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Surgical management of concurrent, coeliac and bilateral iliac artery aneurysms
Cardiovascular
UTTERWORTH EINEMANN
Vol. 3, No. 5, pp. 501-503, 1% Copyright 0 19Y5 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0967-21iw% $10.00 + 0.00 Surgery,
Surgical management of concurrent, cw&kc and bilateral iliac artery aneurysms .-_
-.
I. E. Rodrigus, M. C. J. Berry, A. Gdeedo, P. E. Van Schil and R. G. Vanmaele Department ofSurger)x Division of VascuhrSurgery,Antwev Univerxity HospiitalandMedicalScnool, Edegem,Belgium A 76-year-old man was admitted with bilateral common iliac artery aneurysms found incidentally on computed tomography. Transfemoral diital subtraction arteriography demonstrated atherosclerotic plaques in the aorta with bilateral common iliac artery aneurysms and a coeliac axis aneurysm. The coeliac artery aneurysm was resected and an aortoblfemoral bypass performed with reimplantation of the inferior mesenteric artery into the prosthesis. The patient was well when discharged 2 weeks after operation. The incidence, natural history and management of coeliac axis and iliac artery aneurysms are reviewed. Keywords: coeliac artery aneurysm. iliac artery aneurysm, inferior mesenteric artery
Aneurysms of the coeliac artery are rare and represent only 4% of all splanchnic artery aneurysms. As they are often symptomless the majority are found incidentally. Such lesions are increasingly recognized because of the availability of sonography, computed tomography and arteriography. The risk of rupture is high and surgical resection should be undertaken when appropriate, especially if the coeliac axis aneurysm is associated with other vascular abnormalities. A patient in whom the coeliac axis aneurysm was associated with bilateral iliac artery aneurysms is reported.
Case report A 76-year-old Caucasian man was referred to the Department of Vascular Surgery, Antwerp University Hospital after an episode of urolithiasis when bilateral iliac artery aneurysms were demonstrated on computed tomography (Figure 2). He had a S-year history of bilateral intermittent claudication, weight loss of about 9 kg in 2 years but no upper epigastric or lower abdominal pain. Coronary artery surgery had been performed 7 years earlier. Physical examination of the patient revealed a small pulsatile mass in the epigastrium and pulsatile masses in both lower quadrants, with good femoral pulses but absent peripheral pulses.
Correspondence to: Dr I. Rodrigus, Department Universitair Ziekenhuis Antwerpen, Wilrijkstraat Belgium
of Vascular Surgery, 10, B-2650 Edegem,
CARDIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO 5
Figure 1 Computed tomogram demonstrating a bilateral iliac artery aneurysm. Cross-sectional diameter was 3.86cm on the right side and 4.52cm on the left
Haematological and biochemical laboratory tests were within the normal range. Transfemoral arteriography demonstrated diffuse atheroma, with a significant coeliac axis aneurysm, bilateral common iliac artery aneurysms and occlusion of both the hvpogastric and superficial femoral arteries. Selective coejiac arteriography confirmed the presence of a fusiform aneurysm (2 cm in diameter) of the coeliac axis, not involving the origin of the splenic or hepatic arteries (Figgure 2). Surgical exploration was undertaken through a long midline incision. The suprarenal aorta, the coeliac axis and its tributaries were exposed by division of the hepatoduodenal ligament. The left gastric artery was
501
Vascular case reports
Figure 2 Selective coeliac arteriogram demonstrating a fusiform aneurysm (2 cm in diameter) with the 0 left gastric artery originating in the aneurysm and patency of the b splenic and ) hepatic arteries
ligated and divided to allow better access to the aneurysm. The aneurysm was resected after the coeliac axis had been cross-clamped at its origin and the hepatic and splenic arteries had also been occluded. An end-to-end anastomosis was performed with a 6/O polypropylene running suture. Normal pulses were obtained in the hepatic and splenic arteries after release of the clamps. The cross-clamping time was 15 min. Bilateral fusiform common iliac aneurysms measuring 4 cm in diameter on the right and 5 cm on the left were excluded by ligation. An albumin-coated DeBakey Vasculour II bifurcated Dacron (Bard Vascular Systems, Billerica, USA) prosthesis was anastomosed end-to-end on the infrarenal aorta. As both hypogastric arteries were occluded the inferior mesenteric artery was reimplanted to the graft to restore an adequate blood supply to the left colon and rectum. The distal anastomoses were performed in an end-to-side fashion at the common femoral artery bifurcation. The postoperative course was uneventful with no visceral dysfunction. Patency of the coeliac axis and its two tributaries was demonstrated on intravenous digital subtraction angiography. The patient was discharged 2 weeks after operation and is doing well after 15 months. Microscopic studies of the resected aneurysm revealed degeneration of the elastic tissue and muscle of the artery wall, which was replaced by dense collagenous fibrotic tissue. The aneurysm contained no thrombus.
Discussion The incidence of splanchnic aneurysm is estimated to be 0.2% in the general population’. Involvement of the coeliac axis accounts for only 3-4% of all splanchnic
aneurysms2y 3. There is a male predominance (68.4%) and the majority of such lesions develop after the age of 40 years4. The incidence of iliac artery aneurysm varies from 0.1% to 0.65% in autopsy studies and from 0.9% to 7.8% in series of aortoiliac aneurysms,6. Although associated vascular lesions are common (51.8%), there are few reports of coexisting coeliac and iliac artery aneurysms4r7-lo. The clinical picture is often insidious and vague. Gastrointestinal complaints, including epigastric discomfort, nausea, vomiting and intestinal angina, are common clinical manifestations of coeliac axis aneurysm. Iliac artery aneurysm can cause ureteric obstruction by compression or by associated retroperitoneal fibrosis, as well as intestinal obstruction and lower abdominal pain. With the widespread use of two-dimensional ultrasonography and computed tomography most of these aneurysms are incidental findings. The diagnosis is confirmed by Seldinger angiography. Selective arteriography of the coeliac artery is indicated to obtain a better view of the extent of the aneurysm and to assess the origin and patency of the common hepatic, splenic and left gastric arteries. If left unoperated, these aneurysms have a tendency to rupture lo . The operative mortality rate for unruptured coeliac axis aneurysm is approximately 10% but increases to 80% for ruptured aneurysms. Therefore, the authors believe that all fit patients should be offered resection. Absolute indications for surgery include all symptomatic aneurysms, an aneurysm three to four times the original size of the vessel, evidence of increasing size or a calcified aneurysm greater than 3 cm”’ 13. A solitary iliac artery aneurysm that ruptures has a mortality rate of 50-75% in various reports14. The perioperative mortality rate is 10% in elective procedures and rises to 60-90% in emergency operations for rupture. It is therefore recommended that all iliac artery aneurysms with a diameter of more than 3 cm can be treated surgically14T l5 Treatment of coeliac axis aneurysm consists primarily of resection and reconstruction of the circulation by end-to-end anastomosis for smaller aneurysms or by using autogenous venous or prosthetic graft interposition for larger aneurysms’. Reconstruction of the common hepatic artery should be attempted in every case, but ligation of gastric or splenic arteries will not cause ischaemic damage to the stomach or spleen provided that a good collateral circulation is present”‘*6. Midline xyphopubic incision gives excellent exposure of the coeliac axis and can be extended to a left thoracoabdominal approach through the 7th or 8th intercostal space in obese patients or for large aneurysms. Elective surgery for coeliac axis aneurysm had a
CARDIOVAWJLAR SURGERY OCTOBER 1995 VOL 3 NO S
successful outcome in 91% of 43 cases described b Graham et ~1.‘~ between 19.50 and 1985. Vohra et a1.l ‘5 reported on another 12 patients operated on for coeliac axis aneurysms with one perioperative death caused by acute myocardial infarction. Surgical excision or exclusion by proximal and distal ligation with graft replacement is the treatment of choice for iliac artery aneurysm’*. Endoaneurysmorrhaphy is recommended in large iliac aneurysyms using a retro- or intraperitoneal approach”. When both hypogastric arteries are obstructed, pelvic blood supply to the left colon is at risk, Controversy still exists on reimplantation of the inferior mesenteric artery but this seems indicated in bilateral interruption of hypogastric flowL”. As iliac artery as well as coeliac axis aneurysms have a great tendency to rupture, elective operative intervention as a single procedure is a safe and effective method of treatmenr for patients with concomitant aneurysms.
7. 8. 9.
10.
11. 12.
13. 14.
15.
References I 2. 3. 4. 5. 6.
Skudder I’A Jr. Visceral artery aneurysms. In: Persson AV, Skudder PA Jr, cds. Visceral Vascular Surgery. New York: Marcrl Dekker, 1987: 145-73. Stanley JC, Thompson NW, Fry WJ. Splanchnic artery aneurysms. Arch Surg 1970; 101: 689-97. Deterling RA Jr. Aneurysms of the visceral arteries. 1 Cardiovasc Surg (T&noj 19’71; li: 309-22. Marre Ph, Salomon L. Traitement chirurgical des anevrismes du tronc coeiiaque. A propos d’un cas. Chirurgie 1991; 117: X9-9.5. Kunz R. Aneurysmata bei 35380 Autopsien. Schweiz Med Wochenschr 1980; 110: 142-8. Nachbur BH, Inderbitzi RGC, Bar W. Isolated iliac aneurysms. EurJ Vast Surg 1991; 5: 375-81.
CARDIOVASCULAR SURGERY OCTOBER 199s VOL 3 NO 5
16. 17. 18.
19.
20.
Schumacker HB, Siderys H. Excisional trearment of aneurysm of celiac artery. Ann Surg 1958; 148: 885-9. Haimovici H, Sprayregen S, Eckstein P, Venh FJ~ Geiiac artery aneurysmectomy: case report with review :*f the literature. Surge&~ 1976; 79: 592-6: Belli L, Puttini M. Associated aneurysms of ceir,ri axis, infrarenal aorta and right common iliac artery. i Clcrrdio~~,zscSurg :‘T‘orino~ 1979; 20: 499-502. Graham LM, Stanley JC, Whitehouse WM ir & 01. Coeliac artery aneurysms: historic (1745- 1949) z’cr~u~ contemporary (1950-1984) differences in etiology7 and and managemenr of iliac aneurysms. j Vusc Surg 1988: 8: ?65- 71 Salmon R, Cornud F, Cuinard J et al. Celiac artery aneurysm. J Cardiovasc Surg (Torino) 1980; 21" 712%.t2. Vohra R, Carr MH, Welch M, Tait WF, Iyurrans I>. Walker MG. Management of coeliac artery aneurysm iir ! Snr,g 1991: 78:1375-5. Schroeder RA, Flanagan TL, Kron II., Trtbble C.G. h sate approach to the treatment of iliac artery .~nc~uvxns. .-2nt Surg 1991; 57: 624-6. Minato N, ltoh T, Natsuaki M et ai. Surgrcai trearment oi isolated iliac artery aneurysm with ureteral obstruction and/or renal failure. ] Curdiovasc Surg (Tonno) IY9fi; 3 1: 189-93. Bryne JL, Zaman SN, Meade JW, Aronskl WP. Cfperativc management of bilateral internal ihaz a~trry aneurysms. J Cardrovasc Surg !Toorino) 1989; 30: 24 I .3
Paper accepted 29 April
1994
503
UTTERWORTH EINEMANN
Vol. 3, No. 5, pp. 501-503, 1% Copyright 0 19Y5 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0967-21iw% $10.00 + 0.00 Surgery,
Surgical management of concurrent, cw&kc and bilateral iliac artery aneurysms .-_
-.
I. E. Rodrigus, M. C. J. Berry, A. Gdeedo, P. E. Van Schil and R. G. Vanmaele Department ofSurger)x Division of VascuhrSurgery,Antwev Univerxity HospiitalandMedicalScnool, Edegem,Belgium A 76-year-old man was admitted with bilateral common iliac artery aneurysms found incidentally on computed tomography. Transfemoral diital subtraction arteriography demonstrated atherosclerotic plaques in the aorta with bilateral common iliac artery aneurysms and a coeliac axis aneurysm. The coeliac artery aneurysm was resected and an aortoblfemoral bypass performed with reimplantation of the inferior mesenteric artery into the prosthesis. The patient was well when discharged 2 weeks after operation. The incidence, natural history and management of coeliac axis and iliac artery aneurysms are reviewed. Keywords: coeliac artery aneurysm. iliac artery aneurysm, inferior mesenteric artery
Aneurysms of the coeliac artery are rare and represent only 4% of all splanchnic artery aneurysms. As they are often symptomless the majority are found incidentally. Such lesions are increasingly recognized because of the availability of sonography, computed tomography and arteriography. The risk of rupture is high and surgical resection should be undertaken when appropriate, especially if the coeliac axis aneurysm is associated with other vascular abnormalities. A patient in whom the coeliac axis aneurysm was associated with bilateral iliac artery aneurysms is reported.
Case report A 76-year-old Caucasian man was referred to the Department of Vascular Surgery, Antwerp University Hospital after an episode of urolithiasis when bilateral iliac artery aneurysms were demonstrated on computed tomography (Figure 2). He had a S-year history of bilateral intermittent claudication, weight loss of about 9 kg in 2 years but no upper epigastric or lower abdominal pain. Coronary artery surgery had been performed 7 years earlier. Physical examination of the patient revealed a small pulsatile mass in the epigastrium and pulsatile masses in both lower quadrants, with good femoral pulses but absent peripheral pulses.
Correspondence to: Dr I. Rodrigus, Department Universitair Ziekenhuis Antwerpen, Wilrijkstraat Belgium
of Vascular Surgery, 10, B-2650 Edegem,
CARDIOVASCULAR SURGERY OCTOBER 1995 VOL 3 NO 5
Figure 1 Computed tomogram demonstrating a bilateral iliac artery aneurysm. Cross-sectional diameter was 3.86cm on the right side and 4.52cm on the left
Haematological and biochemical laboratory tests were within the normal range. Transfemoral arteriography demonstrated diffuse atheroma, with a significant coeliac axis aneurysm, bilateral common iliac artery aneurysms and occlusion of both the hvpogastric and superficial femoral arteries. Selective coejiac arteriography confirmed the presence of a fusiform aneurysm (2 cm in diameter) of the coeliac axis, not involving the origin of the splenic or hepatic arteries (Figgure 2). Surgical exploration was undertaken through a long midline incision. The suprarenal aorta, the coeliac axis and its tributaries were exposed by division of the hepatoduodenal ligament. The left gastric artery was
501
Vascular case reports
Figure 2 Selective coeliac arteriogram demonstrating a fusiform aneurysm (2 cm in diameter) with the 0 left gastric artery originating in the aneurysm and patency of the b splenic and ) hepatic arteries
ligated and divided to allow better access to the aneurysm. The aneurysm was resected after the coeliac axis had been cross-clamped at its origin and the hepatic and splenic arteries had also been occluded. An end-to-end anastomosis was performed with a 6/O polypropylene running suture. Normal pulses were obtained in the hepatic and splenic arteries after release of the clamps. The cross-clamping time was 15 min. Bilateral fusiform common iliac aneurysms measuring 4 cm in diameter on the right and 5 cm on the left were excluded by ligation. An albumin-coated DeBakey Vasculour II bifurcated Dacron (Bard Vascular Systems, Billerica, USA) prosthesis was anastomosed end-to-end on the infrarenal aorta. As both hypogastric arteries were occluded the inferior mesenteric artery was reimplanted to the graft to restore an adequate blood supply to the left colon and rectum. The distal anastomoses were performed in an end-to-side fashion at the common femoral artery bifurcation. The postoperative course was uneventful with no visceral dysfunction. Patency of the coeliac axis and its two tributaries was demonstrated on intravenous digital subtraction angiography. The patient was discharged 2 weeks after operation and is doing well after 15 months. Microscopic studies of the resected aneurysm revealed degeneration of the elastic tissue and muscle of the artery wall, which was replaced by dense collagenous fibrotic tissue. The aneurysm contained no thrombus.
Discussion The incidence of splanchnic aneurysm is estimated to be 0.2% in the general population’. Involvement of the coeliac axis accounts for only 3-4% of all splanchnic
aneurysms2y 3. There is a male predominance (68.4%) and the majority of such lesions develop after the age of 40 years4. The incidence of iliac artery aneurysm varies from 0.1% to 0.65% in autopsy studies and from 0.9% to 7.8% in series of aortoiliac aneurysms,6. Although associated vascular lesions are common (51.8%), there are few reports of coexisting coeliac and iliac artery aneurysms4r7-lo. The clinical picture is often insidious and vague. Gastrointestinal complaints, including epigastric discomfort, nausea, vomiting and intestinal angina, are common clinical manifestations of coeliac axis aneurysm. Iliac artery aneurysm can cause ureteric obstruction by compression or by associated retroperitoneal fibrosis, as well as intestinal obstruction and lower abdominal pain. With the widespread use of two-dimensional ultrasonography and computed tomography most of these aneurysms are incidental findings. The diagnosis is confirmed by Seldinger angiography. Selective arteriography of the coeliac artery is indicated to obtain a better view of the extent of the aneurysm and to assess the origin and patency of the common hepatic, splenic and left gastric arteries. If left unoperated, these aneurysms have a tendency to rupture lo . The operative mortality rate for unruptured coeliac axis aneurysm is approximately 10% but increases to 80% for ruptured aneurysms. Therefore, the authors believe that all fit patients should be offered resection. Absolute indications for surgery include all symptomatic aneurysms, an aneurysm three to four times the original size of the vessel, evidence of increasing size or a calcified aneurysm greater than 3 cm”’ 13. A solitary iliac artery aneurysm that ruptures has a mortality rate of 50-75% in various reports14. The perioperative mortality rate is 10% in elective procedures and rises to 60-90% in emergency operations for rupture. It is therefore recommended that all iliac artery aneurysms with a diameter of more than 3 cm can be treated surgically14T l5 Treatment of coeliac axis aneurysm consists primarily of resection and reconstruction of the circulation by end-to-end anastomosis for smaller aneurysms or by using autogenous venous or prosthetic graft interposition for larger aneurysms’. Reconstruction of the common hepatic artery should be attempted in every case, but ligation of gastric or splenic arteries will not cause ischaemic damage to the stomach or spleen provided that a good collateral circulation is present”‘*6. Midline xyphopubic incision gives excellent exposure of the coeliac axis and can be extended to a left thoracoabdominal approach through the 7th or 8th intercostal space in obese patients or for large aneurysms. Elective surgery for coeliac axis aneurysm had a
CARDIOVAWJLAR SURGERY OCTOBER 1995 VOL 3 NO S
successful outcome in 91% of 43 cases described b Graham et ~1.‘~ between 19.50 and 1985. Vohra et a1.l ‘5 reported on another 12 patients operated on for coeliac axis aneurysms with one perioperative death caused by acute myocardial infarction. Surgical excision or exclusion by proximal and distal ligation with graft replacement is the treatment of choice for iliac artery aneurysm’*. Endoaneurysmorrhaphy is recommended in large iliac aneurysyms using a retro- or intraperitoneal approach”. When both hypogastric arteries are obstructed, pelvic blood supply to the left colon is at risk, Controversy still exists on reimplantation of the inferior mesenteric artery but this seems indicated in bilateral interruption of hypogastric flowL”. As iliac artery as well as coeliac axis aneurysms have a great tendency to rupture, elective operative intervention as a single procedure is a safe and effective method of treatmenr for patients with concomitant aneurysms.
7. 8. 9.
10.
11. 12.
13. 14.
15.
References I 2. 3. 4. 5. 6.
Skudder I’A Jr. Visceral artery aneurysms. In: Persson AV, Skudder PA Jr, cds. Visceral Vascular Surgery. New York: Marcrl Dekker, 1987: 145-73. Stanley JC, Thompson NW, Fry WJ. Splanchnic artery aneurysms. Arch Surg 1970; 101: 689-97. Deterling RA Jr. Aneurysms of the visceral arteries. 1 Cardiovasc Surg (T&noj 19’71; li: 309-22. Marre Ph, Salomon L. Traitement chirurgical des anevrismes du tronc coeiiaque. A propos d’un cas. Chirurgie 1991; 117: X9-9.5. Kunz R. Aneurysmata bei 35380 Autopsien. Schweiz Med Wochenschr 1980; 110: 142-8. Nachbur BH, Inderbitzi RGC, Bar W. Isolated iliac aneurysms. EurJ Vast Surg 1991; 5: 375-81.
CARDIOVASCULAR SURGERY OCTOBER 199s VOL 3 NO 5
16. 17. 18.
19.
20.
Schumacker HB, Siderys H. Excisional trearment of aneurysm of celiac artery. Ann Surg 1958; 148: 885-9. Haimovici H, Sprayregen S, Eckstein P, Venh FJ~ Geiiac artery aneurysmectomy: case report with review :*f the literature. Surge&~ 1976; 79: 592-6: Belli L, Puttini M. Associated aneurysms of ceir,ri axis, infrarenal aorta and right common iliac artery. i Clcrrdio~~,zscSurg :‘T‘orino~ 1979; 20: 499-502. Graham LM, Stanley JC, Whitehouse WM ir & 01. Coeliac artery aneurysms: historic (1745- 1949) z’cr~u~ contemporary (1950-1984) differences in etiology7 and and managemenr of iliac aneurysms. j Vusc Surg 1988: 8: ?65- 71 Salmon R, Cornud F, Cuinard J et al. Celiac artery aneurysm. J Cardiovasc Surg (Torino) 1980; 21" 712%.t2. Vohra R, Carr MH, Welch M, Tait WF, Iyurrans I>. Walker MG. Management of coeliac artery aneurysm iir ! Snr,g 1991: 78:1375-5. Schroeder RA, Flanagan TL, Kron II., Trtbble C.G. h sate approach to the treatment of iliac artery .~nc~uvxns. .-2nt Surg 1991; 57: 624-6. Minato N, ltoh T, Natsuaki M et ai. Surgrcai trearment oi isolated iliac artery aneurysm with ureteral obstruction and/or renal failure. ] Curdiovasc Surg (Tonno) IY9fi; 3 1: 189-93. Bryne JL, Zaman SN, Meade JW, Aronskl WP. Cfperativc management of bilateral internal ihaz a~trry aneurysms. J Cardrovasc Surg !Toorino) 1989; 30: 24 I .3
Paper accepted 29 April
1994
503