PMC7327408_01
Preoperative images of the abdominal aortic aneurysm and multiple aneurysms. A. Three-dimensional reconstruction of preoperative computed tomography angiography image showing an infrarenal abdominal aortic aneurysm with a maximum aortic diameter of 39 mm, a left renal artery aneurysm, and bilateral internal iliac artery aneurysms. B. Three-dimensional reconstruction cerebral magnetic resonance image showing multiple intracranial aneurysms.
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Two months later, contrast enhanced computed tomography (CT) revealed an infrarenal fusiform AAA measuring 39 mm in maximum diameter, a 15 mm left renal artery aneurysm, a 14 mm right hypogastric artery aneurysm, and a 12 mm left hypogastric artery aneurysm (Fig. 1A). Cerebral magnetic resonance imaging (MRI) revealed multiple intracranial aneurysms between 8 and 15 mm in the intracavernous portion of the right internal carotid artery and bilateral middle meningeal arteries (Fig. 1B).
Operative findings. A. Operative photograph showing an infrarenal abdominal aortic aneurysm with a maximum aortic diameter of 41 mm. B. Operative photograph of implanted 10-mm Dacron graft in the infrarenal aortic position.
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AAA was 41 mm, and it extended to the aortic bifurcation (Fig. 2A). After heparin infusion at 80 U/kg, the aorta and both common iliac arteries were cross clamped. Reconstruction of the inferior mesenteric artery was performed with a running 7-0 Prolene suture considering the risk of intestinal ischaemia following possible subsequent treatment of bilateral hypogastric artery aneurysms (Fig. 2B).
Pathological findings in the surgically resected abdominal aorta. A. The image shows irregularity and focal loss of the elastic lamina of the media, fibroelastic intimal thickening, and dilatation of the vasa vasorum (arrows). The upper portion of the media shows chronic dissection (asterisk) surrounded by thick elastic tissue (elastica van Gieson stain). B. The high-magnification image of the media (square region of A) shows fragmentation of elastic fibers (elastica van Gieson stain).
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Additionally, diffuse fibro-elastic thickening of the intima, chronic media dissection, slight chronic inflammatory infiltrate, adventitial fibrosis, and dilatation of the vasa vasorum, which were considered secondary changes, were observed (Fig. 3).
Contrast-enhanced computed tomography on postoperative day 7. Three-dimensional reconstruction of postoperative computed tomography angiography showing patency of the graft and reconstructed internal mesenteric artery.
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AAA with patency of the graft and reconstructed inferior mesenteric artery (Fig. 4).
Postoperative follow-up imaging. A: Magnetic resonance image at the 12-month follow-up showing an increase in size of the left renal artery aneurysm from 15 mm to 25 mm. B: Magnetic resonance image at the 14-month follow-up showing an increase in size of the left middle meningeal artery aneurysm from 15 mm to 19 mm. C: Cerebral angiography showing superior sagittal sinus dural arteriovenous fistula.
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Aspirin administration was initiated for post-operative graft thromboprophylaxis. At the 12 month post-operative follow up, abdominal MRI revealed an increase of the left renal artery aneurysm from 15mm to 25 mm (Fig. 5A). Moreover, cerebral MRI revealed an increase of a left middle meningeal artery aneurysm from 15 mm to 19 mm (Fig. 5B) at the 14 month post-operative follow up, for which coil embolisation was also performed successfully. Simultaneously, a superior sagittal sinus dural arteriovenous fistula (AVF) was discovered incidentally on cerebral angiography (Fig. 5C), and transarterial embolisation with N-butyl-2-cyanoacrylate for AVF was also performed.