Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone.

INTRODUCTION: Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. METHODS: A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. RESULTS: Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. CONCLUSION: Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.

Covered stent assisted coil embolization of large Buhler aneurysm in setting of chronic celiac trunk occlusion.

BACKGROUND: The arc of Bühler (AOB) is a residual embryonal anastomosis between the celiac artery (CA) and the superior mesenteric artery (SMA). Although usually asymptomatic, it has clinical relevance when compensatory reverse flow between the SMA and the CA in response to celiac artery obstruction leads to aneurysm formation and bleeding. Endovascular coiling is the mainstay therapy because of the deep AOB retropancreatic location, which hinders open surgery. CASE PRESENTATION: We herein report a case of a 2.8-cm AOB saccular aneurysm and LAM compression of celiac trunk in a 47-year-old man during rehabilitation following motorcycle trauma and vertebral surgery. The patient was considered unsuitable for surgery. Neither conventional coiling nor bare-metal stent and balloon-assisted techniques for coiling were suitable because of the wide necked saccular shape of AOB aneurysm interposed between the SMA and the floor of celiac trunk. To exclude the aneurysm from direct SMA inflow and permit safe and efficient coiling to rule out retrograde sac perfusion, a 9-mm polytetrafluoroethylene stent graft (Viabahn; Gore, Phoenix, AZ, USA) was positioned in the mesenteric artery, followed by antegrade periprosthetic high-density packed coiling of the aneurysm. The AOB remained excluded from mesenteric perfusion. The patient's clinical condition and abdominal contrast-enhanced multislice computed tomographic findings were unremarkable at the 9-year follow-up. CONCLUSION: The 9 year long-term efficacy in our case raises the possibility that perigraft coiling following stent-graft deployment in the SMA may represent a valuable technical option for large Bühler aneurysms that are not amenable to stand-alone coiling.

Superior mesenteric artery mycotic aneurysm repaired with bifurcated saphenous vein graft.

A mycotic aneurysm of the superior mesenteric artery caused by Enterococcus faecalis was successfully treated with aneurysmectomy and reconstruction with a bifurcated saphenous vein graft. A 49-year-old man with a history of type 2 diabetes mellitus and a recent left transmetatarsal amputation for osteomyelitis presented to the emergency department with severe abdominal pain, an unexplained 30-lb weight loss, and wound dehiscence. Computed tomography angiography showed an aneurysm of the superior mesenteric artery and a splenic abscess. The patient underwent splenectomy, surgical resection of the aneurysm, and reconstruction with a bifurcated saphenous vein. Follow-up revealed normal gastrointestinal function and graft patency.

Endovascular Treatment of a Giant Aneurysm of the Aberrant Right Hepatic Artery in a Patient with Osler-Weber-Rendu Syndrome: A Case Report.

Osler-Weber-Rendu syndrome (OWR) is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous or visceral telangiectasias, and arteriovenous malformations in the lungs, liver, brain, and gastrointestinal tract. Hepatic artery aneurysms (HAAs) can also occur in OWR patients. HAAs are the second most common type of visceral artery aneurysm, and mortality rates are high owing to the lack of a tamponade effect. Anatomical variations of the celiacomesenteric vasculature are common, and the most common variation is that of the right hepatic artery originating from the superior mesenteric artery (SMA). We present the endovascular treatment of a patient with OWR and an aberrant right HAA originating from the SMA, with coil embolization and stent grafting. Giant HAAs can be treated endovascularly. However, stent graft placement should be reconsidered because of the need for antithrombotic medication, which may increase the incidence of epistaxis attacks in that patient group.

Spontaneous rupture of a gastroduodenal artery side branch immediately following endovascular treatment of gastroepiploic artery aneurysm or pseudoaneurysm.

Key clinical massage: Pseudoaneurysms and aneurysms of the visceral arteries are rare entities. To the best of our knowledge, rupture of a proximal parental artery during endovascular treatment of a visceral aneurism/pseudoaneurysm has not been reported and should be kept in mind as a tragic possibility immediately following an apparently successful management of them. Abstract: A 55-year-old woman with a history of coronary artery disease was referred to our hospital with abdominal pain as her primary complaint. Early works revealed anemia, a small amount of free peritoneal fluid, and a possible large aneurysm or pseudoaneurysm by the greater curvature of the stomach. She underwent emergency angiography that showed a large aneurism/pseudoaneurysm of the gastroepiploic artery. Successful embolization of the lesion was performed using the isolation technique. Perforation of a side branch of the gastroduodenal artery was observed on the immediate postembolization control angiography. Therefore, parent artery coiling was done immediately with good results. She was symptom-free and stable hemodynamically after the procedure, during the hospital course, and in the follow-ups.

Technical considerations of endovascular management of true visceral artery aneurysms.

BACKGROUND: True visceral artery aneurysms are potentially complex to treat but with advances in technology and increasing interventional radiology expertise over the past decade are now increasingly the domain of the interventional radiologist. BODY: The interventional approach is based on localization of the aneurysm and identification of the anatomical determinants to treat these lesions to prevent aneurysm rupture. Several different endovascular techniques are available and should be selected carefully, dependent on the aneurysm morphology. Standard endovascular treatment options include stent-graft placement and trans-arterial embolisation. Different strategies are divided into parent artery preservation and parent artery sacrifice techniques. Endovascular device innovations now include multilayer flow-diverting stents, double-layer micromesh stents, double-lumen balloons and microvascular plugs and are also associated with high rates of technical success. CONCLUSION: Complex techniques such as stent-assisted coiling and balloon-remodeling techniques are useful techniques and require advanced embolisation skills and are further described.

Repair of Celiomesenteric Trunk Aneurysm and Review of the Literature.

A celiomesenteric trunk (CMT) is a rare anatomic variant of a common origin for the celiac and superior mesenteric arteries. It is further a seldom occurrence to have aneurysmal dilatation of the CMT. Herein, we describe a patient with a CMT aneurysm and his open surgical repair. The open surgical repair included debranching from the right external iliac artery to the splenic and common origin of the superior mesenteric and common hepatic arteries using a bifurcated knitted graft. Postoperative recovery was unremarkable, and follow-up imaging demonstrated an excluded CMT aneurysm with excellent blood flow to the intra-abdominal organs through the bifurcated graft.

Cross clamping of the supraceliac aorta is effective for bleeding control in ruptured giant splenic artery pseudoaneurysm when proximal and distal control of the splenic artery is not possible: a case report.

Splenic artery pseudoaneurysm is the most common of all the visceral artery pseudoaneurysms. Presentation is often variable and the condition demands immediate diagnosis and management because pseudoaneurysm rupture increases morbidity and mortality. It is associated with pancreatitis and other conditions like abdominal trauma, chronic pancreatitis, pseudocyst of the pancreas, liver transplantation, and, rarely, peptic ulcer disease. We present a case of a giant splenic artery pseudoaneurysm measuring 14x8 cm. Proximal and distal control of the vessels could not be achieved during the procedure because of local adhesions and inflammation and it was necessary to cross clamp the supraceliac aorta to control bleeding.

O pseudoaneurisma de artéria esplênica é o mais comum entre os pseudoaneurismas de artérias viscerais. A apresentação geralmente varia e requer diagnóstico e tratamento imediatos, pois a ruptura do pseudoaneurisma aumenta a morbimortalidade. Esse tipo de pseudoaneurisma está associado à pancreatite e a outras condições, como trauma abdominal, pancreatite crônica, pseudocisto de pâncreas, transplante de fígado e, raramente, úlcera péptica. Apresentamos um caso de pseudoaneurisma gigante de artéria esplênica, com tamanho de 14x8 cm. Durante o procedimento, não foi possível alcançar controle proximal e distal dos vasos devido a aderências locais e inflamação, sendo necessário o clampeamento da aorta supracelíaca para controle do sangramento.

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms.

PURPOSE: The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. MATERIALS AND METHODS: Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. RESULTS: A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0-4 vs 2,1-3 vessels). CONCLUSION: Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. CLINICAL IMPACT: Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.

A Ruptured Left Gastric Artery Aneurysm That Neoplasticized during the Course of Coronavirus Disease 2019: A Case Report.

Coronavirus disease 2019 (COVID-19) is an acute respiratory syndrome caused by SARS-CoV-2 and is known to cause respiratory and systemic symptoms. A SARS-CoV-2 infection is involved in aneurysm formation, enlargement, and rupture in medium-sized vessels, such as the cerebral and coronary arteries and the aorta. In contrast, its involvement in forming aneurysms in medium-sized vessels other than the cerebral and coronary arteries has not been reported. An 84-year-old Japanese man with COVID-19 was admitted to our hospital. The treatment course was favorable, and the COVID-19 treatment was completed by the 10th day. On day 14, pancreatic enzymes increased mildly. An abdominal computed tomography revealed a ruptured left gastric aneurysm after spontaneous hemostasis. Arterial embolization was performed. In this patient, a new left gastric aneurysm was suspected of having formed and ruptured during the course of the COVID-19 treatment. To the best of our knowledge, this is the first report of abdominal visceral aneurysm formation caused by COVID-19 in a medium-sized vessel, and it is necessary to remember that aneurysms can be formed at any site when treating this syndrome.

Endovascular treatment of pancreaticoduodenal aneurysm with braided stent-assisted coil embolization using intraoperative cone-beam computed tomography guidance.

Pancreaticoduodenal arterial arcade aneurysms are rare but are prone to rupture. We report the case of a 60-year-old woman with an asymptomatic pancreaticoduodenal artery aneurysm and concomitant celiac trunk occlusion that was treated using an endovascular approach. After percutaneous transfemoral access and superior mesenteric artery cannulation, intraoperative cone-beam computed tomography angiography was performed to better understand the aneurysm morphology and provide image guidance. On selecting the optimal working projection, the aneurysm and distal parent vessel were cannulated and treated by braided stent (low-profile visualized intraluminal support; MicroVention)-assisted coil embolization. Completion angiography and cone-beam computed tomography confirmed successful exclusion of the aneurysm sac and a patent pancreaticoduodenal arcade with a well-apposed stent.

A unique proposed etiology for inferior mesenteric artery aneurysm: A case report.

The etiology of large artery aneurysms has long been established as secondary to atherosclerotic disease and degenerative changes in the vessel walls. Less common, are aneurysms of the visceral arteries; the splanchnic and renal arteries. Rarer yet, are inferior mesenteric artery aneurysms, accounting for approximately 1% of visceral artery aneurysms. While causes range from inflammatory to congenital disease, a proposed etiology of proximal, solitary inferior mesenteric artery aneurysms, is correlated to the "jet disorder phenomenon," first described in a 1990 case report by Sugrue, and Hederman. This paradigm states that aneurysm formation may occur secondary to celiac and superior mesenteric artery occlusion, causing increased, and turbulent arterial flow distally. We present a case that demonstrates a small inferior mesenteric artery aneurysm without findings of celiac or superior mesenteric artery stenosis or occlusion. This patient did, however, have a large thrombosed common hepatic artery aneurysm which may serve as an alternate cause of jet disorder phenomenon. The findings in this case offers support for focused screening of proximal arterial vasculature when an inferior mesenteric artery aneurysm is encountered.

A large series of true pancreaticoduodenal artery aneurysms.

INTRODUCTION: True pancreaticoduodenal artery aneurysms (PDAAs) are rare, and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health system from 2004 to 2019 with true PDAAs, with a focus on risk factors, interventions, and patient outcomes. METHODS: Patients were identified by querying a single health system picture archiving and communication system database for radiographic reports noting a PDAA. A retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests. RESULTS: A total of 59 true PDAAs were identified. Forty aneurysms (68%) were intact (iPDAAs) and 19 (32%) were ruptured (rPDAAs) at presentation. The mean size of rPDAAs was 16.4 mm (median size, 14.0 mm; range, 10-42 mm), and the mean size of iPDAAs was 19.4 mm (median size, 17.5 mm; range, 8-88 mm); this difference was not statistically significant (P = .95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%; P = .017) and less likely to have aneurysmal wall calcifications (6% vs 53%; P = .002). Thirty-seven patients underwent intervention (63%), with eight (22%) undergoing concomitant hepatic revascularization (two stents and six bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAAs experienced an aneurysm-related mortality of 10.5%, whereas those with iPDAAs experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. rPDAAs showed a trend toward the increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%; P = .13). CONCLUSIONS: These findings support previous reports that the rupture risk of PDAAs is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both iPDAAs and rPDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Surgical Excision of a Contained Rupture of an Inferior Mesenteric Aneurysm.

Inferior mesenteric artery (IMA) aneurysms represent the minority of visceral aneurysm presentations. A 57-year-old female was admitted with a symptomatic IMA aneurysm secondary to atherosclerotic disease. She was treated with open excision which revealed a contained ruptured of a true aneurysm. This case highlights the challenges of an accurate preoperative diagnosis of IMA aneurysm and the correct position of the recent guidelines on visceral aneurysms issued by the Society of Vascular Surgery (SVS).

Endovascular Oriented Classification and Treatment of Celiac Trunk Aneurysms: 10 Years Experience.

OBJECTIVE: To propose an endovascular-oriented classification of celiac trunk aneurysms (CTa) and discuss single center results of this rare pathology. METHODS: Data of all patients admitted to our institution for CTa from 2011 to 2021 were prospectively collected. Of them, those who underwent endovascular treatment were retrospectively analyzed. All preoperative CT scans were reviewed and CTa were classified in 4 different configurations based on progressive distal landing zone. We excluded from the classification all cases with median arcuate ligament syndrome (MALS), patients with coexistent aortic dilation or no endovascular proximal neck. Preoperative demographics, intraoperative data and post-operative complications were recorded. All-cause late mortality and complications were identified through a review of office charts and telephone assessment. RESULTS: During the study period 19 patients were referred to our Institution for CTa. Ten patients underwent endovascular treatment (ET). In 6 cases a watchful waiting strategy was adopted, 2 (10.5 %) patients refused ET and one patient without suitable proximal landing zone (< 10 mm) was not proposed to open surgical repair for surgical contraindication but is followed by strict instrumental and clinical evaluation. Six (60%) patients presented type 2 CTa; all of them underwent ET requiring positioning of covered stent-graft and SA embolization. Three (30%) patients presented type 3 CTa; all of them underwent ET with covered stent-graft deployment over the GDA with preliminary embolization. One (10%) patient presented type 4 CTa that was treated by means of covered stent-graft deployment along the right hepatic artery with left hepatic artery embolization. Overall, no major complications and perioperative mortality was observed. CONCLUSION: Celiac trunk aneurysms are rare, and no classifications have still been presented. Stent-graft exclusion provides excellent short-term outcome with no significant morbidity and mortality rate when technically feasible.

Stiff coils enhance shape retention and pressure resistance in an aneurysm model even at low volume.

PURPOSE: To elucidate the characteristics of 3 D frame coils and identify the optimal coil for visceral aneurysms. MATERIAL AND METHODS: Using a vascular model, we compared the postembolization coil distribution and repulsive force of three coils: Guglielmi detachable coil (GDC; stock wire diameter, 0.004 in; primary diameter, 0.015 in), Target XL (0.003, 0.014), and Target XXL (0.003, 0.017). Additionally, the coil area, roundness, and center of gravity were quantitatively compared. The coil repulsive force was measured by compressing the postembolization vessel model with a digital force gauge. RESULTS: There were no significant differences in the coil area and roundness among the three coil types. Compared with the Target coils, the GDC deployed evenly along the vessel wall, its center of gravity was less displaced, and although it had the lowest embolic density, its repulsive force was greater regardless of the number of coils used. CONCLUSIONS: GDC coils with a larger stock wire diameter and a smaller primary diameter unfolded evenly along the wall and had a greater repulsive force. Coil stiffness contributes to coil stability and shape retention, indicating the possibility of preventing recurrence by selecting a frame coil with a focus on coil stiffness.

Morbidity and mortality associated with open repair of visceral aneurysms.

BACKGROUND: The Society for Vascular Surgery (SVS) recently published clinical practice guidelines on the management of visceral aneurysms. However, studies investigating the perioperative outcomes of open repair of visceral aneurysms have been limited to single-center experiences with variable results that span multiple decades. In the present study, we sought to detail the morbidity and mortality associated with open repair of visceral aneurysms using a national database in the contemporary era. METHODS: National Surgical Quality Improvement Program data from 2013 to 2019 were queried for patients who had undergone open repair of visceral aneurysms, which had been classified as mesenteric, renal, or splenic using Current Procedural Terminology and International Classification of Diseases codes. The primary endpoint was the composite of major complications (cardiovascular, pulmonary, progressive renal failure, deep wound infection, return to operating room, sepsis) and 30-day mortality. Logistic regression was used to identify the predictors of the primary endpoint for nonruptured aneurysm cases. RESULTS: Of the 304 aneurysms, 263 were nonruptured (137 mesenteric, 66 renal, 60 splenic) and 41 were ruptured (24 mesenteric, 1 renal, 16 splenic) and had undergone open repair. For those with nonruptured aneurysms, their mean age was 59.4 ± 14.7 years and 48.3% were women. For those with nonruptured aneurysms, the 30-day mortality was 1.9% and the major complication rate was 12.9%. A return to the operating room (5.3%) and prolonged ventilator support (3.8%) were especially common. As expected, rupture was associated with significantly greater mortality (22.0%; P < .001) and major complications (34.1%; P = .001). The use of postoperative transfusion was common in the elective group but was significantly greater in the ruptured group (24.3% vs 80.5%; P < .001). The predictors of the primary outcome for nonruptured aneurysms included male sex (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.28-6.7; P = .011), anticoagulation (not discontinued before surgery) or bleeding disorder (OR, 4.52; 95% CI, 1.37-14.7; P = .012), and albumin <3.0 g/dL (OR, 4.66; 95% CI, 1.17-18.6; P = .029). Neither age nor aneurysm location were significant risk factors. CONCLUSIONS: Open repair of visceral aneurysms was associated with acceptable morbidity and mortality, although these risks are significantly greater once ruptured. Male sex, bleeding risk, and low albumin were all risk factors for adverse events and should be considered for operative planning and postoperative care.

Contemporary Outcomes of in Situ Open Surgical Repair of Mid-Portion and Distal Renal Artery Aneurysms.

INTRODUCTION: The best management of renal artery aneurysms (RAAs) remains controversial, especially when they are located from the mid to distal portions of the main renal artery. Our aim is to evaluate our 10-year experience with in situ open surgical repairs from a cohort of non-proximal RAAs at a single vascular surgery center. METHODS: A retrospective review of a prospectively maintained database of all patients who underwent RAA in situ repairs located from the mid to distal portions of the renal artery at our Institution was performed between 2009 and 2020. Data on patient demographics, comorbidities, aneurysm location and morphology, type of in situ technique, and perioperative data were assessed. Postoperative biomarkers and renal function were collected, and mid-term follow-up results were analyzed. RESULTS: A total of 15 RAA located at mid and distal portions of the renal artery repaired with in situ techniques were performed in 15 patients (nine men, mean age 62.4 ± 6.36 years). At diagnosis, 12 patients were asymptomatic; a history of abdominal pain was found in one patient, and two patients had drug-resistant hypertension. Two patients had already undergone previous unsuccessful attempts of endovascular treatment. All patients presented an aneurysm diameter >20 mm (mean diameter 2.75 ± 5 mm). At admission, mean serum creatinine and glomerular filtration rate were 1.10 ± 0.23 mg/dL and 69.8 ± 9.8 mL/min/1.73 m2, respectively. Nine lesions were present in the distal portion of the renal artery, with 4 cases having ≥3 efferent branches and the other 5 with two efferent branches. The other six RAAs were in the mid-portion: in 4 cases, one efferent branch, and in 2 cases, two efferent branches were involved. All patients underwent in situ open repair: an end-to-end anastomosis was performed in 9 cases, aneurysm resection with primary closure in 3 cases, bypass with graft interposition in 2 cases (one iliac-renal reconstruction), and with vein interposition in 1 case. The mean renal ischemia time was 21.8 ± 9.4 min. A significant decrease on renal function was not observed (mean glomerular filtration rate at discharge: 64.8 ± 12.0 mL/min/1.73m2; P > 0.22). During recovery, one patient developed retroperitoneal hematoma treated conservatively. During follow-up (mean 46 months, range 2-135), one patient developed occlusion of a terminal renal artery branch without decreased kidney function. CONCLUSION: In situ techniques for RAA from the mid to distal portions of the renal artery are technically complex; however, based on our results, these procedures were safe and effective, providing satisfactory early and mid-term outcomes.

Ruptured Left Gastric Artery Aneurysm Associated with Fibromuscular Dysplasia.

Background: Fibromuscular dysplasia is a non-inflammatory, non-atherosclerotic vascular disease that commonly affects renal and carotid arteries but involvement of virtually any vascular territory has been observed.Research Design/ Study sample: This is a case report of a ruptured left gastric artery aneurysm as the first presentation of fibromuscular dysplasia.Data collection: After written consent from the patient, relevant clinical notes and imaging were retrospectively reviewed and critically analysed.Purpose: This case reiterates the importance of considering fibromuscular dysplasia as an uncommon cause of visceral artery aneurysms. In addition, this case shows that the impact of visceral artery vasospasm on endovascular access should not be underestimated and subsequent attempts can be successful after a period of resuscitation.Results: After initial difficulty in endovascular treatment due to visceral vasospasm, the case was successfully managed with with staged open ligation and endovascular embolization after a period of resuscitation.Conclusions: FMD is an important differential diagnosis to consider in cases of visceral aneurysms.

Cross clamping of the supraceliac aorta is effective for bleeding control in ruptured giant splenic artery pseudoaneurysm when proximal and distal control of the splenic artery is not possible: a case report / O clampeamento da aorta supracelíaca é eficaz no controle de sangramento em pseudoaneurisma gigante roto de artéria esplênica quando o controle proximal e distal da artéria esplênica não é possível - relato de caso

Abstract Splenic artery pseudoaneurysm is the most common of all the visceral artery pseudoaneurysms. Presentation is often variable and the condition demands immediate diagnosis and management because pseudoaneurysm rupture increases morbidity and mortality. It is associated with pancreatitis and other conditions like abdominal trauma, chronic pancreatitis, pseudocyst of the pancreas, liver transplantation, and, rarely, peptic ulcer disease. We present a case of a giant splenic artery pseudoaneurysm measuring 14x8 cm. Proximal and distal control of the vessels could not be achieved during the procedure because of local adhesions and inflammation and it was necessary to cross clamp the supraceliac aorta to control bleeding.

Resumo O pseudoaneurisma de artéria esplênica é o mais comum entre os pseudoaneurismas de artérias viscerais. A apresentação geralmente varia e requer diagnóstico e tratamento imediatos, pois a ruptura do pseudoaneurisma aumenta a morbimortalidade. Esse tipo de pseudoaneurisma está associado à pancreatite e a outras condições, como trauma abdominal, pancreatite crônica, pseudocisto de pâncreas, transplante de fígado e, raramente, úlcera péptica. Apresentamos um caso de pseudoaneurisma gigante de artéria esplênica, com tamanho de 14x8 cm. Durante o procedimento, não foi possível alcançar controle proximal e distal dos vasos devido a aderências locais e inflamação, sendo necessário o clampeamento da aorta supracelíaca para controle do sangramento.