Successful transcatheter arterial embolization of a ruptured right gastroepiploic artery aneurysm: A case report.

BACKGROUND: Gastroepiploic artery aneurysms (GEAAs) are extremely rare. Ruptured GEAAs are related to high mortality and often treated by open surgery. We describe a case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). PRESENTATION OF CASE: An 80-year-old woman presented to the emergency department with sudden abdominal pain. We diagnosed her as having a ruptured right GEAA based on the contrast-enhanced computed tomography finding. We performed TAE for the GEAA after resuscitation. The patient had an uneventful recovery and was discharged 10 days after TAE. DISCUSSION: A ruptured GEAA causes high mortality; thus, immediate and adequate treatment is mandatory. Previously, many cases of successful surgical resections of ruptured GEAAs have been reported. In our case, we decided that the patient was not suitable for surgery because of her advanced age and bronchiectasis; therefore, we performed TAE and had a good outcome.
CONCLUSION: In patients at high risk for surgery, TAE can be an effective treatment for a ruptured GEAA.

Introduction

Splanchnic artery aneurysms (SAAs) are rare, and gastroepiploic artery aneurysms (GEAAs) account for only about 0.4% of them [1]. GEAA rupture is associated with a high mortality rate [2]. Few cases of ruptured GEAAs have been reported, and most of those patients were treated by open surgery. We describe the case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). This case report has been written in line with the SCARE criteria [3].

Case report

An 80-year-old woman presented to the emergency room with sudden onset of abdominal pain. She had a history of bronchiectasis with home oxygen therapy. She had a blood pressure of 80/50 mmHg, heart rate of 110 beats/min, body temperature of 35.9 °C, and respiratory rate of 32 breaths/min.

During the abdominal examination, there was diffuse abdominal tenderness and rebound tenderness without muscle guarding. Results of the laboratory investigations showed anemia (hemoglobin level 6.6 g/dl), leukocytosis (white blood cell count, 19 700/mm3), and normal renal function with a serum creatinine level of 0.8 mg/dl. The abdominal ultrasonogram showed a moderate volume of intraperitoneal fluid and an SAA measuring 4 cm in diameter in the lower abdomen, which was of unknown origin. After stabilization of vital signs with fluid resuscitations with 1 l of crystalloid, abdominal contrast-enhanced computed tomography (CT) was performed. The CT scan showed a right GEAA with a diameter of 4 cm without extravasation, as well as a moderate amount of intra-abdominal fluid collection (Fig. 1, Fig. 2). Based on the CT findings, we diagnosed her as having hemorrhagic shock because of rupture of the right GEAA. Considering hemodynamic stability and the operative risks such as advanced age and bronchiectasis, we chose to perform TAE, not open surgery.

Fig. 1

Contrast-enhanced computed tomography scan showing a large aneurysm (arrow) and a moderate amount of intra-abdominal fluid collection (arrowhead).

Fig. 2

Angiogram reconstructed from computed tomography demonstrating a right gastroepiploic artery aneurysms with a diameter of 4 cm (arrow).

The angiogram showed a right GEAA without extravasation (Fig. 3a). Through a 5.5-French (Fr) shepherd hook catheter (Terumo Clinical Supply, Tokyo, Japan) placed in the celiac artery, a 2.2-Fr Progreat microcatheter (Terumo Clinical Supply) was inserted into the distal part of the right GEAA. Embolization was performed using 5 Vortex coils (Boston Scientific, Fremont, CA, USA) and 8 Tornado Coils (Cook, Bloomington, IN, USA) at the proximal and distal arteries of the GEAA. The postembolization angiogram revealed no GEAA filling (Fig. 3b). The patient was given 4 U of packed red blood cells.

Fig. 3

a: Angiogram of the right gastroepiploic artery (GEA) showing a GEA aneurysm (GEAA) (arrow). b: Angiogram of the right GEA showing successful embolization of the distal and proximal arteries of the GEAA.

The contrast-enhanced CT scan obtained 5 days after TAE confirmed no blood flow to the GEAA. The patient had an uneventful recovery and was discharged 10 days after TAE without any complications. The ultrasonogram 3 months after TAE showed no blood flow to the GEAA in the outpatient department. The patient died of exacerbation of bronchiectasis at 5 months after TAE.

Discussion

SAAs are very rare, accounting for 0.1% of cases according to autopsy statistics [4]. GEAAs are extremely rare among all SAAs. Stanley et al. reported that 60% of SAAs are splenic artery aneurysms, followed by hepatic artery aneurysms (20%), superior mesenteric artery aneurysms (5.5%), celiac artery aneurysms (4%), and gastroepiploic artery aneurysms (0.4%) [1]. SAAs are associated with arteriosclerosis, aortic dissection, infection, inflammation, trauma, vasculitis due to collagen disease, and segmental arterial mediolysis [5]. The mortality rate after rupture of these SAAs has been reported to be 70% [2].

The patients with ruptured GEAAs typically present with abdominal pain, unconsciousness, and shock secondary to intraabdominal hemorrhage [6]. Although many patients were diagnosed by angiography previously, those diagnosed by contrast-enhanced CT, as in our case, are increasing. Because of its superior imaging resolution and less invasiveness, CT is a useful modality for diagnosing GEAA.

The treatment options for SAAs, including GEAA, are divided into surgical therapy (the open or laparoscopic approach) and TAE. The treatment strategy for GEAA depends on the patient’s vital signs, age, and comorbidities. In patients with unstable vital signs due to rupture of the GEAA, open surgery should be performed to control bleeding promptly. In patients with stable vital sings, laparoscopic surgery may be an acceptable treatment choice. When patients are stable and at high risk for surgery, TAE can be another option.

According to previous reports, most patients with GEAA were treated by open surgical resection or ligation [7,8]. Successful laparoscopic resections of ruptured and unruptured GEAAs in patients with stable vital signs have been also described in literatures [9,10]. The superficial anatomical location of GEAAs compared to other SAAs makes it easy to perform laparoscopic surgery.

Although TAE is a widely accepted treatment option for other SAAs [11], few cases of GEAAs treated by TAE have been reported [12,13]. In our case, because the patient was at high risk for surgery (advanced age and bronchiectasis with home oxygen therapy) and her vital signs were stable after resuscitation, TAE was considered to be first-line treatment. Additionally, unlike other SAAs, GEAAs can be embolized without any functional disorders. Although TAE is feasible in selected patients, incomplete exclusion may be observed, requiring late reintervention [11]. Since our patient died at 5 months after TAE, the patients who undergo TAE require careful follow-up [11,14].

Conclusions

In our case, contrast-enhanced CT was useful in the diagnosis of GEAA. TAE can be an effective treatment for a ruptured GEAA, especially in patients with a high risk for surgery.

Conflicts of interest

All authors declare no conflicts of interest.

Funding source

No source of funding.

Ethical approval

This case report was approved by the Ethics Committee of Okinawa Prefectural Chubu Hospital. Since our case report does not violate the patient’s privacy, informed consent was not necessary.

Consent

No consent was obtained from the patient in this case report. Because the patient died, and we do not have current address and telephone number of her family, we could not obtain signed consent. Therefore, the chief of Ethics Committee of our hospital has taken responsibility that exhaustive attempts have been made to contact the family and that the paper has been sufficiently anonymised not to cause harm to the patient or their family. We have uploaded this signed document.

Author contributions

Tohru Ishimine: Study design, data collection, writing the paper.

Toshiho Tengan: Review manuscript.

Akio Nakasu: Data collection, obtain images.

Hiroaki Takara: Data collection, review manuscript.

Registration of research studies

Not applicable for case report.

Guarantor

Tohru Ishimine.

Provenance and peer review

Not commissioned, externally peer-reviewed.