Endovascular treatment of huge saccular abdominal aortic aneurysm in a young Behcet patient: mid-term result
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Abdominal aortic aneurysm formation is among the arterial complications of Behcet's disease. Weakness and fragility of aortic walls leads to the development of arterial complications like pseudoaneurysms.
A case of huge saccular abdominal aortic aneurysm in a young Behcet patient who was successfully treated with endovascular stent graft placement is reported, diagnostic and interventional procedures are discussed, and mid-term follow-up results are presented.
Endovascular treatment of abdominal aortic aneurysm complications of young Behcet patients who are not suitable for open surgery and need intervention could be an alternative treatment modality even without performing preprocedural angiography.
KeywordsDigital Subtraction Angiography Abdominal Aortic Aneurysm International Study Group Arterial Aneurysm Behcet Disease
Arterial complications in Behcet's disease are rarely seen and usually involve great arteries like aorta and iliac arteries, and may lead to the perforation of the arterial walls and to the development of the aneurysms and their rupture . Due to weakness and fragility of the aortic wall and arteritis open surgery has some complications like the development pseudoaneurysms. In this case report, an infrarenal huge saccular abdominal aneurysm extending to the left inguinal region in a 32 years old male Behcet patient that was first seen in spinal CT examination performed due to extensive back pain and consequently had a successful stent graft placement is presented.
Behcet disease is first described by Hulusi Behcet, a Turkish dermatologist, in 1937 . It is a multisystemic inflammatory disease that classically causing oral and genital ulcers, and ocular inflammation. It can also affect vascular system. Since it can affect both arteries and veins of all sizes, Behcet vasculopathy is different from other vasculitides .
There is no pathognomonic laboratory test or histologic finding specific to Behcet disease. Thus the diagnosis is based on clinical criteria. Various criteria were proposed (like Mason and Barnes, The Behcet's disease Research Committee of Japan, O'Duffy and Goldstein, International Study Group (ISG) etc). The most commonly used criteria of ISG  require recurrent oral ulceration plus at least two of the following: recurrent genital ulcerations, eye lesions (like uveitis etc), skin lesions (erythema nodosum, folliculitis etc), positive pathergy test. ISG considered subcutaneous thrombophlebitis, deep vein thrombosis and arterial aneurysms as a criterion. Although these have high specifity for Behcet disease, they are not accepted as criteria due to their low sensitivity.
The etiology of Behcet disease is still not certain but systemic vasculitis has an important role. Perivascular lymphocytic and plasma cell infiltration, endothelial cell proliferation and swelling, disruption of elastic lamina, degeneration of the tunica media and vasculitis of the small vessels in vasa vasorum are among the histologic features of venous and arterial lesions [5, 6]
Behcet vasculopathy includes arterial and venous thrombosis formations, subcutaneous thrombophlebitis, venous collateralizations, pulmonary artery aneurysm, arterial aneurysm and occlusions  Arterial aneurysms are more common than arterial thrombosis. Although aorta is the most common site of involvement pulmonary, femoral, subclavian, popliteal and carotid arteries also could be affected. Histologic examinations of the arterial lesions show vasculitis in the vasa vasorum together with thickening in the media and separation of the elastic fibers, which in turn causes development of aneurysms. [6, 7, 8].
Endovascular grafts provide an important alternative to high-risk patients with more invasive surgical procedures. Patients who had endovascular stent graft placement had shorter operating room and hospital stay and less blood loss than open surgery. From the economical stand point the cost of stent graft placement is much higher than open surgery in our country.
Although numerous improvements in catheter, stent and graft technology have been made, there are still some limitations like the size of delivery systems, endoleaks, position of the renal arteries etc. The success rate of endovascular stent grafting is high (90% in low risk patients, 80% in moderate to high risk patients). Short-term mortality (within the 30 days following the procedure) is reported to be 2.5% in low risk group, 8% in high-risk group. Although there is disagreement in reported mortality rates for open surgery , there are reports of mortality rates of between 1.6 %  to 7,6 % [11, 12]. As it is common for all new or minimally invasive techniques, there is a learning curve for endovascular stent grafting that affects both the results and costs. Thus for the best results efficiency and experience are needed.
One of the crucial points of endovascular treatment of aneurysms is accurate and precise measurement of aneurysm. Although CT is highly effective, most of the vascular radiologists still would like to have preprocedural angiography. But in Behcet disease vessel wall vulnerability is extremely high and even minor lesions resulting from diagnostic procedures (e.g. intraarterial angiography etc.) could lead to the formation of aneurysms at the puncture site . Due to the fragility of the aneurysm inherent in Behcet patients and the size of aneurysm, we did not perform diagnostic angiography. All measurements based on CT images and 3D reconstructions helped us to better understand and characterize the neck, dimensions and relations of the aneurysm to other arteries.
Endovascular radiological intervention in the treatment of abdominal aortic aneurysm complications of young Behcet patients, in whom surgery is not suitable and intervention is necessary, could be an alternative treatment modality even without performing preprocedural conventional angiography or DSA using the advantages of helical CT and 3D reconstruction techniques.
Written consent was obtained from the patient for publication of the patient's details.. The manuscript has been presented in the TURK RAD, 17th National Radiology Congress (27–31 September 2000, Istanbul, Turkey) as a poster presentation.
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