- Email: [email protected]
Successful Conservative Management of Inferior Mesenteric Artery Aneurysm with Arteriovenous Fistula: A Case Report
Journal Pre-proof Successful Conservative Management of Inferior Mesenteric Artery Aneurysm with Arteriovenous Fistula: A Case Report Shingo Kunioka, Hiroto Kitahara, Noriyuki Yuasa, Miri Fujita, Norifumi Otani, Hiroyuki Kamiya PII:
S0890-5096(19)30922-7
DOI:
https://doi.org/10.1016/j.avsg.2019.10.067
Reference:
AVSG 4729
To appear in:
Annals of Vascular Surgery
Received Date: 27 November 2018 Revised Date:
5 September 2019
Accepted Date: 2 October 2019
Please cite this article as: Kunioka S, Kitahara H, Yuasa N, Fujita M, Otani N, Kamiya H, Successful Conservative Management of Inferior Mesenteric Artery Aneurysm with Arteriovenous Fistula: A Case Report, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.067. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
1
Successful Conservative Management of Inferior Mesenteric Artery Aneurysm
2
with Arteriovenous Fistula: A Case Report
3 4
Shingo Kunioka1, Hiroto Kitahara2, Noriyuki Yuasa3, Miri Fujita4, Norifumi Otani5,
5
Hiroyuki Kamiya2
6 7
1
8
Japan
9
2
Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
10
3
Department of Radiology, Steel Memorial Muroran Hospital, Hokkaido, Japan
11
4
Department of Pathology, Steel Memorial Muroran Hospital, Hokkaido, Japan
12
5
Department of Cardiovascular Surgery, Sapporo Teishinkai Hospital, Hokkaido, Japan
Department of Cardiovascular Surgery, Steel Memorial Muroran Hospital, Hokkaido,
13 14
Corresponding author: Hiroto Kitahara, MD
15
Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi
16
2-1-1-1, Asahikawa 078-8510, Japan
17
Tel: +81-166-68-2490; Fax: +81-166-68-2499; E-mail: [email protected]
18 19 20 21 22
23
Abstract
24
Inferior mesenteric artery (IMA) aneurysm is a rare occurrence, accounting for
25
1% of all visceral artery aneurysms and is often found incidentally. Surgical resection
26
and endovascular intervention have been first-line treatments because IMA aneurysms
27
have a relatively high risk of life-threatening rupture. Herein, we report the case of a
28
57-year-old man having a large IMA aneurysm with an arteriovenous fistula that was
29
treated conservatively. The IMA aneurysm was incidentally found using computed
30
tomography (CT) and was connected to the splenic vein through the abnormally dilated
31
tortuous vessels of an arteriovenous fistula. Surgical resection was planned initially;
32
however, preoperative follow-up CT revealed that the aneurysm had shrunk with the
33
growth of an intraluminal thrombus. Subsequently, the condition was conservatively
34
managed with serial CT follow-up. Two years after the first visit, the aneurysm had
35
shrunk and been completely replaced with a thrombus.
36 37 38 39 40 41 42 43 44 45 46
47
Introduction
48
We rarely encounter aneurysms, particularly inferior mesenteric artery (IMA)
49
aneurysms, in abdominal visceral arteries. Traditionally, distribution of aneurysms in
50
visceral arteries involves the splenic artery (60%), hepatic artery (20%), superior
51
mesenteric artery (6%), celiac artery (4%), gastric and gastroepiploic arteries (4%),
52
jejunal and ileocolic arteries (3%), pancreatic duodenal and pancreatic arteries (2%),
53
gastroduodenal artery (1.5%), and IMA (<1%).1 Edogawa et al. reviewed 54 IMA
54
aneurysm case reports worldwide and recommended aneurysm repair if the aneurysm’s
55
size exceeded 2 cm at the proximal or 1 cm at the distal IMA, due to increased risk of
56
rupture.2 However, because of IMA aneurysms’ rarity, definitive surgical indication does
57
not yet exist. We experienced an extremely rare case of a large IMA aneurysm with an
58
arteriovenous fistula (AVF), which was successfully managed conservatively with serial
59
computed tomography (CT) follow-up.
60 61
Case Report
62
A 57-year-old man with a history of ulcerative colitis (UC) but no history of
63
abdominal surgery or trauma was referred to our institution. He had been treated with
64
mesalazine (1500 mg/day), and the UC was relatively under control. During imaging
65
work-up, abdominal ultrasonography incidentally found a bulky mass in the pelvis.
66
Contrast-enhanced CT revealed an aneurysm 50 mm × 43 mm in size in the terminal
67
IMA, with abnormal tortuous vessels with tumor-like expansions (69 mm) arising from
68
the aneurysm and flowing into the splenic vein as AVFs (Figure 1). Initially, we
69
considered surgical resection for the IMA aneurysm; however, preoperative follow-up
70
CT showed that the aneurysm had shrunk with intraluminal thrombus (ILT) growth. The
71
man did not have any AVF-related symptoms, such as abdominal pain, gastrointestinal
72
bleeding, colonic ischemia, or portal hypertension. Serial short-interval follow-up CT
73
found the aneurysm and dilated vein shrinking were gradually being replaced with a
74
thrombus (Figure 2). After 2 years, the aneurysm had shrunk to 48 mm × 31 mm and
75
completely changed into a thrombus, entirely enclosing the AVF. The treatment course
76
was uneventful and without any abdominal symptoms, and the latest follow-up CT (5
77
years after the first visit) showed no significant changes (Figure 3).
78 79 80
Discussion
81
We experienced an extremely rare case of IMA aneurysm with an AVF that was
82
managed conservatively without any intervention. To our knowledge, there has been no
83
case report on the spontaneous enclosure of an inferior mesenteric AVF and constructive
84
regression of an IMA aneurysm.
85
IMA aneurysms are rare, accounting for < 1 % of all visceral artery
86
aneurysms.1 They were originally reported by Duke et al., and were treated with
87
surgical vascular reconstruction consisting of bilateral aorto-femoral bypass and a left
88
profunda femoris artery angioplasty; additionally, the IMA was anastomosed into the
89
left limb of a bifurcated graft. Edogawa et al. investigated 22 patients with IMA
90
aneurysm, and found out that atherosclerotic disease was the most common cause of
91
IMA aneurysm.
92
They are often asymptomatic and discovered incidentally with evaluation for
93
other intra-abdominal pathologies. The main etiology of IMA aneurysm is
94
atherosclerotic disease; other reported causes include mycosis, polyarteritis nodosa,
95
dissecting hematoma, Takayasu disease, and tuberculosis.2 In our case, the IMA
96
aneurysm was found incidentally during UC work-up. There are a few studies
97
investigating UC and related vascular disease. Imamura et al. reported a case of
98
coexisting arteritis in a patient with UC. 4 Zancoli et al. reported that inflammatory
99
bowel disease such as UC might affect endothelial function and arterial stiffness and
100
might cause vascular disease.5 Although there has been no report regarding the
101
relationship between UC and IMA aneurysm, regression of UC might have contributed
102
to the IMA aneurysm or AVF in our case.
103
The true prevalence of IMA aneurysm remains unknown. The risk of IMA
104
aneurysm rupture, a life-threatening complication in visceral artery aneurysms, has been
105
reported to be 20 % - 50 %.1 Edogawa et al. suggested that IMA aneurysm size greater
106
than 2 cm at the proximal or 1 cm at the distal IMA should be treated surgically,
107
considering the risk of rupture.2 As the size of the IMA aneurysm in our case was
108
greater than 5 cm, we planned surgical intervention, however, serial follow-up CT
109
showed continuous growth of an ILT concomitant with the shrinking of the aneurysm
110
incidentally, which changed our management plan.
111
The effect of an ILT on aneurysm rupture risk is controversial. Haller et al.
112
reported that ILTs were associated with early rupture of abdominal aortic aneurysms6. In
113
contrast, Thubrikar et al. suggested that an ILT might prevent aneurysm rupture through
114
diminishing wall strain, even though the thrombus allows transmission of luminal
115
pressure to the aneurysm wall.7 Klausner et al. reviewed cases of asymptomatic renal
116
artery aneurysms treated conservatively for a mean follow-up of 36 ± 9 months with no
117
late complications or mortality.8 In our case, serial follow-up CT showed continuous
118
growth of an ILT concomitant with the shrinking of the aneurysm. ILTs in IMA
119
aneurysms may be associated with spontaneous recovery of the aneurysms, in which
120
case patients could be managed with imaging follow-up only, however, further studies
121
will be needed to detect predictors of low rupture risk and spontaneous recovery.
122
Coexisting AVFs might also play an important role in the spontaneous recovery
123
of IMA aneurysms. An AVF is an abnormal communication or passage between an
124
artery and a vein. An inferior mesenteric AVF acts as a left-to-right shunt causing the
125
pathophysiologic alteration of bowel function and manifesting with various symptoms
126
such as abdominal pain, abdominal mass with thrill, upper or lower gastrointestinal
127
bleeding, portal hypertension, ischemic colitis, and cardiac failure.9-11 A previous
128
mini-review of literature reported 17 congenital and 13 acquired inferior mesenteric
129
AVF cases; the mean age of patients was 58 years, and 67.7% of the patients were
130
male.11 Inferior mesenteric AVFs can have congenital, acquired (iatrogenic or traumatic),
131
or idiopathic etiology.9 In our case, the cause of the inferior mesenteric AVF might have
132
been a spontaneous rupture of a preexisting IMA aneurysm into the inferior mesenteric
133
vein as previously reported.12 Koen et al. reported the conservative management of
134
persistent aortocaval fistulas after endovascular aortic repair, suggesting that different
135
pressure dynamics caused by the AVF directly communicating with the low-pressure
136
venous system lowered the pressure in the aneurysmal sac and enhanced its
137
remodeling.13 In the present case, coexisting AVF might allow the IMA aneurysm to
138
drain in a relatively low-pressure venous system, resulting in spontaneous recovery of
139
the aneurysm and enclosing of the AVF itself, more studies were needed to investigate
140
this phenomenon.
141
The optimal management of IMA aneurysm is controversial. Shanley et al.
142
reviewed various treatments options for IMA aneurysm including aneurysmectomy,
143
bypass/revascularization, ligation, aneurysmorrhaphy and embolization.14 Jesus-Silva
144
et al. reported a successful management of giant IMA aneurysm with embolization.15 In
145
this case, IMA catheterization was performed with Simmons II catheter, followed by
146
implantation of two Interlock-18 pushable microcoils (Boston Scientific, Natrick, MA,
147
USA) in a small dilation before its out flow branch and five Interlock-35 pushable coils
148
in the aneurysm lumen. In our case, the aneurysm existed distal of the IMA,
149
embolization might be one of the appropriate treatments if the aneurysms are enlarged
150
in the follow up period.
151 152
Conclusion
153
We experienced an extremely rare case of IMA aneurysm with an AVF that was
154
successfully managed conservatively. Large IMA aneurysms should be treated with
155
surgical or endovascular intervention; however, conservative management may be a
156
treatment option in select cases of coexisting AVFs and ILTs.
157 158
Figure Legends
159
Figure 1. Contrast-enhanced computed tomography findings. Three-dimensional
160
reconstruction shows an inferior mesenteric artery aneurysm (white arrowhead) (A) and
161
dilated vein (white arrow) (B). Coronal plane (C).
162 163
Figure 2. Serial follow-up computed tomography findings. Inferior mesenteric artery
164
aneurysm (white arrowhead) and dilated vein (white arrow). The diameter of the
165
inferior mesenteric artery aneurysm had been continuously shrinking: first visit, 50 mm
166
× 43 mm (A); second visit, 48 mm × 41 mm (B); and 2 years after the first visit, 48 mm
167
× 31 mm (C).
168 169
Figure 3. Computed tomography findings 5 years after the first visit. Three-dimensional
170
reconstruction shows a normal inferior mesenteric artery and vein (A). The IMA
171
aneurysm (white arrowhead) and dilated vein (white arrow) completely became a
172
thrombus (B).
173
References
174
1. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am. 1997; 77:
175 176 177 178 179
425-42. 2. Edogawa S, Shibuya T, Kurose K, et al. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis. 2013; 6: 98-101. 3. Duke LJ, Lamberth WC Jr, Wright CB. Inferior mesenteric artery aneurysm: Case report and discussion. Surgery.1979;85:385-387.
180
4. Imamura R, Hayashi K, Sada KE, et al. Hemoptysis originating from the bronchial
181
artery in Takayasu arteritis with ulcerative colitis. Intern Med. 2018. [Epub ahead of
182
print]. doi: 10.2169/internalmedicine.1463-18.
183 184
5. Zancoli L, Rastelli S, Inserra G, et al. Arterial structure and function in inflammatory bowel disease. World J Gastroenterol. 2015; 28: 11304-11.
185
6. Haller SJ, Crawford JD, Courchaine KM, et al. Intraluminal thrombus is associated
186
with early rupture of abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 1051-58.
187
7. Thubrikar MJ, Robicsek F, Lbrosse M, et al. Effect of thrombus on abdominal aortic
188 189 190 191 192
aneurysm wall dilation and stress. J Cardiovasc Surg 2003; 44: 67-77 8. Klausner JQ, Harlander-Locke MP, Plotnik AN, et al. Current treatment of renal artery aneurysms may be too aggressive. J Vasc Surg. 2014; 59: 1356-61. 9. Lee S, Chung J, Ahn B, et al. Inferior mesenteric arteriovenous fistula. Ann Surg Treat Res. 2017; 93: 255-8.
193
10. Athanasiou Am, Michalinos A, Alexandrou A, et al. Inferior mesenteric
194
arteriovenous fistula: case report and world-literature review. World J Gastroenterol.
195
2014; 20: 8298-303.
196
11. Cheng L, Zhao R, Guo D, et al. Inferior mesenteric arteriovenous fistula with
197
nonpulsatile abdominal mass: a case report and a mini-review. Medicine. 2017; 96:
198
e8717.
199 200
12. Pietri J, Remond A, Reix T, et al. Arterioportal fistulas: twelve cases. Ann Vasc Surg 1990;4:533-9.
201
13. Koen ML, Frederico BG, Ellen VR, et al. Conservative management of persistent
202
aortocaval fistula after endovascular aortic repair. J Vasc Surg. 2013; 54: 1080-3.
203
14. Shanley CJ, Shah NL, Messina LM. Uncommon splanchnic artery aneurysms:
204
pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and
205
colic. Ann Vasc Surg. 1996;10:506–15.
206
15. Jesus-Silva SG, Moraes-Silva MA, Rieira BC, Nasser F, Cardoso RS.Short- and
207
long-term follow-up after transarterial embolization of a giant inferior mesenteric
208
artery aneurysm.J Vasc Surg Cases Innov Tech. 2018;4:315-318.
S0890-5096(19)30922-7
DOI:
https://doi.org/10.1016/j.avsg.2019.10.067
Reference:
AVSG 4729
To appear in:
Annals of Vascular Surgery
Received Date: 27 November 2018 Revised Date:
5 September 2019
Accepted Date: 2 October 2019
Please cite this article as: Kunioka S, Kitahara H, Yuasa N, Fujita M, Otani N, Kamiya H, Successful Conservative Management of Inferior Mesenteric Artery Aneurysm with Arteriovenous Fistula: A Case Report, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.067. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
1
Successful Conservative Management of Inferior Mesenteric Artery Aneurysm
2
with Arteriovenous Fistula: A Case Report
3 4
Shingo Kunioka1, Hiroto Kitahara2, Noriyuki Yuasa3, Miri Fujita4, Norifumi Otani5,
5
Hiroyuki Kamiya2
6 7
1
8
Japan
9
2
Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
10
3
Department of Radiology, Steel Memorial Muroran Hospital, Hokkaido, Japan
11
4
Department of Pathology, Steel Memorial Muroran Hospital, Hokkaido, Japan
12
5
Department of Cardiovascular Surgery, Sapporo Teishinkai Hospital, Hokkaido, Japan
Department of Cardiovascular Surgery, Steel Memorial Muroran Hospital, Hokkaido,
13 14
Corresponding author: Hiroto Kitahara, MD
15
Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi
16
2-1-1-1, Asahikawa 078-8510, Japan
17
Tel: +81-166-68-2490; Fax: +81-166-68-2499; E-mail: [email protected]
18 19 20 21 22
23
Abstract
24
Inferior mesenteric artery (IMA) aneurysm is a rare occurrence, accounting for
25
1% of all visceral artery aneurysms and is often found incidentally. Surgical resection
26
and endovascular intervention have been first-line treatments because IMA aneurysms
27
have a relatively high risk of life-threatening rupture. Herein, we report the case of a
28
57-year-old man having a large IMA aneurysm with an arteriovenous fistula that was
29
treated conservatively. The IMA aneurysm was incidentally found using computed
30
tomography (CT) and was connected to the splenic vein through the abnormally dilated
31
tortuous vessels of an arteriovenous fistula. Surgical resection was planned initially;
32
however, preoperative follow-up CT revealed that the aneurysm had shrunk with the
33
growth of an intraluminal thrombus. Subsequently, the condition was conservatively
34
managed with serial CT follow-up. Two years after the first visit, the aneurysm had
35
shrunk and been completely replaced with a thrombus.
36 37 38 39 40 41 42 43 44 45 46
47
Introduction
48
We rarely encounter aneurysms, particularly inferior mesenteric artery (IMA)
49
aneurysms, in abdominal visceral arteries. Traditionally, distribution of aneurysms in
50
visceral arteries involves the splenic artery (60%), hepatic artery (20%), superior
51
mesenteric artery (6%), celiac artery (4%), gastric and gastroepiploic arteries (4%),
52
jejunal and ileocolic arteries (3%), pancreatic duodenal and pancreatic arteries (2%),
53
gastroduodenal artery (1.5%), and IMA (<1%).1 Edogawa et al. reviewed 54 IMA
54
aneurysm case reports worldwide and recommended aneurysm repair if the aneurysm’s
55
size exceeded 2 cm at the proximal or 1 cm at the distal IMA, due to increased risk of
56
rupture.2 However, because of IMA aneurysms’ rarity, definitive surgical indication does
57
not yet exist. We experienced an extremely rare case of a large IMA aneurysm with an
58
arteriovenous fistula (AVF), which was successfully managed conservatively with serial
59
computed tomography (CT) follow-up.
60 61
Case Report
62
A 57-year-old man with a history of ulcerative colitis (UC) but no history of
63
abdominal surgery or trauma was referred to our institution. He had been treated with
64
mesalazine (1500 mg/day), and the UC was relatively under control. During imaging
65
work-up, abdominal ultrasonography incidentally found a bulky mass in the pelvis.
66
Contrast-enhanced CT revealed an aneurysm 50 mm × 43 mm in size in the terminal
67
IMA, with abnormal tortuous vessels with tumor-like expansions (69 mm) arising from
68
the aneurysm and flowing into the splenic vein as AVFs (Figure 1). Initially, we
69
considered surgical resection for the IMA aneurysm; however, preoperative follow-up
70
CT showed that the aneurysm had shrunk with intraluminal thrombus (ILT) growth. The
71
man did not have any AVF-related symptoms, such as abdominal pain, gastrointestinal
72
bleeding, colonic ischemia, or portal hypertension. Serial short-interval follow-up CT
73
found the aneurysm and dilated vein shrinking were gradually being replaced with a
74
thrombus (Figure 2). After 2 years, the aneurysm had shrunk to 48 mm × 31 mm and
75
completely changed into a thrombus, entirely enclosing the AVF. The treatment course
76
was uneventful and without any abdominal symptoms, and the latest follow-up CT (5
77
years after the first visit) showed no significant changes (Figure 3).
78 79 80
Discussion
81
We experienced an extremely rare case of IMA aneurysm with an AVF that was
82
managed conservatively without any intervention. To our knowledge, there has been no
83
case report on the spontaneous enclosure of an inferior mesenteric AVF and constructive
84
regression of an IMA aneurysm.
85
IMA aneurysms are rare, accounting for < 1 % of all visceral artery
86
aneurysms.1 They were originally reported by Duke et al., and were treated with
87
surgical vascular reconstruction consisting of bilateral aorto-femoral bypass and a left
88
profunda femoris artery angioplasty; additionally, the IMA was anastomosed into the
89
left limb of a bifurcated graft. Edogawa et al. investigated 22 patients with IMA
90
aneurysm, and found out that atherosclerotic disease was the most common cause of
91
IMA aneurysm.
92
They are often asymptomatic and discovered incidentally with evaluation for
93
other intra-abdominal pathologies. The main etiology of IMA aneurysm is
94
atherosclerotic disease; other reported causes include mycosis, polyarteritis nodosa,
95
dissecting hematoma, Takayasu disease, and tuberculosis.2 In our case, the IMA
96
aneurysm was found incidentally during UC work-up. There are a few studies
97
investigating UC and related vascular disease. Imamura et al. reported a case of
98
coexisting arteritis in a patient with UC. 4 Zancoli et al. reported that inflammatory
99
bowel disease such as UC might affect endothelial function and arterial stiffness and
100
might cause vascular disease.5 Although there has been no report regarding the
101
relationship between UC and IMA aneurysm, regression of UC might have contributed
102
to the IMA aneurysm or AVF in our case.
103
The true prevalence of IMA aneurysm remains unknown. The risk of IMA
104
aneurysm rupture, a life-threatening complication in visceral artery aneurysms, has been
105
reported to be 20 % - 50 %.1 Edogawa et al. suggested that IMA aneurysm size greater
106
than 2 cm at the proximal or 1 cm at the distal IMA should be treated surgically,
107
considering the risk of rupture.2 As the size of the IMA aneurysm in our case was
108
greater than 5 cm, we planned surgical intervention, however, serial follow-up CT
109
showed continuous growth of an ILT concomitant with the shrinking of the aneurysm
110
incidentally, which changed our management plan.
111
The effect of an ILT on aneurysm rupture risk is controversial. Haller et al.
112
reported that ILTs were associated with early rupture of abdominal aortic aneurysms6. In
113
contrast, Thubrikar et al. suggested that an ILT might prevent aneurysm rupture through
114
diminishing wall strain, even though the thrombus allows transmission of luminal
115
pressure to the aneurysm wall.7 Klausner et al. reviewed cases of asymptomatic renal
116
artery aneurysms treated conservatively for a mean follow-up of 36 ± 9 months with no
117
late complications or mortality.8 In our case, serial follow-up CT showed continuous
118
growth of an ILT concomitant with the shrinking of the aneurysm. ILTs in IMA
119
aneurysms may be associated with spontaneous recovery of the aneurysms, in which
120
case patients could be managed with imaging follow-up only, however, further studies
121
will be needed to detect predictors of low rupture risk and spontaneous recovery.
122
Coexisting AVFs might also play an important role in the spontaneous recovery
123
of IMA aneurysms. An AVF is an abnormal communication or passage between an
124
artery and a vein. An inferior mesenteric AVF acts as a left-to-right shunt causing the
125
pathophysiologic alteration of bowel function and manifesting with various symptoms
126
such as abdominal pain, abdominal mass with thrill, upper or lower gastrointestinal
127
bleeding, portal hypertension, ischemic colitis, and cardiac failure.9-11 A previous
128
mini-review of literature reported 17 congenital and 13 acquired inferior mesenteric
129
AVF cases; the mean age of patients was 58 years, and 67.7% of the patients were
130
male.11 Inferior mesenteric AVFs can have congenital, acquired (iatrogenic or traumatic),
131
or idiopathic etiology.9 In our case, the cause of the inferior mesenteric AVF might have
132
been a spontaneous rupture of a preexisting IMA aneurysm into the inferior mesenteric
133
vein as previously reported.12 Koen et al. reported the conservative management of
134
persistent aortocaval fistulas after endovascular aortic repair, suggesting that different
135
pressure dynamics caused by the AVF directly communicating with the low-pressure
136
venous system lowered the pressure in the aneurysmal sac and enhanced its
137
remodeling.13 In the present case, coexisting AVF might allow the IMA aneurysm to
138
drain in a relatively low-pressure venous system, resulting in spontaneous recovery of
139
the aneurysm and enclosing of the AVF itself, more studies were needed to investigate
140
this phenomenon.
141
The optimal management of IMA aneurysm is controversial. Shanley et al.
142
reviewed various treatments options for IMA aneurysm including aneurysmectomy,
143
bypass/revascularization, ligation, aneurysmorrhaphy and embolization.14 Jesus-Silva
144
et al. reported a successful management of giant IMA aneurysm with embolization.15 In
145
this case, IMA catheterization was performed with Simmons II catheter, followed by
146
implantation of two Interlock-18 pushable microcoils (Boston Scientific, Natrick, MA,
147
USA) in a small dilation before its out flow branch and five Interlock-35 pushable coils
148
in the aneurysm lumen. In our case, the aneurysm existed distal of the IMA,
149
embolization might be one of the appropriate treatments if the aneurysms are enlarged
150
in the follow up period.
151 152
Conclusion
153
We experienced an extremely rare case of IMA aneurysm with an AVF that was
154
successfully managed conservatively. Large IMA aneurysms should be treated with
155
surgical or endovascular intervention; however, conservative management may be a
156
treatment option in select cases of coexisting AVFs and ILTs.
157 158
Figure Legends
159
Figure 1. Contrast-enhanced computed tomography findings. Three-dimensional
160
reconstruction shows an inferior mesenteric artery aneurysm (white arrowhead) (A) and
161
dilated vein (white arrow) (B). Coronal plane (C).
162 163
Figure 2. Serial follow-up computed tomography findings. Inferior mesenteric artery
164
aneurysm (white arrowhead) and dilated vein (white arrow). The diameter of the
165
inferior mesenteric artery aneurysm had been continuously shrinking: first visit, 50 mm
166
× 43 mm (A); second visit, 48 mm × 41 mm (B); and 2 years after the first visit, 48 mm
167
× 31 mm (C).
168 169
Figure 3. Computed tomography findings 5 years after the first visit. Three-dimensional
170
reconstruction shows a normal inferior mesenteric artery and vein (A). The IMA
171
aneurysm (white arrowhead) and dilated vein (white arrow) completely became a
172
thrombus (B).
173
References
174
1. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am. 1997; 77:
175 176 177 178 179
425-42. 2. Edogawa S, Shibuya T, Kurose K, et al. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis. 2013; 6: 98-101. 3. Duke LJ, Lamberth WC Jr, Wright CB. Inferior mesenteric artery aneurysm: Case report and discussion. Surgery.1979;85:385-387.
180
4. Imamura R, Hayashi K, Sada KE, et al. Hemoptysis originating from the bronchial
181
artery in Takayasu arteritis with ulcerative colitis. Intern Med. 2018. [Epub ahead of
182
print]. doi: 10.2169/internalmedicine.1463-18.
183 184
5. Zancoli L, Rastelli S, Inserra G, et al. Arterial structure and function in inflammatory bowel disease. World J Gastroenterol. 2015; 28: 11304-11.
185
6. Haller SJ, Crawford JD, Courchaine KM, et al. Intraluminal thrombus is associated
186
with early rupture of abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 1051-58.
187
7. Thubrikar MJ, Robicsek F, Lbrosse M, et al. Effect of thrombus on abdominal aortic
188 189 190 191 192
aneurysm wall dilation and stress. J Cardiovasc Surg 2003; 44: 67-77 8. Klausner JQ, Harlander-Locke MP, Plotnik AN, et al. Current treatment of renal artery aneurysms may be too aggressive. J Vasc Surg. 2014; 59: 1356-61. 9. Lee S, Chung J, Ahn B, et al. Inferior mesenteric arteriovenous fistula. Ann Surg Treat Res. 2017; 93: 255-8.
193
10. Athanasiou Am, Michalinos A, Alexandrou A, et al. Inferior mesenteric
194
arteriovenous fistula: case report and world-literature review. World J Gastroenterol.
195
2014; 20: 8298-303.
196
11. Cheng L, Zhao R, Guo D, et al. Inferior mesenteric arteriovenous fistula with
197
nonpulsatile abdominal mass: a case report and a mini-review. Medicine. 2017; 96:
198
e8717.
199 200
12. Pietri J, Remond A, Reix T, et al. Arterioportal fistulas: twelve cases. Ann Vasc Surg 1990;4:533-9.
201
13. Koen ML, Frederico BG, Ellen VR, et al. Conservative management of persistent
202
aortocaval fistula after endovascular aortic repair. J Vasc Surg. 2013; 54: 1080-3.
203
14. Shanley CJ, Shah NL, Messina LM. Uncommon splanchnic artery aneurysms:
204
pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and
205
colic. Ann Vasc Surg. 1996;10:506–15.
206
15. Jesus-Silva SG, Moraes-Silva MA, Rieira BC, Nasser F, Cardoso RS.Short- and
207
long-term follow-up after transarterial embolization of a giant inferior mesenteric
208
artery aneurysm.J Vasc Surg Cases Innov Tech. 2018;4:315-318.