Prise en charge des anévrismes des artères digestives. Étude rétrospective de 23 cas

doi:10.1016/S0003-3944(02)00746-0

Annales de Chirurgie

Volume 127, Issue 4, April 2002, Pages 281-288

https://doi.org/10.1016/S0003-3944(02)00746-0 Get rights and content

Résumé

But de l’étude : Évaluer la symptomatologie et les résultats du traitement des anévrismes des artères digestives.

Patients et méthode : Étude rétrospective de 23 patients (14 hommes et 9 femmes, âge moyen = 51 ans) traités dans deux services hospitalo-universitaires. Les critères étudiés ont été : les caractéristiques de l’anévrisme (siège, taille, nombre, étiologie), le mode de traitement et la survenue de complications postopératoires.

Résultats : Les anévrismes étaient localisés au niveau de l’artère splénique chez 13 patients (56 %), de l’artère mésentérique supérieure chez cinq patients (22 %), de l’artère hépatique chez trois patients (13 %), et gastro-épiploïque chez deux patients (9 %). Au total, 31 anévrismes (24 anévrismes vrais et sept faux-anévrismes) étaient présents chez les 23 patients. Le diagnostic était essentiellement fait par le scanner abdominal. Les anévrismes étaient rompus chez sept patients (30 %). Il n’y avait pas de corrélation entre la taille de l’anévrisme et la survenue d’une rupture. Le traitement des anévrismes était chirurgical 26 fois (84 %) ou une embolisation radiologique trois fois (10 %) ; une abstention était décidée deux fois (6 %). Aucun décès n’a été constaté.

Conclusion : Les résultats du traitement chirurgical des anévrismes des artères digestives observés dans cette série, la fréquence élevée et l’absence de facteur prédictif des ruptures conduisent à proposer un traitement chirurgical de première intention. L’embolisation percutanée pourrait être réservée aux contre-indications de la chirurgie et aux anévrismes difficilement accessibles.

Abstract

Study aim: To evaluate symptoms and results of the treatment of aneuryms of digestive arteries.

Patients and method: Retrospective study of 23 patients (14 male and 9 female, mean age=51 years) treated in two departements of academic hospital. We studied the aneurysm caracteristics (location, number, size, etiology) the type of treatment, and occurence of post-operative complications.

Results: The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastro-epiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occured in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed.

Conclusion: The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contre-indication of surgery and when aneurysms are poorly accessible to surgery.

Section snippets

Patients et méthodes

Vingt-trois patients (14 hommes et neuf femmes), âgés en moyenne de 51 ans (extrêmes : 27–72 ans), ont été pris en charge de janvier 1980 à juin 2001 dans un service hospitalo-universitaire de chirurgie vasculaire ou de chirurgie digestive. Pour chaque patient, les données suivantes étaient recueillies : âge, sexe, mode de diagnostic de l’anévrisme, caractéristiques de l’anévrisme (siège, taille, nombre, étiologie), type de traitement, complications postopératoires (pendant la durée

Résultats

Chez les 23 patients, la plus fréquente localisation des anévrismes viscéraux (tableau I) était l’artère splénique (13 patients, 57 %). Les autres localisations étaient : l’artère mésentérique supérieure chez cinq patients (22 %), l’artère hépatique chez trois patients (13 %), et l’artère gastro-épiploïque chez deux patients (9 %). Dans un cas, un anévrisme gastro-épiploïque était associé à une sténose du tronc cœliaque. Parmi ces 23 patients, six avaient des anévrismes multiples (n = 2 ou 3)

Discussion

La distribution des anévrismes des artères digestives de cette série est similaire à celle rapportée dans la littérature 11, 12, à une exception près. En effet, nous avons constaté une inversion de prévalence entre les anévrismes de l’artère mésentérique supérieure et ceux de l’artère hépatique. Le taux de patients ayant un anévrisme de l’artère mésentérique supérieure était de 22 % dans cette série alors qu’il se situe dans la littérature entre 3,5 et 8,5 % 5, 9. À l’opposé, le taux de

Conclusion

Cette étude suggère d’une part que les anévrismes des artères digestives rompus, correspondant à 30 % des anévrismes, doivent être opérés en urgence afin de limiter le risque de mortalité. D’autre part, la prise en charge élective des anévrismes asymptomatiques ou symptomatiques sans signe de rupture doit être également chirurgicale quels que soient leurs diamètres. Trois raisons plaident en faveur de cette attitude :

•
la fréquence élevée des ruptures anévrismales ;
•
l’absence de facteur –

Références (27)

J.C Stanley et al.
Clinical importance and management of splanchnic artery aneurysms
J Vasc Surg
(1986)
S.C Carr et al.
Current management of visceral artery aneurysms
Surgery
(1996)
C Carmeci et al.
Visceral artery aneurysms as seen in a community hospital
Am J Surg
(2000)
L.M Messina et al.
Visceral artery aneurysms
Surg Clin North Am
(1997)
S.G Mattar et al.
The management of splenic artery aneurysms : experience with 23 cases
Am J Surg
(1995)
C.J Shanley et al.
Common splanchnic artery aneurysms : splenic, hepatic, and coeliac
Ann Vasc Surg
(1996)
L.M Graham et al.
Celiac artery aneurysms : historic (1745–1949) versus contemporary (1950–1984) differences in etiology and clinical importance
J Vasc Surg
(1985)
D.C Cassada et al.
Mesenteric pseudoaneurysm resulting from septic embolism
Ann Vasc Surg
(1998)
O Glehen et al.
Anévrismes des artères hépatiques
Ann Chir
(2001)
M.J Arca et al.
Splenic artery aneurysms : Methods of laparoscopic repair
J Vasc Surg
(1999)

O Rokke et al.

The diagnosis and management of splanchnic artery aneurysm

Scand J Gastroenterol

(1996)

D Psathakis et al.

Present management of hepatic artery aneurysms

Vasa

(1992)

R.J Holdsworth et al.

Ruptured splenic artery aneurysm in pregnancy : a review

Br J Obstet Gynecol

(1992)

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Editor's Choice – Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS)
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Concomitant aneurysms are found in up to one third of patients with visceral artery aneurysms.277,279–282 These include other visceral arteries (4–44%),20,21,277,281,283–286 the thoraco-abdominal aorta and iliac arteries (3–27%),277,279,281,286 and intracranial arteries (3–4%).277,281,286 Abdominal organ transplant recipients may be at increased risk of aneurysmal degeneration of mesenteric arteries.287
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The purpose of this study was to identify subgroups with different risks of progression and their appropriate management among the heterogeneous group of 112 patients diagnosed with splanchnic aneurysm.
Using radiology databases and medical records of our institution (Hospital Édouard-Hérriot, Lyon, France), we undertook a retrospective review of all patients diagnosed with splanchnic artery aneurysms from 1995 to 2011. Cases were analyzed by aneurysm location, etiology and a distinction was also made between true and false aneurysms.
False aneurysms were more likely than true aneurysms to be diagnosed as symptomatic and/or ruptured (TA: 50/66 patients asymptomatic vs. FA: 16/46 asymptomatic, P < 0.05) with a rupture rate of 59% (27/46) which was unrelated to the size of aneurysms. Percutaneous treatment was carried in the majority of patients with a final success rate of 91%. Peripancreatic true aneurysms were associated in 75% of cases with celiac occlusive disease and diagnosed mostly in symptomatic patients (7/9: 78%) with a rupture rate of 44% unrelated to their size. Radiologic treatment has faced problems due to failure of catheterization and incomplete embolization, although there have been cases in which delayed occlusion was achieved. Common true aneurysms were incidental findings in 87% (57/66) of patients with 3 ruptured aneurysms which were larger than 2 cm. Observation in that group was safe: significant growth was seen only in one patient and the embolization required was successful. Splanchnic false aneurysms and peripancreatic true aneurysms carried a high and an unpredictable risk of rupture that warranted prompt endovascular treatment as soon as possible.
Stratification by localization and by the true or false appearance of the aneurysm was an effective (means of identifying) way to identify subgroups with different risks of progression. False aneurysms and peripancreatic true aneurysms carried a high and unpredictable risk of rupture. The splanchnic aneurysms should have been treated in the case of patients of childbearing age, size ≥ 20 mm, and in the case of liver transplantation. Other splanchnic aneurysms should either have been observed, if smaller than 2 cm. In the absence of rigorous published comparisons, surgical and endovascular methods should have been considered equally suitable in the elective treatment of these patients.
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Les anévrysmes des artères digestives représentent une entité pathologique rare avec un risque de rupture associé à un taux de mortalité élevé, souvent asymptomatique, ils sont alors découverts fortuitement à l’occasion d’un examen pour autre visée diagnostique. Nous rapportons trois cas d’anévrysmes digestifs : un du tronc cœliaque, un de l’artère mésentérique supérieure sur maladie de Behçet et un de l’artère splénique, qui ont été traités chirurgicalement avec succès.
The aneurysms of digestive arteries are a rare pathological entity, with a risk of rupture associated to a high mortality rate, often asymptomatic, then they are discovered incidentally during a exam for other diagnostic purposes. We report three cases of digestive aneurysms, one of celiac trunk, one of mesenteric artery on behçet disease, and one of splenic artery, which were treated surgically with success.
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Distinguishing between therapeutic contingency and surgical complication is sometimes not easy, especially when rare events occur. We report the case of a patient who presented with an intraperitoneal haemorrhage following laminectomy and discuss the implications of surgery in this complication.
A 77-year-old woman, suffering from radiculopathy due to lumbar stenosis underwent a laminectomy in the prone position. On admission she presented with high blood pressure and obesity as significant comorbidities. A few hours after surgery, she collapsed and underwent a thoraco-abdominal CT-scan. The examination revealed a ruptured hepatic artery aneurysm. It is the first case published in the medical literature after lumbar surgery. The aim of this article was to discuss the responsibility of the surgeon and surgery, particularly the surgical positioning of the ruptured aneurysm.
After reviewing the literature we did not find any evidence to attribute the rupture of this hepatic artery aneurysm to lumbar surgery. This adverse event could be attributed to therapeutic contingency. In cases of patient complaint, this situation depends on national solidarity.
Il est parfois difficile de différencier l’aléa thérapeutique de la complication chirurgicale, d’autant plus que l’événement s’avère exceptionnel. Nous rapportons le cas d’une patiente ayant présenté une hémorragie intrapéritonéale survenu au décours d’une laminectomie, posant le problème de l’imputabilité du geste chirurgical.
Une patiente de 77 ans souffrant de radiculalgies secondaires à un canal lombaire étroit a été opérée par laminectomie sans instrumentation avec recalibrage, en position décubitus ventral sur quatre coussins. La patiente présentait comme principales comorbidités, un surpoids important et une hypertension artérielle. Les suites immédiates ont été marquées par l’apparition d’un choc hémorragique motivant un scanner abdominal. Cet examen a révélé la présence d’un anévrisme rompu de l’artère hépatique, situation non recensée dans la littérature. Cet événement nous a amené à discuter de sa prise en charge, de l’imputabilité du positionnement opératoire et ses possibles conséquences sur les pressions intra-abdominales, ainsi que de la responsabilité potentielle du médecin.
Après une revue de la littérature, nous n’avons pas pu mettre en évidence de lien direct entre la chirurgie lombaire et la rupture anévrysmale, évènement pouvant être attribué à un aléa thérapeutique. En cas de plainte, cette situation dépendrait de la solidarité nationale.
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The early results of open surgical treatment of ADAs in terms of morbidity/mortality have been evaluated better than the late results. Mortality has been shown to vary between 1.3% and 11%, and early morbidity between 9% and 40%.4–7,10 Our death rates are located in the lower fork (1.7%) and reflect the validity of our surgical attitude associated with a thorough preoperative evaluation.
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Between January 2000 and March 2010, 60 patients were operated on for 78 aneurysms of the digestive arteries at our institution. The mean age of patients was 61 years (31–84 years). The average lesion diameter was 33 mm (range 10–90 mm). Topographic distribution involved the coeliac trunk in 23 cases (30%), hepatic artery in 20 (26%), splenic artery in 19 (24%), superior mesenteric artery in 11 (14%), gastroduodenal artery in 3 (4%), and pancreaticoduodenal arteries in 2 (3%). Twenty patients (33%) were symptomatic, 1 of whom presented with aneurysmal rupture (1.7%). Follow-up was prospective and an actuarial analysis was carried out. Only 3 patients (5%) were lost to follow-up.
Hospital mortality was 1.7% (upper gastrointestinal bleeding from gastric metastases of a kidney cancer). Postoperative complications were mainly respiratory (18%), digestive (18%), and renal (13%). Five reintervention procedures (8%) were necessary: 2 for colonic ischemia; 1 for intestinal bleeding; 1 for secondary graft infection due to peritonitis; and 1 for drainage of an acute pancreatitis. The average follow-up was 42 months (range 1–120 months). The actuarial survival rates were 98% at 1 month and 1 year, and 97% at 5 and 10 years, respectively. One late death occurred at 22 months (bronchopulmonary cancer). Three late reinterventions were carried out: 2 re-establishments of digestive continuity and 1 embolization for a recurrent aneurysm 7 years after the initial operation. The primary patency rate of the revascularizations was 98% at 1 month and 1 year, and 95% at 5 and 10 years. The rates of indemnity of restenosis or thrombosis were 98% at 1 month and 1 year, and 95% and 93% to 5 and 10 years, respectively. The rates of freedom of reintervention on bypasses were 98% at 1 month and 1 and 5 years, and 97% at 10 years.
Open surgical treatment of aneurysms of the digestive arteries offers excellent long-term results in terms of patency. It is with these late results that endovascular techniques will have to be compared to define the best therapeutic strategy.
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Citation Excerpt :
In order to better evaluate the results of open repair and endovascular repair of SRAAs, we reviewed the literature. In all, we identified 1299 patients with 1528 aneurysms from 29 different publications2–29 from the last ten years, including the present study. Among those series, eight included patients with pseudoaneurysms.
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All patients with SRAAs diagnosed from 1995 to 2010 in St Marys Hospital (London, UK) and Henri Mondor Hospital (Créteil, France) were reviewed. Preoperative clinical and anatomical data, operative management and outcomes were recorded from the charts and analyzed.
40 patients with 51 SRAAs were identified. There were 21 males and 19 females with a mean age of 57 ± 14.9 years. The aneurysms locations were: 14 (27%) renal, 11 (22%) splenic, 7 (14%) celiac trunk, 7 (14%) superior mesenteric artery, 4 (8%) hepatic, 4 (8%) pancreaticoduodenal arcades, 3 (6%) left gastric and 1 (2%) gastroduodenal. 4 patients presented with a ruptured SRAA. 17 SRAAs in 16 patients were treated by open repair, 15 in 15 patients were treated endoluminally and 17 (mean diameter: 18 mm, range: 8–75 mm) were managed conservatively. One patient with metastatic pulmonary cancer with two mycotic aneurysms of the superior mesenteric artery (75 mm) and celiac trunk (15 mm) was palliated. After endovascular treatment, the immediate technical success rate was 100%.
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Article originalPrise en charge des anévrismes des artères digestives. Étude rétrospective de 23 casManagement of visceral artery aneurysms. Retrospective study of 23 cases.

Résumé

Abstract

Section snippets

Patients et méthodes

Résultats

Discussion

Conclusion

J Vasc Surg

Surgery

Am J Surg

Surg Clin North Am

Am J Surg

Ann Vasc Surg

J Vasc Surg

Ann Vasc Surg

Ann Chir

J Vasc Surg

The diagnosis and management of splanchnic artery aneurysm

Scand J Gastroenterol

Present management of hepatic artery aneurysms

Vasa

Ruptured splenic artery aneurysm in pregnancy : a review

Br J Obstet Gynecol

Article original
Prise en charge des anévrismes des artères digestives. Étude rétrospective de 23 casManagement of visceral artery aneurysms. Retrospective study of 23 cases.