He did not attend hospital for subsequent follow-up imaging, but on telephone review remains well one year post-procedure with no recurrence of any PARP activity of his symptoms. In this case, follow up imaging would have been useful to
examine for involution of the pseudoaneurysm and continued exclusion, as well as resolution of splaying of the vessels. Discussion This unique case comprises both the first description of a variant of SMA syndrome caused by a traumatic SMA pseudoaneurysm, and the first account of successful treatment of both the aneurysm and duodenal obstruction by endovascular stent placement. Two similar cases were described in 1990 , however, in these cases, obstruction was caused by rupture of an SMA pseudoaneurysm, treated with open surgery. Barium meal examination is useful for the diagnosis of SMA syndrome . It demonstrates both narrowing of the fourth part of the duodenum with increased transit time, proximal dilatation and uncoordinated peristaltic activity. Such functional information is not readily obtainable from CT. CT proved to be the
key modality for diagnosis in this patient. It enabled detection of the pseudoaneurysm and its relationship to the SMA. CT with 3D reconstruction has been used in SMA syndrome to demonstrate reduction of the angle between the SMA and the aorta . Despite the paucity of cases of SMA pseudoaneurysm, several reports describe successful endovascular treatment of this condition. not Open surgery is often rendered difficult by the underlying cause of the psuedoaneurysm DMXAA (such as pancreatitis) or by Trichostatin A in vivo adhesions, which increase the risk of failure
of open vascular reconstruction and of anaesthesia in the unstable patient . Other options for treatment of this condition include placement of coils, injection of thrombin or N-butyl-2-cyanoacrylate (glue) . This case presented an unusual challenge, as two problems needed addressing; stenting of the aneurysm to prevent subsequent rupture, and exclusion of the aneurysm sac to encourage involution and thus relieve the SMA syndrome. The immediate resolution of this patient’s symptoms was most likely due to loss of pressure within the aneurysm sac by exclusion of arterial inflow. Data on possible shrinkage of aneurysm sacs post-stenting are conflicting, with one large series of 90 endovascular repairs of a range of visceral artery aneurysms demonstrating no shrinkage at follow-up imaging . However, one study reported shrinkage of abdominal aortic aneurysms post-stent placement . This phenomenon, in addition to decreased pressure within the sac, may be helpful in the treatment of aortoduodenal syndrome, which has hitherto only been treated by open repair. Conclusions A unique case of a variant of SMA syndrome secondary to a pseudoaneurysm is presented. Exclusion of the aneurysm and relief of the obstruction were simultaneously achieved by placement of a stent.