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Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft
Volume 34, July 2016
Abstracts Accepted for Presentation During the 34th Annual Meeting of the Southern California Vascular Surgical Society
Visceral artery aneurysms comprise a small portion of all peripheral vascular aneurysms. Of these, the splenic artery is most commonly affected, while celiac artery involvement is rare. Repair is recommended for symptomatic aneurysms or those exceeding two centimeters in diameter. Most reported repairs for celiac artery aneurysms involve surgical excision with or without bypass grafting, but endovascular treatments are becoming more common. We present a case of a 75 year-old male with proximal celiac and distal splenic artery aneurysms treated with combined percutaneous coil embolization and aortic cuff stent graft placement. The splenic aneurysm sac and proximal splenic artery were coil embolized. Attempts to place a covered stent across the celiac artery aneurysm were unsuccessful from both femoral and brachial approaches. We then coil embolized the celiac artery distal to the aneurysm but proximal to the gastroduodenal branch. Coils were also placed into the celiac artery aneurysm sac and left gastric artery. There was insufficient neck length to place coils into the proximal celiac artery. Consequently, an aortic cuff stent graft was deployed across celiac artery origin to obliterate the inflow. There was no liver dysfunction afterwards due to retrograde flow through a patent gastroduodenal artery. To our knowledge, this approach of excluding celiac artery inflow using an aortic stent graft to treat a proximal celiac artery aneurysm has not been reported. The above method resulted in successful exclusion of his multiple aneurysms, and the patient continues to do well over one year later. http://dx.doi.org/10.1016/j.avsg.2016.05.072
Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft
41
supraceliac aortosplenic and aortohepatic bypass using a bifurcated Dacron graft. Discussion: HAA are rarely reported in the surgical literature, given the low incidence. We performed an in-depth review of HAA management from 2000-2013. The majority are asymptomatic with diagnoses occurring incidentally or after rupture. Patients are more often male, with an average age of 60 years. The average aneurysm size at diagnosis is 2.8-cm. Repair is recommended if symptomatic, rapidly enlarging or greater than 2-cm in diameter. Both endovascular and open repair have been described. Given the anatomy of our patient’s HAA, endovascular repair was not an option. Her GDA originated from the aneurysm, providing retrograde flow to the occluded celiac axis, and thus requiring a bifurcated bypass. Conclusion: HAA is a rare and dangerous condition, with many who ultimately rupture. Given the high mortality, these patients should be closely monitored and surgical repair should be at the forefront of treatment. There is ongoing debate over endovascular versus open repair. http://dx.doi.org/10.1016/j.avsg.2016.05.073
Access to Post Hospitalization Acute Care Facilities Depends On Payer Status for Open Abdominal Aortic Repair and Lower Extremity Bypass in the VQI Jesus G. Ulloa, Chi-Hong Tseng, Melinda Maggard-Gibbons, Karen Woo, MD, and David A. Rigberg, MD
Katie E. Shean, MD, Scott R. Johnson, MD, and Nikhil Kansal, MD
University of California, Los Angeles, Los Angeles, CA.
St. Elizabeth’s Medical Center, Boston, MA.
Objective: Post acute care facilities play an important role in clinical recovery and functional outcomes that uninsured patients may not have access to. Our objective was to explore if there is an association between discharge disposition and insurance status. Methods: We retrospectively reviewed patients in the Vascular Quality Initiative undergoing open abdominal aortic repair (oAAR), infra-inguinal bypass (IB) or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed effects logistic regression analysis; with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, SNF or Rehab by payer status adjusting for patient, operative and postoperative characteristics. Results: Study cohort comprised 18,478 procedures (oAAR¼2,817; IB¼11,572; SI¼4,089) after excluding procedures with missing data and in hospital deaths. 24% of the cohort was discharged to a SNF or Rehab site. On univariate analysis, the odds of discharge home was 4.38 (95% CI 3.33 e 5.77) for uninsured as compared to
Sponsored by: John S. Lane, III, MD Introduction: Hepatic artery aneurysms (HAA) are uncommon, with only 500 cases noted in the literature. They have the highest rate of rupture among all splanchnic artery aneurysms, warranting aggressive management strategy. We present an interesting case report demonstrating this rare visceral pathology followed by an extensive literature review of HAA management to better describe the operative indications for repair of this arterial anomaly. Case Report: We present the case of a 72-year-old female with an incidental mass seen on CT scan. Angiogram was performed, demonstrating a 6.0-cm bi-lobed aneurysm; the first portion involved the proximal common hepatic artery and the second included the proper hepatic artery, as well as the origin of the gastroduodenal artery (GDA). The proximal celiac artery appeared occluded with retrograde flow into the celiac axis circulation via the GDA. She underwent open repair of the aneurysm with
Abstracts Accepted for Presentation During the 34th Annual Meeting of the Southern California Vascular Surgical Society
Visceral artery aneurysms comprise a small portion of all peripheral vascular aneurysms. Of these, the splenic artery is most commonly affected, while celiac artery involvement is rare. Repair is recommended for symptomatic aneurysms or those exceeding two centimeters in diameter. Most reported repairs for celiac artery aneurysms involve surgical excision with or without bypass grafting, but endovascular treatments are becoming more common. We present a case of a 75 year-old male with proximal celiac and distal splenic artery aneurysms treated with combined percutaneous coil embolization and aortic cuff stent graft placement. The splenic aneurysm sac and proximal splenic artery were coil embolized. Attempts to place a covered stent across the celiac artery aneurysm were unsuccessful from both femoral and brachial approaches. We then coil embolized the celiac artery distal to the aneurysm but proximal to the gastroduodenal branch. Coils were also placed into the celiac artery aneurysm sac and left gastric artery. There was insufficient neck length to place coils into the proximal celiac artery. Consequently, an aortic cuff stent graft was deployed across celiac artery origin to obliterate the inflow. There was no liver dysfunction afterwards due to retrograde flow through a patent gastroduodenal artery. To our knowledge, this approach of excluding celiac artery inflow using an aortic stent graft to treat a proximal celiac artery aneurysm has not been reported. The above method resulted in successful exclusion of his multiple aneurysms, and the patient continues to do well over one year later. http://dx.doi.org/10.1016/j.avsg.2016.05.072
Hepatic Artery Aneurysm with Occlusion of the Celiac Axis: Repair Using a Bifurcated Graft
41
supraceliac aortosplenic and aortohepatic bypass using a bifurcated Dacron graft. Discussion: HAA are rarely reported in the surgical literature, given the low incidence. We performed an in-depth review of HAA management from 2000-2013. The majority are asymptomatic with diagnoses occurring incidentally or after rupture. Patients are more often male, with an average age of 60 years. The average aneurysm size at diagnosis is 2.8-cm. Repair is recommended if symptomatic, rapidly enlarging or greater than 2-cm in diameter. Both endovascular and open repair have been described. Given the anatomy of our patient’s HAA, endovascular repair was not an option. Her GDA originated from the aneurysm, providing retrograde flow to the occluded celiac axis, and thus requiring a bifurcated bypass. Conclusion: HAA is a rare and dangerous condition, with many who ultimately rupture. Given the high mortality, these patients should be closely monitored and surgical repair should be at the forefront of treatment. There is ongoing debate over endovascular versus open repair. http://dx.doi.org/10.1016/j.avsg.2016.05.073
Access to Post Hospitalization Acute Care Facilities Depends On Payer Status for Open Abdominal Aortic Repair and Lower Extremity Bypass in the VQI Jesus G. Ulloa, Chi-Hong Tseng, Melinda Maggard-Gibbons, Karen Woo, MD, and David A. Rigberg, MD
Katie E. Shean, MD, Scott R. Johnson, MD, and Nikhil Kansal, MD
University of California, Los Angeles, Los Angeles, CA.
St. Elizabeth’s Medical Center, Boston, MA.
Objective: Post acute care facilities play an important role in clinical recovery and functional outcomes that uninsured patients may not have access to. Our objective was to explore if there is an association between discharge disposition and insurance status. Methods: We retrospectively reviewed patients in the Vascular Quality Initiative undergoing open abdominal aortic repair (oAAR), infra-inguinal bypass (IB) or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed effects logistic regression analysis; with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, SNF or Rehab by payer status adjusting for patient, operative and postoperative characteristics. Results: Study cohort comprised 18,478 procedures (oAAR¼2,817; IB¼11,572; SI¼4,089) after excluding procedures with missing data and in hospital deaths. 24% of the cohort was discharged to a SNF or Rehab site. On univariate analysis, the odds of discharge home was 4.38 (95% CI 3.33 e 5.77) for uninsured as compared to
Sponsored by: John S. Lane, III, MD Introduction: Hepatic artery aneurysms (HAA) are uncommon, with only 500 cases noted in the literature. They have the highest rate of rupture among all splanchnic artery aneurysms, warranting aggressive management strategy. We present an interesting case report demonstrating this rare visceral pathology followed by an extensive literature review of HAA management to better describe the operative indications for repair of this arterial anomaly. Case Report: We present the case of a 72-year-old female with an incidental mass seen on CT scan. Angiogram was performed, demonstrating a 6.0-cm bi-lobed aneurysm; the first portion involved the proximal common hepatic artery and the second included the proper hepatic artery, as well as the origin of the gastroduodenal artery (GDA). The proximal celiac artery appeared occluded with retrograde flow into the celiac axis circulation via the GDA. She underwent open repair of the aneurysm with