celiac artery aneurysm is a quite uncommon vascular lesion , accounting for 5.1% of all splanchnic artery aneurysms . although rare , celiac artery aneurysm carries a definite risk for rupture and other complications .
however , because of its rarity , no strong consensus concerning indications for intervention of asymptomatic celiac artery aneurysm exists in the literature . due to more frequent use of cross - sectional imaging , the dilemma of choosing the appropriate therapeutic option has become increasingly more important .
herein , we present a case of an un - ruptured celiac artery aneurysm that was treated by surgical repair and also discuss the appropriate therapeutic strategy based on a literature review .
a 72-year - old female visited our department with complaints of fever and general fatigue .
the patient s medical history included type 2 diabetes mellitus with poor control and hypertension .
arrival revealed that her blood pressure was 147/62  mmhg , heart rate was 104 beats / min with regular rhythm , blood oxygen saturation was 95% under atmospheric conditions , and body temperature was 38.7  c .
blood analyses revealed 11,260 white blood cells/l with 80.6% neutrophils and 0.69  mg / dl c - reactive protein ) ; mild hypoalbuminemia ( 3.3  g / dl ) ; coagulant dysfunction ( fibrin / fibrinogen degradation products ; 7  g / dl fibrinogen ; and 2.1  g / ml d - dimer ) , and severely impaired glucose tolerance ( 157  mg / dl and 11.2% hemoglobin a1c ) .
she weighed 52.4  kg , was 150  cm tall , and had a body mass index was 23.3  kg / m . inspection of the palpebral conjunctiva revealed no evidence of anemia .
chest auscultation revealed no signs of abnormal heart murmurs and no rales or other abnormal respiratory sounds .
the abdomen was slightly distended and her peristalsis was normal ; no tenderness was observed in the upper abdomen .
she was then diagnosed with bacteremia by urinary tract infection and antibacterial medicine ( cefmetazole 2  g per day ) was initiated .
transesophageal echocardiography was performed to investigate infective endocarditis , revealing no vegetation at her valves .
contrast - enhanced computed tomography ( ct ) was performed for investigating her urological abnormalities , revealing no urological deformities but a 28    30  mm sized aneurysm at the trunk of the celiac artery ( fig .
the proper hepatic artery was dominantly supplied from the celiac artery , the left gastric artery being bifurcated from the celiac trunk , and the celiac artery and the splenic and common hepatic artery had a common trunk ( fig .
surgical repair of the aneurysm was performed after confirmation of negative blood culture for bacteria on day 32 .
firstly , lesser omentum and crus of diaphragm were incised to expose abdomen aorta at the level of the trunk of the celiac artery .
after that , the superior mesenteric artery was taped at the trunk of the small bowel mesentery .
abdominal aorta was clamped both at the head of celiac artery and at the level of renal artery to prevent blood flow .
the distal celiac artery of the aneurysm was cut and 8  mm size prosthetic graft was anamotosed .
another end of the prosthetic graft was anamostosed through the dorsum of duodenum to abdominal aorta below the level of renal artery ( fig.1d , e , f ) .
celiac artery aneurysm is an uncommon type of splanchnic artery aneurysm that carries a high risk for mortality if it ruptures .
a total of 9.1% of celiac artery aneurysms are accompanied by abdominal aortic aneurysms  ; solitary celiac artery aneurysms not accompanied by other aneurysms are extremely rare .
etiology of celiac artery aneurysm includes infectious diseases , atherosclerosis , trauma , or congenital conditions .
other causes of celiac artery aneurysm include medial necrosis , inflammation , trauma , and median arcuate ligament syndrome . in our patient ,
the cause of the aneurysm was presumably derived from atherosclerosis due to the poor - controlled diabetes mellitus , hypertension , and aging .
since most patients are asymptomatic , celiac artery aneurysm is frequently incidentally discovered by imaging modalities for the investigation of other conditions or diseases .
the major presentation of celiac artery aneurysm is gastrointestinal symptoms , including abdominal pain , nausea , vomiting , appetite loss , or symptoms of mesenteric ischemia .
the risk of rupture of 1522  mm diameter celiac artery aneurysms is 5% ; in contrast , the risk of rupture in > 30  mm diameter aneurysms is 5070% . in general ,
treatment is considered for asymptomatic patients when the aneurysm is larger than 20  mm in diameter , .
the rudiment of operative treatment is the resection or closure of the aneurysm along with revascularization of peripheral branches that bifurcate from the celiac artery aneurysm .
surgical repair of the aneurysm with prosthetic grafts demonstrated more preferable long - term results than by using saphenous veins ; thereby , prosthetic grafts might become the mainstay of surgical aneurysm repair .
surgical treatment of a celiac artery aneurysm that involves the confluence of trifurcation is challenging , with a mortality risk of 5% , .
when the aneurysm is removed without the vascular reconstruction , the blood flow from the super mesenteric artery to the hepatic artery should be carefully examined before surgery . in recent years , with advances in interventional radiology , catheter embolization is also attempted . when catheter embolization is adopted , the blood flow from the super mesenteric artery to the hepatic artery should be confirmed . clearly , if gross liver ischemia is found after aneurysm resection , revascularization of the hepatic artery is necessary , either by antegrade supraceliac aortohepatic bypass or retrograde inflow from the infrarenal segment of the aorta or the common iliac arteries . in our case ,
angiography confirmed that the blood flow of the proper hepatic artery was dominantly supplied by the celiac artery and the gastroduodenal artery was patent and large .
endovascular techniques , including stent implantation and embolization of aneurysms are feasible in the setting of advanced age and underlying diseases ; while surgical intervention is a safe and effective method in selected cases , . in our patient ,
endovascular treatment was considered unsuitable because the patient just recovered from bacteremia and the possibility of an infective aneurysm could not be excluded .
in addition , surgical intervention was not likely to be challenging considering the anatomical location of the aneurysm and the patient s favorable general condition . clearly , the celiac artery aneurysm in our patient was concluded not derived from infections based on the clinical course and operative findings .
a question may be raised about why this patient should have undergone ct although she did not present any abdominal complaints .
patients with urosepsis should be scrutinized with imaging modalities in search of urological abnormalities or malformations irrespective of their symptoms .
although rare , clinicians should be aware of celiac artery aneurysms and make efforts to discover them at an early stage , even during the investigation of other diseases or symptoms .
furthermore , early treatment of unruptured celiac artery aneurysm may sometimes be required to protect rupture or mesenteric ischemia from distal embolization .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request  .
hiromichi naito , atsuyoshi iida , tetsuya yumoto and kohei tsukahara contributed to the study design , data collections , data analysis , writing and review .
consents , permissions , and releases were obtained where authors wished to include case details or images of patients and any other individuals in an elsevier publication .
 highlightsalthough rare , celiac artery aneurysm may carry a definite risk for rupture and other complications.because of its rarity , no strong consensus concerning indications for intervention of asymptomatic celiac artery aneurysm exists in the literature.clinicians awareness regarding this rare entity and efforts to discover before rupturing are imperative . 