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Answer: Superior Mesenteric Artery Aneurysm
The patient was urgently taken to the operating room. Intraoperative angiography failed to visualize the aneurysm despite multiple selective views of the celiac trunk, superior mesenteric artery (SMA), and renal arteries. However, a displacement of the SMA branches secondary to the mass effect was identified with 1 of the arterial arcades sharply cutting off above the area of the largest vascular paucity. On transabdominal exploration, a large nonpulsatile mass in the middle portion of the jejunal mesentery was encountered, consistent with a thrombus-filled aneurysm (Figure 3). It was sharply dissected, and proximal and distal vascular control was obtained. The aneurysm sac was opened, a large amount of thrombus was evacuated, and a single feeding branch of the SMA was identified. This vessel was repaired from the inside using a fine Prolene suture (Ethicon Inc, Somerville, New Jersey). The entire bowel was closely inspected and no evidence of bowel ischemia was noted. A segment of the aneurysmal wall was sent for pathologic and microbiologic examination. The cavity of the aneurysm was left open. The patient had an uneventful postoperative course and was discharged in good health on the fifth postoperative day.
Intraoperative picture showing a 6-cm mass in the mesentery of the small bowel.
Visceral artery aneurysms are rare clinical entities; this is reported at initial presentation in 22% of cases, with mortality reaching 9%. The aneurysms of the SMA are the third most common among all visceral vessel aneurysms. However, the SMA is the artery most frequently involved in developing mycotic aneurysm.1Both surgical and endovascular techniques have been used for the management of visceral artery aneurysms. Endovascular options include use of covered stents and coil embolization.2Surgical options include aneurysm resection with or without arterial reconstruction. Both saphenous vein and prosthetic conduits were used for vascular conduits with the latter contraindicated in the presence of an infected operative field.
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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery(http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.
Correspondence:Faisal Aziz, MD, Department of Surgery, New York Medical College, Munger Pavilion, Ste 211, Valhalla, NY 10595 (firstname.lastname@example.org).
Accepted for Publication:October 30, 2008.
Author Contributions:Study concept and design: Aziz and Laskowski. Acquisition of data: Aziz, Babu, and Laskowski. Analysis and interpretation of data: Aziz, Sullivan, and Laskowski. Drafting of the manuscript: Aziz and Sullivan. Critical revision of the manuscript for important intellectual content: Aziz, Babu, and Laskowski. Statistical analysis: Aziz. Administrative, technical, and material support: Aziz, Sullivan, and Laskowski. Study supervision: Aziz and Babu.
Financial Disclosure:None reported.
Image of the Month—Diagnosis. Arch Surg. 2009;144(5):483–484. doi:10.1001/archsurg.2009.50-b
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