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Celiac artery aneurysm: An uncommon risk of blunt abdominal trauma
Authors: Anas Abdullah MBBS; George E Reese MRCS; Hamish Hamilton FRCS
Department of Vascular Surgery, Chase Farm Hospital, The Ridgeway, Enfield, Middlesex, UK, EN2 8JL
Coeliac artery aneurysms are rarely seen clinically. We report an unusual case of a large coeliac artery aneurysm in a boxer who presented with vague abdominal pain and pulsatile epigastric mass
aneurysm, coeliac artery, selective coeliac angiography.
We present the case of a 61-year-old semi-professional ex-boxer who presented with a six week history of epigastric pain radiating to the right upper quadrant of his abdomen. He was previously fit and well on no medication and was a lifelong non-smoker. He had suffered repeated blunt injury to his abdomen throughout his boxing career. Initially he presented to his family doctor who prescribed a proton pump inhibitor and arranged an abdominal ultrasound scan. This showed a pulsatile visceral mass in the midline, anterior to the supra-renal abdominal aorta measuring 8.5 x 7.4 x 7.8cm. Subsequently a CT scan of the Abdomen confirmed a large (8.5cm x 6.5cm) aneurysm arising from the coeliac trunk. (Fig. 1) The mass effect of the aneurysm had disturbed the normal anatomy displacing the pancreas anteriorly. The CT demonstrated the splenic and the left gastric arteries were arising from the aneurysm. Further investigation with selective coeliac angiography confirmed the vascular anatomy. (Fig. 2) Endovascular and open surgical management were considered, however it was felt that there was not a viable endovascular option therefore open surgery was planned. At operation the coeliac aneurysm was approached via a roof top incision. The suprarenal aorta was exposed via the lesser omentum and the coeliac aneurysm was exposed, as were the branches to the left gastric, hepatic, and splenic arteries. Proximal and distal control was obtained with vascular clamps placed on the aorta and the distal tributaries. The origin of the coeliac artery was over sewn, and the aneurysm sac was resected (Fig. 3). Interestingly a by-pass graft to the hepatic artery was not needed as the patient had sufficient collateral follow originating from the superior mesenteric artery, this was confirmed by an intraoprative Doppler (Fig. 4). Gross and microscopic evaluation of the surgical specimen confirmed that it was an atheromatous coeliac artery aneurysm. The patient’s recovery was complicated by a chest infection that was treated with antibiotics and he was discharged 7 days later.
Figure 1. A large 8.5cm x 6.5cm aneurysm seen arising from the coeliac trunk.
Figure 2. A selective mesenteric angiogram showing the aneurysm arising from the coeliac trunk.
Figure 3 . Image of the resected aneurismal sac
Figure 4. Angiography of the Superior Mesenteric Artery shows collateral supply to the liver
Coeliac artery aneurysms are one of the rarest forms of splanchnic artery aneurysm. Since the anomaly was first described in 1745, fewer than 180 cases have been reported in the international medical literature.
Aneurysms of the coeliac artery are rare vascular lesions that represent only 3.6% to 4% of splanchnic artery aneurysms.
Early recognition and intervention are crucial, because the operative mortality rate associated with ruptured coeliac artery aneurysms is 40% compared with only 5% for nonruptured aneurysms.
Rupture of coeliac artery aneurysms is associated with significant clinical morbidity and mortality rates. On the basis of abdominal aortic aneurysm data, Rokke and colleagues found that the risk of coeliac artery aneurysm rupture can range from 5% for aneurysms that are from 15 to 22 mm in diameter to 50-70% for aneurysms with a diameter of more than 32 mm.
The common causes of coeliac artery aneurysms are arteriosclerosis and medial degeneration. Trauma, dissection, and Takayasu arteritis are other causes. Syphilitic aneurysms are now uncommon.
The 1st successful surgical treatment of a coeliac aneurysm was reported by Shumacker in 1958. Since that time, surgery has been performed in most cases. A variety of techniques have been successful, including aneurysmorrhaphy, aneurysmectomy alone or in combination with aortoceliac anastomosis, hepatic–coeliac anastomosis, hepatic/splenic–thoracoabdominal aorta graft bypass, hepatic/splenic–coeliac interposition graft, hepatic–superior mesenteric artery bypass, aortocoeliac bypass, and aortohepatic bypass, using a saphenous vein or prosthetic graft.
Advances in endovascular techniques have led to successful endoluminal exclusion of aortic aneurysms. Endoluminal exclusion may be a viable therapeutic option for some patients with coeliac artery aneurysms and some investigators have reported successful transluminal embolization However the operative mortality for non-ruptured coeliac aneurysms approximates that of infra-renal abdominal aortic aneurysm surgery. Therefore while data remains sparse for this rare vascular pathology treatment may be safely attempted by open surgery.
Coeliac arterial aneurysms are rare, but with significant risk of rupture, multiple methods of treatment have been successful and early recognition and intervention is crucial.
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