Guideline sources The following summarized guidelines for the evaluation and management of mesenteric artery aneurysm are prepared by our editorial team based on guidelines from the Society for Vascular Surgery (SVS 2020), the American College of Gastroenterology (ACG 2020), and the European Society for Vascular Surgery (ESVS 2017). 1 2 3 Guidelines 1. Screening and diagnosis Indications for screening: consider screening for gastroduodenal artery and pancreaticoduodenal artery aneurysms with CT angiography or duplex ultrasound in patients with median arcuate ligament syndrome. C 2. Diagnostic investigations Diagnostic imaging: https://web.pathway.md/diseases/rec4jRk9GH8Nn0Rl7 1/4 6/30/23, 1:01 AM Mesenteric artery aneurysm Pathway As per SVS 2020 guidelines, obtain CT angiography as the diagnostic tool of choice in patients with suspected superior mesenteric artery, jejunal artery, ileal artery, colic artery, gastroduodenal artery, or pancreaticoduodenal artery aneurysms. B Show 4 more As per ESVS 2017 guidelines, obtain CT angiography for the diagnosis, anatomical characterization, and procedural planning in patients with mesenteric artery aneurysms. B Screening for vasculitis: consider screening all patients with jejunal, ileal, and colic artery aneurysms for vasculitis with routine inflammatory markers. C Screening for other aneurysms: Consider obtaining abdominal axial imaging in patients with jejunal, ileal or colic artery aneurysms to screen for concomitant abdominal aneurysms. C Consider obtaining one-time screening CT angiography or MRA of the head, neck, and chest in patients with segmental arterial mediolysis. C 3. Medical management Non-operative management: consider offering medical treatment in patients with nonruptured, asymptomatic ileal, jejunal, of colic artery aneurysms associated with polyarteritis nodosa. C 4. Therapeutic procedures Indications for repair: As per ACG 2020 guidelines, consider offering treatment in asymptomatic patients with aneurysms of the pancreaticoduodenal and gastroduodenal arcade, intraparenchymal hepatic artery branches, female patients of childbearing age, and recipients of a liver transplant, irrespective of aneurysm diameter. C Show 2 more As per SVS 2020 guidelines, repair all true superior mesenteric artery aneurysms and pseudoaneurysms as soon as the diagnosis is made regardless of size. A Show 3 more As per ESVS 2017 guidelines, perform urgent repair in patients with true symptomatic aneurysms of the mesenteric arteries, irrespective of aneurysm diameter or location. B Show 3 more Endovascular repair: As per SVS 2020 guidelines, perform an endovascular repair, if anatomically feasible, as the first approach in all patients with superior mesenteric artery aneurysms. B Show 5 more https://web.pathway.md/diseases/rec4jRk9GH8Nn0Rl7 2/4 6/30/23, 1:01 AM Mesenteric artery aneurysm Pathway As per ESVS 2017 guidelines, consider performing endovascular repair over open surgery in anatomically suitable patients with mesenteric aneurysms due to lower perioperative morbidity. C 5. Surgical interventions Surgical repair: As per SVS 2020 guidelines, consider performing open surgical ligation or aneurysm excision in patients with jejunal, ileal, or colic artery aneurysms when laparotomy is being considered for hematoma evacuation or bowel assessment for viability. C Show 2 more As per ESVS 2017 guidelines, perform arterial reconstruction over occlusion, when technically possible, in patients with mesenteric aneurysms not at high risk for surgery. B 6. Follow-up and surveillance Follow-up imaging: As per ACG 2020 guidelines, obtain follow-up imaging initially in 6 months, then at 1 year and subsequently every 1-2 years in asymptomatic patients with mesenteric aneurysms < 2 cm in diameter (excluding aneurysms of the pancreaticoduodenal and gastroduodenal arcade, intraparenchymal hepatic artery branches, females of childbearing age, and recipients of a liver transplant). B As per SVS 2020 guidelines, consider offering careful observation of superior mesenteric artery aneurysms because of dissection unless refractory symptoms develop. C Show 4 more As per ESVS 2017 guidelines, consider obtaining follow-up imaging every 2-3 years in patients with asymptomatic true aneurysms of the mesenteric arteries with a diameter < 25 mm. C Show 2 more Clinical findings Symptoms Past medical history Abdominal pain Acute mesenteric ischemia Nausea Beh et's syndrome Vomiting Connective tissue diseases Gastrointestinal bleeding Social history Polyarteritis nodosa SLE IV drug use Abdominal exam https://web.pathway.md/diseases/rec4jRk9GH8Nn0Rl7 3/4 6/30/23, 1:01 AM Mesenteric artery aneurysm Pathway Pulsatile abdominal mass References 1. M Bj rck, M Koelemay, S Acosta et al. Editor's Choice Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Apr;53 4 460 510. Open 2. Rabih A Chaer, Christopher J Abularrage, Dawn M Coleman et al. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg. 2020 Jul;72 1S 3S 39S. Open 3. Douglas A Simonetto, Ashwani K Singal, Guadalupe Garcia-Tsao et al. ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation. Am J Gastroenterol. 2020 Jan;115 1 18 40. Open https://web.pathway.md/diseases/rec4jRk9GH8Nn0Rl7 4/4