Detection of anomalous splenic artery aneurysms with three-dimensional contrast-enhanced MR angiography

Endovascular coil embolization for an anomalous splenic artery aneurysm with a splenomesenteric trunk

We present a case of a splenic artery (SA) aneurysm (SAA) that had arisen abnormally from the superior mesenteric artery in a 63-year-old man who underwent successful endovascular treatment. Although SAAs characterized by this anatomic abnormality are rare, in all 46 reported cases, the SAAs were located at the root of the SA and had originated abnormally from the superior mesenteric artery. This location is different from that of orthotopic SAAs, which are mostly located in the distal third of the SA. The differences in hemodynamics due to the anatomic abnormalities might play an important role in the formation of the anomalous SAAs.

A Case of a Huge Inferior Vena Cava Leiomyosarcoma: Precise Preoperative Evaluation with Gadobutrol-Enhanced MRI

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumour with poor prognosis. Surgical resection is the first line of treatment to achieve the best possible outcome. However, precise preoperative evaluation is essential to guide therapeutic decisions. Here, the preoperative evaluation potential of gadobutrol-enhanced magnetic resonance imaging (MRI) was assessed in the management of a 42-year-old patient with a large IVC mass.

Methods

The patient first underwent enhanced computed tomography (CT), but the relationship between the left renal vein and the mass in the dilated IVC was ambiguous, and it remained unclear whether the right hepatic vein was invaded by the lesion. To make a precise assessment of the tumour, the patient subsequently underwent high-resolution MRI angiography examination combined with high-concentration contrast medium gadobutrol.

Results

MRI demonstrated the integrity of the right hepatic vein and the left renal vein. Following a multidisciplinary consultation, a complicated surgery including complete resection of the mass, artificial vessel replacement of IVC, total hepatectomy, and bilateral nephrectomy with liver and kidney auto-transplantation was performed successfully. The surgical plan formulated after reviewing the MRI preoperatively was adhered to the course of the surgery. Postoperative CT re-examination showed that the blood flow of the artificial blood vessel and the right hepatic vein was unobstructed. Histopathological examination confirmed the tumour to be a leiomyosarcoma.

Conclusion

Preoperative imaging diagnosis and assessment have important implications for the surgical planning of IVC leiomyosarcoma. High-resolution MRI angiography examination with high concentration contrast medium gadobutrol may be of particular benefit in IVC tumours.

A systematic review on clinical features and management of true giant splenic artery aneurysms

BACKGROUND

True giant splenic artery aneurysms (GSAAs) >5 cm are rare and present unique therapeutic challenges. The aim of this study was to evaluate the anatomic and clinical characteristics of these lesions and the current surgical and endovascular techniques available for their treatment.

METHODS

A systematic review of the literature from 2004 to 2018 and the personal experience of the authors with management of GSAAs are presented. A total of 92 GSAA cases were reviewed. Analyses were performed on anatomic and clinical features and management modalities and outcomes of GSAA, including reintervention, morbidity, and mortality.

RESULTS

GSAA presented at a mean age of 56.1 ± 17.3 years, with no sex predilection; 73% were symptomatic at presentation. Abdominal pain was the presenting symptom in >50% of cases; 34% percent were ruptured, with an overall mortality rate of 12.5%. This group often presented with gastrointestinal bleeding or hemodynamic collapse. The aneurysms were almost evenly distributed across the splenic artery and were not uncommonly associated with arteriovenous fistula formation (8.7%). There were 88 patients who had surgical (53.4%), endovascular (44.3%), or combination (2.3%) therapy. The most commonly performed procedure was aneurysmectomy and splenectomy with or without additional resection. Overall, surgical treatment had a lower morbidity (P = .041) than endovascular therapy and comparable reintervention and mortality rates.

CONCLUSIONS

GSAAs are uncommon vascular lesions, with distinct clinical features and aneurysm characteristics. Considering their high risk of rupture, timely diagnosis and management are essential to attain a satisfactory outcome. Surgery remains the standard treatment of these lesions. Endovascular intervention is a viable alternative in high-risk patients, particularly those with lesions <10 cm or with anomalous origin.

Strategies for endovascular treatment of complicated splenic artery aneurysms

OBJECTIVE

Endovascular treatment (ET) is being increasingly used for splenic artery aneurysms (SAAs), but systematic treatment strategies have not been defined. We set out to investigate the optimal strategies for ET of complicated SAAs (CSAAs).

METHODS

CSAAs were classified into three types: type I, rupture or impending rupture; type II, at the origin of the splenic artery; and type III, having an aberrant splenic artery from the splenomesenteric trunk (type IIIA) or celiacomesenteric trunk (type IIIB). SAAs treated at our center during the last decade were reviewed, and CSAAs were selected for analysis. Patients' demographics, clinical manifestations, aneurysm characteristics, ET strategies, and outcomes were analyzed.

RESULTS

A total of 154 SAAs were identified, with 24 (15.6%) being CSAAs. Open surgery was employed in two patients, whereas 22 patients underwent ET. There were 3 patients with type I (type IIIA co-occurred in one of them), 5 with type II, and 15 with type III CSAAs. Treatment strategies included the following: immediate and thorough exclusion with embolization of the collaterals for type I; and dense embolization of the sac and outflow artery, with or without embolization of the inflow artery, or covered stent placement in the splenomesenteric trunk or celiacomesenteric, for types II and III. Technical success was achieved in 21 patients (95.5%). Mean follow-up was 33.7 ± 31.2 months (range, 1.5-117.0 months). The aneurysms remained completely thrombosed and unenlarged in 21 patients (95.5%). Reintervention was needed in one patient (4.5%) for persistent sac enlargement. The covered stent was asymptomatically occluded in one patient (11.1%). No hepatic or intestinal ischemia or death developed perioperatively or during the follow-up period.

CONCLUSIONS

With reasonable strategies toward the urgency and thoroughness needed for aneurysm exclusion as well as the anatomic challenges, ET appeared to be feasible, safe, and effective in the management of CSAAs.

Aneurysm of the Anomalous Splenic Artery Arising from Superior Mesenteric Artery Treated by Coil Embolization: A Report of Two Cases and Literature Review

BACKGROUND

Aneurysm of splenic artery (SA) which arises from the superior mesenteric artery (SMA) is a very rare condition. The aim of this study was to present our experience with 2 such patients treated by coil embolization.

METHODS

A 33-year-old man and a 61-year-old woman were incidentally identified with aneurysms of the SA which arose from the SMA. Endovascular therapy of coil embolization was chosen to treat the aneurysm.

RESULTS

Follow-up computed tomography showed no change in the location of the coils and occlusion of majority of the aneurysm sac. The 2 patients have been doing well during a 26-month and 10-month follow-up period, respectively.

CONCLUSIONS

Combined with the experience of the previous literature, we think coil embolization can be cost-effective and minimally invasive in selected cases, depending on the morphology and site of the lesion.

Successful treatment of aberrant splenic artery aneurysm with a combination of coils embolization and covered stents

BACKGROUND

Aneurysms of an aberrant splenic artery originating from the superior mesenteric artery (SMA) are extremely rare; however, they are clinically important because possible rupture could be catastrophic. The methods of treatment for this condition include surgical resection, minimally invasive techniques (include laparoscopic technique) and endovascular therapy. The purpose of this study is to evaluate the efficacy of coils embolization combined with covered stents to treat aberrant splenic artery aneurysm (SAA).

CASES PRESENTATION

We report four consecutive cases of aberrant SAA that the aberrant splenic artery was embolized with coils and the superior mesenteric artery was excluded with a covered stent and an up-to-date review of all previous cases in the field. A follow-up computed tomography performed 6 to 12 months postoperatively showed persistent exclusion with marked shrinkage of the aneurysm sac.

CONCLUSIONS

The authors believe although early results are promising, further careful follow-up will be needed to determine the long-term clinical efficacy, safety and applicability of this approach.

Anomalous splenic artery aneurysm

Aneurysms of the splenic artery are the most common visceral aneurysm. A splenomesenteric trunk, which involves the splenic artery arising from the superior mesenteric artery (SMA), is rare and occurs in less than 1% of patients. Thus splenic artery aneurysms (SAAs) with an anomalous origin from the SMA are quite rare. We report our experience with the surgical management of a 2.6-cm aneurysm involving a splenic artery arising from the SMA in a 40-year-old woman. This was treated with surgical resection with preservation of the spleen. A discussion about SAAs and the management of aneurysms arising from a splenomesenteric trunk follows.

The multidetector computed tomography angiography (MDCTA) in the diagnosis of splenic artery aneurysm and pseudoaneurysm

Splenic artery aneurysm is the most frequent visceral artery aneurysm and rupture of the aneurysm is associated with a high mortality rate. It is important to discriminate between a true aneurysm and a pseudoaneurysm that may be caused by pancreatitis, iatrogenic and postoperative causes, trauma and peptic ulcer disease. Multidetector-row CT angiography (MDCTA) allows detailed visualization of the vascular anatomy and may allow identification of aneurysms and pseudoaneurysms that affect the splenic artery. The objective of this article is to provide a review of the general characteristics of splenic artery aneurysms and pseudoaneurysms and to describe the findings of MDCTA.