Alysha Vartevan D.O., Patricio Rossi M.D., Daryl EberM.D, Javier Casillas M.D, Beatrice Madrazo M.D. DEPARTMENT OF RADIOLOGY, LARKIN COMMUNITY HOSPITAL

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