Vascular celiac aneurysm

Vascular Case Presentation:

Vascular Case Presentation GOTHI Vascular Group.

History ::

History : 70 Y male patient presented with severe abdominal pain and palpable pulsatile abdominal mass He had previous , MI 3 years ago, and cholecystectomy 20 years ago , No history of DM ,

Examination ::

Examination : Patient looks jaundiced ,and dehydrated. With pulsating abdomianl mass which is tender , and incisional hernia from a kocher scar of cholecystectomy . Chest Exam :NAD Cardiac Exam :NAD Lower limb oedema .

Investigations ::

Investigations : FBC , U+E , LVT , CXR , Echo , Abdom U/S , 3 D CT angiogram , Abdom CT .clotting profile .

3 D CT angiogram:

3 D CT angiogram

3 D CT angiogram:

3 D CT angiogram

What to do ?:

Patient developed obstructive jaundice and gastric outlet obstruction with clotting derangements What to do ?

Mr.Hussein Rabee:

Mr.Hussein Rabee Dear Mr.Mohamed > >Thank you very much for consulting me for this intenteresting saccular celiac a aneurysm. >On the base of angiogram and without knowing the history or age: >Vasculitis, mycotic ot traumatic can be a cause rather than atherosclerotic. >Surgery is an highly invasive treatment with high morbidity. Endovascular with risk of mesenteric ischemia is a better alternative if he relatively young. >If he is old ( > 70 y) or unfit, nothing to done may be wise. >The patient needs counselling in any way. >My best regards >Hussein Rabee >

Mr.Ahmed Halawa:

Mr.Ahmed Halawa Dear Mohamed What is the condition of the hart, how recent is the MI, what is the ejection fraction ratio. He needs biliary drianage through PTD, as ERCP and biliary stenting could be extremly difficult due to the gastric outlet obstruction. He will lose his renal function after the operation (If he survives). In the view of his age, the size of the aneurysm, the co-morbid factors, just drian his bile and keep him comfortable. I will forward this e-mail to Hussein Rabee for further advise Sincerely Ahmed M K Ahmed  MSc  FRCS  MD

Pro .D.Raithel:

Pro .D.Raithel Dear Dr. El-Farok, I think, that this patient should be treated by open vascular surgery. I am not sure, whether he could be treated endovascularly. With best regards, Prof. Dr. med. D. Raithel

Mr.John Wolfe:

Mr.John Wolfe Dear Mohamed Thank you for your email about this patient. An aneurysm of this size clearly needs surgery and this should be performed from within the sac of the aneurysm - no other dissection should be required other than exposure of the iliac bifurcation and the supra-coeliac aorta through the lesser sac. This will provide aortic control so that the aneurysm can be dealt with. At this size surgery seems necessary despite his considerable comorbidity. If you wish me to review him in London I would be delighted to do so. Best wishes and good luck, John Wolfe

MR.Amr Gad:

MR.Amr Gad Dear Dr.El Farouk Thank u for asking my advise about this high risk patient , I am afraid to tell u that u are obliged to explore this patient as  a trial to save his life i would prefere if it is posible to explore the distal part of the hepatic artery first and control it and then u perform an aorto hepatic bypass to the distal segment from a healthy distal part of the aorta and then attack the aneurysm itself after supraceliac aortic crossclamping and then u can ligate all the arteries branshing from the aneurysm if there is no stump of the celiac artery from aorta u can close the aortic defect by patch graft , iam not sure if this proposal is applicable to this case , The descision of the plan will be mainly intra-operatively .i wish u good luck and god bless u, AMR GAD

Mr.Giorgio Biasi:

Mr.Giorgio Biasi Dear Dr. El-Farok, we had a similar case few months ago with in addition a gastric carcinoma. We are actually preparing a short case report of the case. We introduced a balloon, via femoral access, positioned at the very origin of the celiac artery. At this point I would suggest that you open the patient, open the sac of the aneurysm, controll with Fogarty catheters, the back bleeding from the other vessels (splenic / hepatic)and finally exclude the aneurysm and revascularize the splenic and hepatic (eventually only the hepatic)with a graft interposition from the aorta. Let me know Giorgio M. Biasi, MChir FACS FRCS

Mr.Agiad Kotoby:

Mr.Agiad Kotoby Dear Dr Omar Nice to hear from you. This sounds like an interesting case.I have read the reply from Dr Ohki. The images are not clear and it may be more useful to have pictures from a CT angiogram to evaluate the aneurysm. If the patient is not a surgical candidate it may still be possible to advance a stent graft across the origin of the celiac depending on the detail of the anatomy on the cross sections CT angio. One alternative would be to put a stent graft at the origin extending into the splenic artery after occluding the distal hepatic either through the aneurysm or through the pancreatico-duodenal arcade. It is an interesting and challenging case for which a solution can be found Aghiad Al-Kutoubi MD,FRCR, DMRD Professor & Chairman Dept of Diagnostic Radiology The American University of Beirut Medical

Mr.Takao Ohki:

Mr.Takao Ohki Dear Mohamed due to the pre-existing mass effect, i believe that open surgery with or without bypass is the best approach. if the patient is truly a non surgical candidate, i think you should coil embolize the splenic, and common hepatic artery. then you should pack the aneurysm with multiple coils. i do not believe that any covered stent will be able to bridge the celiac and the hepatic artery. best regards, Chief, Division of Vascular and Endovascular Surgery Associate Professor of Surgery Montefiore Medical Center Albert Einstein

What to do ?:

What to do ? Problems : Celiac aneurysm . Obstructive jaundice. Gastric outlet obstruction . Chronic renal impairment Coagulopaty .

Do Literature search:

Do Literature search Celiac aneurysm = 999 + English + human = 560 + endovascular = 78

Summary:

Summary 180 cases reported world wide Rate or rupture 72 % to 86 % Mortality from 40 % to 90 % No unified treatment approach It is case by case basis

This is what I did ?:

This is what I did ?

Slide 20:

Thank You

This is what happened:

This is what happened Aneurysm decreased pulsations and occluded on the third day Patient continued to deteriorate generally Had 7 units of FFP Jaundice improved Sudden death on the third day of massive PE