Diagnosis
Concurrent Superior Mesenteric Artery and
Right Renal Artery Aneurysms
Case 1
Contributors
Dr.S. K. Joshi,Dr.Jitender R Chintala Dr.Preetam B Patil,Dr.Muralidhar. K.
Radiological Findings, Disease course, and Management
Ultrasound Abdomen
Findings
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Ill-defined mixed echoic mass (white arrow ) in the region of superior mesenteric artery
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Increased diameter and internal flow in SMA (black arrow) on colour doppler image
Poor acoustic window hampered further ultrasound assessment
Multidetector Computed Tomography
Plain study
Non-contrast axial section at the level of kidney shows
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Large well encapsulated heterogeneous density lesion (Thick white arrow) in the region of the superior mesenteric artery and right renal artery with areas of calcifications and multiple air pockets within it.
Post contrast study
Post contrast axial section at the level of kidney shows
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Thrombosed aneurysms of superior mesenteric artery (Thin white arrow) and right renal artery (Red arrow) measuring 33x30 mm and 36x30 respectively at their origins
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Atrophic Right kidney (Yellow arrow)
Volume Rendering Technique and Maximum Intensity Projection
Volume rendering technique (VRT) & Maximum intensity projection (MIP) images show
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Aneurysmal dilatation of superior mesenteric artery (Thin yellow arrow) and right renal artery (Thick white arrow)
Discussion
Incidence
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Visceral artery aneurysms are potentially lethal and very rare
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Estimated incidence of 0.1–2.0%,of which incidence of superior mesenteric artery aneurysms is 5.5%
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Renal artery aneurysms have traditionally not been included in reviews of VAA, but they are in fact one of the common VAA,15%–22% of cases
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Though the number of case reports of these aneurysms have increased due to the availability of tomographic methods, reports of concurrent aneurysms of superior mesenteric artery and the right renal artery are rare.
Sex predilection
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VAAs occur equally among men and women
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SMA aneurysms occur predominantly in men most often diagnosed in the fifth decade of life and
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RAAs aneurysms have a female preponderance
Causes
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Inflammation and infection -35% of all VAAs
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Remainder due to atherosclerosis, fibromuscular dysplasia, mycotic embolization, congenital anomalies, spontaneous dissection, collagen vascular disease, and various autoimmune disorders
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Fibromuscular dysplasia is a common cause of RAAs, with degenerative aneurysms, vasculitis , and trauma accounting for most of the others.
Clinical Features
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Clinical symptoms vague not providing enough information to reach a diagnosis
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RAAs are associated with hypertension in up to 73% of cases and hematuria in 30% of cases
Site
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Most aneurysms of the abdominal aorta arise below origin of renal arteries, so resection is not associated with serious ischemic damage to vital structures
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Most of RAA are saccular and noncalcified Tend to occur at the bifurcation of the MRA and SMA Aneurysms can be saccular or fusiform Commonly found in the proximal 5 cm of the artery.
Diagnosis
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Though rare, if such lesions are suspected CT-scan should be performed
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CT can accurately demonstrate the site, nature, extent and complexities involved in such aneurysms as in this case
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Ultrasound and doppler is the preliminary modality but gives limited details
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Angiography is invasive and better avoided
Conclusion
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VAAs are rare, superior mesenteric artery aneurysms are rarer still and concurrent SMA and right renal artery aneurysms are one of the rarest
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Making a clinical diagnosis is difficult
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Multi-detector computed tomography is an excellent non-invasive modality in diagnosing the site, nature, extent and complexities involved in it with better patient compliance
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Ultrasound modality gives limited details
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Angiography is invasive and better avoided
References
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Van Berge Henegouwen DP, van Dongen RJAM. In: Heberer G, van Dongen RJAM, editors. Vascular surgery: visceral arterial aneurysms. Berlin, Heidelberg: Springer-Verlag, 1989:284–293
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Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, Ouriel K. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276–283
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Klein GE, Szolar DH, Breinl E, Raith J, Schreyer HH. Endovascular treatment of renal artery aneurysms with conventional non-detachable micro- coils and Guglielmi detachable coils. Br J Urol 1997;79:852–860
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DeBakey, M. E., D. A. Cooley and 0. Creech, Jr.: Resection of the Aorta for Aneurysms and Occlusive Disease with Particular Reference to the Use of Hypothermia. Analysis of 240 Cases. Trans. Amer. Coll. Cardiology, 5: 153, 1955
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Salam TA, Lumsden AB, Martin LG, Smith RB 3rd. Nonoperative management of visceral aneurysms and pseudoaneurysms. Am J Surg 1992;164:215–219
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Henke PK, Cardneau JD, Welling TH 3rd, et al. Renal artery aneurysms: a 35-year clinical experience with 252 aneurysms in 168 patients. Ann Surg 2001;234:454–463