CASE REPORT
Pos e io Gas ic A e y Aneu ysm
Miguel Lemos Gomes
a,b,*
, Alice Lopes
a,b
, Gonçalo Sob inho
a,b,c
, Luís Mendes Ped o
a,b,c
a
Vascula Su ge y eHea and Vessels Depa men , Hospi al de San a Ma ia (CHLN), Lisbon, Po ugal
b
Lisbon Academic Medical Cen e, Lisbon, Po ugal
c
Medical School, Uni e si y o Lisbon, Lisbon, Po ugal
In oduc ion: Aneu ysms o small abdominal essels a e ex emely a e; howe e , e en mino aneu ysmal
accesso y a e ies can up u e, leading o po en ially a al consequences. The pu pose o his pape is o epo a
case o coil embolisa ion o an aneu ysmal pos e io gas ic a e y.
Case p esen a ion: The au ho s desc ibe he case o a 66 yea old emale pa ien wi h an aneu ysm o he
pos e io gas ic a e y. Coil embolisa ion was pe o med. The six mon h ollow up compu ed omog aphy
angiog am e ealed exclusion o he aneu ysm.
Discussion: The p esen ed case is exceedingly a e. This ype o aneu ysm has o be kep in mind as a possible
cause o bleeding, despi e he limi ed in o ma ion ega ding hei na u al his o y.
Conclusion: Owing o he sa e y and applicabili y o he endo ascula echnique, i is nowadays p obably he bes
ea men al e na i e o his ype o aneu ysm.
Ó2018 The Au ho (s). Published by Else ie L d on behal o Eu opean Socie y o Vascula Su ge y. This is an
open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
A icle his o y: Recei ed 2 Augus 2018, Re ised 26 Sep embe 2018, Accep ed 28 Sep embe 2018,
Keywo ds: Pos e io gas ic aneu ysm, Coil, Embolisa ion, Visce al aneu ysm, Endo ascula p ocedu e
INTRODUCTION
Aneu ysms o small abdominal essels a e ex emely a e;
gas ic a e y aneu ysms (GAAs) and gas oepiploic aneu-
ysms oge he ep esen less han 4% o all splanchnic
a e y aneu ysms. The ae iology has been a ibu ed o
a he oscle osis, auma, and in ec ion.
1
A ew como bid
condi ions a e also commonly p esen , namely pep ic ulce
disease, asculi is, and panc ea i is.
2
The majo i y o hese aneu ysms a e loca ed along he
le o igh gas ic a e ies, whe eas aneu ysms along he
g ea e cu a u e o he s omach a e encoun e ed much
less equen ly, a a epo ed a io o 1:10.
3
The ue na u al his o y o his ype o aneu ysm is un-
known.
1
Howe e , e en mino aneu ysmal accesso y a e ies
can up u e, leading o po en ially a al consequences. I is
known ha mo e han 90% o epo ed GEAs a e up u ed
on ini ial p esen a ion.
The pu pose o his pape is o epo a case o coil
embolisa ion o an aneu ysmal pos e io gas ic a e y.
In o med consen was ob ained.
Case epo
A 66 yea old emale pa ien wi h a pas medical his o y o
b eas and endome ial cance , gas o-esophageal eflux
disease (GERD), hype ension, and smoking habi s, unde -
wen abdominal compu ed omog aphy angiog aphy (CTA)
because o complain s o abdominal pain. Inciden ally, an
aneu ysm o he pos e io gas ic a e y was iden ified
(no mal essel 2 mm; aneu ysmal essel 12 mm; Fig. 1). She
was only aking omep azole (20 mg). The e was no his o y
o auma. Endoscopy e ealed findings compa ible wi h he
unde lying disease (GERD). The labo a o y wo kup was
no mal.
Unde local anaes hesia and using a pe cu aneous igh
emo al app oach, a 80 cm 6F in oduce shea h (Flexo
S anda d In oduce , Cook Medical, Blooming on, IN, USA)
was placed in he splenic a e y o suppo . Ca he e isa ion
o he pos e io gas ic a e y was pe o med using a 0.014
inch guidewi e (P oVia 9 Guidewi e, Med onic, Minneap-
olis, MN, USA) suppo ed by a 4F 110 cm s aigh ca he e
(Radio ocus Glideca h, Te umo Co po a ion, Japan). Coil
embolisa ion was pe o med in he aneu ysmal sac (i was
no possible o ca he e ise he ou flow essel) and in he
a e en essel, using 3/2 coils (To nado coils, Cook Medical,
Blooming on, IN, USA) (Fig. 2).
The p ocedu e was une en ul and he pa ien was dis-
cha ged he ollowing day. The six mon h ollow up CTA
e ealed exclusion o he aneu ysm, main enance o he
splenic flow and no splenic o gas ic in a c ion (Fig. 3).
* Co esponding au ho . Lisboa, 1649-035, Po ugal.
E-mail add ess: [email p o ec ed] (Miguel Lemos Gomes).
2405-6553/Ó2018 The Au ho (s). Published by Else ie L d on behal o
Eu opean Socie y o Vascula Su ge y.This is an open access a icle unde he
CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
h ps://doi.o g/10.1016/j.ej ss .2018.09.002
EJVES Sho Repo s (2018) 41, 5e7
DISCUSSION
The pos e io gas ic a e y (PGA) has been known since
1740, ha ing been named in 1745 by Halle . I s su gical
impo ance is ela ed o he isk o gas ic ischaemia in
splenec omy and neoplas ic su ge y p ocedu es.
4
In mos
cases i o igina es om he le gas ic o he splenic a -
e ies nea he coeliac unk,
5
ascends behind he pos e io
pa ie al pe i oneum o he omen al bu sa, and supplies he
supe io po ion o he pos e io wall o he gas ic body,
nea he ca diac a ea, and he undus. I usually a ises om
he supe io aspec o he splenic a e y, in he middle hi d,
and a e ages 2 mm in diame e (i s diame e is la ge han
he sho gas ic a e ies and some imes ma ches he size o
he le gas ic a e y).
4
Owing o he a i y o hese aneu-
ysms, he e a e no guidelines o hei managemen . They
mos equen ly de elop seconda y o an adjacen inflam-
ma o y p ocess.
6
O he causes include medial degene a-
ion, a e ioscle osis, auma, a e i is, fib omuscula
dysplasia, and connec i e issue diso de s. Also, myco ic
isce al a e y aneu ysms as a esul o in ec ed h ombo-
emboli o seeding o an exis ing aneu ysm ha e been
epo ed.
6
Pa ien s wi h isce al a e y aneu ysms a e o en
asymp oma ic and he diagnosis is inciden al. Howe e ,
some pa ien s may p esen wi h ague abdominal discom-
o o li e h ea ening bleeding because o up u e in o he
gas oin es inal ac o he pe i oneal ca i y,
6
which is
associa ed wi h mo bidi y and mo ali y
7
(as high as 70%
2
).
Any GAA disco e ed be o e up u e should, he e o e, be
epai ed.
In he pas , eme gency o up u ed cases we e usually
managed by lapa o omy; open su gical epai included
aneu ysmec omy and liga ion. Re ascula isa ion p ocedu es
we e indica ed only in special se ings.
7,8
P esen ly, an
endo ascula app oach a e diagnos ic CTA is he p e e ed
me hod in mos cen es.
Fo non-eme gency aneu ysms, a success ul lapa oscopic
app oach has also been epo ed.
8
Selec i e a e ial angiog aphy wi h endo ascula coil
embolisa ion is possible in some cases,
7
such he one e-
po ed he e. The echnique when dealing wi h saccula
aneu ysms should include embolisa ion o bo h he p ox-
imal and dis al eeding a e ies along wi h coil deploymen
inside he sac (especially i he e e en essel canno be
embolised). P oximal embolisa ion alone should no be
pe o med because he aneu ysm may ec ui a obus
e og ade ascula supply.
9
A ull ascula assessmen in hese cases is ecommended
as concomi an isce al aneu ysms may exis .
7
The p esen ed case is exceedingly a e and no p e i-
ously epo ed in he li e a u e. This ype o aneu ysm
has o be kep in mind as a possible cause o bleeding,
despi e he limi ed in o ma ion ega ding hei na u al
his o y.
Figu e 1. Aneu ysm o he pos e io gas ic a e y on compu ed
omog aphy angiog aphy.
Figu e 2. Angiog aphy documen ing he aneu ysm and he final
esul , a e coil embolisa ion.
6Miguel Lemos Gomes e al.
CONCLUSION
PGA aneu ysms a e ex emely a e and when endo ascula
ea men is easible, i is p obably he bes al e na i e.
CONFLICTS OF INTEREST
None.
FUNDING
None.
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Figu e 3. Compu ed omog aphy angiog aphy demons a ing exclusion o he pos e io gas ic a e y aneu ysm.
Gas ic A e y Aneu ysm 7