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Open Resection Of Gastroduodenal Artery Aneurysm With Fistulization Into The Duodenum 17 Years After Coil Embolization In A Patient With Caroli Disease
Shreef Said, M.D, Benjamin Crews, Cecilia Lee, Anand Brahmandam, Aditi Kapil, Cassius Iyad Ochoa Chaar.
Yale University, School of Medicine, new haven, CT, USA.
DEMOGRAPHICS:A 57-year-old female presented with hematemesis, hematochezia, and hemorrhagic shock.
HISTORY:The patient had a complex history of polycystic kidney and hepatic disease, Caroli disease with portal hypertension, and had a functioning renal transplant. She had multiple small visceral aneurysms (<2cm) and history of coil embolization of a 4 cm gastroduodenal artery (GDA) aneurysm 17 years prior to presentation. Urgent endoscopy revealed duodenal ulceration over an underlying large mass with an actively oozing vessel that failed an attempt at treatment with banding. A computed tomography angiography (CTA) showed extensive aneurysmal disease and a 5.3 cm previously coiled GDA aneurysm with evidence of blood in the stomach. (Fig.1A,1B) An arteriogram showed high flow at the previously coiled GDA aneurysm and attempted additional coil embolization failed to control the bleeding.
PLAN:Patient was taken to the OR for exploration by vascular and general surgery with suspicion of an arterial-enteric fistula (AEF) arising from the GDA aneurysm. Through a subcostal Chevron incision, the feeding arteries to the aneurysm were identified, and proximal and distal control were obtained. (Fig.1C) Circumferential dissection of the aneurysm was performed, except for the area of fistulization. The aneurysm was opened, and several coils from prior embolization were removed, including those extending into the duodenum. (Fig.1D) The aneurysm was then completely resected, and the enterotomy was closed with an omental patch. A nasojejunal tube (NJT) was placed and secured distal to site of duodenal repair. Postoperative period was uneventful. Patient was discharged after 10 days. After two years, patient remains functional with CTA showing absence of recurrence in GDA and stable small visceral aneurysms.
DISCUSSION:Visceral aneurysms, including GDA, are rarely associated with autosomal recessive polycystic kidney and hepatic disease. AEF is a fatal complication which warrants early diagnosis and management. Even though, endovascular techniques have improved and are widely used, their durability in young patients is still not very well studied. Monitoring visceral aneurysms after coiling is limited because of artifact and carries significant radiation exposure and cost in patients with long life expectancy. Open surgical repair remains the only definitive treatment of visceral aneurysms.
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