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.

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.

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.

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.

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.

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.

Outcomes After Open and Endovascular Repair of Non-Ruptured True Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Coeliac Artery Compression: A Multicentre Retrospective Study.

OBJECTIVE: True aneurysms of the peri-pancreatic arcade (PDAA) have been attributed to increased collateral flow related to coeliac axis (CA) occlusion by a median arcuate ligament (MAL). Although PDAA exclusion is currently recommended, simultaneous CA release and the technique to be used are debated. The aim of this retrospective multicentre study was to compare the results of open surgical repair of true non-ruptured PDAA with release or CA bypass (group A) vs. coil embolisation of PDAA and CA stenting or laparoscopic release (group B). METHODS: From January 1994 to February 2019, 57 consecutive patients (group A: 31 patients; group B: 26 patients), including 35 (61%) men (mean age 56 ± 11 years), were treated at three centres. Twenty-six patients (46%) presented with non-specific abdominal pain: 15 (48%) in group A and 11 (42%) in group B (p = .80). RESULTS: No patient died during the post-operative period. At 30 days, all PDAAs following open repair and embolisation had been treated successfully. In group A, all CAs treated by MAL release or bypass were patent. In group B, 2/12 CA stentings failed at < 48 hours, and all MAL released by laparoscopy were successful. Median length of hospital stay was significantly greater in group A than in group B (5 vs. 3 days; p = .001). In group A, all PDAAs remained excluded. In group B, three PDAA recanalisations following embolisation were treated successfully (two redo embolisations and one open surgical resection). At six years, Kaplan-Meier estimates of freedom for PDAA recanalisation were 100% in group A, and 88% ± 6% in group B (p = .082). No PDAA ruptured during follow up. In group A, all 37 CAs treated by MAL release were patent, and one aortohepatic bypass occluded. In group B, five CAs occluded: four after stenting and the other after laparoscopic MAL release with two redo stenting and three aortohepatic bypasses. Estimates of freedom from CA restenosis/occlusion were 95% ± 3% for MAL release or visceral bypass, and 60% ± 9% for CA stenting (p = .001). Two late restenoses following CA stenting were associated with PDAA recanalisation. CONCLUSION: Current data suggest that open and endovascular treatment of PDAA can be performed with excellent post-operative results in both groups. However, PDAA embolisation was associated with few midterm recanalisations and CA stenting with a significant number of early and midterm failures.

Endovascular treatment of visceral aneurysms and pseudoaneurysms.

Visceral artery aneurysm (VAA) is a rare and potentially life-threatening condition, defined as true artery aneurysms and pseudoaneurysms of splanchnic circulation and renal artery. This study reports our experience in the diagnosis and endovascular treatment of visceral artery aneurysms (VAAs) over a 10-year period. Between 2008 and 2018, a total of 24 VAAs in 21 patients were diagnosed by clinical symptoms and a combination of imaging techniques, such as Doppler ultrasound, computed tomography angiogram, and catheter angiogram. All patients underwent endovascular treatment to exclude aneurysms. Oral antiplatelet medicine was administered, and imaging examination was performed during follow-up. Technical success was achieved in all 21 patients, and no periprocedural complications occurred. Endovascular coiling alone was employed in 10 aneurysms. Coiling was combined with gelfoam in 2 aneurysms. Coiling was assisted by stent in 4 aneurysms. Covered stents were deployed in 8 aneurysms individually. Clinical symptoms disappeared or highly improved in all patients after treatment. None of the patients showed recurrent symptoms after discharge. However, two cases with new aneurysms after 6 and 8 months, respectively, and one case with in-stent thrombosis after 12 months were reported during follow-up. This study may justify the efficacy of percutaneous endovascular coil embolization and stent deployment. It also provides beneficial experience about how to choose appropriate various endovascular strategies based on both clinical symptoms and aneurysm anatomy condition.

Inferior pancreaticoduodenal artery aneurysms and Dunbar syndrome. Experience with the open surgery.

INTRODUCTION: Median arcuate ligament or Dunbar syndrome is a rare vascular disorder causing celiac trunk stenosis or occlusion due to the extrinsic compression by the median arcuate ligament. A visceral aneurysm may develop as a complication. PATIENTS AND METHODS: We experienced an inferior pancreaticoduodenal artery aneurysm presentation in two female patients with the median arcuate syndrome previously diagnosed. One patient presented with postprandial abdominal pain and weight loss and the other one was asymptomatic. RESULTS: We described our experience with the both patients being successfully treated surgically. CONCLUSIONS: Awareness of possible repercussions of the celiac trunk stenosis to peripancreatic arteries should be elevated. Restoration of physiological blood flow by removing pathologic anatomy should be performed. Since there is no correlation between the size of a visceral aneurysm and the risk of rupture, having a high postrupture mortality, pancreaticoduodenal artery aneurysms should be treated even if asymptomatic. Surgical treatment remains the mainstay treatment of the Dunbar syndrome complicated by visceral aneurysms.

Endovascular treatment of an asymptomatic hepatic artery aneurism: case report.

We report a case of an asymptomatic, 77-year-old, male patient with arterial hypertension and no other comorbidities or risk factors for coronary disease. During a routine abdominal ultrasound examination, he was diagnosed with a hepatic vascular mass with an approximate diameter of 5 cm. Abdominal computed angiotomography was requested, showing an aneurysm of the hepatic artery, with maximum diameter of up to 5.2 cm, longest longitudinal axis of 7.2 cm, and a maximum true lumen caliber of 3.0 cm. We opted for endovascular aneurysm repair with implantation of three sequential Lifestream covered vascular stents (7x58mm, 8x58mm, and 8x37mm), successfully diverting the flow through the stents and excluding the aneurysm. The patient remains asymptomatic and free from clinical complications 2 years after the procedure. Control examinations with arterial duplex ultrasound 6 and 12 months after the procedure showed good flow through the stents with no leakage into the aneurysmal sac.

The role of emergency presentation and revascularization in aneurysms of the peripancreatic arteries secondary to celiac trunk or superior mesenteric artery occlusion.

OBJECTIVE: The goal of this study was to analyze our 10-year experience in the treatment of aneurysms of the collateral circulation secondary to steno-occlusions of the celiac trunk (CT) or superior mesenteric artery (SMA). METHODS: In the last 10 years, 32 celiac-mesenteric aneurysms were detected (25 true aneurysms and seven pseudoaneurysms) in 25 patients with steno-occlusion of the CT or SMA. All cases were diagnosed and treated at our center, with either surgical or endovascular approach. As open surgery, we performed aneurysmectomy and revascularization; as endovascular treatment we performed both the embolization (or graft exclusion) of the aneurysm sac, and embolization of afferent and efferent arteries. RESULTS: Sixteen patients (64%) underwent endovascular treatment, accounting for 66% of aneurysms (21/32). Six patients (24%) and seven associated aneurysms (22%) underwent open surgery. Three asymptomatic patients (12%), representing a total of four aneurysms (12%), were not treated. For endovascular procedures, the technical success rate was 90%, with a 56% clinical success rate. For open surgery, clinical and technical success were achieved in five patients (83%) and six procedures (86%), respectively. Sixty-eight percent of patients (17/25) were treated in an emergency setting, using either endovascular (88%) or open (12%) approaches. Although technical success was achieved in more than 85% of these procedures for both approaches, clinical success was reached less frequently among patients with an acute presentation (P = .041). Regardless of the type of treatment, CT or SMA revascularization during the first procedure did not show an increased rate of clinical success (P = .531). However, we reported four cases of visceral ischemia after an endovascular approach without revascularization, with three open surgical corrections required. The mean follow-up was 41 months (range, 0-136 months). CONCLUSIONS: Neither of the approaches described qualifies as a standard optimal choice. We suggest a tailored therapeutic approach based on the clinical condition at the time of diagnosis and specific vascular anatomy.

Visceral artery anomalies in patients with Alagille syndrome.

BACKGROUND: Intracranial and pulmonary vascular anomalies are well-known complications and causes of mortality in AGS; however, visceral artery anomalies are less commonly recognized. Herein, we present a retrospective analysis of our experience with pediatric LDLT that focuses on the current problems with and treatments for visceral artery anomalies in AGS after LDLT. METHODS: Between May 2001 and December 2017, 294 LDLTs were performed for 285 pediatric recipients. Of these, 13 LDLTs (4.4%) for 12 AGS patients were performed. We classified the visceral artery anomalies into aneurysms and stenosis. RESULTS: The overall incidence of visceral aneurysm was 2 of 12 recipients (16.7%) and included a SMA aneurysm in one patient and an IPDA aneurysm with a subsequent SPA aneurysm in one patient; the ages of the diagnosis of visceral aneurysm were 16.3, 21.1, and 21.7 y, respectively. An endovascular treatment was performed for a progressive IPDA saccular aneurysm (12.0 × 14.5 × 15.0 mm). The overall incidence of visceral artery stenosis was 7 of 12 recipients (58.3%) and the median age at the diagnosis of visceral artery stenosis was 15.5 y (range 1.7-22.9 y). All 3 AGS patients with RA stenosis suffered from renal dysfunction (eGFR of 51, 78, and 51 mL/min/1.73m2 ). CONCLUSION: The morbidity of visceral artery anomalies is not negligible. The performance of periodic imaging examinations is necessary, even for infants, because it is difficult to detect visceral vascular anomalies in the infant stage.

Selective occlusion of splenic artery aneurysms with the coil packing technique: the impact of packing density on aneurysm reperfusion correlated between contrast-enhanced MR angiography and digital subtraction angiography.

PURPOSE: The aim was to evaluate the relationship between coil packing densities after splenic artery aneurysm (SAA) treatment using detachable microcoils and rates of SAA reperfusion and to suggest a post-treatment surveillance protocol using contrast-enhanced MRA. MATERIALS AND METHODS: Evaluated were 16 patients (4 men; mean age 46.7), who underwent true SAA embolization using detachable microcoils (Concerto, Medtronic). SAAs were treated by selective coil packing (CP) or stent-assisted coil exclusion (SAC). Contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) were performed at 3 months post-procedure and correlated. RESULTS: Primary CP was used in 13 patients, while SAC was used in three patients. On follow-up, complete aneurysm occlusion was seen in seven patients (43.8%). Sac reperfusion occurred in nine patients (56.2%) and was demonstrated in all CE-MRA and six DSA studies. Mean aneurysm packing density was 20.10 ± 8.05% for the CP group and 32.90 ± 11.95% for the SAC group (p = 0.038). There was a significant difference in the incidence of aneurysm sac reperfusion on CE-MRA study between CP and SAC (9 vs. 0). No sac reperfusion was seen in aneurysms with packing densities ≥ 29%, irrespective of either embolization method. CONCLUSION: Favorable midterm results for coil packing of SAAs seem to depend on the coil packing density with a coil volume approximately a quarter of the aneurysm volume being most effective. Follow-up should involve the use of CE-MRA as this modality has been shown to be superior over DSA in detecting aneurysm reperfusion and coil compaction. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Covered stenting and transcatheter embolization of splenic artery aneurysms in diabetic patients: A review of endovascular treatment of visceral artery aneurysms in the current era.

Diabetes mellitus is associated with both microvascular and macrovascular complications, which can result in visceral aneurysms as for example splenic artery aneurysms: in their management, an endovascular treatment, less invasive than surgery, is generally preferred. Endovascular treatment of splenic artery aneurysms can be based either on covered stenting (CS) or transcatheter embolization (TE). CS generally allows aneurysm exclusion with vessel preservation, while TE usually determines target artery occlusion with potential risk of distal ischemia. We performed a review of the existing literature on endovascular treatment of visceral artery aneurysms (VAAs) and psudoaneurysms (VAPAs) in the current era.

Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms.

Objectives Visceral arterial aneurysms may be treated using open surgery or endovascular repair, but the best approach remains controversial. This was a retrospective study aiming to compare open surgery and endovascular treatment strategies for visceral arterial aneurysms. Methods The study included all 93 patients who were admitted with visceral artery aneurysms between January 2001 and January 2011 at the Department of Vascular Surgery, Changhai Hospital, Shanghai, China. All cases underwent either open or endovascular procedures. Overall survival and adverse events were compared between the groups. Success rate, blood loss, length of surgery, and length of hospital stay were also compared. The patients were followed up at three, six, and 12 months then every year until April 2014. Results Open surgery was performed on 34 patients and endovascular procedures on 59. There were no differences in characteristics of the patients between the open surgery and endovascular groups. The perioperative complication rate was 52.9 and 13.6% in the open surgery and endovascular groups, respectively. Mean follow-up was 36.8 months (range: 11 months to 10 years). The one- and five-year survival rates were 100 and 60.6%, respectively, in the open surgery group, compared to 100 and 84.5% in the endovascular group. Multivariate analysis for factors related to overall survival showed that there was a significant relationship with the treatment approach (HR = 0.479, 95%CI: 0.278-0.825; P = 0.008) and the presence of false aneurysm (HR = 2.929, 95%CI: 1.388-6.180, P = 0.005). Conclusions Endovascular repair could be considered as an effective method for visceral artery aneurysm. Endovascular repair showed lower perioperative complication rates and better long-term survival.

3D-Printed Visceral Aneurysm Models Based on CT Data for Simulations of Endovascular Embolization: Evaluation of Size and Shape Accuracy.

OBJECTIVE: The objective of this study is to verify the accuracy of 3D-printed hollow models of visceral aneurysms created from CT angiography (CTA) data, by evaluating the sizes and shapes of aneurysms and related arteries. SUBJECTS AND METHODS: From March 2006 to August 2015, 19 true visceral aneurysms were embolized via interventional radiologic treatment provided by the radiology department at our institution; aneurysms with bleeding (n = 3) or without thin-slice (< 1 mm) preembolization CT data (n = 1) were excluded. A total of 15 consecutive true visceral aneurysms from 11 patients (eight women and three men; mean age, 61 years; range, 53-72 years) whose aneurysms were embolized via endovascular procedures were included in this study. Three-dimensional-printed hollow models of aneurysms and related arteries were fabricated from CTA data. The accuracies of the sizes and shapes of the 3D-printed hollow models were evaluated using the nonparametric Wilcoxon signed rank test and the Dice coefficient index. RESULTS: Aneurysm sizes ranged from 138 to 18,691 mm3 (diameter, 6.1-35.7 mm), and no statistically significant difference was noted between patient data and 3D-printed models (p = 0.56). Shape analysis of whole aneurysms and related arteries indicated a high level of accuracy (Dice coefficient index value, 84.2-95.8%; mean [± SD], 91.1 ± 4.1%). CONCLUSION: The sizes and shapes of 3D-printed hollow visceral aneurysm models created from CTA data were accurate. These models can be used for simulations of endovascular treatment and precise anatomic information.

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.

Robotic Surgery for Elective Repair of Visceral and Renal Artery Aneurysms: A Systematic Review.

Background: The treatment choice of visceral artery aneurysms in an elective setting is debated. The durability and the risk of reintervention with endovascular treatment are still reasons for concern, whereas open surgery is invasive and burdened by major complications. In anecdotal reports and isolated studies, robotic-assisted surgery seems to provide the possibility of a minimally invasive treatment and the durability of traditional open surgery, but the literature supporting this view is scarce. This review aims to collect the results of robotic-assisted surgery in the treatment of visceral artery aneurysms. Methods: A systematic search of the main research databases was performed: the study endpoints were mortality and conversion rates, perioperative morbidity, and freedom from late complications and reinterventions. Results: We identified 16 studies on 53 patients. All cases underwent successful resection, with three conversions to laparoscopy. Perioperative and aneurysm-related mortality were nil. Over a median follow-up of 9 months, two reinterventions were reported (3.6%). Conclusion: The robotic technique is safe and effective in treating splenic and renal artery aneurysms, and it should be considered as a valuable alternative to endovascular and open repair, although larger sample sizes and a longer-term follow-up are necessary to confirm such results.

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.