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Successful resection of two simultaneous aneurysms of the superior mesenteric and right renal artery
Eur J Vasc Surg 8, 642-644 (1994)
CASE REPORT Successful Resection of Two Simultaneous Aneurysms of the Superior Mesenteric and Right Renal Artery Holger Rupprecht, Herbert Braig, Hans Schweiger and Klaus G~inther
Department of Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
Introduction
Abdominal CT-scan and digital substraction angiography showed the correct diagnosis of an Aneurysms of the superior mesenteric artery are very aneurysm of the superior mesenteric artery and the rare with an estimated incidence of 0.008 per cent. 1 right renal artery, the latter only seen on angiography After the first successful resection of such an aneu- (Figs 1 and 2). rysm in 1949 by Cooley and DeBakey2 only 13 further A laparotomy was performed through a median successful operations were performed up to 1971.3 incision and a degree of retroperitoneal fibrosis found Most of these aneurysms were mycotic associated with the vena cava and aorta tightly adherent to each with subacute bacterial endocarditis. 3 Aneurysms of other. Soft tissue and paraaortic lymph nodes were the renal artery are also uncommon with a reported taken for histologic examination: in frozen section incidence between 0.1 to 0.76 per cent. 4-7 Their there were no signs of any infection and in paraffin etiology is unclear, s-l° section only histiocytosis of the lymph node sinus, and The successful surgical treatment of a combina- slight fibrosis of fatty tissue was found. After exposing tion of an aneurysm of the superior mesenteric artery the left renal vein, retracting the pancreas upward and and the renal artery has, to our knowledge, never been dissecting the mesentery of the small intestine, a reported before. We report on a patient who under- saccular aneurysm of the superior mesenteric artery went aorto-mesenteric and aorto-renal Gore-tex 8 cm long and 4 cm diameter was found. After bypasses because of synchronous aneurysms of the right renal artery and the superior mesenteric artery, both of non-infectious etiology.
Case Report A normotensive 73-year-old man, suffering from rapidly increasing hypogastric pain radiating to the right back, was admitted with a suspected dissecting aortic aneurysm. He als~ reported postprandial pain and diarrhoea especially after big meals during the last weeks and a weight loss of about 10 kg in 6 months. The only other feature shown was an unexplaine d anemia. Please address all correspondence to: Holger Rupprecht, ChirurgischeKlinik der Universit~it Erlangen-Niirnberg,Maximilians- Fig. 1. AbdominalCT-scanshowingthe superior mesentericartery platz, 8520 Erlangen, Germany aneurysm (arrow).
0950-821X/94/050642+03$08.00/0 © 1994W. B. Saunders CompanyLtd.
Superior Mesenteric and Right Renal Artery Aneurysms
643
Fig. 3. Line-diagram of the intraoperative situation illustrating the superior mesenteric artery aneurysm (1) and the aneurysm of the right renal artery (2) with the aorto-mesenteric (3) and aorto-renal bypass (4).
Fig. 2. Digital substraction angiography showing the superior mesenteric artery aneurysm (1) and the right renal artery aneurysm (2).
retracting the left renal vein, the origin of the right renal artery was exposed with a 3 cm aneurysm attached posteriorly to the vena cava. The right hemicolon was released and retracted to the left to gain access to the right kidne~ and the suprarenal veins were ligated. An 8 m m Gore-tex prosthesis was anastomosed end-to-side to the front of the aorta, passed behind the vena cava and anastomosed end-toside to the distal renal artery which was partially excluded with a Satinsky clamp. The right renal artery was then ligated at its origin and distal to the aneurysm. Another 8 m m Gore-tex prosthesis was anastomosed end-to-side to the superior mesenteric arter~ distal to the aneurysm and end-to-side to the aorta about 1 cm cranial to the bifurcation. After this procedure the aneurysm was ligated proximally and distally and partially resected. Histological examination of the wall of the aneurysm showed no evidence of a n y infection. Fig. 3 illustrates the intraoperative
situation showing both aneurysms and both bypasses. On the eighth postoperative d a y routine digital substraction angiography showed a partial thrombosis of the aorto-mesenteric bypass. Through a transverse graft incision thrombus was extracted with the help of a Fogarty catheter. Clinically flow in both directions was excellent and the incision was closed. The patient recovered well without complications and was discharged 4 weeks after the first operation. After unsatisfactory weight gain his persistent anemia was found to be due to acute myeloid leucaemia from which the patient died one year later.
Discussion
The aetiology of mesenteric and renal artery aneurysms are thought to be different. Sixty per cent of mesenteric aneurysms are said to be mycotic and 20% atherosclerotic. 11 Renal artery aneurysms have been classified into four types by Poutasse: (1) the saccular aneurysm with secondary atherosclerotic features which is the most common; (2) the poststenotic fusiform type, most frequently associated with fibromuscular dysplasia; (3) the dissecting aneurysm; and (4) the false aneurysm. 1°" 13, 14 Renal artery aneurysms are often associated with abdominal or flank pam and hypertension, while superior mesenteric artery aneurysms can cause epigastric discomfort and sometimes abdominal angina. However, both types of aneurysms m a y be asymptomatic and the first presentation m a y be rupture. A pulsatile abdominal mass m a y be present in nearly Eur J Vasc Surg Vol 8, September 1994
644
H. Rupprecht et aL
50% of superior mesenteric artery aneurysms. 11 Clinically this is often mistaken for an aortic aneurysm but CT-scan or angiography reveals the true diagnosis. The indication for surgical treatment is controversial and except for pain and acute rupture exact criteria for surgical intervention are not well defined. Operative treatment of renal artery aneurysms should be performed in cases of arterial hypertension with elevated renal vein renin and abnormal renal split function.1° Furthermore patients with rapidly enlarging saccular aneurysms or with a diameter of more than 2 cm, should be repaired because of the risk of rupture. 1° False and dissecting aneurysms should also be repaired immediately.1° For women of childbearing age operation should be considered, because of the danger of rupture during pregnancy.9"~2 Hupp states that all renal artery aneurysms should be resected because of the possibility of microembolism causing fixed renal hypertension. 7 Surgical treatment of superior mesenteric artery aneurysms also appears justified in light of the seemingly common occurrence of rupture or arterial occlusion. ~1 The surgical procedures in the treatment of superior mesenteric artery aneurysms range from simple aneurysmorraphy, ligation and aneurysmal resection with or without arterial reconstruction or bypass. Sometimes resection of ischaemic bowel must be performed. Artificial material may be used if an infectious etiology has been excluded - - as it was in our case, otherwise autologous vein is to be preferred. The same principles apply to renal artery aneurysms. The possible procedures are nephrectom3~ and resection with direct reconstruction or bypass procedures. The latter may also be combined with ligation or aneurysmorraphy. The advantage of the aorto-renal bypass described is that it can be performed without or with only minimal renal ischaemia. The combination of a superior mesenteric artery aneurysm together with a renal artery aneurysm has, to our knowledge, never been published before. The diagnosis of the renal artery aneurysm alone would
Eur J Vasc Surg Vol 8, September 1994
not have been an indication to operate on this 73-yearold patient. However, it was necessary to repair the superior mesenteric artery aneurysm which was causing intestinal ischaemia. During the course of the operation we decided to also repair the renal artery aneurysm because its diameter was 3 cm. This additional procedure did not present any difficulties and the patient remained stable throughout the entire operation. References 1 GRAHAMJSr McCoLLUM CHI DEBAKEYME. Aneurysms of the splanchnic arteries. Am J Surg 1980; 140: 797-801. 2 DEBAKEY ME, COOLEY DA. Successful resection of mycotic aneurysm of superior mesenteric artery. Am Surg 1953; 19: 202-212. 3 MANDEL SR, MACFm JA, CAPPS JH. Superior mesenteric artery aneurysm: A report of the fourteenth successful case. Am Surg 1971; 32: 293-297. 4 lPPoLrro JJ/LEVEEN HH. Treatment of renal artery aneurysms. J Urol 1960; 83: 10-16. 5 THAM G, EKELUNDn~ HERRLINK, LINDSTEDTEL, OLINT, BERGENTZ S-E. Renal artery aneurysms - - natural history and prognosis. Ann Surg 1983; 197: 348-352. 6 ERDSMANG. Angionephrography and suprarenal angiography. Acta Radiol 1957; 155 (Suppl): 104-116, 7 HuPP T, ALLENBERGJR, POST K, ROEREN Tr MEIER M r CLORIUSJH. Renal artery aneurysm: surgical indications and results. Eur J Vasc Surg 1992; 6: 477-486. 8 STANSBY GPr HILSON AJW, HAMILTON G. Renovascular hypertension secondary to renal artery aneurysm detected by captopril-renography. Eur ] Vasc Surg 1991; 5: 343-346. 9 HAGEMANJH, SMITHRF, SZlLAGYIDE, ELLIOTTJP. Aneurysms of the renal artery: problems of prognosis and surgical management. Surgery 1978; 84: 563-572. 10 VAN WAY CW. Renal artery aneurysms and arteriovenous fistulas. In: RUTtmRFORD RB, ed. Vascular Surgery. 3rd ed. Philadelphia: WB Saunders Company, 1989: 1274-1285. 11 STANLEYJC, ZELENOCK GB. Splanchnic artery aneurysms. In: RUTHERFORDRB, ed. Vascular Surgery. 3rd ed. Philadelphia: W.B. Saunders Company, 1989: 969-983. 12 HUBERT JP, PAIROLEROPC, KAZMIER FJ. Solitary renal artery aneurysm. Surgery 1980; 88: 557-565. 13 POUTASSEEF. Renal artery aneurysms: Their natural history and surgery. J Urol 1966; 95: 297-306. 14 POUTASSE EF. Renal artery aneurysms. J Urol 1975; 113: 443-449.
Accepted 26 May 1993
CASE REPORT Successful Resection of Two Simultaneous Aneurysms of the Superior Mesenteric and Right Renal Artery Holger Rupprecht, Herbert Braig, Hans Schweiger and Klaus G~inther
Department of Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
Introduction
Abdominal CT-scan and digital substraction angiography showed the correct diagnosis of an Aneurysms of the superior mesenteric artery are very aneurysm of the superior mesenteric artery and the rare with an estimated incidence of 0.008 per cent. 1 right renal artery, the latter only seen on angiography After the first successful resection of such an aneu- (Figs 1 and 2). rysm in 1949 by Cooley and DeBakey2 only 13 further A laparotomy was performed through a median successful operations were performed up to 1971.3 incision and a degree of retroperitoneal fibrosis found Most of these aneurysms were mycotic associated with the vena cava and aorta tightly adherent to each with subacute bacterial endocarditis. 3 Aneurysms of other. Soft tissue and paraaortic lymph nodes were the renal artery are also uncommon with a reported taken for histologic examination: in frozen section incidence between 0.1 to 0.76 per cent. 4-7 Their there were no signs of any infection and in paraffin etiology is unclear, s-l° section only histiocytosis of the lymph node sinus, and The successful surgical treatment of a combina- slight fibrosis of fatty tissue was found. After exposing tion of an aneurysm of the superior mesenteric artery the left renal vein, retracting the pancreas upward and and the renal artery has, to our knowledge, never been dissecting the mesentery of the small intestine, a reported before. We report on a patient who under- saccular aneurysm of the superior mesenteric artery went aorto-mesenteric and aorto-renal Gore-tex 8 cm long and 4 cm diameter was found. After bypasses because of synchronous aneurysms of the right renal artery and the superior mesenteric artery, both of non-infectious etiology.
Case Report A normotensive 73-year-old man, suffering from rapidly increasing hypogastric pain radiating to the right back, was admitted with a suspected dissecting aortic aneurysm. He als~ reported postprandial pain and diarrhoea especially after big meals during the last weeks and a weight loss of about 10 kg in 6 months. The only other feature shown was an unexplaine d anemia. Please address all correspondence to: Holger Rupprecht, ChirurgischeKlinik der Universit~it Erlangen-Niirnberg,Maximilians- Fig. 1. AbdominalCT-scanshowingthe superior mesentericartery platz, 8520 Erlangen, Germany aneurysm (arrow).
0950-821X/94/050642+03$08.00/0 © 1994W. B. Saunders CompanyLtd.
Superior Mesenteric and Right Renal Artery Aneurysms
643
Fig. 3. Line-diagram of the intraoperative situation illustrating the superior mesenteric artery aneurysm (1) and the aneurysm of the right renal artery (2) with the aorto-mesenteric (3) and aorto-renal bypass (4).
Fig. 2. Digital substraction angiography showing the superior mesenteric artery aneurysm (1) and the right renal artery aneurysm (2).
retracting the left renal vein, the origin of the right renal artery was exposed with a 3 cm aneurysm attached posteriorly to the vena cava. The right hemicolon was released and retracted to the left to gain access to the right kidne~ and the suprarenal veins were ligated. An 8 m m Gore-tex prosthesis was anastomosed end-to-side to the front of the aorta, passed behind the vena cava and anastomosed end-toside to the distal renal artery which was partially excluded with a Satinsky clamp. The right renal artery was then ligated at its origin and distal to the aneurysm. Another 8 m m Gore-tex prosthesis was anastomosed end-to-side to the superior mesenteric arter~ distal to the aneurysm and end-to-side to the aorta about 1 cm cranial to the bifurcation. After this procedure the aneurysm was ligated proximally and distally and partially resected. Histological examination of the wall of the aneurysm showed no evidence of a n y infection. Fig. 3 illustrates the intraoperative
situation showing both aneurysms and both bypasses. On the eighth postoperative d a y routine digital substraction angiography showed a partial thrombosis of the aorto-mesenteric bypass. Through a transverse graft incision thrombus was extracted with the help of a Fogarty catheter. Clinically flow in both directions was excellent and the incision was closed. The patient recovered well without complications and was discharged 4 weeks after the first operation. After unsatisfactory weight gain his persistent anemia was found to be due to acute myeloid leucaemia from which the patient died one year later.
Discussion
The aetiology of mesenteric and renal artery aneurysms are thought to be different. Sixty per cent of mesenteric aneurysms are said to be mycotic and 20% atherosclerotic. 11 Renal artery aneurysms have been classified into four types by Poutasse: (1) the saccular aneurysm with secondary atherosclerotic features which is the most common; (2) the poststenotic fusiform type, most frequently associated with fibromuscular dysplasia; (3) the dissecting aneurysm; and (4) the false aneurysm. 1°" 13, 14 Renal artery aneurysms are often associated with abdominal or flank pam and hypertension, while superior mesenteric artery aneurysms can cause epigastric discomfort and sometimes abdominal angina. However, both types of aneurysms m a y be asymptomatic and the first presentation m a y be rupture. A pulsatile abdominal mass m a y be present in nearly Eur J Vasc Surg Vol 8, September 1994
644
H. Rupprecht et aL
50% of superior mesenteric artery aneurysms. 11 Clinically this is often mistaken for an aortic aneurysm but CT-scan or angiography reveals the true diagnosis. The indication for surgical treatment is controversial and except for pain and acute rupture exact criteria for surgical intervention are not well defined. Operative treatment of renal artery aneurysms should be performed in cases of arterial hypertension with elevated renal vein renin and abnormal renal split function.1° Furthermore patients with rapidly enlarging saccular aneurysms or with a diameter of more than 2 cm, should be repaired because of the risk of rupture. 1° False and dissecting aneurysms should also be repaired immediately.1° For women of childbearing age operation should be considered, because of the danger of rupture during pregnancy.9"~2 Hupp states that all renal artery aneurysms should be resected because of the possibility of microembolism causing fixed renal hypertension. 7 Surgical treatment of superior mesenteric artery aneurysms also appears justified in light of the seemingly common occurrence of rupture or arterial occlusion. ~1 The surgical procedures in the treatment of superior mesenteric artery aneurysms range from simple aneurysmorraphy, ligation and aneurysmal resection with or without arterial reconstruction or bypass. Sometimes resection of ischaemic bowel must be performed. Artificial material may be used if an infectious etiology has been excluded - - as it was in our case, otherwise autologous vein is to be preferred. The same principles apply to renal artery aneurysms. The possible procedures are nephrectom3~ and resection with direct reconstruction or bypass procedures. The latter may also be combined with ligation or aneurysmorraphy. The advantage of the aorto-renal bypass described is that it can be performed without or with only minimal renal ischaemia. The combination of a superior mesenteric artery aneurysm together with a renal artery aneurysm has, to our knowledge, never been published before. The diagnosis of the renal artery aneurysm alone would
Eur J Vasc Surg Vol 8, September 1994
not have been an indication to operate on this 73-yearold patient. However, it was necessary to repair the superior mesenteric artery aneurysm which was causing intestinal ischaemia. During the course of the operation we decided to also repair the renal artery aneurysm because its diameter was 3 cm. This additional procedure did not present any difficulties and the patient remained stable throughout the entire operation. References 1 GRAHAMJSr McCoLLUM CHI DEBAKEYME. Aneurysms of the splanchnic arteries. Am J Surg 1980; 140: 797-801. 2 DEBAKEY ME, COOLEY DA. Successful resection of mycotic aneurysm of superior mesenteric artery. Am Surg 1953; 19: 202-212. 3 MANDEL SR, MACFm JA, CAPPS JH. Superior mesenteric artery aneurysm: A report of the fourteenth successful case. Am Surg 1971; 32: 293-297. 4 lPPoLrro JJ/LEVEEN HH. Treatment of renal artery aneurysms. J Urol 1960; 83: 10-16. 5 THAM G, EKELUNDn~ HERRLINK, LINDSTEDTEL, OLINT, BERGENTZ S-E. Renal artery aneurysms - - natural history and prognosis. Ann Surg 1983; 197: 348-352. 6 ERDSMANG. Angionephrography and suprarenal angiography. Acta Radiol 1957; 155 (Suppl): 104-116, 7 HuPP T, ALLENBERGJR, POST K, ROEREN Tr MEIER M r CLORIUSJH. Renal artery aneurysm: surgical indications and results. Eur J Vasc Surg 1992; 6: 477-486. 8 STANSBY GPr HILSON AJW, HAMILTON G. Renovascular hypertension secondary to renal artery aneurysm detected by captopril-renography. Eur ] Vasc Surg 1991; 5: 343-346. 9 HAGEMANJH, SMITHRF, SZlLAGYIDE, ELLIOTTJP. Aneurysms of the renal artery: problems of prognosis and surgical management. Surgery 1978; 84: 563-572. 10 VAN WAY CW. Renal artery aneurysms and arteriovenous fistulas. In: RUTtmRFORD RB, ed. Vascular Surgery. 3rd ed. Philadelphia: WB Saunders Company, 1989: 1274-1285. 11 STANLEYJC, ZELENOCK GB. Splanchnic artery aneurysms. In: RUTHERFORDRB, ed. Vascular Surgery. 3rd ed. Philadelphia: W.B. Saunders Company, 1989: 969-983. 12 HUBERT JP, PAIROLEROPC, KAZMIER FJ. Solitary renal artery aneurysm. Surgery 1980; 88: 557-565. 13 POUTASSEEF. Renal artery aneurysms: Their natural history and surgery. J Urol 1966; 95: 297-306. 14 POUTASSE EF. Renal artery aneurysms. J Urol 1975; 113: 443-449.
Accepted 26 May 1993