AJR 2002; 178:1459-1461
© American Roentgen Ray Society
Percutaneous Treatment of a Superior Mesenteric Artery Pseudoaneurysm Using a Stent-Graft
Miloslav Rocek1,
Jan H. Peregrin1,
Juraj Dutka1,
Miroslav Ryska2,
Frantisek Bêlina2 and
Jarmila Lastovcková1
1 Department of Diagnostic and Interventional Radiology, Institute for Clinical
and Experimental Medicine,
Víde
ská 1958/9, 140 21 Prague
4, Czech Republic.
2 Department of Transplant Surgery, Institute for Clinical and Experimental
Medicine, 140 [UNK]21 Prague 4, Czech Republic.
Received November 17, 2000;
accepted after revision December 18, 2001.
Supported by grant 309/97/K048 by the Grant Agency of the Czech
Republic.
Address correspondence to M. Ro
ek.
Introduction
Aneurysms and pseudoaneurysms of visceral arteries are rare, yet clinically
serious, vascular lesions. Many will not be detected until their rupture,
which often results in the death of the patient
[1]. The standard surgical
approach is resection of aneurysms exceeding 2 cm in diameter and of all
pseudoaneurysms; the rationale of surgery is prevention of rupture
[2]. Percutaneous techniques
offer an alternative form of therapy, and the number of reported cases treated
with embolization has been rising steadily. We report our experience with the
use of a prosthetic stentgraft in the treatment of a large pseudoaneurysm of
the superior mesenteric artery (SMA).
Subject and Methods
A 39-year-old man was repeatedly hospitalized for acute exacerbation of
chronic pancreatitis from alcoholic causes, with secondary diabetes mellitus
and liver cirrhosis. Eighteen months before hospitalization, a pseudocyst
jejunostomy was established because of a pseudocyst of the pancreatic head.
The size of the pseudocyst diminished after the procedure, and the patient's
status improved, although he complained of occasional epigastric discomfort. A
month before his admission, he experienced intense pressure pain propagating
into his back, intensifying on inspiration and within 30 min after a meal. The
patient was fatigued and lost weight. Abdominal sonography and CT revealed a
communication of the pseudocyst with the SMA forming a mural thrombus and a
pseudoaneurysm 7 cm in diameter. No clinical signs of bleeding were noted.
Flush abdominal angiography confirmed a large pseudoaneurysm filling on
selective angiography from the central segment of the SMA, which was markedly
displaced anteriorly (Figs. 1A
and 1B). We treated the
pseudoaneurysm by excluding it with a stent-graft placed percutaneously.
Broad-spectrum prophylactic antibiotic coverage was provided before and 24 hr
after the procedure.
After catheterizing the SMA using a conventional 5-French diagnostic Cobra
catheter and a Storq guidewire (Cordis, Miami, F1), we advanced a 260-cm
Amplatz Super Stiff (Cordis) guidewire to the SMA periphery, distal to the
site of the pseudoaneurysm origin. Next, an 8-French Supra Arrow-Flex sheath
(Arrow, Reading, PA), 80 cm long, was advanced over the guidewire to the site
of contrast leakage into the pseudoaneurysm. The site of the pseudoaneurysm
origin was covered with a prosthetic stent-graft with a variable diameter of
4-9 mm and a length of 28 mm (Jostent Peripheral Stent Graft; Jomed,
Rangendingen, Germany). The stent-graft was mounted on a Vas-Cath balloon
catheter (diameter, 6 mm; length, 4 cm) (Angiomed/Bard, Karlsruhe, Germany);
implantation was performed by inflating the balloon at 6 atm over 30 sec. We
used the Jostent Peripheral Stent Graft because it was the only commerically
available covered stent in our country at this time. It was readily implanted
in the selected vessel segment. This stent-graft is a combination of a
150-µm-thick layer of expandable polytetrafluoroethylene material
(internodal distance, 70 µm) sandwiched between two balloon-expandable
stainless steel stents. Polytetrafluoroethylene is regarded as the least
thrombogenic graft material available. The stent-graft is expandable up to 9
mm and can be introduced through a 7- to 8-French introducer sheath, depending
on the size of the balloon and the length of the stent-graft. The stent-graft
has been reported to shorten to 26 mm using a 6-mm balloon catheter.
Results
Placement of the stent-graft resulted in total exclusion of the
pseudoaneurysm and occlusion of two SMA branches originating close to the
aneurysmal neck (ileojejunal artery proximal to the neck and ileocolic artery
distal to the neck). Distal reconstitution of both occluded arteries was
provided via immediate retrograde filling from the mesenteric artery arcade
(Figs. 1C and
1D). No signs of visceral
ischemia were noted. The patient's abdominal pain subsided soon after the
procedure. Anticoagulation therapy with warfarin (for 6 months) was initiated,
and the patient was discharged from the hospital on postprocedure day 6.
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Fig. 1C. —39-year-old man with intense pressure abdominal pain.
Selective angiogram obtained after stent-graft implantation
(arrowheads) shows two SMA branches (ileojejunal and ileocolic)
occluded proximally.
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Fig. 1D. —39-year-old man with intense pressure abdominal pain. Late
selective angiogram shows immediate retrograde filling (arrows)
through collateral arteries. Image was created by superimposition of early
(white arteries) and late (black arteries) frame of SMA arteriogram.
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Follow-up selective angiography of the SMA at 3 months did not show
contrast leakage into the pseudocyst/pseudoaneurysm. The anterior deviation of
the SMA shown on the initial study (Figs.
1A and
1B) was significantly reduced
on the 3-month follow-up angiography. Minor irregularities indicative of
neointimal hyperplasia were found in the stent-graft (Figs.
1E and
1F). Follow-up helical CT
undertaken at the same time detected a residual pseudocyst and a thrombus. The
pseudocyst had shrunk to more than half its original size. Follow-up CT 9
months later showed further regression of the original lesion. At 30-month
follow-up, the patient was asymptomatic except for one episode of
self-limiting acute pancreatitis.
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Fig. 1E. —39-year-old man with intense pressure abdominal pain.
Follow-up selective angiograms of SMA obtained 3 months after A-D show
no contrast leakage into pseudocyst/pseudoaneurysm. Note minor irregularities
(arrowheads) indicative of neointimal hyperplasia in stent-graft.
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Fig. 1F. —39-year-old man with intense pressure abdominal pain.
Follow-up selective angiograms of SMA obtained 3 months after A-D show
no contrast leakage into pseudocyst/pseudoaneurysm. Note minor irregularities
(arrowheads) indicative of neointimal hyperplasia in stent-graft.
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Discussion
SMA aneurysms are the third most common visceral artery aneurysms (splenic
and celiac artery aneurysms occurring more frequently), accounting for 5.5% of
all such aneurysms and are almost always located in the first 5 cm of the SMA
[1]. The causes of SMA
aneurysms and pseudoaneurysms are diverse. Mesenteric pseudoaneurysms are
believed to be the result of autodigestion of the arterial walls caused by
release of pancreatic enzymes during pancreatitis
[3]. Another possibility is a
pseudocystic pressure erosion into the adjacent artery (this possibility is
supported by the marked deviation of the SMA in our patient). We cannot rule
out injury during surgery, which included biopsy of the wall of the
pseudocyst. However, the time from surgery to the development of complaints
appears to be too long. Other causes of aneurysm and pseudoaneurysm formation
include nonsurgical trauma, arteriosclerosis, infection, medial necrosis,
collagen vascular disease, arteritis, or dissection
[4,
5].
Unlike any other visceral artery aneurysms, most SMA aneurysms are
symptomatic. Typically, patients present with moderate to severe abdominal
pain that is usually progressive. The most serious complication is bleeding.
Bleeding due to pseudoaneurysm rupture is a relatively rare, yet lethal,
complication of pancreatitis. The mortality rate is as high as 37%
[6]. In our patient, abdominal
pain was not associated with clinical manifestations of bleeding.
At present, standard treatment is surgery, which involves ligation of the
vessel below and above the aneurysm and, most important, aneurysm resection
[1]. The current recommendation
is to resect all visceral vessel aneurysms and pseudoaneurysms larger than 2
cm in diameter to avoid rupture
[2]. Alternative therapeutic
modalities are percutaneous techniques, mainly embolization procedures
[3,
7]. There has been a single
report of treatment of an SMA pseudoaneurysm with an autogenous vein-covered
stent. The technique was chosen as the best approach in a patient with
recurrent gastrointestinal bleeding in a potentially infected area
[5].
Prosthetic stent-grafts are another option for percutaneous treatment of
these aneurysms. Obliteration of the aneurysmal neck results in effective
obliteration of the aneurysm and in reduction of the risk of rupture or distal
embolization [8]. Although
prosthetic stent-grafts have been used in various areas of the vascular system
[8], we have found only one
report of its use in the treatment of an SMA aneurysm or pseudoaneurysm
[9].
In conclusion, an SMA pseudoaneurysm was successfully treated with a
percutaneously placed prosthetic stent-graft, avoiding surgical treatment.
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Introduction
Subject and Methods
