Case Report

The Endovascular Treatment of a Ruptured Aneurysm of the Middle Colic Artery Combined With an Isolated Dissection of Superior Mesenteric Artery: Report of a Case

Vascular and Endovascular Surgery 2014, Vol. 48(4) 352-355 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413518615 ves.sagepub.com

Eun Mi Ham, PhD1, Byung Sun Cho, MD2, Jin Bong Ye, MD2, Yun Su Mun, MD2, Young Jin Choi, MD2, and Oh Sang Kwon, MD2

Abstract Background: Ruptured aneurysm of the middle colic artery is very rare. Its concomitance with isolated dissection of the superior mesenteric artery (SMAD) has not yet been reported in the literature. Case report: A previously well 56-year-old man was referred to our hospital with acute-onset pain throughout the entire abdomen. A ruptured aneurysm of the middle colic artery and isolated SMAD were revealed using a computed tomography (CT) scan. Coil embolization was successfully performed for a ruptured aneurysm of the middle colic artery. During the immediate postprocedural period, the patient had ischemic colitis, but he recovered in a few days with conservative treatment. Close observation was elected to address the SMAD because the condition was not thought to be responsible for any symptoms. The CT scan followed after 2 years showed no change in SMAD. Conclusions: We successfully performed endovascular treatment for a ruptured aneurysm of the middle colic artery. For the incidentally detected SMAD, close observational management was chosen. Keywords middle colic artery aneurysm rupture, superior mesenteric artery dissection, endovascular therapy, coil embolization

Introduction Ruptured aneurysm of the middle colic artery is extremely rare. Its etiology and the optimal treatment modality are not well understood. Moreover, its concomitance with isolated superior mesenteric artery dissection (SMAD) and association has not yet been reported in the literature. We report herein a successful, uncomplicated endovascular treatment of a ruptured middle colic artery aneurysm with a concomitantly detected isolated SMAD.

Case Report A previously well 56-year-old man was referred to our hospital with acute-onset pain throughout the entire abdomen. Two days previously, he had sudden-onset moderate abdominal pain with accompanying general myalgia, vomiting, and diarrhea. He later developed syncope. Upon arrival, the patient’s blood pressure was 80/50 mm Hg, and his pulse rate was 78/min. Signs of abdominal irritation were present upon physical examination. The laboratory findings showed mild leukocytosis (white blood cell count: 10970/mL) and no anemia (red blood cell count: 15.1 g/dL, hematocrit: 43.5%). An abdominal computed tomography (CT) scan was immediately performed under the impression of peritonitis. He had no history of hypertension or other medical disease.

The CT scan showed features of a ruptured aneurysm of the middle colic artery with a hematoma around the transverse mesocolon and extending through the retroperitoneal space to lesser sac, intraperitoneal fluid collection, and isolated dissection of the superior mesenteric artery (SMA; Figure 1). We planned an endovascular approach to therapy. We elected to address the SMA using an RH catheter (Cook, Bloomington, Indiana) and performed an angiography. The middle colic artery had luminal irregularities, and the feeding vessel of the aneurysm originated from a false lumen of isolated SMAD. The middle colic artery aneurysm occurred after first branching and had 2 large draining collaterals. We also found an isolated SMAD with a patent false lumen beginning from the proximal SMA. We selected the middle colic artery and collaterals using a Progreat guidewire and microcatheter

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Department of Nursing, Konkuk University, Chungju, South Korea Department of Surgery, Eulji University School of Medicine, Daejeon, South Korea 2

Corresponding Author: Byung Sun Cho, Department of Surgery, Eulji University School of Medicine and Eulji University Hospital, 1306 Dunsan-dong, Seo-gu, Daejeon, South Korea. Email: [email protected]

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Figure 1. Abdominal computed tomography (CT) angiography. A, The CT shows a middle colic artery aneurysm, hematoma in the transvers mesocolon, and superior mesentric artery dissection (SMAD). B, The CT angiography shows a middle colic artery aneurysm and SMAD with a patent false lumen.

Figure 2. Superior mesenteric artery (SMA) angiography. A, The SMA angiography shows a middle colic artery aneurysm with its collaterals and superior mesentric artery dissection (SMAD). B, Multiple luminal irregularities are present along the middle colic artery. C, Completion angiography demonstrates that a middle colic artery and its branches were successfully occluded by microcoils.

(Terumo, Fujinomiya, Japan). Ten Tornado microcoils (Cook) were used to exclude the aneurysm from the circulation, 3 for inflow and 7 microcoils for outflow exclusion, respectively. The aneurysm was not detected on completion of the angiography (Figure 2). A few hours after the procedure, the abdominal pain was further aggravated and a high fever subsequently developed. Signs of peritoneal irritation were evident upon physical examination. A CT scan was performed under the impression of ischemic colitis. The CT scan demonstrated a hypodense segmental colon wall thickening in the transverse colon with decreased enhancement, which was suggestive of ischemic colitis (Figure 3). The patient was recovered with bowel rest,

parenteral nutrition, and antibiotics within a few days. For the treatment of an isolated SMAD, because the observation of SMAD was an incidental finding and there was no surgical indication, such as bowel necrosis or arterial rupture, we decided to treat the patient using only follow-up CT imaging. The patient was discharged and resumed his normal activity without any further complications.

Discussion Aneurysms of the SMA branch, particularly of the middle colic artery, are extremely rare.1 Only 2% of all reported splanchnic artery aneurysms have been located in the distribution of the

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Figure 3. Postprocedural abdominal computed angiography (CT) shows segmental hypodense wall thickening in the transverse colon.

jejunal, ileal, or colic arteries.2 A middle colic artery aneurysm concomitant with isolated dissection of the SMA has not yet been reported in the medical literature. This case may be the first such report in the English language literature. The common causes of middle colic artery aneurysm are atherosclerosis, angiodysplasia, arteritis, and infection. Among these, segmental arterial mediolysis (SAM) is the most common.1 Multiple aneurysms and wall irregularity have been described as the primary characteristics of segmental arterial mediolysis.3 In this case, wall irregularities were present on the middle colic artery. Angiography and CT scan revealed no additional aneurysms in the visceral arteries. The middle colic aneurysm in this case might be associated with SAM. Isolated SMAD has been shown to be associated with cystic medial degeneration, atherosclerosis, and fibromuscular disease.2 Coexistence of SAM and cystic degeneration was reported in a patient with aneurysms of the abdominal aorta and the iliac artery.4 However, in this case, the etiologic association of middle colic artery aneurysm with SMAD is not definite. Most of the reported middle colic artery aneurysms have presented with rupture.5 According to a literature review, of the 28 aneurysm cases, only 3 cases were asymptomatic.1 Our case was diagnosed due to the rupture of the aneurysm. We judged that our patient’s abdominal pain originated from the ruptured aneurysm, not from the SMAD because most of the pain from the SMAD originated from stenosis of the SMA.6 Sarcina et al1 reported that both ultrasound and CT are unlikely to localize these aneurysms due to their small size. Angiography is the best way to diagnose and localize these lesions. However, some authors have reported that the CT scan is advantageous to diagnose these lesions during the early stages, while angiography is advantageous for intervention.7 We performed a CT scan first, which allowed us to confirm the anatomy of the middle colic artery aneurysm, including the feeding vessel and collaterals. We also detected the asymptomatic isolated dissection of the SMA. Of all the mesenteric branch artery aneurysms, colic aneurysms are the most likely to rupture; therefore, they should be considered for intervention at an early stage.8

The previous treatment for middle colic artery aneurysm was surgery, such as the ligation of vessels, resection of the aneurysm, or resection including bowel. Sarcina et al1 reported the first successful arterial reconstruction in a case of a middle colic artery aneurysm. Naito et al5 first reported a successful endovascular treatment for middle colic artery aneurysm. There has been some fear of a risk of complication after endovascular treatment, including bowel ischemia and persistence of the aneurysm after endovascular treatment; however, there have been many reports of successful endovascular treatment, even in a patient who had impaired collateral circulation because she underwent a right hemicolectomy and open abdominal aortic aneurysm repair.1,9-11 Kasirajan et al12 reported on the failure of catheterization and coil embolization in a case that represented a failure to catheterize the neck of the pseudoaneurysm, which arose from a branch of the middle colic artery. We successfully performed endovascular treatment with microcoils. Although the patient had temporary ischemic colitis, he recovered in a few days with conservative treatment. It has not yet been established how to approach an incidentally detected SMAD. In this case, we continued to monitor the SMAD closely for 3 reasons. First, the SMAD of the patient had a patent false lumen. Second, the patient had no symptoms associated with SMAD. Finally, there was no surgical indication such as bowel necrosis or arterial rupture. In recent reports of incidentally detected SMAD, patients were safely followed up without any sort of therapeutic intervention.6,13 The CT scan followed after 2 years showed no change in SMAD. We successfully performed endovascular treatment for a ruptured aneurysm of the middle colic artery. Close observational management was chosen for the incidentally detected SMAD. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by research funds from Konkuk University, 2013.

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The endovascular treatment of a ruptured aneurysm of the middle colic artery combined with an isolated dissection of superior mesenteric artery: report of a case.

Ruptured aneurysm of the middle colic artery is very rare. Its concomitance with isolated dissection of the superior mesenteric artery (SMAD) has not ...
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