Ali Kamran  ( King Faisal Hospital, Taif, KSA )
Nausheen Yaqoob  ( Department of Surgery, Liaquat National Hospital Karachi, Pakistan. )
Rufina Soomro  ( Department of Surgery, Liaquat National Hospital Karachi, Pakistan. )
Moizuddin  ( Department of Surgery, Liaquat National Hospital Karachi, Pakistan. )

neurysms of coeliac artery are extremely rare and account for less than 4% of all splanchnic aneurysms. The detection of such aneurysms, which are often asymptomatic, is mostly occasional. Approximately 15% to 20% of the cases may get complicated by rupture with a mortality rate of around 80%. A reported case of a 55 year old male, who presented with pain and palpable mass in left upper abdomen was diagnosed to have coeliac artery aneurysm. Diagnosis was made on CT scan with selective visceral angiography. Simple ligation with partial excision of the coeliac artery aneurysm was performed.

Aneurysms of coeliac artery are extremely rare and account for less than 4% of all splanchnic aneurysms.¹ Since 1958, when Schumaker reported the first case that was successfully treated surgically, only 69 cases have been reported in the international literature.² The detection of such aneurysms, which are often asymptomatic, is mostly occasional. Approximately 15% to 20% of the cases may get complicated by rupture with a mortality rate of around 80%.² Twenty-one cases have been reported in Japan only of these uncommon aneurysms.³
We report the case of a 55 year old male, who presented with pain and a palpable mass in left upper abdomen. He was diagnosed to have coeliac artery aneurysm on CT scan with selective visceral angiography. Simple ligation with partial excision of the coeliac artery aneurysm was performed. Patient had an uneventful recovery with no major complications post-operatively.

A 55 year-old male presented to the surgery clinic with pain and a slowly expanding mass in the left upper quadrant of the abdomen for the last nine months. There was no history of trauma, fever, altered bowel habits, abdominal or chest infections. He was a known smoker for the past ten years. He had hypertension and was a known patient of ischaemic heart disease and had myocardial infarction twice in the recent past. At the time of presentation, the patient was afebrile with a blood pressure of 130/90 mm Hg and a heart rate of 80/min. Abdominal examination revealed a large pulsatile mass in the left hypochondrium. Rest of the general physical examination was unremarkable. Routine laboratory investigations were within normal limits. X-ray abdomen did not reveal any abnormality. An aneurysm of 8.7 x 6.3 cm size, most probably originating from splenic artery was found on abdominal ultrasound. A contrast enhanced computed tomography [(Fig1)]  confirmed the ultrasonographic findings. A selective splanchnic angiogram (Figure 1 & 2) was performed which showed that aneurysm was originating from coeliac trunk with rapid and  [(Fig2)]  turbid flow in it. Due to the patient's poor cardiac status angiographic embolisation was planned. This procedure failed because of the broad neck of aneurysm with turbulent flow of blood and surgical intervention was planned. Operatively, the aneurysm was found separate from spleen and splenic artery and was adherent posteriorly with the pancreas. Simple ligation with partial excision of coeliac artery aneurysm was performed. Histologically, it showed degeneration and loss of elastic fibers and atherosclerotic lesions. Post-operative recovery was uneventful.

Aneurysms of the coeliac trunk are the rarest forms of aneurysms of visceral arteries. Due to an increased use of sonography, computed tomography and arteriography more and more cases have been diagnosed in recent past,⁴ and in 1985 only, 108 cases were reported in the literature.⁵
Association of coeliac artery aneurysm with other splanchnic aneurysms is well documented in the literature. Associated aortic aneurysms are noted in 18% of the patients with coeliac artery aneurysms, while other splanchnic artery aneurysms affected 38% of these patients.¹ Saliou et al⁶ have reported a case of coeliac artery aneurysm associated with multiple splanchnic artery aneurysms involving the gastroepiploic and hepatic arteries. The coeliac artery was ligated and the liver revascularized by direct anastomosis of the common hepatic artery to the aorta, by laparotomy.
D' Ayala et al⁷ have reported an unusual case of a large coeliac artery aneurysm in a patient with associated visceral occlusive disease. A coeliac artery aneurysm associated with Behçet's disease is extremely rare. Maeda et al⁸ presented a case of successful surgical treatment for an impending rupture of a large coeliac artery aneurysm with a wide proximal neck in a patient associated with Behçet's disease.
Arteriosclerosis and medial degeneration are the most common pathological changes that are observed in celiac artery aneurysms.¹ Traumatic aneurysms due to penetrating injuries are uncommon. Post-stenotic dilatation occasionally progress to frank aneurysmal change and is an uncommon cause of these lesions. Mycotic coeliac artery aneurysms are also very rare. Most coeliac artery aneurysms are asymptomatic with no sex predilection. Abdominal discomfort localised to the epigastrium accompanies in more than 60% of symptomatic coeliac artery aneurysms. These lesions are apparent as pulsatile abdominal masses in nearly 30% of the cases.¹
The most serious complication of coeliac artery aneurysmal disease is rupture. Although, aneurysmal disruption is most often associated with intra-peritoneal haemorrhage, communication with gastro-intestinal tract can occur, or rarely may present as haemoptysis and haemothorax.⁹ Mortality in operative treatment of patients with ruptured coeliac artery aneurysms is 40% compared with only 5% for those with non-ruptured coeliac artery aneurysms.¹
Surgical treatment of these lesions is warranted except when operative risks contraindicate any abdominal operation.^1,10 Aneurysmectomy with arterial reconstruction accounts for 50% of reported operations, while coeliac axis ligation with interruption of antegrade blood flow through the common hepatic, left gastric and splenic vessels has been undertaken in 35% of reported operations.⁵ Ranica et al¹¹ described a case of aneurysm of coeliac trunk dealt with aneurysmectomy and reconstruction by means of graft. The aneurysmectomy and the reconstruction have been executed by means of a prosthetic graft finish-terminal in Dacron, succeeding in preserving the three arteries originating from the coeliac trunk (left gastric, hepatic, splenic arteries). Ghoddousi et al¹² reported a case of coeliac artery aneurysm treated electively by resection and graft replacement between the aorta, common hepatic artery and superior mesenteric artery. Although excision with arterial reconstruction is usually recommended, endoaneurysmorrhaphy can also be considered in selected cases as Gupta¹³ and colleagues described a case of coeliac artery aneurysm treated successfully by endoaneurysmorrhaphy.

1. Stanley JC, Zelenock GB. Splanchnic artery aneurysms. In: Rutherford RB, editor. Vascular Surgery. 4th ed.  Philadelphia: WB Saunders, pp 1124-81 
2. Veraldi GF, Dorrucci V, de Manzoni G, Guglielmi A, Laterza E, Rombola G, Pasetto E. Aneurysm of the celiac trunk: diagnosis with US-color-Doppler. Presentation of a new case and review of the literature. Hepatogastroenterology 1999;46:781-3
3. Matsukura I, Iwai T, Inoue Y. Celiac artery aneurysm: report of two surgical cases. Surg Today 1999;29:948-52
4. Risher WH, Hollier LH, Bolton JS, Ochsner JL. Celiac artery aneurysms. Ann Vasc Surg 1991;5: 392-5
5. Graham LM, Stanley JC, Whitehouse WM Jr, Zelenock GB, Wakefield TW, Cronenwett JL, et al. Celiac artery aneurysms: historic (1745-1949) versus contemporary (1950-1984) differences in etiology and clinical importance. J Vasc Surg 1985; 2: 757-64
6. Saliou C, Kassab M, Duteille F. Aneurysm of the coeliac artery. Cardiovasc Surg 1996; 4:552-5.
7. D'Ayala M, Deitch JS, deGraft-Johnson J, Nguyen E, McGagh D, Gwertzman GA,et al. Giant celiac artery aneurysm with associated visceral occlusive disease. Vascular 2004; 12 :390-3.
8. Maeda H, Umezawa H, Goshima M, Hattori T, Nakamura T, Negishi N, et al. An impending rupture of a celiac artery aneurysm in a patient with Behçet's disease - extra-anatomic aorto-common hepatic artery bypass: report of a case. Surg Today 2008; 38:163-5.
9. Carrel D, Cohle SD, Chapman AJ, et al. Fatal hemothorax from mycotic celiac artery aneurysm. Am J Forensic Med Pathol 1992; 13: 233-7
10. Salam TA, Lumsden AB, Martin LG, Smith RB 3rd.  Nonoperative management of visceral aneurysms and pseudoaneurysms. Am J Sur. 1992;164: 215-9
11. Ranica R, Lanzani A, Longhi F, Stringhi E. [Celiac artery aneurysm: a case report] Minerva Chir 2008; 63:65-8
12. Ghoddousi I, Kojouri K, Fazel I. Coeliac artery aneurysm: a case report. Cardiovasc Surg 1996; 4:555-6
13. Gupta R, Khanna SK, Chaudhary A, Tyagi S, Tempe DK. Coeliac artery aneurysm: a case report. Cardiovasc Surg.1996;4 :550-2.