V. Aneurysm rupture secondary to transcatheter embolization. AIR 1979;132:553-556. 12. Mandel SR, Jaques PE Sanofsky S, et al. Nonoperative management of peripancreatic arterial aneurysms: A 10 year s experience. Ann Surg 1987;205:126-128. 13. Beebe HG, Mc Farlaine S, Raker EJ. Supraceliac aortomesenteric bypass for intestinal ischemia. J Vasc Surg 1987;5:749754. 14. Kieny R, Batellier J, Kretz JG. Aortic reimplantation of t h e superior mesenteric artery for atherosclerotic lesions of the visceral arteries: Sixty cases. Ann Vasc Surg 1990;4:122-125. 15. Rapp JH, Reilly LM, Qvarfordt PG. Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia. J Vasc Surg 1986;3:799-806. 16. Taylor LM, Moneta GL. Intestinal ischemia. Ann Vasc Surg 1991;5:403-406. 17. Tegtmeyer CJ, Selby JB. Balloon angioplasty of the visceral arteries (renal and mesentenc circulation): Indications, results, and complications. In Moore WS, Ahn SS, eds. Endovascular Surgery. Philadelphia: WB Saunders, 1989, pp 223257.
Aneurysm of the Gastroduodenal Artery Associated With Stenosis of the Superior Mesenteric Artery Pierre Gouny, MD, Sumio FukuL MD, Armand Aymard, MD, Benoit Decaix, MD, Herve Moty, MD, Jean-Jacques Merland, MD, and Oscar Nussaume, MD, Paris, France
A 68-year-old patient was hospitalized after the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. This patient had severe heart failure, which led to acute pulmonary edema and inoperable triple-vessel coronary disease. In the first of two procedures the superior mesenteric artery was dilated; 48 hours later the gastroduodenal artery aneurysm was embolized with minicoils and acryl glue. Immediate and follow-up arteriograms at 10 months showed that results were satisfactory. Transluminal treatment of both lesions is an alternative to surgical treatment, especially in high-risk patients. (Ann Vasc Surg 1994;8:281-284.)
An a n e u r y s m in a n artery bridging two o t h e r arteries, one of w h i c h is occluded or stenotic, is m o s t often the c o n s e q u e n c e of a local high-flow state. The vascularity of the territory ordinarily supplied by the stenotic or occluded artery is t h e r e b y e n s u r e d by increased flow in the collateral ( a n a s t o m o t i c ) artery. This is responsible for turbulences, w h i c h can in t u m provoke aneurysmal dilation of the arterial w a l l ) The m o s t freq u e n t l y reported association of this type w i t h i n the a b d o m e n is anemrysm of the g a s t r o d u o d e n a l artery w i t h stenosis of the celiac axis. 2 In the only previously reported case of a n e u r y s m of the gast r o d u o d e n a l artery associated w i t h stenosis of the superior m e s e n t e r i c artery (SMA), the patient was treated via a two-step surgical procedure. 3 In the first operation the a n e u r y s m , w h i c h h a d ruptured, was treated u r g e n t l y by suture ligation. A few weeks later the stenotic SMA was r e c o n s t r u c t e d
From the Service de Chirurgie Vasculaire et Thoracique, H6pital Rothschild, and Service de Neuroradiologie, H~pital Lariboisidre, Paris, France. Reprint requests: O. Nussaume, MD, Service de Chirurgie Vasculaire et Thoracique, H6pital Rothschild, 33 Boulevard de Picpus, 75012 Paris, France.
by transposition of the splenic artery. To the best of our k n o w l e d g e complete endovascular treatm e n t of a n a n e u r y s m of the g a s t r o d u o d e n a l artery associated w i t h stenosis of the SMA has never b e e n reported.
CASE R E P O R T A 68-year-old man was admitted to the hospital in November 1991 for circulatory problems of the left fourth toe. Aortography led to the incidental discovery of an aneurysm of the gastroduodenal artery associated with stenosis of the SMA. Although this patient had a 20 pack-year smoking habit, he did not have a history of alcohol abuse, pancreatitis, or abdominal surgical operations. In 1968 he had a myocardial infarction. Since that date he has experienced noninvalidating angina and ischemic heart failure, which led to acute pulmonary edema in November 1991. Cardiac catheterization in 1990 showed severe triple-vessel coronary disease. The patient's general and cardiac status precluded coronary bypass or angioplasty. No abdominal pain or loss of weight was noted. Examination of the abdomen did not reveal any bruit or mass. Aortograms showed a 3 cm aneurysm of the gastroduodenal artery immediately proximal to the origin of the superior duodenopancreatic artery (Fig. 1) and a postostial stenosis of the SMA (Fig. 2). Pulsed abdominal Duplex 281
282
Gouny et al.
Annals of vascular Surgery
Fig. 3. Plain film showing embolization of the aneurysm of the gastroduodenal artery via selective catheterization using mmicoils.
Fig. 1. Aortogram of aneurysm of the gastroduodenal artery immediately proximal to the superior pancreaticoduodenal artery.
Fig. 2. Selective arteriogram of postostial stenosis of the SMA.
Fig. 4. Aortogram 10 months after the double translumihal procedure showing the absence of restenosis of the S/VIA. The minicoils are visible in the aneurysm of the gastroduodenal artery, which is not opacified.
Vol. 8, No. 3 1994
scanning showed that the stenosis was hemodynamically equivalent to a short occlusion with well-pulsed reinjection from the distal end. Turbulent flow was found in the gastroduodenal aneurysm. Since this patient was considered at high risk for surgery, we elected to pursue percutaneous transcatheter treatment. Two successive procedures were performed. The first procedure took place on December 4, 1991. intraoperative films showed a 2 cm long, very tight, irregular, postostial, centered stenosis of the SMA that was responsible for a considerable upstream circulatory delay. The SMA and all of its branches were opacified by the gastroduodenal artery. The stenosis was dilated with a 5 F angioplasty catheter using a 2 cm • 6 m m balloon. Follow-up arteriograms showed that the residual stenosis was < 30%. Visualization of the comm o n hepatic artery now showed that the gastroduodehal artery was still dilated; the circulating flow was slow and the SMA was no longer injected via the gastroduodenal artery. The aneurysm was embolized 48 hours later with minicoils and acryl glue (Fig. 3). Follow-up arteriograms showed that the aneurysmal sac was almost completely excluded and that the initial segments of the gastroduodenal and the right gastroepiploic arteries were patent. The patient did not experience any abdominal symptoms and serum amylase remained stable during and after the procedure: The patient was discharged on day 5. Arteriograms obtained 10 months later showed that the gastroduodenal artery remained embolized. The caliber of the SMA was satisfactory (Fig. 4). One month after transvascular treatment of the intestinal arteries a popliteal to peroneal artery bypass was performed under regional anesthesia and resulted in healing of the fourth toe.
DISCUSSION A h i g h - f l o w state in a collateral artery b e t w e e n t w o intestinal arteries, o n e of w h i c h is occluded or stenotic, c a n c a u s e a n e u r y s m a l f o r m a t i o n . Pressure m e a s u r e m e n t s in the n e c k of the a n e u r y s m before a n d after r e c o n s t r u c t i o n c a n c o n f i r m this. S p o n t a n e o u s t h r o m b o s i s of the a n e u r y s m of the g a s t r o d u o d e n a l artery can also be c o n f i r m e d r o e n t g e n o g r a p h i c a l l y after isolated r e c o n s t r u c t i o n of the celiac axis. 4'5 Our o b s e r v a t i o n is similar to t h a t of Q u a n d a l l e et al. x w h o reported a p a n c r e atic arcade a n e u r y s m a s s o c i a t e d w i t h stenosis of the celiac axis. Before dilatation the SMA a n d its b r a n c h e s w e r e opacified t h r o u g h the gast r o d u o d e n a l artery. Once t r a n s l u m i n a l angiop l a s t y h a d b e e n p e r f o r m e d , the SMA could be visualized directly a n d flow t h r o u g h the gast r o d u o d e n a l artery w a s n o t e d to be slow. Thus the g a s t r o d u o d e n a l artery w a s the collateral artery s u p p l y i n g the stenotic SMA. O t h e r possible
Aneurysm of gastroduodenaI artery with stenosis of SMA 283
causes of isolated a n e u r y s m of the g a s t r o d u o d e nal artery are chronic pancreatitis, w h i c h w a s e l i m i n a t e d in our case, a n d a t h e r o m a . An a n e u r y s m in a n intestinal artery m u s t be treated b e c a u s e of the risk of rupture, 6'7 especially w h e n the d i a m e t e r is large (3 c m in our patient). Surgical t r e a t m e n t of g a s t r o d u o d e n a l artery ane u r y s m consists of exclusion b y ligation of the arteries p r o x i m a l a n d distal to the a n e u r y s m w i t h or w i t h o u t excision of the a n e u r y s m . The topogr a p h y of the a n e u r y s m a n d size of the artery m a y occasionally m a k e it m o r e difficult to reestablish vascular continuity. Vascular reconstruction, however, is n o t m a n d a t o r y b e c a u s e of the m u l tiple a n a s t o m o t i c p a t h w a y s s u r r o u n d i n g the d u o d e n u m a n d pancreas. W h e n the a n e u r y s m is c o n t a i n e d w i t h i n the pancreatic p a r e n c h y m a , p a n c r e a t o d u o d e n e c t o m y m a y be the only w a y to control the a n e u r y s m , z6"8 T r a n s l u m i n a l embolization consists of i n t r o d u c i n g a c a t h e t e r into the artery a n d injecting coils or glue i n t o the a n e u r y s m . 9'1~ C a u t i o n m u s t be exercised, however, as r u p t u r e of the a n e u r y s m h a s b e e n reported in three cases b e c a u s e of excessive pressure e m ployed to inject the glue. n I n six p a t i e n t s w i t h a n e u r y s m due to chronic pancreatitis u n d e r g o i n g e m b o l i z a t i o n a n d followed for 10 years, no a n e u r y s m a l r u p t u r e or c o m p l i c a t i o n distal to the t h r o m b o s e d a n e u r y s m w a s r e p o r t e d ) 2_ Surgical r e c o n s t r u c t i o n of the SMA c a n be a c c o m p l i s h e d either b y direct r e i m p l a n t a t i o n , anterograde or r e t r o g r a d e bypass, or t r a n s a o r t i c enda r t e r e c t o m y . The rate of successful surgical reconstruction of the SMA is 80% at a m e a n follow-up of 4 to 8 years. ~3~6 P e r c u t a n e o u s t r a n s l u m i n a l a n g i o p l a s t y of the SMA is possible only w h e n the stenosis is located distal to the o s t i u m a n d w h e n the guidewire passes t h r o u g h the stenosis. This t e c h n i q u e is associated w i t h a 48% success rate at 1 year. ~7 Isolated stenosis of a n intestinal artery requires r e c o n s t r u c t i o n only w h e n associated w i t h i n t e s t i n a l a n g i n a or, in our case, w h e n associated w i t h a n o t h e r lesion. Isolated reconstruction of the stenosis w i t h o u t treating the a n e u r y s m does n o t theoretically preclude rupture; on the o t h e r h a n d , t w o cases of s p o n t a n e o u s t h r o m bosis of small a n e u r y s m s h a v e b e e n r e p o r t e d after isolated t r e a t m e n t of stenosis of the celiac axis. 4"~ Moreover, isolated ligation of the a n e u r y s m can lead to i s c h e m i a in the territory of the stenotic artery. Q u a n d a l l e et al., 2 in a survey of the literature, f o u n d 23 cases of stenosis or occlusion of the celiac axis associated w i t h a n e u r y s m of a pancrea t i c o d u o d e n a l artery. Six of these p a t i e n t s did n o t u n d e r g o elective t r e a t m e n t a n d 17 u n d e r w e n t
284
Annals of Vascular Surgery
Gouny et al.
resection or ligation of the aneurysm, three by pancreaticoduodenectomy. Reconstruction of the celiac artery territory was achieved in six cases only (35%). Two of these cases, however, involved isolated division of the arcuate ligament. The tolerance to ischemia was evaluated by observing the intestinal organs during the operation. This type of evaluation does not allow us to predict the ultimate outcome i n the case of isolated cure of aneurysm. The territory distal to the stenosis remains at risk because the direct collateral circulation has been suppressed. New collaterals can develop, making a new aneurysm possible. CONCLUSION In our opinion the association of an aneurysm of the gastroduodenal artery with stenosis of the SMA requires a two-step treatment approach. In our patient a transvascular procedure was performed at 48-hour intervals. Repeated puncture of the artery increased the risk of hemorrhage, but the small caliber of the material used (5 F) helped decrease the trauma to the vessels. When the aneurysm is treated first, intestinal ischemia may not be diagnosed immediately, as in the case of open surgery. Reconstruction of the stenosis must be the first step w h e n transvascular treatment is planned. The frequency of restenosis after transluminal angioplasty is higher than after surgical revascularization. Special attention must be paid to the surveillance of these patients by pulsed Doppler or follow-up arteriograms. In patients at high risk t h e transluminal method avoids the cardiac and pulmonary complications of laparotomy.
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