Rare arterial and venous aneurysms of the gastrointestinal tract


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Alysha Vartevan D.O., Patricio Rossi M.D., Daryl EberM.D,
Javier Casillas M.D, Beatrice Madrazo M.D.

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Rare arterial and venous aneurysms of the gastrointestinal tract

  1. 1. RARE  ARTERIAL  AND  VENOUS  ANEURYSMS  OF  THE  GASTROINTESTINAL  TRACT   Alysha  Vartevan  D.O.,    Patricio  Rossi  M.D.,  Daryl  Eber  M.D,  Javier  Casillas  M.D,  Beatrice  Madrazo  M.D.     DEPARTMENT  OF  RADIOLOGY,  LARKIN  COMMUNITY  HOSPITAL/NOVA  SOUTHEASTERN  COLLEGE  OF  OSTEOPATHIC  MEDICINE   Splanchnic  aneurysms  consNtute  an  uncommon,  but   clinically  relevant,  form  of  abdominal  vascular  disease   which   shows   a   high   mortality   rate   in   emergency   surgery.   The   arteries   involved   include:   splenic,   hepaNc,   celiac,   superior   mesenteric,   ileocolic,   gastroduodenal,   and   inferior   mesenteric.   Intra-­‐ abdominal  venous  aneurysms  can  also  occur  such  as   portal  vein  aneurysms  and  superior  mesenteric  vein   aneurysms.   The   paNents   can   present   asymptomaNcally   with   non-­‐specific   abdominal   pain   or  with  intense  pain  and  hemodynamic  compromise   requiring   emergent   surgical   intervenNon.   The   most   common   intra-­‐abdominal   aneurysms   include   aorNc,   iliac   artery,   and   splenic   artery.   We   present   cases   of   rare   intra-­‐abdominal     aneurysms   including   superior   mesenteric  vein,  portal  vein,  gastro-­‐duodenal  artery,   celiac  artery,  ileocolic  artery  and  inferior  mesenteric   artery  aneurysms.   INTRODUCTION   Superior   mesenteric   vein   aneurysms   are   very   rare   with   only   10   published  cases  (1).  PaNents  presented  with  vague  abdominal  pain   or   asymptomaNcally.   Because   of   the   anatomical   locaNon,   a   superior   mesenteric   vein   aneurysm   can   compress   adjacent   extrahepaNc   bile   ducts   and   the   duodenum   (2).   Elevated   bilirubin   and   transaminase   levels   were   described   in   2   cases   (1).   Theories   about  the  origin  of  these  aneurysms  have  been  proposed  including   local  inflammatory  processes  and  congenital  abnormaliNes  (2).                 SUPERIOR  MESENTERIC  VEIN   ANEURYSM   Case 1: 55-year-old female with cryptogenic cirrhosis and portal hypertension that required TIPS. The patient was referred to our institution for further evaluation due to suspected TIPS malfunction. Fig 1A Fig 1B Fig 1C Aneurysms   of   the   gastroduodenal   artery   are   rare.   They   are   o_en   associated   with   pancreaNc   pathology   or   secondary   to   atherosclerosis.  Computed  tomography  and  Doppler  ultrasound  have   shown   to   be   effecNve   in   idenNfying   these   lesions.   ComplicaNons   include   bleeding   into   the   intraperitoneal   or   retroperitoneal   spaces   (4).   Other   rare   complicaNons   described   include   rupture   into   the   portal  vein  and/or  into  a  pancreaNc  pseudocyst  (5).     GASTRO-­‐DUODENAL  ARTERY   ANEURYSM   CASE 5: Fig 5A Fig 5B These   aneurysms   are   also   rare.   They   can   be   asymptomaNc   and   appear  as  an  incidental  finding  on  rouNne  examinaNon  or  they  can   present   as   abdominal   apoplexy   with   sudden   abdominal   pain   and   hemodynamic  collapse.  Atherosclerosis  is  the  most  common  eNology,   however  they  have  been  incidentally  found  in  paNents  with  Ehlers-­‐ Danlos  and  Lupus.   ILEOCOLIC  ARTERY  ANEURYSM   Fig. 6A-B: CECT shows a large heterogeneous mass in the right side of the abdomen, anterolateral to the aorta (arrowhead) with the epicenter in the mesentery. Fig 6A Fig 6B Aneurysms  of  the  celiac  artery  are  rare  and  include  approximately   4%   of   all   visceral   artery   aneurysms.     These   aneurysms   are   o_en   asymptomaNc  and  incidentally  detected  in  the  sixth  decade  of  life.     In   recent   years,   the   increased   use   of   cross-­‐secNonal   imaging   has   improved  the  detecNon  rate  of  these  aneurysms  (6).    Although  rare,   the  risk  of  rupture  and  other  complicaNons  warrant  elecNve  repair,   especially  in  paNents  with  aneurysms  greater  than  two  cenNmeters.   CELIAC  ARTERY  ANEURYSM   CASE 7: Celiac Artery Aneurysms CASE 8: Fig. 7A: Plain CT shows a large, oval, irregular structure with a calcified wall (red arrow) located anterolateral to the aorta (arrowhead). Note the areas of increase density representing acute bleed (blue arrow). Fig. 7B: CECT shows the irregular lumen and demonstrates active extravasation (arrowheads). Fig 7A Fig 7B Fig 8: CECT shows a fusiform celiac artery aneurysm of 2.0 cm in diameter (black arrow). Patient was post-op AAA repair. Aneurysms  of  the  Inferior  Mesenteric  Artery  (IMA),  Arch  of  Riolan,   are   very   rare,   accounNng   for   only   0.5%   of   all   visceral   arterial   aneurysms.   The   most   common   cause   of   these   aneurysms   is   atherosclerosis.  The  most  common  locaNon  for  these  aneurysms  is   in  the  proximal  trunk  of  the  artery.  The  most  common  manifestaNon   of  an  IMA  aneurysm  is  an  asymptomaNc  pulsaNle  abdominal  mass.   Once  diagnosed,  the  method  of  choice  for  treatment  is  surgical(7).   Inferior  Mesenteric  Artery     Case 9: Arch of Riolan Aneurysm and Polyarteritis Nodosa Fig 9A Fig 9B Fig 9C Aneurysm   of   the   portal   vein,   iniNally   described   by   Barzilai   and   Kleckner   in   1956   (3),   is   an   uncommon   enNty   with   less   than   one   hundred  published  cases  worldwide.    These  aneurysms  are  defined   by  an  increase  focal  diameter  of  the  portal  vein  greater  than  one   and   a   half   to   two   cenNmeters.   It   most   commonly   occurs   at   the   juncNon   of   the   superior   mesenteric   and   splenic   veins   or   at   the   portal  bifurcaNon.    Portal  vein  aneurysms  can  occur  secondarily  in   the   seings   of   portal   hypertension,   pancreaNNs,   trauma,   and   hepatocellular   disease.     Histopathologically,   these   acquired   aneurysms  can  exhibit  inNmal  thickening  and  medial  hypertrophy.     However,   the   lack   of   portal   hypertension   or   other   pathologic   processes   in   several   reported   cases   of   portal   vein   aneurysms   support   other   proposed   eNologies   including   congenital   origin.     Among   these   congenital   causes,   an   intrinsic   weakness   of   the   vascular  wall  or  failure  of  regression  of  the  right  primiNve  vitelline   vein  have  been  proposed  (2).     Portal  Vein  Aneurysm   Case 2: 51-year-old male complaining of non-specific abdominal pain Case 3: 45-year-old male with incidental finding on US Case 4: 48-year-old female, complaining of right upper quadrant pain Fig. 2A-B: Contrast enhanced CT images through the hepatic hilum demonstrate a homogeneously enhancing round structure with markedly different diameters at the two shown levels. Fig. 3A: CT image shows a large oval hypodensity in the region of the porta hepatis (arrow). Fig. 3B: Axial T1-W image demonstrates flow void signal in the same region. Fig. 3C: T2-W Fat Sat. sequence shows focal hyperintensity with flow void in the periphery compatible with turbulent flow. The combination of these findings is consistent with a portal vein aneurysm. Note the incidental simple cysts in the left lobe of the liver. Fig. 4A: Non contrast T1-W shows focal oval dilatation with flow void signal at the junction of the main and right portal veins. In Fig. 4B this structure demonstrates strong homogeneous enhancement identical to the adjacent portal vein branches. Gray scale US shown in Fig. 4C : again confirms the presence of the lesion. These findings were diagnostic of a proximal right portal vein aneurysm. Fig 2A Fig 2B Fig 3A Fig 3B Fig 3C Fig 4A Fig 4B Fig 4C REFERENCES: 1- Wolosker N, Zerati, et al. Aneurysm of Superior Mesenteric Vein: Case report with a 5 year follow-up and review of the literature. J Vascular Surgery 2004; 39: 459-461. 2- Furcher A. and Turner M. Aneurysms of the portal vein and superior mesenteric vein. Abdominal Imaging 1997; 22: 287-292. 3- Barzilai R. and Kleckner M.S. Jr. Hemocholecyst following ruptured aneurysm of portal vein. Archives of Surgery 1956; 72: 725-727. 4- Jamal HZ, and KP Block. Endoscopic appearance of gastroduodenal artery aneurysm. Gastrointestinal Endoscopy 1999; 50:862-863. Contrast enhanced axial CT image demonstrates the stent inside the main portal vein (arrow), note the numerous collaterals around the right portal vein consistent with partial cavernous transformation (arrowhead). CECT demonstrates the stent at the level of the portal confluence. CECT shows a pseudoaneurysm of the SMV (blue arrow). Findings suggest stent migration due to venous dilatation secondary to venous hypertension and subsequent intimal hyperplasia around the proximal aspect of the stent with formation of a distal pseudoaneurysm. Fg. 5A-B: CECT demonstrating a large heterogeneous mass in the area of the head of the pancreas (arrow). The lesion extends inferiorly and there is a focal area of intense enhancement consistent with a vascular structure. This was consistent with a gastroduodenal artery pseudoaneurysm within a pancreatic pseudocyst. Note the dilatation of the pancreatic duct and the presence of calcifications in the pancreas consistent with chronic pancreatitis CASE 6: Young patient with history of Lupus (SLE), diiffuse abdominal pain and dropping hematocrit This vascular structure corresponds to the portal vein (arrow). Note the distal dilatation with normal proximal caliber and no signs of portal hypertension. These findings are consistent with a portal vein aneurysm. In addition there is free fluid around the liver and diffuse high signal consistent with active extravasation (arrow) Fig. 9A-B: CT without contrast showing an area of high density in the left mesentery and left lower quadrant with small amount of free fluid (arrows). Fig. 9C: T1-W Fat. Sat. post gadolinium image demonstrates a central round hyperintense mass (arrow) surrounded by low signal representing a mesenteric aneurysm with surrounding hematoma. 5- Yeh TS, Jan YY, Jeng LB, et al. Massive extra-enteric gastrointestinal hemorrhage secondary to splanchnic artery aneurysms. Hepatogastroenterology 1997; 44:1152-1156. 6- Soudack M, Gaitini D, and Ofner A. Celiac artery aneurysm: diagnosis by color Doppler sonography and three- dimensional CT angiography. J Clin Ultrasound 1999; 27:49-51. 7Davidovic Lazar B, Vasic Dragan M, and Colic Momcilo I. Inferior Mesenteric Artery Aneurysm: Case Report and Review of Literature. Asian J of Surgery 2003; 26 (6); 176-179. CASES PRESENTED FROM LARKIN COMMUNITY HOSPITAL, HEALTH CARE IMAGING, AND JACKSON HOSPITAL UNIVERSITY OF MIAMI Gastro-Duodenal Artery Pseudoaneurysm 58-year-old male presents with abdominal pain s/p AAA stent