Visceral artery aneurysm

At laparotomy through a midline incision, multiple adhesions were noted. There were blood clots in the pelvis. An aneurysm, 25 cm in dimension was found eroding into the root of the mesocolon and small-bowel mesentery. The duodenum was kocherized and the porta hepatis dissected. A splenectomy was done. The greater curve of the stomach was mobilized. The proximal aorta was dissected free and taped for proximal control, as was the infrarenal aorta. What was thought to be the right hepatic artery was identified and traced back to the celiac artery, where it was discovered that the celiac artery was involved in the origin of the aneurysm. The celiac artery was approximately 5 cm in diameter. On further dissection, an aberrant right hepatic artery was found coming off the superior mesenteric artery. The neck of the aneurysm at the level of the celiac artery was ligated with Prolene suture. Pulsation ceased in the aneurysm. An aneurysmectomy was not done. Intraoperatively the patient was given 4 units of packed red blood cells and 2.5 L of crystalloid solution. By postoperative day 2 his hemoglobin level was 97 g/L, the international normalized ratio was 1.3 and the aspartate aminotransferase (AST) level was 1803 U/L. On postoperative day 4 the AST level had decreased to 532 U/L. Angiography showed no flow through the celiac artery and a replaced right hepatic artery coming off the superior mesenteric artery (Pig. 2).