Quaretti Pietro, Corti Riccardo, D'Agostino Antonio Mauro, Bozzani Antonio, Moramarco Lorenzo Paolo, Cionfoli Nicola
Interventional Radiology Unit, Fondazione IRCCS Policlinico San Matteo, V.Le Golgi 19, Pavia, 27100, Italy.
Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
CVIR Endovasc. 2024 Jan 10;7(1):9. doi: 10.1186/s42155-023-00416-4.
The arc of Bühler (AOB) is a residual embryonal anastomosis between the celiac artery (CA) and the superior mesenteric artery (SMA). Although usually asymptomatic, it has clinical relevance when compensatory reverse flow between the SMA and the CA in response to celiac artery obstruction leads to aneurysm formation and bleeding. Endovascular coiling is the mainstay therapy because of the deep AOB retropancreatic location, which hinders open surgery.
We herein report a case of a 2.8-cm AOB saccular aneurysm and LAM compression of celiac trunk in a 47-year-old man during rehabilitation following motorcycle trauma and vertebral surgery. The patient was considered unsuitable for surgery. Neither conventional coiling nor bare-metal stent and balloon-assisted techniques for coiling were suitable because of the wide necked saccular shape of AOB aneurysm interposed between the SMA and the floor of celiac trunk. To exclude the aneurysm from direct SMA inflow and permit safe and efficient coiling to rule out retrograde sac perfusion, a 9-mm polytetrafluoroethylene stent graft (Viabahn; Gore, Phoenix, AZ, USA) was positioned in the mesenteric artery, followed by antegrade periprosthetic high-density packed coiling of the aneurysm. The AOB remained excluded from mesenteric perfusion. The patient's clinical condition and abdominal contrast-enhanced multislice computed tomographic findings were unremarkable at the 9-year follow-up.
The 9 year long-term efficacy in our case raises the possibility that perigraft coiling following stent-graft deployment in the SMA may represent a valuable technical option for large Bühler aneurysms that are not amenable to stand-alone coiling.
布勒尔弓（AOB）是腹腔干（CA）与肠系膜上动脉（SMA）之间残留的胚胎期吻合支。虽然通常无症状，但当腹腔干阻塞时，SMA与CA之间的代偿性逆流导致动脉瘤形成和出血时，它就具有临床意义。由于AOB位于胰后深部，阻碍了开放手术，血管内栓塞是主要的治疗方法。
我们在此报告一例47岁男性，在摩托车创伤和椎体手术后康复期间，发现一个2.8厘米的AOB囊状动脉瘤和腹腔干的淋巴管肌瘤病（LAM）压迫。该患者被认为不适合手术。由于AOB动脉瘤呈宽颈囊状，位于SMA和腹腔干底部之间，传统的栓塞术、裸金属支架和球囊辅助栓塞技术均不适用。为了使动脉瘤不直接接受SMA的血流，并允许安全有效地进行栓塞以排除瘤腔逆行灌注，在肠系膜动脉中置入了一个9毫米的聚四氟乙烯覆膜支架（Viabahn；美国戈尔公司，亚利桑那州凤凰城），随后对动脉瘤进行顺行性假体周围高密度填充栓塞。AOB仍未接受肠系膜灌注。在9年的随访中，患者的临床状况和腹部增强多层计算机断层扫描结果均无异常。
我们病例中的9年长期疗效提示，在SMA中置入覆膜支架后进行假体周围栓塞，对于不适合单独栓塞的大型布勒尔动脉瘤可能是一种有价值的技术选择。
