- Email: [email protected]
Middle Colic Artery Aneurysm: A Case Report and Review of the Literature
Case Reports Middle Colic Artery Aneurysm: A Case Report and Review of the Literature Cecilia Wanchen Huo, Melbourne, Australia
We report a case of a ruptured middle colic artery (MCA) aneurysm in a 48-year-old previously healthy man. Coil embolization was attempted without success. The patient then underwent resection of the MCA and the transverse colon with a satisfactory outcome. Twenty-six previously published cases dating back to 1930 were reviewed, revealing the cause of the MCA aneurysm to be idiopathic in most cases. However, necrotizing arteritis, polyarteritis nodosa, and hypertension have been associated. The aneurysm is commonly managed with laparotomy, as well as arterial resection with or without transverse colectomy, although transcatheter arterial embolization has been successful in four published cases.
The middle colic artery (MCA) arises from the superior mesenteric artery inferior to or near the pancreatic head. It supplies the transverse colon and, occasionally, the ascending colon in the region of the hepatic flexure.1 Bleeding from an MCA aneurysm may be insidious or acute. Despite its rare occurrence, this condition can be catastrophic. We report a case of a bleeding MCA aneurysm in a 48-year-old man. A comprehensive literature search was also performed; however, more evidence may be needed to draw conclusions on the natural history and management paradigms for this problem.
CASE REPORT A 48-year-old Caucasian man presented with a 1-week history of intermittent, sharp, and central abdominal pain accompanied by nausea and vomiting to a local hospital. His medical history included a gastric ulcer that healed 25 years ago. There was no previous or family history of aneurysms, infectious diseases, or autoimmune Department of Vascular Surgery, St. Vincent’s Hospital, Melbourne, Australia. Correspondence to: Cecilia W. Huo, MBBS, BMED SCI, Department of Vascular Surgery, St. Vincent’s Hospital, PO Box 2900, Victoria Parade, Melbourne 3065, Australia; E-mail: [email protected] Ann Vasc Surg 2012; 26: 571.e1e571.e6 DOI: 10.1016/j.avsg.2011.07.023 Ó Annals of Vascular Surgery Inc. Published online: February 10, 2012
disorder. He was not taking any medication, and he had quit smoking 6 years earlier. His hemoglobin dropped from 12.7 to 10.7 g/dL within 1 day of presentation, and an initial computed tomography (CT) scan showed a dense area of fluid and edema in the upper mesentery. He was then transferred to our hospital for further management. Both his thromboplastin time and prothrombin ratio were within the normal ranges. Liver function tests, along with amylase and lipase, were also unremarkable. Repeat 3-phase CT scan suggested an aneurysm arising from either the MCA or the pancreaticoduodenal artery, as shown in Figure 1. CT angiography confirmed a markedly abnormal MCA with dissection and beading as well as a pseudoaneurysm over a long segment (Fig. 2). Mesenteric embolization was initially attempted through the inferior mesenteric artery and marginal artery; however, a microcatheter was unable to pass the splenic flexure because of the small caliber of the marginal artery at this point. An additional attempt was made to traverse the MCA with a microcatheter, but this method proved to be unsuccessful. This procedure was abandoned because, at this stage, it had been attempted for 3 hours. An elective laparoscopy was then performed, revealing a large mesocolic hematoma. The procedure was converted to the open approach. A 6 6 cm hematoma was found in situ, extending to the root of the superior mesenteric artery. The abnormal MCA and the transverse colon were resected. Microscopically, there was hemorrhage, cholesterol clefting, and fat necrosis, with multinucleate foreign bodyetype giant cells within the fat of the aneurysmal wall. No other features were noted.
571.e1
571.e2 Case reports
Fig. 1. Abdominal computed tomography (CT). The axial view of the CT scan shows dense fluid and edema. The arrow points to the bleeding aneurysm.
Fig. 2. Catheter-based angiogram. It shows tortuous middle colic artery with beading and an aneurysm. Postoperatively, the patient’s recovery was uneventful, with the hemoglobin level gradually returning to normal.
DISCUSSION The true incidence of MCA aneurysms is unknown. They represent fewer than 3% of visceral aneurysms, which are collectively uncommon.2 Clinically, they are usually considered as a clinical entity together with other mesenteric artery aneurysms. However, this study focused on examining the causes and the management of MCA aneurysms. A summary of previous cases is illustrated in Table I. Based on previously published data, patients
Annals of Vascular Surgery
with ruptured MCA aneurysms typically presented with acute abdominal pain associated with nausea, vomiting, and a sudden decrease in the hemoglobin level. They generally resembled patients who have mesenteric infarction or a perforated gastric ulcer. Occasionally, an MCA aneurysm can present as subacute intermittent abdominal pain of up to 6 months’ duration if there is a slow leak or a warning bleed.14 Therefore, a high index of suspicion and utilization of CT and angiography are paramount in detecting the disease. In particular, superior mesenteric angiogram has been used to make the diagnosis in recent years.12 A diagnostic imaging algorithm is suggested in Figure 3. As Table I shows, 12 of 26 cases were female, with a median age of 62 years. Among those women, four of the specimens showed necrotizing arteritis, three cases were idiopathic, and one appeared to be caused by tuberculosis; and histological details were not provided in the reports for the other four specimens. The men affected had a median age of 61 years. Of these cases, one was caused by a1antitrypsin deficiency, another one seemed to be related to tuberculosis, two were due to polyarteritis nodosa, and three were associated with hypertension. However, the exact blood pressure was often not stated in the reports. In terms of management, five patients were treated by transcatheter embolization, and the remaining patients underwent laparotomy, arterial resection, or ligation, with or without colectomy. Both approaches showed satisfactory postoperative and long-term results. It is noteworthy that the patient who was managed with intravenous antibiotics and hydrocortisone died only 5 hours after the onset of abdominal pain.27 In addition, as a negative publication bias likely exists against mesenteric aneurysms treated with poor outcomes, more study is required before generalizing favorable outcomes reported with surgical and embolization management in existing literature. The etiology and natural history of MCA aneurysm remain a mystery. Atherosclerosis and hypertension have been suggested to be associated; however, a link to abdominal aortic aneurysms has rarely been described.26 Patients with previous endocarditis, tuberculosis, a1-antitrypsin deficiency, segmental arterial mediolysis, fibrodysplasia, and vasculitis may present with recurrent or multiple visceral aneurysms.7,14,28 One patient who had an aneurysmal MCA also had Marfan syndrome, although the histology of the aneurysm showed no connection to Marfan syndrome.4 It has been suggested that the threshold for treating asymptomatic lesions should be an aneurysmal
Age, sex
Comorbidities
Chief symptoms
Management
13
19, F
Tuberculosis
24
32, M
Marfan syndrome
Abdominal pain of 6 mo duration Sudden abdominal pain, shock
35
37, F
PAN, emphysema
46
38, F
SLE, hypertension
57
44, F
Arterial fibrodysplasia
68
51, M
Hypertension, tuberculosis
79
51, F
Rheumatoid arthritis
810
52, M
Lower abdominal pain
911
53, M
Emphysema, a1-antitrypsin deficiency Nil
Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial resection
1012
56, M
Abdominal pain
112
57, M
Hypertension, chronic bronchitis, renal calculi Nil
1212
61, M
1313
62, F
Lower back pain, nausea, and vomiting Sudden abdominal pain, nonbloody diarrhea, collapse Shock
Abdominal pain of 6 d duration Sudden abdominal pain
Periumbilical colicky pain
Long-term complications (>6 mo)
Histopathology
Nil
Nil
N/A
N/A
N/A
NAD and no features of Marfan
Nil
Nil
Nil
Nil
Features of necrotizing arteritis NAD and no features of SLE
Nil
Nil
Medial dysplasia consistent with fibrodysplasia
Nil
Nil
Respiratory infection
Nil
N/A
Nil
False aneurysm in the specimen Arterial wall necrosis with neutrophil infiltration, consistent with arteritis Elastin degeneration
Laparotomy, arterial N/A resection, and transverse colectomy Laparotomy and arterial Nil resection
N/A
Nil
A mixture of a pseudoaneurysm and true aneurysms N/A
Transcatheter microcoil Nil embolization N/A Laparotomy, arterial resection, and transverse colectomy
Nil
N/A
Well-controlled hypertension
Severe abdominal pain, diarrhea Abdominal pain, nausea, and vomiting
N/A
Hypercholesterolemia, hypertension, diverticulosis
Periumbilical severe and intermittent pain, nausea, and vomiting
Laparotomy and arterial resection
Nil
Acute arteritis with complete destruction of the wall, and extensive inflammatory reaction Idiopathic thinning of the arterial wall
Nil
(Continued)
Case reports 571.e3
Patient
Perioperative complications
Vol. 26, No. 4, May 2012
Table I. Summary of published cases of MCA aneurysms
Perioperative complications
Long-term complications (>6 mo)
Patient
Age, sex
Comorbidities
Chief symptoms
Management
1414
62, M
PAN
Sudden severe abdominal pain
Laparotomy and ligation of Nil the MCA
N/A
1515
64, F
Rheumatoid arthritis
Abdominal pain
Nil
1616
68, M
1717
69, F
Renal clear cell carcinoma Rheumatoid arthritis, PAN, bilateral breast cancer
Umbilical and right lower abdominal pain Dyspnea, epigastric pain, nausea and vomiting
Laparotomy, arterial Nil resection, and transverse colectomy Laparotomy and arterial Nil resection N/A IV penicillin, chloromycetin, and hydrocortisone
1818
69, F
N/A
Abdominal pain
1919
69, F
2020
70, M
Hypertension, diverticulosis N/A
2121
72, F
Well-controlled hypertension
2222
73, M
Acute pancreatitis
2323
75, M
Atherosclerosis
2424
76, F
Previous right hemicolectomy and ligation of the inferior mesenteric artery during open abdominal aortic aneurysm repair
Sudden massive melaena Transcatheter microcoil and loss of consciousness embolization
Transmural fibrinoid necrosis of the vessel wall, consistent with acute states of PAN Microscopic appearance consistent with PAN
Nil
Attenuated tunica intima and tunica media Died 5 hr after Postmortem: fibrinoid the onset of necrosis, disruption of abdominal elastic fiber, and cellular pain infiltration with neutrophils, consistent with PAN Nil N/A
Nil
Nil
N/A
Nil
Nil
N/A
Nil
Nil
N/A
Nil
Nil
Pseudoaneurysm
Nil
Died a week later from bronchopneumonia Nil
N/A
Nil
Nil
N/A
Annals of Vascular Surgery
Transcatheter microcoil embolization 48-hr history of abdominal Laparotomy and arterial pain and nausea ligation Abdominal pain Laparotomy, arterial resection, and transverse colectomy Dyspepsia and epigastric Endoaneurysmectomy discomfort with a short segment of stretch ultrathin PTFE interposition Epigastric pain Transcatheter microcoil embolization Abdominal pain Laparotomy and arterial and vomiting ligation
Histopathology
571.e4 Case reports
Table I. Continued
Case reports 571.e5
MCA, middle colic artery; F, female; M, male; N/A, not available; NAD, no abnormality detected; SLE, systemic lupus erythematosus; PAN, periarteritis nodosa; PTFE, polytetrafluoroethylene.
Nil Nil Aneurysmectomy and patch closure with autologous vein N/A, M N/A 2626
N/A
Nil 78, M 2525
Renal calculi, gout
Abdominal pain (6 d), nausea, and diarrhea
Laparotomy, arterial resection, and right hemicolectomy
Nil
Destruction of tunica interna and media, no definitive evidence of atherosclerosis or arteritis N/A
Vol. 26, No. 4, May 2012
Fig. 3. Diagnostic imaging algorithm. In the setting of a suspected mesenteric aneurysm, CT is more sensitive than abdominal X-ray at detecting bleeding. Angiography is the gold standard at delineating the aneurysm.
diameter of >2 cm, above which, ruptures occur frequently. Elective open surgical repair was shown to give satisfactory results in both the perioperative and long-term periods.21,26 The exception to this could be in cases of aneurysms caused by autoimmune etiologies, which were reported to resolve after high-dose prednisone treatment.15 With the advent of the minimally invasive endovascular approach in recent years, coil embolization and stent-graft repair provide an effective alternative way to treat MCA aneurysms, especially if the aneurysm is small.2 The success rate for embolizing visceral arteries was reported to be 98% for 48 procedures in one study.29 Tajima et al. reported a case in which a 76-year-old woman had a ruptured MCA on a background of previous right hemicolectomy and ligation of the inferior mesenteric artery for open abdominal aortal aneurysm repair. A microballoon occlusion test was performed first to predict postembolization colonic ischemia risk; the patient was then successfully treated by coil embolization.24 However, coil embolization poses the risk of incomplete exclusion of the aneurysm, bowel ischemia, and aneurysm ruptures. In addition, considering the common tortuosity of the vessel, endovascular
571.e6 Case reports
repair may not be feasible.21,26 Arterial reconstruction or resection with partial colectomy may be necessary if large segments of the arteries are involved and the viability of the bowel is dubious. Overall, the management of MCA aneurysm may require input from interventional radiologist, vascular surgeons, and general/colorectal surgeons.
I would like to express my gratitude to Mr. Rodney Woods for his support and guidance in this study. REFERENCES 1. Jamieson G, Hoffmann DC. Colectomy: colonic conduits: the anatomy of the colon. In: The anatomy of general surgical operations. United Kingdom: Churchill Livingstone, 2006. pp 75e6. 2. Hirokawa T, Sawai H, Yamada K, et al. Middle-colic artery aneurysm associated with segmental arterial mediolysis, successfully managed by transcatheter arterial embolization: report of a case. Surg Today 2009;39:144e7. 4. Srinivasan R, Parvin SD, Lambert D. Spontaneously ruptured middle colic artery aneurysm in a patient with Marfan’s syndrome. Eur J Vasc Surg 1990;4:317e8. 3. Verma BS, Bose AK, Bhatia HC, Katoch R. Superior mesenteric artery branch aneurysm diagnosed by ultrasound. Br J Radiol 1991;64:169e71. 5. Woods AC Jr, Parry RG, Detmer DE. Successful surgical treatment of massive abdominal hemorrhage due to periarteritis nodosa. Arch Surg 1968;97:541e3. 6. Whitehead S. Ruptured middle colic artery aneurysm. Postgrad Med J 1979;55:818e9. 7. Butter GD, van Bockel JH, Aarts JC. Arterial fibrodysplasia: rapid progression complicated by rupture of a visceral aneurysm into the gastrointestinal tract. J Vasc Surg 1988;7:449e53. 8. Kataoka M, Naruse M, Watarai N, et al. Retroperitoneal bleeding due to a ruptured aneurysm of the middle colic artery. Jpn J Surg 1984;14:150e4. 9. Webb J, Payne WH. Abdominal apoplexy in rheumatoid arthritis. Aust Ann Med 1970;19:168e70. 10. Mitchell MB, McAnena O, Rutherford R. Ruptured mesenteric artery aneurysm in a patient with alpha1-antitrypsin deficiency: etiologic implications. J Vasc Surg 1993;17:420e4. 11. Matsuyama T, Kawabori K, Nakatsuka H, et al. Mesenteric bleeding due to a ruptured aneurysm of the middle colic artery. Hiroshima J Med Sci 1986;35:293e7. 12. Boijsen E, Gothlin J, Hallbook T, et al. Preoperative angiographic diagnosis of bleeding aneurysms of abdominal visceral arteries. Radiology 1969;93:781e91.
Annals of Vascular Surgery
13. Wachman J, Schoen RE. Intermittent abdominal pain with aneurysm of the middle colic artery. Am J Gastroenterol 1995;90:499e501. 14. Selke FW, Williams GB, Donovan DL, Clarke RE. Management of intra-abdominal aneurysms associated with periarteritis nodosa. J Vasc Surg 1986;4:294e8. 15. Lindberg C, Stridbeck H. Aneurysms of the superior mesenteric artery and its branches. Gastrointest Radiol 1992;17: 132e4. 16. Sato T, Itoh M, Ohta N, et al. Spontaneous ruptured middle colic artery aneurysm with concurrent renal cell carcinoma. Hepatogastroenterology 2001;48:678e80. 17. Akbarian M. Abdominal apoplexy in polyarteritis nodosa. Am J Dig Dis 1966;11:63e7. 18. Naito A, Toyota N, Ito K. Embolization of a ruptured middle colic artery aneurysm. Cardiovasc Intervent Radiol 1995;18: 56e8. 19. David V, Sullivan K, Carter W. Role of selective arteriography in the diagnosis of a ruptured middle colic artery aneurysm. Cardiovasc Intervent Radiol 1994;17:167e9. 20. Slors JF, Taat CW, van Berge Henegouwen DP, Mallonga ET. Rupture of an aneurysm of the middle colic artery. Neth J Surg 1982;34:174e6. 21. Sarcina A, Bellosta R, Magnaldi S, Luzzani L. Aneurysm of the middle colic artery-case report and literature review. Eur J Vasc Endovasc Surg 2000;20:198e200. 22. Toyonaga T, Nagaoka S, Ouchida K, et al. Case of a bleeding pseudoaneurysm of the middle colic artery complicating acute pancreatitis. Hepatogastroenterology 2002;49: 1141e3. 23. Bruce J. Massive spontaneous intraperitoneal haemorrhage. Lancet 1937;19:1451e4. 24. Tajima T, Yoshimitsu K, Inokuchi H, et al. Microballoon occlusion test to predict colonic ischemia after transcatheter embolization of a ruptured aneurysm of the middle colic artery. Cardiovasc Intervent Radiol 2008;31:828e32. 25. Chino O, Kijima H, Shibuya M, et al. A case report: spontaneous rupture of dissecting aneurysm of the middle colic artery. Tokai J Exp Clin Med 2004;29:155e8. 26. Pulli R, Dorigo W, Troisi N, et al. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg 2008;48:334e42. 27. Akbarian M. Abdominal apoplexy in polyarteritis nodosa. Am J Dig Dis 1966;11:63e7. 28. Hirokawa T, Sawai H, Yamada K, et al. Middle-colic artery aneurysm associated with segmental arterial mediolysis, successfully managed by transcatheter arterial embolization: report of a case. Surg Today 2009;39: 144e7. 29. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysm. J Vasc Surg 2007;45:276e83.
We report a case of a ruptured middle colic artery (MCA) aneurysm in a 48-year-old previously healthy man. Coil embolization was attempted without success. The patient then underwent resection of the MCA and the transverse colon with a satisfactory outcome. Twenty-six previously published cases dating back to 1930 were reviewed, revealing the cause of the MCA aneurysm to be idiopathic in most cases. However, necrotizing arteritis, polyarteritis nodosa, and hypertension have been associated. The aneurysm is commonly managed with laparotomy, as well as arterial resection with or without transverse colectomy, although transcatheter arterial embolization has been successful in four published cases.
The middle colic artery (MCA) arises from the superior mesenteric artery inferior to or near the pancreatic head. It supplies the transverse colon and, occasionally, the ascending colon in the region of the hepatic flexure.1 Bleeding from an MCA aneurysm may be insidious or acute. Despite its rare occurrence, this condition can be catastrophic. We report a case of a bleeding MCA aneurysm in a 48-year-old man. A comprehensive literature search was also performed; however, more evidence may be needed to draw conclusions on the natural history and management paradigms for this problem.
CASE REPORT A 48-year-old Caucasian man presented with a 1-week history of intermittent, sharp, and central abdominal pain accompanied by nausea and vomiting to a local hospital. His medical history included a gastric ulcer that healed 25 years ago. There was no previous or family history of aneurysms, infectious diseases, or autoimmune Department of Vascular Surgery, St. Vincent’s Hospital, Melbourne, Australia. Correspondence to: Cecilia W. Huo, MBBS, BMED SCI, Department of Vascular Surgery, St. Vincent’s Hospital, PO Box 2900, Victoria Parade, Melbourne 3065, Australia; E-mail: [email protected] Ann Vasc Surg 2012; 26: 571.e1e571.e6 DOI: 10.1016/j.avsg.2011.07.023 Ó Annals of Vascular Surgery Inc. Published online: February 10, 2012
disorder. He was not taking any medication, and he had quit smoking 6 years earlier. His hemoglobin dropped from 12.7 to 10.7 g/dL within 1 day of presentation, and an initial computed tomography (CT) scan showed a dense area of fluid and edema in the upper mesentery. He was then transferred to our hospital for further management. Both his thromboplastin time and prothrombin ratio were within the normal ranges. Liver function tests, along with amylase and lipase, were also unremarkable. Repeat 3-phase CT scan suggested an aneurysm arising from either the MCA or the pancreaticoduodenal artery, as shown in Figure 1. CT angiography confirmed a markedly abnormal MCA with dissection and beading as well as a pseudoaneurysm over a long segment (Fig. 2). Mesenteric embolization was initially attempted through the inferior mesenteric artery and marginal artery; however, a microcatheter was unable to pass the splenic flexure because of the small caliber of the marginal artery at this point. An additional attempt was made to traverse the MCA with a microcatheter, but this method proved to be unsuccessful. This procedure was abandoned because, at this stage, it had been attempted for 3 hours. An elective laparoscopy was then performed, revealing a large mesocolic hematoma. The procedure was converted to the open approach. A 6 6 cm hematoma was found in situ, extending to the root of the superior mesenteric artery. The abnormal MCA and the transverse colon were resected. Microscopically, there was hemorrhage, cholesterol clefting, and fat necrosis, with multinucleate foreign bodyetype giant cells within the fat of the aneurysmal wall. No other features were noted.
571.e1
571.e2 Case reports
Fig. 1. Abdominal computed tomography (CT). The axial view of the CT scan shows dense fluid and edema. The arrow points to the bleeding aneurysm.
Fig. 2. Catheter-based angiogram. It shows tortuous middle colic artery with beading and an aneurysm. Postoperatively, the patient’s recovery was uneventful, with the hemoglobin level gradually returning to normal.
DISCUSSION The true incidence of MCA aneurysms is unknown. They represent fewer than 3% of visceral aneurysms, which are collectively uncommon.2 Clinically, they are usually considered as a clinical entity together with other mesenteric artery aneurysms. However, this study focused on examining the causes and the management of MCA aneurysms. A summary of previous cases is illustrated in Table I. Based on previously published data, patients
Annals of Vascular Surgery
with ruptured MCA aneurysms typically presented with acute abdominal pain associated with nausea, vomiting, and a sudden decrease in the hemoglobin level. They generally resembled patients who have mesenteric infarction or a perforated gastric ulcer. Occasionally, an MCA aneurysm can present as subacute intermittent abdominal pain of up to 6 months’ duration if there is a slow leak or a warning bleed.14 Therefore, a high index of suspicion and utilization of CT and angiography are paramount in detecting the disease. In particular, superior mesenteric angiogram has been used to make the diagnosis in recent years.12 A diagnostic imaging algorithm is suggested in Figure 3. As Table I shows, 12 of 26 cases were female, with a median age of 62 years. Among those women, four of the specimens showed necrotizing arteritis, three cases were idiopathic, and one appeared to be caused by tuberculosis; and histological details were not provided in the reports for the other four specimens. The men affected had a median age of 61 years. Of these cases, one was caused by a1antitrypsin deficiency, another one seemed to be related to tuberculosis, two were due to polyarteritis nodosa, and three were associated with hypertension. However, the exact blood pressure was often not stated in the reports. In terms of management, five patients were treated by transcatheter embolization, and the remaining patients underwent laparotomy, arterial resection, or ligation, with or without colectomy. Both approaches showed satisfactory postoperative and long-term results. It is noteworthy that the patient who was managed with intravenous antibiotics and hydrocortisone died only 5 hours after the onset of abdominal pain.27 In addition, as a negative publication bias likely exists against mesenteric aneurysms treated with poor outcomes, more study is required before generalizing favorable outcomes reported with surgical and embolization management in existing literature. The etiology and natural history of MCA aneurysm remain a mystery. Atherosclerosis and hypertension have been suggested to be associated; however, a link to abdominal aortic aneurysms has rarely been described.26 Patients with previous endocarditis, tuberculosis, a1-antitrypsin deficiency, segmental arterial mediolysis, fibrodysplasia, and vasculitis may present with recurrent or multiple visceral aneurysms.7,14,28 One patient who had an aneurysmal MCA also had Marfan syndrome, although the histology of the aneurysm showed no connection to Marfan syndrome.4 It has been suggested that the threshold for treating asymptomatic lesions should be an aneurysmal
Age, sex
Comorbidities
Chief symptoms
Management
13
19, F
Tuberculosis
24
32, M
Marfan syndrome
Abdominal pain of 6 mo duration Sudden abdominal pain, shock
35
37, F
PAN, emphysema
46
38, F
SLE, hypertension
57
44, F
Arterial fibrodysplasia
68
51, M
Hypertension, tuberculosis
79
51, F
Rheumatoid arthritis
810
52, M
Lower abdominal pain
911
53, M
Emphysema, a1-antitrypsin deficiency Nil
Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial ligation Laparotomy, arterial resection, and transverse colectomy Laparotomy and arterial resection
1012
56, M
Abdominal pain
112
57, M
Hypertension, chronic bronchitis, renal calculi Nil
1212
61, M
1313
62, F
Lower back pain, nausea, and vomiting Sudden abdominal pain, nonbloody diarrhea, collapse Shock
Abdominal pain of 6 d duration Sudden abdominal pain
Periumbilical colicky pain
Long-term complications (>6 mo)
Histopathology
Nil
Nil
N/A
N/A
N/A
NAD and no features of Marfan
Nil
Nil
Nil
Nil
Features of necrotizing arteritis NAD and no features of SLE
Nil
Nil
Medial dysplasia consistent with fibrodysplasia
Nil
Nil
Respiratory infection
Nil
N/A
Nil
False aneurysm in the specimen Arterial wall necrosis with neutrophil infiltration, consistent with arteritis Elastin degeneration
Laparotomy, arterial N/A resection, and transverse colectomy Laparotomy and arterial Nil resection
N/A
Nil
A mixture of a pseudoaneurysm and true aneurysms N/A
Transcatheter microcoil Nil embolization N/A Laparotomy, arterial resection, and transverse colectomy
Nil
N/A
Well-controlled hypertension
Severe abdominal pain, diarrhea Abdominal pain, nausea, and vomiting
N/A
Hypercholesterolemia, hypertension, diverticulosis
Periumbilical severe and intermittent pain, nausea, and vomiting
Laparotomy and arterial resection
Nil
Acute arteritis with complete destruction of the wall, and extensive inflammatory reaction Idiopathic thinning of the arterial wall
Nil
(Continued)
Case reports 571.e3
Patient
Perioperative complications
Vol. 26, No. 4, May 2012
Table I. Summary of published cases of MCA aneurysms
Perioperative complications
Long-term complications (>6 mo)
Patient
Age, sex
Comorbidities
Chief symptoms
Management
1414
62, M
PAN
Sudden severe abdominal pain
Laparotomy and ligation of Nil the MCA
N/A
1515
64, F
Rheumatoid arthritis
Abdominal pain
Nil
1616
68, M
1717
69, F
Renal clear cell carcinoma Rheumatoid arthritis, PAN, bilateral breast cancer
Umbilical and right lower abdominal pain Dyspnea, epigastric pain, nausea and vomiting
Laparotomy, arterial Nil resection, and transverse colectomy Laparotomy and arterial Nil resection N/A IV penicillin, chloromycetin, and hydrocortisone
1818
69, F
N/A
Abdominal pain
1919
69, F
2020
70, M
Hypertension, diverticulosis N/A
2121
72, F
Well-controlled hypertension
2222
73, M
Acute pancreatitis
2323
75, M
Atherosclerosis
2424
76, F
Previous right hemicolectomy and ligation of the inferior mesenteric artery during open abdominal aortic aneurysm repair
Sudden massive melaena Transcatheter microcoil and loss of consciousness embolization
Transmural fibrinoid necrosis of the vessel wall, consistent with acute states of PAN Microscopic appearance consistent with PAN
Nil
Attenuated tunica intima and tunica media Died 5 hr after Postmortem: fibrinoid the onset of necrosis, disruption of abdominal elastic fiber, and cellular pain infiltration with neutrophils, consistent with PAN Nil N/A
Nil
Nil
N/A
Nil
Nil
N/A
Nil
Nil
N/A
Nil
Nil
Pseudoaneurysm
Nil
Died a week later from bronchopneumonia Nil
N/A
Nil
Nil
N/A
Annals of Vascular Surgery
Transcatheter microcoil embolization 48-hr history of abdominal Laparotomy and arterial pain and nausea ligation Abdominal pain Laparotomy, arterial resection, and transverse colectomy Dyspepsia and epigastric Endoaneurysmectomy discomfort with a short segment of stretch ultrathin PTFE interposition Epigastric pain Transcatheter microcoil embolization Abdominal pain Laparotomy and arterial and vomiting ligation
Histopathology
571.e4 Case reports
Table I. Continued
Case reports 571.e5
MCA, middle colic artery; F, female; M, male; N/A, not available; NAD, no abnormality detected; SLE, systemic lupus erythematosus; PAN, periarteritis nodosa; PTFE, polytetrafluoroethylene.
Nil Nil Aneurysmectomy and patch closure with autologous vein N/A, M N/A 2626
N/A
Nil 78, M 2525
Renal calculi, gout
Abdominal pain (6 d), nausea, and diarrhea
Laparotomy, arterial resection, and right hemicolectomy
Nil
Destruction of tunica interna and media, no definitive evidence of atherosclerosis or arteritis N/A
Vol. 26, No. 4, May 2012
Fig. 3. Diagnostic imaging algorithm. In the setting of a suspected mesenteric aneurysm, CT is more sensitive than abdominal X-ray at detecting bleeding. Angiography is the gold standard at delineating the aneurysm.
diameter of >2 cm, above which, ruptures occur frequently. Elective open surgical repair was shown to give satisfactory results in both the perioperative and long-term periods.21,26 The exception to this could be in cases of aneurysms caused by autoimmune etiologies, which were reported to resolve after high-dose prednisone treatment.15 With the advent of the minimally invasive endovascular approach in recent years, coil embolization and stent-graft repair provide an effective alternative way to treat MCA aneurysms, especially if the aneurysm is small.2 The success rate for embolizing visceral arteries was reported to be 98% for 48 procedures in one study.29 Tajima et al. reported a case in which a 76-year-old woman had a ruptured MCA on a background of previous right hemicolectomy and ligation of the inferior mesenteric artery for open abdominal aortal aneurysm repair. A microballoon occlusion test was performed first to predict postembolization colonic ischemia risk; the patient was then successfully treated by coil embolization.24 However, coil embolization poses the risk of incomplete exclusion of the aneurysm, bowel ischemia, and aneurysm ruptures. In addition, considering the common tortuosity of the vessel, endovascular
571.e6 Case reports
repair may not be feasible.21,26 Arterial reconstruction or resection with partial colectomy may be necessary if large segments of the arteries are involved and the viability of the bowel is dubious. Overall, the management of MCA aneurysm may require input from interventional radiologist, vascular surgeons, and general/colorectal surgeons.
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