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Dissecting Aneurysm of the Celiac Trunk: A Case Report
Dissecting Aneurysm of the Celiac Trunk: A Case Report Xavier Untereiner, Benjamin Kretz, Amelie Camin-Kretz, Alexandra Tibuleac, Wei ming Gu, Bernadette Faller, and Lucien Matysiak, Colmar, France
Aneurysms of visceral arteries are relatively rare entities. Spontaneous isolated celiac artery dissection is an uncommon diagnosis, with only a few reported cases. We report the case of 52-year-old man who had an asymptomatic celiac trunk dissecting aneurysm detected by tomographic angiography. Because of the combined risk of rupture and ischemia, we decided to treat this lesion by a conventional bypass.
Aneurysms of visceral arteries are rare and of unknown physiopathology. These aneurysms mainly concern the splenic artery (60%); other visceral locations are less frequent (the celiac trunk 4%, the superior mesenteric artery 5.5%, the left gastric artery and the gastroepiploic artery 4%).1,2 These aneurysms are encountered in polyaneurysmal diseases in 38% of cases, and in 18% of cases, the patient also presents with aneurysm of the abdominal aorta.3 This condition is serious because of the risk of aneurysm rupture.4 As for dissection of the celiac trunk or other visceral arteries, they are most often related to the extension of aortic dissection. Isolated dissection of the celiac trunk is rare and only a few cases have been reported in the literature.5e9 The majority of dissecting aneurysms, defined as cleavage between the intimae and the external elastic lamina of the artery leading to an infiltrated and distended cavity, concern the thoracic and abdominal aorta. We report here on a
Department of Vascular Surgery, Centre Hospitalier Pasteur, Colmar, France. Correspondence to: Benjamin Kretz, MD, Service de Chirurgie Vasculaire, Centre Hospitalier Pasteur, Colmar, Service de Chirurgie Vasculaire, CH Pasteur, 39 Avenue de la Liberte, Colmar 68000, France; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1037.e1–1037.e4 http://dx.doi.org/10.1016/j.avsg.2013.08.017 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 14, 2013; manuscript accepted: August 12, 2013; published online: December 16, 2013.
patient who presented an isolated dissecting aneurysm of the celiac trunk.
CASE STUDY Our patient was a 52-year-old man with a history of childhood pulmonary tuberculosis, left side pleurisy, and severe persistent arterial hypertension that was refractory to aggressive medical treatment in the context of familial arterial hypertension. During medical tests to discover a secondary cause for the severe arterial hypertension, abdominal wall computed tomography (CT) angiography revealed a dissecting aneurysm of the celiac trunk (Fig. 1). This aneurysm was 7.6 mm from the origin of the celiac trunk, 12.6 mm in diameter (for an upstream celiac trunk diameter of 6 mm), and 23.9 mm long. The aneurysm extended to the division into the splenic artery and the common hepatic artery and had no signs of calcification or thrombus. There were no signs of deficient visceral perfusion, and the dissection did not extend beyond the celiac trunk. The assessment was completed by arteriography, which confirmed the diagnosis but did not reveal the dissecting aspect of the aneurysm (Fig. 2). The arteriography revealed no other sites of arterial aneurysm, although transthoracic echocardiography showed ectasia of the ascending aorta, measuring 34 mm. Given the diameter of the aneurysm (twice that of the normal celiac trunk), the refractory nature of the arterial hypertension, and 1037.e1
1037.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Computed tomography angiography, dissection of the celiac trunk.
Fig. 3. Intraoperative appearance, ligation of the left gastric artery and common hepatic artery and the splenic artery as controls. Fig. 2. Preoperative angiography showing the aneurysm of the celiac trunk. The dissection is not visible.
the resulting risk of rupture of the aneurysm or extension of the dissection, surgical treatment was chosen. The surgical procedure involved bi-infracostal laparotomy. The aneurysm was approached after opening the small omentum and sectioning the crura of the diaphragm. Systemic heparin (1.5 mg/ kg) was given, and the aorta above and below the celiac trunk and the branches of the celiac trunk were clamped (Fig. 3).The aneurysm was resected, revealing the dissection within the wall of the celiac
trunk. The left gastric artery and the origin of the celiac trunk were ligated. We created a bypass between the aorta above the celiac trunk and the celiac trunk using a 7-mm-diameter Dacron prosthesis. Examination of the surgical specimen confirmed the dissecting aneurysm (Fig. 4). The postoperative course was uneventful, and the patient was discharged after 11 days. The pathologic examination of the aneurysm wall confirmed the dissecting nature of the aneurysm but revealed no evidence of a connective tissue disease (Fig. 5).
Vol. 28, No. 4, May 2014
Fig. 4. Surgical specimen of the celiac trunk.
DISCUSSION Dissecting aneurysms of the celiac trunk are rare, and to our knowledge this is the first reported case. This case raises 3 questions: (1) from a pathogenic point of view, was this a preexisting isolated aneurysm complicated by a dissection, or was this a dissection, localized on the celiac trunk, that progressed to aneurysmal dilation by weakening the artery wall? (2) How would such a lesion evolve: rupture, digestive ischemia by extension of the dissection? (3) What therapy should be proposed: conventional surgery or endovascular treatment? Regardless of the pathogenic hypothesis, we thought it was important to consider the lesion first as an aneurysm of the celiac trunk. In many cases, these aneurysms are asymptomatic (41.5%)10 or associated with nonspecific symptoms (abdominal angina or isolated epigastric pain). They are mainly diagnosed when intraperitoneal rupture occurs, even though the risk of rupture is relatively low, estimated at 13%.1,2,11 The risk seems to be greater in infectious aneurysms and in those >2 cm in diameter. Mortality in ruptured aneurysm is evaluated at 40 to 100%.11,12 Diagnosis is based on ultrasound scans and CT angiography, which is increasingly used in the exploration of abdominal pathologies. This explains the increasingly frequent discovery of asymptomatic visceral vascular lesions, as was the case in our patient. Arteriography performed as a supplementary examination in such cases remains a matter of debate because it contributes little to the diagnosis and is nephrotoxic. Indeed, given the risks, and the information that it provides compared with other tests,
Case reports 1037.e3
arteriography is now indicated as a secondary examination.13 However, arteriography still has a role to play in determining the approaches for endovascular therapy.14,15 Although there is no question about the indication for surgery in cases of rupture or gastrointestinal ischemia complicating a celiac trunk aneurysm or secondary dissection from aortic dissection, surgery seems to be the route proposed by most authors for asymptomatic aneurysms of the celiac trunk.2,11,12,16,17 We considered it essential to treat this dissecting aneurysm because of its diameter and because of the refractory nature of the patient’s hypertension, both of which are associated with an increased risk of rupture or extension of the dissection. According to the literature, rupture usually occurs when a visceral artery aneurysm’s diameter is >20 mm, which is currently the indication for surgical treatment of asymptomatic lesions.18,19 In our case, the diameter was twice that of the origin of the celiac trunk, which is another criteria that indicates increased risk of rupture and, as shown in the perioperative pictures of our case, diameter was probably underestimated by CT. The first resection of an aneurysm of a digestive artery was reported by Cooley and DeBakey in 1953.20 and the first surgical approach to an aneurysm of the celiac trunk was reported by Shumacker in 1958.16 Today, endovascular treatment can be considered in the management of these aneurysms. The choice between conventional and endovascular surgery is influenced by general and local conditions, the dimensions of the aneurysm, the extension of the dissection in the celiac trunk, the existence of a proximal and distal neck, and etiology. A number of case reports on successful endovascular treatment of aneurysm of the celiac trunk have been published recently.14,15,21,22 Two other cases of dissecting aneurysm of the celiac trunk have been published. Both were treated by endovascular approach. The first case described by Messenger et al. was treated by embolization of the left hepatic branches and the gastroduodenal artery (coils) and by stenting of the proximal celiac trunk to prevent dissection extension.23 The case described by Batt et al. was treated by embolization of the celiac trunk branches and the origin of the celiac trunk (coils and plug).24 In these 2 cases, no ischemic lesions have been observed. Drawbacks of endovascular repair are the risk of aneurysmal recanalization and ischemic risk in patients with poor collateral flow. Another novel treatment for a celiac trunk aneurysm has been described by Gabrielli et al. It consists
1037.e4 Case reports
of a hybrid procedure: left splenorenal bypass and direct splenic approach to deploy a stent across the splenic and the hepatic arteries.25 We chose to use conventional treatment given the form of the dissecting aneurysm and, most important, because of the absence of a distal neck, which provides an anchor for the stent graft. The most frequent approach is via supraumbilical median laparotomy, but transversal or bi-infracostal laparotomy can also be used. We opted for a biinfracostal incision, which offered excellent access to the celiac trunk. We chose to use a Dacron prosthesis for the bypass to revascularize the celiac trunk because, according to the literature, there seems to be no significant difference, in terms of results, between the use of a vein or prosthetic material if the aneurysm is not septic.1,26 In addition, we chose to ligate the left gastric artery because it is a simple procedure and because the gastric blood supply is mainly provided by the left gastroepiploic artery.4
CONCLUSION We report this case because of its unusual character. Although it was not possible to determine whether the aneurysm was complicated by dissection or vice versa, we believe it is appropriate to treat this type of lesion in all patients because of the high risk of complications, either rupture of the aneurysm or ischemia by extension of the dissection, especially if the lesion is associated with visceral vascular lesions, particularly in the superior mesenteric artery. REFERENCES 1. Zelenock GB, Graham LM, Whitehouse WM Jr, et al. Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg 1980;115:497e501. 2. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997;77:425e42. 3. Graham LM, Stanley JC, Whitehouse WM Jr, et al. Celiac artery aneurysms: historic (1745e1949) versus contemporary (1950-e1984) differences in etiology and clinical importance. J Vasc Surg 1985;2:757e64. 4. Pintilie DG, Zamfir CL, Paduraru D, Raileanu C. Characteristics of anastomoses between the celiac trunk and the superior mesenteric artery [in Romanian]. Rev Med Chir Soc Med Nat Iasi 2003;107:826e30. 5. Fenoglio L, Allione A, Scalabrino E, et al. Spontaneous dissection of the celiac artery: a pitfall in the diagnosis of acute abdominal pain. Presentation of two cases. Dig Dis Sci 2004;49:1223e7.
Annals of Vascular Surgery
6. D’Ambrosio N, Friedman B, Siegel D, et al. Spontaneous isolated dissection of the celiac artery: CT findings in adults. AJR Am J Roentgenol 2007;188:W506e11. 7. Glehen O, Feugier P, Aleksic Y, et al. Spontaneous dissection of the celiac artery. Ann Vasc Surg 2001;15:687e92. 8. Matsuo R, Ohta Y, Ohya Y, et al. Isolated dissection of the celiac arteryda case report. Angiology 2000;51:603e7. 9. Kim JH, Roh BS, Lee YH, et al. Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol 2004;5:134e8. 10. Marre P, Salomon L. Surgical treatment of aneurysms of the celiac trunk. Apropos of a case [article in French]. Chirurgie 1991;117:89e95. 11. Palumbo N, Cevolani M, Faggioli GL, et al. Problems of indications for the treatment of aneurysm of the visceral arteries [article in Italian]. Minerva Chir 1995;50:747e55. 12. Shanley CJ, Shah NL, Messina LM. Common splanchnic artery aneurysms: splenic, hepatic, and celiac. Ann Vasc Surg 1996;10:315e22. 13. Pineau S, Vidal V, Monnet O, et al. Explorations radiologiques preoperatoires en chirurgie vasculaire. [43-015]. EMC Tech Chirurg Vasc 2007;12:1e22. 14. Atkins BZ, Ryan JM, Gray JL. Treatment of a celiac artery aneurysm with endovascular stent graftingda case report. Vasc Endovascular Surg 2003;37:367e73. 15. Knobloch K, Lotz J, Fischer S, et al. Interventional stent graft placement for aneurysm of the celiac trunk. Eur J Vasc Endovasc Surg Extra 2002;4:39e41. 16. Schumaker HB, Siderys H. Excisional treatment of aneurysm of the celiac artery. Ann Surg 1958;148:885e9. 17. Rengo M, Terrinoni V, Lamazza A, et al. Treatment of an aneurysm of the coeliac axis by transluminal steel wire occlusion. Eur J Vasc Endovasc Surg 1997;13:88e90. 18. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276e83. discussion 283. 19. Marone EM, Mascia D, Kahlberg A, et al. Is open repair still the gold standard in visceral artery aneurysm management? Ann Vasc Surg 2011;25:936e46. 20. De Bakey ME, Cooley DA. Successful resection of mycotic aneurysm of superior mesenteric artery; case report and review of literature. Am Surg 1953;19:202e12. 21. Gabelmann A, Gorich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9: 38e47. 22. Bautista-Hernandez V, Gutierrez F, Capel A, et al. Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behcet’s disease. J Endovasc Ther 2004;11:222e5. 23. Messenger DE. Repair of an extensive, dissecting coeliac artery aneurysm by an endovascular approach. Eur J Radiol Extra 2006;58:89e92. 24. Batt M, Baque J. Successful percutaneous embolization of a symptomatic celiac artery dissection with aneurysmal dilation with detachable vascular plugs. J Vasc Surg 2011;54:1812e5. 25. Gabrielli R, Rosati MS, Siani A, et al. Hybrid procedure for celiac trunk aneurysm repair via left reno-splenic bypass and stent-graft deployment. Tex Heart Inst J 2012;39:408e11. 26. Brown OW, Hollier LH, Pairolero PC, McCready RA. Uncommon visceral artery aneurysms. South Med J 1983;76: 1000e1.
Aneurysms of visceral arteries are relatively rare entities. Spontaneous isolated celiac artery dissection is an uncommon diagnosis, with only a few reported cases. We report the case of 52-year-old man who had an asymptomatic celiac trunk dissecting aneurysm detected by tomographic angiography. Because of the combined risk of rupture and ischemia, we decided to treat this lesion by a conventional bypass.
Aneurysms of visceral arteries are rare and of unknown physiopathology. These aneurysms mainly concern the splenic artery (60%); other visceral locations are less frequent (the celiac trunk 4%, the superior mesenteric artery 5.5%, the left gastric artery and the gastroepiploic artery 4%).1,2 These aneurysms are encountered in polyaneurysmal diseases in 38% of cases, and in 18% of cases, the patient also presents with aneurysm of the abdominal aorta.3 This condition is serious because of the risk of aneurysm rupture.4 As for dissection of the celiac trunk or other visceral arteries, they are most often related to the extension of aortic dissection. Isolated dissection of the celiac trunk is rare and only a few cases have been reported in the literature.5e9 The majority of dissecting aneurysms, defined as cleavage between the intimae and the external elastic lamina of the artery leading to an infiltrated and distended cavity, concern the thoracic and abdominal aorta. We report here on a
Department of Vascular Surgery, Centre Hospitalier Pasteur, Colmar, France. Correspondence to: Benjamin Kretz, MD, Service de Chirurgie Vasculaire, Centre Hospitalier Pasteur, Colmar, Service de Chirurgie Vasculaire, CH Pasteur, 39 Avenue de la Liberte, Colmar 68000, France; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1037.e1–1037.e4 http://dx.doi.org/10.1016/j.avsg.2013.08.017 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 14, 2013; manuscript accepted: August 12, 2013; published online: December 16, 2013.
patient who presented an isolated dissecting aneurysm of the celiac trunk.
CASE STUDY Our patient was a 52-year-old man with a history of childhood pulmonary tuberculosis, left side pleurisy, and severe persistent arterial hypertension that was refractory to aggressive medical treatment in the context of familial arterial hypertension. During medical tests to discover a secondary cause for the severe arterial hypertension, abdominal wall computed tomography (CT) angiography revealed a dissecting aneurysm of the celiac trunk (Fig. 1). This aneurysm was 7.6 mm from the origin of the celiac trunk, 12.6 mm in diameter (for an upstream celiac trunk diameter of 6 mm), and 23.9 mm long. The aneurysm extended to the division into the splenic artery and the common hepatic artery and had no signs of calcification or thrombus. There were no signs of deficient visceral perfusion, and the dissection did not extend beyond the celiac trunk. The assessment was completed by arteriography, which confirmed the diagnosis but did not reveal the dissecting aspect of the aneurysm (Fig. 2). The arteriography revealed no other sites of arterial aneurysm, although transthoracic echocardiography showed ectasia of the ascending aorta, measuring 34 mm. Given the diameter of the aneurysm (twice that of the normal celiac trunk), the refractory nature of the arterial hypertension, and 1037.e1
1037.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Computed tomography angiography, dissection of the celiac trunk.
Fig. 3. Intraoperative appearance, ligation of the left gastric artery and common hepatic artery and the splenic artery as controls. Fig. 2. Preoperative angiography showing the aneurysm of the celiac trunk. The dissection is not visible.
the resulting risk of rupture of the aneurysm or extension of the dissection, surgical treatment was chosen. The surgical procedure involved bi-infracostal laparotomy. The aneurysm was approached after opening the small omentum and sectioning the crura of the diaphragm. Systemic heparin (1.5 mg/ kg) was given, and the aorta above and below the celiac trunk and the branches of the celiac trunk were clamped (Fig. 3).The aneurysm was resected, revealing the dissection within the wall of the celiac
trunk. The left gastric artery and the origin of the celiac trunk were ligated. We created a bypass between the aorta above the celiac trunk and the celiac trunk using a 7-mm-diameter Dacron prosthesis. Examination of the surgical specimen confirmed the dissecting aneurysm (Fig. 4). The postoperative course was uneventful, and the patient was discharged after 11 days. The pathologic examination of the aneurysm wall confirmed the dissecting nature of the aneurysm but revealed no evidence of a connective tissue disease (Fig. 5).
Vol. 28, No. 4, May 2014
Fig. 4. Surgical specimen of the celiac trunk.
DISCUSSION Dissecting aneurysms of the celiac trunk are rare, and to our knowledge this is the first reported case. This case raises 3 questions: (1) from a pathogenic point of view, was this a preexisting isolated aneurysm complicated by a dissection, or was this a dissection, localized on the celiac trunk, that progressed to aneurysmal dilation by weakening the artery wall? (2) How would such a lesion evolve: rupture, digestive ischemia by extension of the dissection? (3) What therapy should be proposed: conventional surgery or endovascular treatment? Regardless of the pathogenic hypothesis, we thought it was important to consider the lesion first as an aneurysm of the celiac trunk. In many cases, these aneurysms are asymptomatic (41.5%)10 or associated with nonspecific symptoms (abdominal angina or isolated epigastric pain). They are mainly diagnosed when intraperitoneal rupture occurs, even though the risk of rupture is relatively low, estimated at 13%.1,2,11 The risk seems to be greater in infectious aneurysms and in those >2 cm in diameter. Mortality in ruptured aneurysm is evaluated at 40 to 100%.11,12 Diagnosis is based on ultrasound scans and CT angiography, which is increasingly used in the exploration of abdominal pathologies. This explains the increasingly frequent discovery of asymptomatic visceral vascular lesions, as was the case in our patient. Arteriography performed as a supplementary examination in such cases remains a matter of debate because it contributes little to the diagnosis and is nephrotoxic. Indeed, given the risks, and the information that it provides compared with other tests,
Case reports 1037.e3
arteriography is now indicated as a secondary examination.13 However, arteriography still has a role to play in determining the approaches for endovascular therapy.14,15 Although there is no question about the indication for surgery in cases of rupture or gastrointestinal ischemia complicating a celiac trunk aneurysm or secondary dissection from aortic dissection, surgery seems to be the route proposed by most authors for asymptomatic aneurysms of the celiac trunk.2,11,12,16,17 We considered it essential to treat this dissecting aneurysm because of its diameter and because of the refractory nature of the patient’s hypertension, both of which are associated with an increased risk of rupture or extension of the dissection. According to the literature, rupture usually occurs when a visceral artery aneurysm’s diameter is >20 mm, which is currently the indication for surgical treatment of asymptomatic lesions.18,19 In our case, the diameter was twice that of the origin of the celiac trunk, which is another criteria that indicates increased risk of rupture and, as shown in the perioperative pictures of our case, diameter was probably underestimated by CT. The first resection of an aneurysm of a digestive artery was reported by Cooley and DeBakey in 1953.20 and the first surgical approach to an aneurysm of the celiac trunk was reported by Shumacker in 1958.16 Today, endovascular treatment can be considered in the management of these aneurysms. The choice between conventional and endovascular surgery is influenced by general and local conditions, the dimensions of the aneurysm, the extension of the dissection in the celiac trunk, the existence of a proximal and distal neck, and etiology. A number of case reports on successful endovascular treatment of aneurysm of the celiac trunk have been published recently.14,15,21,22 Two other cases of dissecting aneurysm of the celiac trunk have been published. Both were treated by endovascular approach. The first case described by Messenger et al. was treated by embolization of the left hepatic branches and the gastroduodenal artery (coils) and by stenting of the proximal celiac trunk to prevent dissection extension.23 The case described by Batt et al. was treated by embolization of the celiac trunk branches and the origin of the celiac trunk (coils and plug).24 In these 2 cases, no ischemic lesions have been observed. Drawbacks of endovascular repair are the risk of aneurysmal recanalization and ischemic risk in patients with poor collateral flow. Another novel treatment for a celiac trunk aneurysm has been described by Gabrielli et al. It consists
1037.e4 Case reports
of a hybrid procedure: left splenorenal bypass and direct splenic approach to deploy a stent across the splenic and the hepatic arteries.25 We chose to use conventional treatment given the form of the dissecting aneurysm and, most important, because of the absence of a distal neck, which provides an anchor for the stent graft. The most frequent approach is via supraumbilical median laparotomy, but transversal or bi-infracostal laparotomy can also be used. We opted for a biinfracostal incision, which offered excellent access to the celiac trunk. We chose to use a Dacron prosthesis for the bypass to revascularize the celiac trunk because, according to the literature, there seems to be no significant difference, in terms of results, between the use of a vein or prosthetic material if the aneurysm is not septic.1,26 In addition, we chose to ligate the left gastric artery because it is a simple procedure and because the gastric blood supply is mainly provided by the left gastroepiploic artery.4
CONCLUSION We report this case because of its unusual character. Although it was not possible to determine whether the aneurysm was complicated by dissection or vice versa, we believe it is appropriate to treat this type of lesion in all patients because of the high risk of complications, either rupture of the aneurysm or ischemia by extension of the dissection, especially if the lesion is associated with visceral vascular lesions, particularly in the superior mesenteric artery. REFERENCES 1. Zelenock GB, Graham LM, Whitehouse WM Jr, et al. Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg 1980;115:497e501. 2. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997;77:425e42. 3. Graham LM, Stanley JC, Whitehouse WM Jr, et al. Celiac artery aneurysms: historic (1745e1949) versus contemporary (1950-e1984) differences in etiology and clinical importance. J Vasc Surg 1985;2:757e64. 4. Pintilie DG, Zamfir CL, Paduraru D, Raileanu C. Characteristics of anastomoses between the celiac trunk and the superior mesenteric artery [in Romanian]. Rev Med Chir Soc Med Nat Iasi 2003;107:826e30. 5. Fenoglio L, Allione A, Scalabrino E, et al. Spontaneous dissection of the celiac artery: a pitfall in the diagnosis of acute abdominal pain. Presentation of two cases. Dig Dis Sci 2004;49:1223e7.
Annals of Vascular Surgery
6. D’Ambrosio N, Friedman B, Siegel D, et al. Spontaneous isolated dissection of the celiac artery: CT findings in adults. AJR Am J Roentgenol 2007;188:W506e11. 7. Glehen O, Feugier P, Aleksic Y, et al. Spontaneous dissection of the celiac artery. Ann Vasc Surg 2001;15:687e92. 8. Matsuo R, Ohta Y, Ohya Y, et al. Isolated dissection of the celiac arteryda case report. Angiology 2000;51:603e7. 9. Kim JH, Roh BS, Lee YH, et al. Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol 2004;5:134e8. 10. Marre P, Salomon L. Surgical treatment of aneurysms of the celiac trunk. Apropos of a case [article in French]. Chirurgie 1991;117:89e95. 11. Palumbo N, Cevolani M, Faggioli GL, et al. Problems of indications for the treatment of aneurysm of the visceral arteries [article in Italian]. Minerva Chir 1995;50:747e55. 12. Shanley CJ, Shah NL, Messina LM. Common splanchnic artery aneurysms: splenic, hepatic, and celiac. Ann Vasc Surg 1996;10:315e22. 13. Pineau S, Vidal V, Monnet O, et al. Explorations radiologiques preoperatoires en chirurgie vasculaire. [43-015]. EMC Tech Chirurg Vasc 2007;12:1e22. 14. Atkins BZ, Ryan JM, Gray JL. Treatment of a celiac artery aneurysm with endovascular stent graftingda case report. Vasc Endovascular Surg 2003;37:367e73. 15. Knobloch K, Lotz J, Fischer S, et al. Interventional stent graft placement for aneurysm of the celiac trunk. Eur J Vasc Endovasc Surg Extra 2002;4:39e41. 16. Schumaker HB, Siderys H. Excisional treatment of aneurysm of the celiac artery. Ann Surg 1958;148:885e9. 17. Rengo M, Terrinoni V, Lamazza A, et al. Treatment of an aneurysm of the coeliac axis by transluminal steel wire occlusion. Eur J Vasc Endovasc Surg 1997;13:88e90. 18. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276e83. discussion 283. 19. Marone EM, Mascia D, Kahlberg A, et al. Is open repair still the gold standard in visceral artery aneurysm management? Ann Vasc Surg 2011;25:936e46. 20. De Bakey ME, Cooley DA. Successful resection of mycotic aneurysm of superior mesenteric artery; case report and review of literature. Am Surg 1953;19:202e12. 21. Gabelmann A, Gorich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9: 38e47. 22. Bautista-Hernandez V, Gutierrez F, Capel A, et al. Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behcet’s disease. J Endovasc Ther 2004;11:222e5. 23. Messenger DE. Repair of an extensive, dissecting coeliac artery aneurysm by an endovascular approach. Eur J Radiol Extra 2006;58:89e92. 24. Batt M, Baque J. Successful percutaneous embolization of a symptomatic celiac artery dissection with aneurysmal dilation with detachable vascular plugs. J Vasc Surg 2011;54:1812e5. 25. Gabrielli R, Rosati MS, Siani A, et al. Hybrid procedure for celiac trunk aneurysm repair via left reno-splenic bypass and stent-graft deployment. Tex Heart Inst J 2012;39:408e11. 26. Brown OW, Hollier LH, Pairolero PC, McCready RA. Uncommon visceral artery aneurysms. South Med J 1983;76: 1000e1.