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Splenic Artery Transposition For Treatment Of Gastroduodenal Artery Aneurysm
Prateek Sharma, MBBS, Monica Silva, DO, Ali Hakim, MD, Luciano Vargas, MD, Jonathan Thompson, MD.
University of Nebraska medical center, Omaha, NE, USA.
DEMOGRAPHICS: A 60-year-old Caucasian woman, nonsmoker, non-alcoholic, with history of endometriosis (status post total abdominal hysterectomy), hypertension, cholecystectomy for cholelithiasis, and appendectomy.
HISTORY: The patient presented with sudden sharp epigastric pain radiating to the back, without prior episodes. She was hemodynamically stable with epigastric tenderness. Labs showed lipase in the 1200s, consistent with pancreatitis. CT angiography (CTA) revealed a normal pancreas, complete celiac artery occlusion with distal flow via superior mesenteric artery collaterals, and two gastroduodenal artery aneurysms (GDA) measuring 2.3 cm and 0.5 cm.
PLAN: After stabilization, the patient underwent surgery one-week later. Intraoperatively, celiac artery occlusion from ligamentous compression was confirmed, and patch angioplasty was not feasible. The larger GDA aneurysm was ligated, the smaller excised, and a 7 cm length splenic artery transposition was performed for aortohepatic bypass to maintain hepatic flow. The patient had an uncomplicated recovery, was discharged in a week, and follow-up CTA after three months showed a patent bypass with mild narrowing at origin and thrombosed GDA aneurysm.
DISCUSSION: GDA aneurysms are rare, ~1.5% of visceral artery aneurysms, with an incidence of 0.01-0.2% in the general population. Risk factors include pancreatitis, trauma, and iatrogenic injury. Because rupture is common and carries high mortality, all identified GDA aneurysms warrant treatment regardless of size. Endovascular techniques, such as transcatheter coil embolization or covered stent placement, are typically considered first-line. In our patient, embolization carried a potential high risk of hepatic ischemia without concomitant celiac revascularization and endovascular celiac revascularization was also unlikely to provide durable benefit due to extrinsic compression. Surgical options include ligation or aneurysmectomy with arterial reconstruction, typically utilizing non-autogenous or vein grafts. In this case, due to celiac occlusion not suitable for patch angioplasty, splenic artery transposition was selected as a more durable and readily available option compared with celiac bypass using venous or prosthetic conduits. This approach avoided an additional anastomosis and is particularly useful when vein grafts are unavailable or contamination is a concern. In summary, GDA aneurysms require prompt treatment. Both endovascular and open surgical options are viable, with approach individualized to anatomy and patient factors.
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