The best of 2025 - peripheral and splanchnic aneurysms and mesenteric vascular disease

I am delighted to present “The best of 2025 - peripheral and splanchnic aneurysms and mesenteric vascular disease.” In this article, I summarize and opine on cases from the 2025 Journal of Vascular Surgery: Cases, Innovations, and Techniques that stood out to me for various reasons—a novel approach, technology, or a well-executed standard technique with a twist. Although case reports capture the esoteric, they also impart lasting wisdom. I encourage the reader to review those articles of interest and to save these nuggets of knowledge for future use.

From the February 2025 issue, Carroll and colleagues¹ describe their management of a large gastroduodenal artery aneurysm. The Society for Vascular Surgery visceral aneurysm guidelines recommend repair of gastroduodenal aneurysms at any size due to their high risk for rupture.² Endovascular coiling is appealing and generally considered first-line therapy for these cases. Despite densely packing coils in the gastroduodenal artery aneurysm in this case, there was dramatic growth from 5 cm to 7.5 cm 1 year later. The authors caution that persistent flow can maintain pressurization of the aneurysm. Whenever technically feasible, occluding both the inflow and outflow vessels to the aneurysm should be performed. I refer to this as “shutting the back and front doors.” When this is not possible, as in this case, more intense surveillance is reasonable. Computed tomography surveillance can be falsely reassuring, because coil artifact can obscure aneurysm sac expansion, particularly in cases with more subtle growth. The authors converted to an open operation with a primary repair of the hepatic artery and a beautiful result. This thought-provoking case—with an ultimately successful open repair—serves as a cautionary tale to the reader about limitations of endovascular exclusion of visceral aneurysms and postintervention surveillance.

The next case from El-Qawaqzeh et al³ utilizes a totally endovascular approach to revascularize an occluded superior mesenteric artery (SMA)—retrograde! An initial attempt at antegrade approach to a heavily calcified SMA occlusion was unsuccessful. The authors utilized meticulous technique and knowledge of the specific mesenteric anatomic collaterals to navigate through the gastroduodenal and pancreaticoduodenal artery with microcatheters until a wire could be navigated retrograde through the SMA and exteriorized. The authors caution that staying in the true lumen is best for this technique. With the wire as “body floss,” the authors further advise maintaining a microcatheter well into the pancreaticoduodenal artery to avoid a shearing, “cheese cutter” injury in this more delicate collateral. Another interesting step in this case was the use of a lithotripsy balloon in the heavily calcified artery to facilitate stenting.

Inability to cross a chronic total occlusion of the SMA comes up in practice, probably more frequently than we acknowledge, as it is not a publishable event. Retrograde open mesenteric stenting has gained traction over the past decade for acute mesenteric ischemia and is also an option for chronic mesenteric ischemia.⁴ However, a laparotomy is less desirable in a person with frailty, malnutrition, or a hostile abdomen. This case presents a unique option for recanalization, provided the patient has developed collaterals and that the interventionalist can circumnavigate them safely and skillfully.

A case of nutcracker syndrome is captured in a “Vascular Images” report in which a laparoscopic suture was used to externally fixate the stent to the renal vein, a technique that has been previously described in detail.^5,6 Reports of stent migration to the vena cava and the heart unfortunately pepper the literature.⁷ Adjuvant fixation could mitigate the risk of this most feared complication. Good techniques to prevent stent migration in general include extending the stent into the more distal renal vein and using intravascular ultrasound to determine appropriate oversizing. Some authors tout open repair for this condition.⁸

Advanced laparoscopy skills are not standard in many vascular surgery training programs, but collaboration with other specialists with this expertise is feasible in practice. I was also curious how much time the renal vein dissection and fixation adds to the total procedure. A totally percutaneous approach is very attractive for this diagnosis—there may be opportunities to develop technology with intrinsic fixation in the future.

The next case report illustrates the importance of a critical tenet in vascular surgical care—excellent exposure. A giant subclavian artery saccular aneurysm was exposed via a supraclavicular approach, and the surgeons appropriately made the decision to extend the proximal incision with a partial sternotomy.⁹ A primary end-to-end repair of the subclavian artery was then performed. This case stands out due to the excellent judgment not to skimp on exposure when needed, as the consequences of inadequate exposure can be dire.

Continuing with the theme of optimal exposure, the case from Kotsis and colleagues demonstrates an elegant repair of a giant renal artery aneurysm (RAA).¹⁰ RAAs are rare, and data on the management of renal artery aneurysms is derived from the Very Low Frequency Disease Consortium.¹¹ Although RAA repair is generally advised at a threshold of 3 cm or in women of childbearing age, the rarity of this condition warrants special consideration for younger patients, rapid growth, and saccular configuration. It is interesting that the patient in this case initially underwent an attempted endovascular repair. Endovascular repair is tempting for these RAAs but can be limited by proximity to branches or the renal hilum. A standard open exposure and the renal bypass was tolerated very well in this case. Readers may also wish to review the options for open RAA repair, which include bypass, patch, and ex vivo reconstruction.

In the case report from Fukunaga and colleagues,¹² a Candida albicans aneurysm of the SMA was treated successfully. This patient had a chronic aortic dissection with the SMA coming off both true and false lumens. The surgeons for this case truly thought “outside the box” by using an in situ right gastroepiploic artery to perform anastomoses to the distal jejunal arteries. The use of in situ gastroepiploic artery is extrapolated from cardiac surgery in which this conduit can be used for right coronary artery or posterior descending artery bypass. Saphenous vein adjunctive bypasses were considered if additional jejunal branches needed bypass but would have been less ideal as a primary conduit with the compromised SMA inflow. Mycotic aneurysms harbor high morbidity and mortality—those involving the SMA are particularly perilous. Recurrent infection will lead to ongoing degeneration and hemorrhage. I commend the authors for their clever and meticulous operation on this patient.

The etiology for rare tibioperoneal trunk (TPT) aneurysms includes infection, Behçet’s, trauma, and autoimmune disease. Tan et al describe an idiopathic TPT aneurysm in a young woman who was pregnant at the time of diagnosis.¹³ This case raises important issues about performing vascular surgery in pregnant patients with regards to trimester timing, anesthetic choice, and fluoroscopy risk to the fetus. Although endovascular approaches have been described for TPT aneurysms,¹⁴ short landing zones and potential for vessel sacrifice with all three tibial arteries in proximity may be problematic. Nonetheless, endovascular options may be a consideration in patients with suitable anatomy who are higher risk for open surgery and understand the potential limitations. I was delighted to see that a standard open repair with interposition graft was selected for durable repair in this young patient.

Median arcuate ligament syndrome (MALS) is a challenging condition to diagnose and treat. The authors from the Mayo Clinic managed a complex case beautifully.¹⁵ First, the patient underwent a thoughtful gastrointestinal workup. Then, a positive response to celiac ganglion block was achieved. In this case, not only was typical celiac artery compression noted, but the SMA was also compressed. This case serves to remind us that respiratory expiration accentuates the compression in MALS whether that is by duplex ultrasound or dynamic computed tomography angiography/magnetic resonance angiography. The patient was treated with an open release of the bulky median arcuate ligament and skeletonization of the arteries. The authors also point out the importance of resection of the celiac ganglion, which is generally accepted to mediate the pain in this condition. The patient had durable relief at 1 year post surgery. Robotic or laparoscopic releases are often selected as minimally invasive treatment for a diagnosis for MALS. This case highlights the value of open surgical decompression as another option to resect dense compressive tissue and should also be considered in recurrent cases.

The final case is a pilot study that integrates virtual reality (VR) technology into case planning.¹⁶ The authors examined 10 visceral artery aneurysms that had already been repaired. Ten surgeons each reviewed three cases using proprietary three-dimensional VR software and headset in which they could rotate and examine the images. The images were first processed in Terarecon and then uploaded to the VR platform. Most of the surgeons felt VR enhanced their ability to visualize the anatomy and collateral branches and that the imagery influenced how they would approach an endovascular or open intervention. The exploration of visceral aneurysms was particularly well-suited to this technology, as these pathologies often occur near branches and the anatomy can be distorted by the aneurysm. It is encouraging that the learning curve was quick. No doubt this technology is fascinating and may be translatable as an educational and practice tool, provided the cost is acceptable.

I hope the reader enjoyed learning about visceral aneurysms, compression syndromes, and unusual peripheral aneurysms. This collection of cases captures techniques and innovation, representing the “Best of 2025” from all over the world.

Funding

None.

Disclosures

None.