DOI:10.2214/AJR.07.3255
AJR 2008; 191:826-833
© American Roentgen Ray Society
Visceral Artery Aneurysms: Evaluation Using 3D Contrast-Enhanced MR Angiography
Qi Liu1,
Jian Ping Lu,
Fei Wang,
Li Wang,
Ai Guo Jin,
Jian Wang and
Jian Ming Tian
1 All authors: Department of Radiology, Changhai Hospital, Second Military
Medical University, 174 Changhai Rd., Shanghai, Shanghai 200433, China.
Received October 3, 2007;
accepted after revision March 22, 2008.
Address correspondence to J. P. Lu
(luping{at}sh163.net).
Abstract
OBJECTIVE. Visceral artery aneurysms are uncommon, but they are
clinically important because of the high incidence of rupture and
life-threatening hemorrhage. Visceral artery aneurysms in patients with
vascular anatomic variations are extremely rare, but detecting these
variations is significant in this setting to determine the best treatment
strategy; therefore, a thorough assessment of the aneurysm and of the vascular
anatomy before treatment is paramount.
CONCLUSION. Three-dimensional contrast-enhanced MR angiography is a
noninvasive technique for the diagnosis and display of visceral artery
aneurysms. It can provide 3D anatomic information that is needed for surgery
or embolization.
Keywords: abdomen • aneurysms • MR angiography • splanchnic aneurysms • visceral artery aneurysms
Introduction
Visceral artery aneurysms are uncommon, but more are being reported because
of the widespread use of high-resolution imaging techniques. To date, fewer
than 4,000 cases have been reported, but most articles have reported only a
few cases or even an individual case
[1,
2].
Visceral artery aneurysms are clinically important because of the high
incidence of rupture and life-threatening hemorrhage, with mortality rates of
20–75% depending on the location of the aneurysm
[3]. Considering the natural
history of visceral artery aneurysms and the risk of rupture, there is general
agreement in the literature to treat these lesions even when they are
asymptomatic. No standard treatment protocol for visceral artery aneurysms has
been established. In general, treatment is considered for patients with an
aneurysm that is twice the diameter of a normal vessel, those who have an
aneurysm that is rapidly growing, those with symptoms attributable to the
aneurysm, and women of childbearing age
[4].
Treatment of visceral artery aneurysms can be performed by either surgery
or endovascular procedures and should be individualized depending on the
location of the aneurysm, regional vascular anatomy, and associated or
coexisting conditions [5].
Individual anatomy plays an important role in determining the best treatment
strategy for visceral artery aneurysms. Moreover, the visceral arteries
exhibit a number of anatomic variations and performing procedures to treat an
aneurysm without prior knowledge of the anatomy of the vessels may lead to
serious consequences [6].
Therefore, a thorough assessment of the visceral vasculature is required
before treatment.
In the past, catheter-based angiography was a reference standard for
detecting vascular diseases. Today, noninvasive techniques, such as CT
angiography and 3D contrast-enhanced MR angiography (CE-MRA), are being used
instead of angiography
[7–9].
These techniques can confirm the diagnosis of visceral artery aneurysm,
delineate the feeding vessels, depict collateral blood flow, reveal any other
aneurysms, and show anatomic variations of the vessels. Furthermore, these
techniques can provide 3D anatomic information that is needed for surgery or
embolization. However, few reports about 3D CE-MRA in the evaluation of
visceral artery aneurysms have been published. This article displays the
usefulness of 3D CE-MRA in the evaluation of visceral artery aneurysms and
related vascular variations.
Three-Dimensional CE-MRA Technique
Three-dimensional CE-MRA was per formed using a 1.5-T whole-body system
(Magnetom Avanto, Siemens Medical Solutions). Initially, coronal, axial, and
sagittal 2D true fast images with steady-state precession were obtained
through the major abdominal vessels and organs. CE-MRA was then performed in
the coronal plane using a 3D radiofrequency-spoiled interpolated FLASH
sequence with asymmetric k-space sampling in a readout and phase-encoding
direction. The other parameters included the following: TR/TE, 2.96/1.21 ms;
flip angle, 25°; field of view, 400 x 400 mm; matrix, 196 x
512; slice thickness, 1.0 mm; bandwidth, 690 Hz per pixel; and acquisition
time, 18 seconds with an integrated parallel acquisition technique factor of
2. Gadolinium diethylenetriamine pentaacetic acid (0.2 mmol/kg) was
administered at a rate of 3 mL/s through an antecubital vein using a power
injector and was followed by a 15-mL saline flush at the same flow rate. The
scanning delay time was determined on the basis of a test bolus. An unenhanced
scan was obtained before contrast material administration followed by arterial
and venous scans with separate breath-holds. Source images were subtracted and
transferred to the workstation (Leonardo, Siemens Medical Systems) for 3D
reconstructions, mainly using volume rendering and multiplanar
reconstruction.
Visceral Artery Aneurysms
In order of decreasing incidence frequency of visceral artery aneurysms,
the arteries involved are splenic (60%), hepatic (20%), superior mesenteric
(5.5%), and celiac (4%) arteries; rarely, gastroduodenal, renal,
pancreatic–duodenal, jejunal, ileocolic, and inferior mesenteric
arteries are involved [2].
Splenic artery aneurysms are usually asymp tomatic. The risk of rupture is
estimated to be between 2% and 10%, with a mortality rate of 36%
[10]. Splenic artery aneurysms
are usually saccular and occur most often in the distal portion of the splenic
artery (Fig. 1), although they
also can be located in other portions of the splenic artery (Fig.
2A,
2B). Aneurysms of the proximal
or middle portion of the splenic artery may be treated by aneurysmectomy and
end-to-end anastomosis or simple ligation and exclusion without arterial
reconstruction. Splenectomy should be performed when an aneurysm is localized
at the splenic hilus [2].
Because endovascular treatment has become increasingly popular, coil
embolization can be used to treat distal splenic aneurysms and stent-grafts
are more suitable for proximally located aneurysms
[4]. Three-dimensional CE-MRA
can depict the location and morphology of an aneurysm and its relationship
with the feeding artery. The 3D display, which is of great help for planning
surgery and endovascular treatment, is more clear on 3D CE-MRA images than on
digital subtraction angiography images (Fig.
3A,
3B,
3C,
3D).
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Fig. 1 —Distal splenic artery aneurysm in 52-year-old woman with
liver cirrhosis. Coronal volume-rendered image shows 1.9 x 2.3 cm
aneurysm in distal portion of splenic artery. Patient was treated with
aneurysmectomy and splenectomy.
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Fig. 2A —41-year-old woman with mid splenic artery aneurysm. Coronal
oblique (A) and axial oblique, from inferior viewing orientation
(B), volume-rendered images show 1.8 x 2.5 cm aneurysm in middle
portion of splenic artery. Patient was treated with coil embolization 5 days
after contrast-enhanced MR angiography.
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Fig. 2B —41-year-old woman with mid splenic artery aneurysm. Coronal
oblique (A) and axial oblique, from inferior viewing orientation
(B), volume-rendered images show 1.8 x 2.5 cm aneurysm in middle
portion of splenic artery. Patient was treated with coil embolization 5 days
after contrast-enhanced MR angiography.
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Fig. 3A —66-year-old woman with large proximal splenic artery aneurysm
and small distal splenic artery aneurysm. SA = splenic artery, CA = celiac
artery, HA = hepatic artery, SMA = superior mesenteric artery. Coronal oblique
(A) and axial oblique, from superior viewing orientation (B),
volume-rendered images reveal 2.6 x 3.3 cm aneurysm (narrow
arrowhead) arising from proximal portion of splenic artery and 1.3
x 1.8 cm aneurysm (wide arrowhead) within distal portion of
splenic artery.
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Fig. 3B —66-year-old woman with large proximal splenic artery aneurysm
and small distal splenic artery aneurysm. SA = splenic artery, CA = celiac
artery, HA = hepatic artery, SMA = superior mesenteric artery. Coronal oblique
(A) and axial oblique, from superior viewing orientation (B),
volume-rendered images reveal 2.6 x 3.3 cm aneurysm (narrow
arrowhead) arising from proximal portion of splenic artery and 1.3
x 1.8 cm aneurysm (wide arrowhead) within distal portion of
splenic artery.
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Fig. 3C —66-year-old woman with large proximal splenic artery aneurysm
and small distal splenic artery aneurysm. SA = splenic artery, CA = celiac
artery, HA = hepatic artery, SMA = superior mesenteric artery. Oblique
posteroanterior volume-rendered image shows relationship of large aneurysm to
its feeding artery (black arrowhead, C) more clearly than
digital subtraction angiography image (D). Both aneurysms (white
arrowhead, C) were embolized by coils.
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Fig. 3D —66-year-old woman with large proximal splenic artery aneurysm
and small distal splenic artery aneurysm. SA = splenic artery, CA = celiac
artery, HA = hepatic artery, SMA = superior mesenteric artery. Oblique
posteroanterior volume-rendered image shows relationship of large aneurysm to
its feeding artery (black arrowhead, C) more clearly than
digital subtraction angiography image (D). Both aneurysms (white
arrowhead, C) were embolized by coils.
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Most hepatic artery aneurysms are extrahepatic (78%) and single (92%)
[5,
11]. Aneurysms of the common
hepatic artery can safely be treated by ligation and excision and by
embolization, stenting, or both. Hepatic perfusion is maintained by the
gastroduodenal and right gastric arteries. Aneurysms of the hepatic artery
proper (i.e., distal to the gastroduodenal artery) necessitate excision and
reconstruction with an autologous conduit. Intrahepatic aneurysms can be
treated with resection, ligation, or embolization
[1,
5]. Three-dimensional CE-MRA
can confirm the location of an aneurysm and its relationship with surrounding
vessels. Moreover, 3D CE-MRA can display mural thrombus in an aneurysm that
cannot be shown by digital subtraction angiography (Fig.
4A,
4B,
4C,
4D).
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Fig. 4A —72-year-old woman with common hepatic artery aneurysm and
celiac artery aneurysm. Coronal volume-rendered (A) and digital
subtraction angiography (B) images show 3.5 x 4.0 cm aneurysm
(white arrowhead, A) of common hepatic artery and 1.8 x
3.2 cm fusiform aneurysm (black arrowhead, A) of celiac
artery.
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Fig. 4B —72-year-old woman with common hepatic artery aneurysm and
celiac artery aneurysm. Coronal volume-rendered (A) and digital
subtraction angiography (B) images show 3.5 x 4.0 cm aneurysm
(white arrowhead, A) of common hepatic artery and 1.8 x
3.2 cm fusiform aneurysm (black arrowhead, A) of celiac
artery.
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Fig. 4C —72-year-old woman with common hepatic artery aneurysm and
celiac artery aneurysm. Multiplanar reconstruction (C) and true fast
imaging with steady-state precession (D) images reveal partial thrombus
(asterisk) in aneurysm. Patient was treated with coil embolization
for common hepatic artery aneurysm and celiac artery aneurysm was not treated.
Four months after treatment, reembolization with coils and absorbable gelatin
sponge (Gelfoam, Upjohn) was performed for recurrence. In D, arrowhead
= aneurysm.
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Fig. 4D —72-year-old woman with common hepatic artery aneurysm and
celiac artery aneurysm. Multiplanar reconstruction (C) and true fast
imaging with steady-state precession (D) images reveal partial thrombus
(asterisk) in aneurysm. Patient was treated with coil embolization
for common hepatic artery aneurysm and celiac artery aneurysm was not treated.
Four months after treatment, reembolization with coils and absorbable gelatin
sponge (Gelfoam, Upjohn) was performed for recurrence. In D, arrowhead
= aneurysm.
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In contrast to other visceral artery aneurysms, most superior mesenteric
artery aneurysms are symptomatic with abdominal pain. Ruptured superior
mesenteric artery aneurysms have a mortality rate of up to 30%. Superior
mesenteric artery aneurysms are primarily located in the first 5 cm of the
vessel (Fig. 5). Surgical
treatment with aneurysmorrhaphy and simple ligation is the most frequently
used technique. In recent years, endovascular therapy with stents, coils, or
both stents and coils has become a feasible therapeutic option.
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Fig. 5 —54-year-old man with superior mesenteric artery aneurysm.
Oblique sagittal volume-rendered image shows 3.0 x 6.5 cm aneurysm
arising from proximal and middle portions of superior mesenteric artery.
Patient was under close observation because he refused surgery.
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Aneurysms of the celiac artery are unusual and frequently are asymptomatic.
The mortality rates for rupture of celiac artery aneurysms that have been
reported are up to 100% [2].
Celiac artery aneurysms are usually fusiform (Fig.
6A,
6B). CE-MRA can display the
relationship of an aneurysm with the bifurcation of the celiac artery (Fig.
7A,
7B,
7C).
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Fig. 6A —63-year-old man with celiac artery aneurysm. Coronal
(A) and axial, from inferior viewing orientation (B),
volume-rendered images show 1.7 x 2.5 cm aneurysm of celiac artery.
Patient was treated with aneurysmectomy. Follow-up contrast-enhanced MR
angiography (not shown) performed 1 month after operation showed patency of
splenic and hepatic arteries via collaterals.
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Fig. 6B —63-year-old man with celiac artery aneurysm. Coronal
(A) and axial, from inferior viewing orientation (B),
volume-rendered images show 1.7 x 2.5 cm aneurysm of celiac artery.
Patient was treated with aneurysmectomy. Follow-up contrast-enhanced MR
angiography (not shown) performed 1 month after operation showed patency of
splenic and hepatic arteries via collaterals.
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Fig. 7A —59-year-old woman with celiac artery aneurysm. Coronal
volume-rendered (A); axial, from inferior viewing orientation,
volume-rendered (B); and axial multiplanar reconstruction (C)
images show 4.2 x 5.2 cm aneurysm at bifurcation of celiac artery (CA,
C) involving orifice of common hepatic artery (HA, B) and
splenic artery (SA, B). Patient was treated with aneurysmectomy.
Follow-up contrast-enhanced MR angiography (not shown) 1 month after operation
showed patency of splenic and hepatic arteries via collaterals.
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Fig. 7B —59-year-old woman with celiac artery aneurysm. Coronal
volume-rendered (A); axial, from inferior viewing orientation,
volume-rendered (B); and axial multiplanar reconstruction (C)
images show 4.2 x 5.2 cm aneurysm at bifurcation of celiac artery (CA,
C) involving orifice of common hepatic artery (HA, B) and
splenic artery (SA, B). Patient was treated with aneurysmectomy.
Follow-up contrast-enhanced MR angiography (not shown) 1 month after operation
showed patency of splenic and hepatic arteries via collaterals.
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Fig. 7C —59-year-old woman with celiac artery aneurysm. Coronal
volume-rendered (A); axial, from inferior viewing orientation,
volume-rendered (B); and axial multiplanar reconstruction (C)
images show 4.2 x 5.2 cm aneurysm at bifurcation of celiac artery (CA,
C) involving orifice of common hepatic artery (HA, B) and
splenic artery (SA, B). Patient was treated with aneurysmectomy.
Follow-up contrast-enhanced MR angiography (not shown) 1 month after operation
showed patency of splenic and hepatic arteries via collaterals.
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Multiple aneurysms are estimated to occur in approximately 20% of all
visceral artery aneurysms
[10]. They are mainly located
in the splenic artery (Fig. 3A,
3B,
3C,
3D) and occasionally are
located in different visceral arteries (Figs.
4A,
4B,
4C,
4D and
8). Multiple aneurysms
involving multiple visceral arteries (Fig.
9A,
9B,
9C,
9D) are extremely rare. CE-MRA
can display multiple aneurysms at one time.
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Fig. 8 —53-year-old woman with splenic artery aneurysm and left renal
artery aneurysm. Coronal volume-rendered image shows 1.2 x 1.4 cm
aneurysm (wide arrowhead) of distal portion of splenic artery and 2.0
x 2.3 cm aneurysm (narrow arrowhead) of distal portion of left
renal artery. Patient was under regular observation without treatment because
of stable size and special position of renal aneurysm.
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Fig. 9A —32-year-old woman with multiple visceral artery aneurysms.
Coronal (A–C) and sagittal (D) volume-rendered images show
multiple aneurysms involving celiac artery, superior mesenteric artery and its
branches, and bilateral renal arteries. Patient was under observation.
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Fig. 9B —32-year-old woman with multiple visceral artery aneurysms.
Coronal (A–C) and sagittal (D) volume-rendered images show
multiple aneurysms involving celiac artery, superior mesenteric artery and its
branches, and bilateral renal arteries. Patient was under observation.
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Fig. 9C —32-year-old woman with multiple visceral artery aneurysms.
Coronal (A–C) and sagittal (D) volume-rendered images show
multiple aneurysms involving celiac artery, superior mesenteric artery and its
branches, and bilateral renal arteries. Patient was under observation.
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Fig. 9D —32-year-old woman with multiple visceral artery
aneurysms.A–D, Coronal (A–C) and sagittal (D)
volume-rendered images show multiple aneurysms involving celiac artery,
superior mesenteric artery and its branches, and bilateral renal arteries.
Patient was under observation.
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Related Unusual Vascular Variations
The unusual embryologic development of the ventral splanchnic arteries can
lead to considerable variations. Visceral artery variations are relatively
common, but two variations are closely related to visceral artery aneurysms:
One variation is an aneurysm at the proximal portion of the splenic artery
with an anomalous origin from the superior mesenteric artery; this pattern is
very rare, with only 11 cases reported to date, all of which are case reports
[6,
12,
13]
(Fig. 10). Visceral artery
aneurysms accompanied with this variation are extremely rare but are
clinically significant. This anatomic variation will greatly change the
treatment strategy, especially for surgery. The deep retropancreatic position
of aneurysms and of the affected arteries limits the field of view for the
surgeon and complicates surgical management. Knowledge of existing aberrations
is important in planning and conducting a surgical or endovascular procedure
to avoid catastrophic complications
[14].
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Fig. 10 —48-year-old woman with anomalous splenic artery aneurysm.
Coronal volume-rendered image shows 5.0 x 6.0 cm aneurysm in proximal
portion of splenic artery just after anomalously arising from superior
mesenteric artery and shows hepatic artery arising from abdominal aorta alone.
Patient was treated with coil, absorbable gelatin sponge (Gelfoam, Upjohn),
and glue embolization. Nine months after treatment, she was treated with
splenectomy because of splenic abscess.
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The other visceral artery variation that is closely related to a visceral
artery aneurysm is an aneurysm at the bifurcation of a common
gastrohepatosplenomesenteric trunk or celiomesenteric trunk (CMT) formation.
In the embryo, visceral arteries develop from the primitive dorsal abdominal
aorta by four roots that are initially separated and joined together by a
longitudinal ventral anastomosis. If the ventral anastomosis does not
disappear, a common gastrohepatosplenomesenteric trunk or CMT develops. The
superior mesenteric artery arises from this trunk after the emergence of a
short trunk that gives rise to the hepatic and splenic arteries. A CMT is
extremely rare, accounting for fewer than 1% of all abnormalities of the
visceral arteries. Only three cases of aneurysms of the CMT have been reported
in the literature [15]. CEMRA
not only can show a CMT aneurysm and its relationship with surrounding vessels
but also can provide significant follow-up information after surgery (Fig.
11A,
11B,
11C,
11D,
11E). CMT accompanied with
multiple aneurysms has not been reported (Fig.
12A,
12B) to our knowledge.
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Fig. 11A —45-year-old man with celiomesenteric trunk aneurysm. Coronal
oblique (A) and sagittal (B) arterial phase volume-rendered
images show 3.1 x 3.7 cm aneurysm arising from celiac artery just after
bifurcation of celiomesenteric trunk.
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Fig. 11B —45-year-old man with celiomesenteric trunk aneurysm. Coronal
oblique (A) and sagittal (B) arterial phase volume-rendered
images show 3.1 x 3.7 cm aneurysm arising from celiac artery just after
bifurcation of celiomesenteric trunk.
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Fig. 11D —45-year-old man with celiomesenteric trunk aneurysm. Coronal
oblique (D) and sagittal (E) volume-rendered images after
aneurysmectomy and arterial ligation show patency of hepatic artery and
splenic artery.
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Fig. 11E —45-year-old man with celiomesenteric trunk aneurysm. Coronal
oblique (D) and sagittal (E) volume-rendered images after
aneurysmectomy and arterial ligation show patency of hepatic artery and
splenic artery.
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Fig. 12A —31-year-old man with multiple aneurysms accompanied with
celiomesenteric trunk. Coronal volume-rendered images show multiple aneurysms
involving splenic artery and common hepatic artery that arise from
celiomesenteric trunk. Patient was not treated because of complex anatomic
configuration of aneurysms.
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Fig. 12B —31-year-old man with multiple aneurysms accompanied with
celiomesenteric trunk. Coronal volume-rendered images show multiple aneurysms
involving splenic artery and common hepatic artery that arise from
celiomesenteric trunk. Patient was not treated because of complex anatomic
configuration of aneurysms.
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Summary
Visceral artery aneurysms are a very rare but a clinically important form
of vascular disease. Imaging assessment before treatment is important to
attain a better representation of the arterial anatomy and variations and
guide selection of an appropriate treatment. Three-dimensional CE-MRA is a
fast, accurate, and noninvasive technique for the diagnosis and display of
visceral artery aneurysms. It can provide 3D and accurate anatomic information
that can be used for surgical or endovascular treatment. Three-dimensional
CE-MRA can replace diagnostic invasive angiography in most cases.
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Abstract
Introduction
