侧支血流相关肠系膜上动脉瘤慢性近肾腹主动脉闭塞

侧支血流相关肠系膜上动脉瘤慢性近肾腹主动脉闭塞
Collateral flow-related superior mesenteric artery aneurysm in chronic juxtarenal aortic occlusion

侧支血流相关肠系膜上动脉瘤慢性近肾腹主动脉闭塞A

侧支血流相关肠系膜上动脉瘤慢性近肾腹主动脉闭塞B

A 82-year-old woman was investigated for back pain and incidentally found to have a 40-mm saccular aneurysm arising from the superior mesenteric artery (SMA) within 5 mm of the origin (A and B). In addition, a short segment of chronic complete occlusion was present in the abdominal aorta immediately caudal to the SMA origin, extending to the origin of the inferior mesenteric artery (IMA; B; Video, online only). Hypertrophy of the collateral arcade vessels (10 mm in size) between the SMA and IMA, including the artery of Drummond, was present, forming the dominant collateral flow bypassing the occlusion (A and B). The appearance was consistent with an SMA aneurysm likely related to hyperdynamic collateral flow through the SMA-IMA collateral pathway as a result of chronic aortic occlusion. Although the patient was asymptomatic, in view of the size of the SMA aneurysm, surgical and endovascular repair of the aneurysm was offered but was declined by the patient.
对一个82岁的女人进行了背部疼痛检查，偶然发现一个40毫米的囊状动脉瘤起源于肠系膜上动脉（SMA）距离原点5毫米（A和B）。此外，在腹主动脉尾部立即出现一个短段的慢性完全闭塞，到达肠系膜上动脉（SMA）起点，延伸至肠系膜下动脉起点（IMA；B；视频、在线）。侧支血管肥大（10毫米大小）SMA和IMA之间，包括德拉蒙德（Drummond）动脉，是存在的，形成占主导地位的侧支血流绕过闭塞（A和B）。外观与肠系膜上动脉瘤可能相关，高动力侧支血流通过SMA-IMA侧支通路，由于慢性主动脉闭塞相关一致。虽然病人是无症状的，鉴于在SMA动脉瘤的大小，提供了动脉瘤手术和腔内修复方案，但病人拒绝了。

DISCUSSION
讨论
Chronic occlusion of the abdominal aorta is uncommon, and the patient’s symptomatology depends on the degree of collateralization that bypasses the occlusion. Symptoms may be absent in patients when good collateral flow has been established. Collateral pathways in chronic aortic occlusion are well described, and dominant visceralvisceral collateral pathways (commonly the SMA-IMA arcade) are the most common when the occlusion is at the juxtarenal level.1 Significant hypertrophy of the dominant collateral pathway vessels is common, secondary to increased flow. Such hyperdynamic flow could then result in vessel wall injury and subsequent aneurysm formation in the collateral vessels. Treatment of a visceral aneurysm is usually offered when the aneurysm diameter is >20 mm, due to the perceived increased risk of rupture.2,3 Surgical (aneurysmectomy) and endovascular (coiling/endografting) approaches are both accepted therapeutic options.
腹主动脉的慢性闭塞是罕见的，和病人的症状取决于侧支循环绕过阻塞的程度。当良好的侧支血流已建立的患者，其症状可能是不存在的。慢性主动脉闭塞侧支循环有很好的描述，并且主导内脏侧支循环（通常在SMA-IMA中心）是最常见的在遮挡在近肾水平【1】。显性侧支血管的显著肥大是常见的，继发流量增加。这样的动力流可以导致侧支血管壁损伤和随后的动脉瘤的形成。一个内脏动脉瘤的治疗通常是当动脉瘤直径大于20毫米时，由于感觉破裂的风险增加。【2，3】单纯外科手术（切除）和血管内（卷/内支架治疗）方法都是接受的治疗方案。

REFERENCES
1. Hardman RL, Lopera JE, Cardan RA, Trimmer CK, Josephs SC. Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial essay. AJR
Am J Roentgenol 2011;197:W519-24.
2. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms.
J Vasc Surg 2007;45:276-83; discussion: 283.
3. Sachdev U, Baril DT, Ellozy SH, Lookstein RA, Silverberg D, Jacobs TS, et al. Management of aneurysms involving branches of the celiac and superior
mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg 2006;44:718-24.


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