Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Comparative Efficacy and Safety of Self-Expandable vs. Balloon-Expandable Stent Grafts in Visceral Artery Aneurysm Management

PURPOSE

This study assesses the efficacy and safety of self-expandable (SE) versus balloon-expandable (BE) stent grafts for managing visceral artery aneurysms (VAAs), focusing on procedural success and complication rates.

MATERIALS AND METHODS

We conducted a retrospective analysis of VAA patients treated at our institution from April 2006 to September 2021. The study reviewed patient demographics, aneurysm characteristics, treatment details, and outcomes, including endoleaks.

RESULTS

Among the 23 patients analyzed, splenic artery aneurysms represented 44% of cases. Fifteen patients were treated with balloon-expandable stent grafts (BE SGs), and eight patients were treated with self-expandable stent grafts (SE SGs). For saccular aneurysms, the average neck size was 10.10 ± 8.70 mm in the BE group versus 18.50 ± 3.40 mm in the SE group (p = 0.23), with an average sac size of 20.10 ± 18.9 mm in the BE group versus 15.60 ± 12.7 mm in the SE group (p = 0.16). The average sac-to-neck ratio was 1.69 ± 2.23 in the BE group versus 1.38 ± 0.33 in the SE group (p = 0.63). The BE group exhibited a significantly higher endoleak rate (60%) compared to the SE group (12.5%; p = 0.03).

CONCLUSIONS

While further investigation is needed to fully assess the outcomes of stent graft treatment for VAAs, initial data show a significantly higher endoleak rate with BE SGs compared to SE SGs. The SE SGs may offer better outcomes due to their superior ability to conform to tortuous and mobile visceral arteries.

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: A Literature Review

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described.

Clinical outcomes after surgical decompression of median arcuate ligament syndrome-An observational study

BACKGROUND AND OBJECTIVES

Median arcuate ligament syndrome is caused by compression and stenosis of the celiac artery. Incision of the median arcuate ligament improves persistent abdominal symptoms. The study aimed at evaluating the outcomes in patients who underwent median arcuate ligament syndrome decompression using a self-report questionnaire.

METHODS

This single-center retrospective study included patients with median arcuate ligament syndrome who underwent decompression surgery between April 2021 and February 2023. The medical records were retrospectively reviewed.

RESULTS

Ten patients were included in the study. Laparotomy and laparoscopic surgeries were performed in seven and three patients, respectively. The median operation time was 147 minutes. The median hospitalization period after the operation was seven days. The degrees of celiac artery stenosis before and after surgery were compared and the per cent diameter stenosis did not significantly improve; five of 10 patients (50%) had > 50% stenosis in the celiac artery after the operation. Compared to the baseline, the scores of upper gastrointestinal symptoms significantly improved during the six months' period (p < 0.001). Additionally, we evaluated the influence of post-operative per cent diameter stenosis and divided the patients into two groups (≥ 50% vs, < 50%). The scores of upper gastrointestinal (GI) symptoms in both groups improved significantly from baseline. However, the symptomatic improvement at six months in the post-operative per cent diameter stenosis < 50% group was significantly greater than that in the ≥ 50% group (p = 0.016). The scores of lower gastrointestinal symptoms did not change significantly during the six-month period.

CONCLUSION

Decompression surgery for median arcuate ligament syndrome could improve upper gastrointestinal symptoms regardless of the post-operative per cent diameter stenosis.

Right Hepatic Artery Pseudoaneurysm Post-laparoscopic Cholecystectomy: A Case Report of Endovascular Stent-Graft Management

Gallstone-related diseases like cholelithiasis contribute significantly to global morbidity and mortality. Laparoscopic cholecystectomy (LC) is the gold standard for gallbladder removal but is associated with rare but severe complications, including hepatic artery pseudoaneurysms (PAs). A 72-year-old female presented with acute abdominal pain and upper gastrointestinal bleeding following a recent LC. Laboratory studies confirmed anemia with a hemoglobin level of 10 g/dL. Liver function tests were deranged, showing elevated alanine aminotransferase (ALT) at 209 U/L, aspartate aminotransferase (AST) at 472 U/L, total bilirubin levels at 3.29 mg/dL, and direct bilirubin levels at 2.7 mg/dL. A contrast-enhanced computed tomography scan revealed a PA adjacent to the right hepatic artery. Given the strong suspicion of a hepatic PA as the source of her symptoms, an endovascular stent was placed by an interventional radiologist. Post-procedure, the patient showed a favorable clinical course with cessation of symptoms and was discharged after eight days. This case emphasizes the importance of early identification of hepatic artery PAs following LC, a potentially life-threatening complication. It also suggests that endovascular stent placement can be an effective alternative to traditional transarterial embolization for managing these PAs. Additional research is needed to evaluate the long-term effectiveness and safety of these two methods in comparison.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms

BACKGROUND

Endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms is an effective, minimally invasive treatment that has been successfully used since the early 1990s, with refined and expanded techniques and tools currently offering excellent outcomes. Due to increased detection of such lesions in recent years, many of which are asymptomatic, revision of the indications for intervention and the correct endovascular treatment approaches has become essential.

PURPOSE

This document will presume that the indication for treatment is clear and approved by the multidisciplinary team and will define the standards required for the performance of each intervention, as well as their relative advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of the endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in endovascular treatments. The writing group reviewed the existing literature on visceral and renal artery aneurysms and pseudoaneurysms, performing an evidence search using PubMed to identify publications in English and relating to human subjects from 1990 to 2022. The final recommendations were formulated through consensus.

RESULTS

Endovascular treatment has an established role in the successful management of visceral and renal artery aneurysms and pseudoaneurysms, and this Standards of Practice document provides up-to-date recommendations for its safe performance.

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review

Background

Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management.

Case Presentation

We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully.

Conclusion

A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.

Nutcracker Phenomenon as a Result of Celiomesenteric Trunk Aneurysm

A common origin of the celiac trunk and superior mesenteric artery is exceedingly rare, and aneurysms of this common trunk are even rarer. According to our literature search, there are no reported cases of nutcracker syndrome or phenomenon involving this rare aneurysmal anomaly. Repair of such anomalies is standardly via open surgical approach with few reported cases of endovascular repair. We describe a patient with an aneurysm of the celiomesenteric trunk resulting in nutcracker phenomenon of the left renal vein. The celiomesenteric trunk aneurysm was repaired endovascularly, resulting in decreased surrounding inflammation and improvement of the left renal vein compression.

A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre

INTRODUCTION

Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management.

METHODS

Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020).

RESULTS

There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention.

CONCLUSION

In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

Visceral artery aneurysms (VAAs) are rare, usually asymptomatic and incidentally discovered during a routine radiological examination. Shared guidelines suggest their treatment in the following conditions: VAAs with diameter larger than 2 cm, or 3 times exceeding the target artery; VAAs with a progressive growth of at least 0.5 cm per year; symptomatic or ruptured VAAs. Endovascular treatment, less burdened by morbidity and mortality than surgery, is generally the preferred option. Selection of the best strategy depends on the visceral artery involved, aneurysm characteristics, the clinical scenario and the operator's experience. Tortuosity of VAAs almost always makes embolization the only technically feasible option. The present narrative review reports state of the art and new perspectives on the main endovascular and other interventional options in the treatment of VAAs. Embolization techniques and materials, use of covered and flow-diverting stents and percutaneous approaches are accurately analyzed based on the current literature. Visceral artery-related considerations and targeted approaches are also provided and discussed.

Giant visceral artery pseudoaneurysm treated with endovascular transradial coil embolization

Visceral artery pseudoaneurysms (PSAs) are relatively rare, and cases associated with distal vasculature of the superior mesenteric artery are largely unreported. Visceral artery PSAs, without intervention, can lead to morbidity or mortality from rupture or mesenteric ischemia. Historically, open aneurysmectomy is the gold standard; however, endovascular modalities have emerged as the first-line treatment in patients who are poor surgical candidates and/or have unfavorable anatomy. Herein, we describe a case of a symptomatic PSA of the distal superior mesenteric artery treated via the transradial approach with endovascular coil embolization, showing successful aneurysmal exclusion and preservation of enteric collateral flow.

Aneurysms of pancreaticoduodenal arcade: Clinical profile and endovascular strategies

Background and Aim

Pancreaticoduodenal arcade aneurysms (PDAAs) are uncommon lesions associated with a significant risk of rupture and mortality. This study describes the etiology, clinical presentation, and endovascular management strategies of PDAAs across a spectrum of indications.

Methods

The clinical records of patients with PDAAs referred for endovascular management from January 2018 till November 2019 were retrospectively reviewed. Data on presenting symptoms, associated etiologies, and outcomes after endovascular treatment were collected and studied.

Results

We found 15 patients with false and 1 patient with true aneurysm of pancreatoduodenal arcade (PDA). The associated conditions were coeliac artery stenosis, severe necrotizing pancreatitis, and chronic pancreatitis or iatrogenic (postendoscopic papillotomy and percutaneous metallic biliary stenting). The main presenting feature was gastrointestinal bleed, while 2 patients had abdominal pain and 1 had gastric outlet obstruction. A multiphase computed tomography scan demonstrated the ruptured aneurysm in all patients. Site of origin of PDAA influenced the choice of transarterial endovascular strategy (coiling for aneurysms of main trunk of arteries and glue injection for those arising from small arterial branches). This was carried out in an emergency setting for 12 patients and as an elective procedure in 4 patients. Technical success was demonstrated in all patients and clinical success in 14. The two patients who had rebleed were salvaged by repeat endovascular procedure. Postembolization syndrome was seen in three patients.

Conclusions

With advancing technology, endovascular strategies continue to evolve. Careful attention to ensure hemodynamic resuscitation and stability, correction of pre‐existing coagulopathy and attention to technique can lead to the possibility of endovascular approaches as a dependable option in the management of ruptured PDAAs.

Balloon-assisted coil embolization (BACE) of a wide-necked aneurysm of the inferior pancreaticoduodenal artery

Background

Aneurysms of the pancreaticoduodenal arcades are an uncommon pathology, with a prevalence of 2%, and could be congenital or acquired. Treatment of visceral aneurysms is therefore generally recommended when the aneurysmal sac equals or exceeds 2 cm. Wide-necked (> 4 mm) and main artery branch aneurysms represent a challenge for conventional endovascular coil embolization due to the risk of coil migration.

Main body

This case describes the technical feasibility of balloon-assisted coil embolization (BACE) in the treatment a wide neck aneurysm of inferior pancreatic duodenal artery due to celiac axis occlusion.

Short conclusion

In case of celiac trunk occlusion, BACE is a safe procedure associated with optimal technical success rates, in order to treat the aneurysms and to preserve splanchnic vascularization.

Causal Relationship between Celiac Stenosis and Pancreaticoduodenal Artery Aneurysm: Interpretation by Simulation Using an Electric Circuit

Pancreaticoduodenal artery (PDA) aneurysm and celiac artery (CA) stenosis are rare diseases in themselves. Interestingly, however, there are more cases documented in the literature in which these two disease entities occurred together than could be coincidental, and CA stenosis has been suggested as the provocative condition in developing PDA aneurysm. This study is aimed at examining the causal relationship between CA stenosis and PDA aneurysm by simulating the splanchnic circulation with an electric circuit. A patient with multiple PDA aneurysms and collaterals with CA stenosis was treated in our institution using hybrid techniques. The patient's pre- and postoperative status was simulated using an electric circuit, and the two possible scenarios were tested for compatibility: the stenosis-first scenario vs. the aneurysm-first scenario. The simulation was performed in two ways: using Simulink® software (MATLAB® Release 2018b) and actual circuit construction on a breadboard. The stenosis-first scenario showed that as the CA stenosis progresses, the blood flow through PDA increases, favoring the development of an aneurysm and/or collaterals if the artery was already compromised by a weakening condition. On the other hand, the aneurysm-first scenario also showed that if the aneurysm or collaterals developed first, the aneurysm will steal the blood flow through the CA, causing it to collapse if the artery was already compromised by increased wall tension. Contrary to the common belief, this study showed that in patients suffering from concurrent CA stenosis and PDA aneurysm, either condition could develop first and predispose the development of the other. The simulation of splanchnic blood flow with an electric circuit provides a useful tool for analyzing rare vascular diseases that are difficult to provoke in clinical and animal studies.

Rupture of visceral artery aneurysm following elective spinal surgery: a case report and review

INTRODUCTION

Visceral artery aneurysms (VAA), an uncommon disorder of splanchnic vasculature, are associated with significant morbidity and mortality. Despite largely being amenable to endovascular therapies, the initial management of symptomatic VAA typically falls under the care of general surgeons. It is thus essential to have knowledge of the diagnosis and treatment of VAA and to be cognisant of deviations from normal gastrointestinal vasculature.

CASE PRESENTATION

In this paper, we describe the case of a 72-year-old male presenting with a VAA following elective spinal surgery, followed by a review of the clinical diagnosis and management of VAA.

CONCLUSION

Visceral artery aneurysm must be considered as a differential diagnosis for acute abdominal pain and anaemia in the post-operative period following all major operations. Knowledge of the clinical features of VAA and indications for specific intervention are essential for all general surgeons. Furthermore, it is imperative to recognise deviations from normal vasculature of the gastrointestinal tract.

Double-Lumen Balloons, Are They Only Useful in Neurointerventions? Preliminary Outcomes of Double-Lumen Balloon-Assisted Embolization of Visceral Artery Aneurysms

Objectives:

This study aimed to assess the feasibility and results of double-lumen balloon-assisted embolization of visceral artery aneurysms (VAAs).

Methods:

Nine patients (mean age, 55.3 ± 10.8 years) diagnosed with VAA (superior mesenteric, n = 5; splenic, n = 2; renal, n = 2) and undergoing double-lumen balloon-assisted embolization were included in this study. Magnetic resonance angiogram (MRA) was used in the 6-month follow-up to assess the aneurysms and patency of the parent arteries.

Results:

All patients were successfully treated with no reports of morbidity or mortality. Residual filling of the aneurysm neck was detected in 2 patients at the end of the procedure, but those parts were found to be stable in the sixth-month MRA. In 1 patient with renal aneurysm, a stent had to be deployed using a double-lumen balloon catheter because of the prolapse of the coil into the main artery. In another patient with a very large-necked superior mesenteric artery aneurysm, additional coils could be used at the same time thanks to the double-lumen balloon as the coils were not stabilized enough during embolization with the microcatheter coils. Liquid embolic agent was also used in this patient from the same lumen because of the large diameter of the aneurysm.

Conclusions:

Double-lumen balloons, which are mostly used in neurointerventional procedures, can be efficiently used as in the treatment of VAAs due to their ability to deploy stent and perform coil-liquid embolization through 1 lumen.

Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report

BACKGROUND

When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established.

CASE PRESENTATION

A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45.

CONCLUSION

Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

Management strategies for true and dissecting visceral artery aneurysms

BACKGROUND

Visceral artery aneurysms (VAA) are rare and the literature regarding management strategies is limited. The study aim was to evaluate our 13-year experience with VAA treatment including conservative, open surgical and endovascular therapy.

METHODS

This retrospective single-center study included 37 patients (31 male, median age 70 years [46-79 years]) with true and dissecting VAA treated between January 2006 and December 2018. Indications for invasive therapy were ruptured (N.=1) and symptomatic (N.=8) VAA or asymptomatic VAA>20 mm (N.=15). The decision on the treatment type was made after interdisciplinary (vascular surgeons/radiologists) discussion.

RESULTS

The aneurysms affected the celiac trunk (N.=18, 49%), the splenic artery (N.=11, 30%), the superior mesenteric artery (SMA, N.=6, 16%), the hepatic artery (N.=5, 14%) and proximal SMA side branches (N.=2, 5%). Six patients had multiple VAA, one had an intrahepatic artery aneurysm and one had peripheral mesocolic artery aneurysms plus a VAA. 46% of the patients (N.=17) had coexisting aneurysms in other vascular territories. Thirteen patients were managed conservatively (median VAA diameter 15 [14-25] mm), 18 underwent open surgery with venous or prosthetic bypass or interposition graft implantation and 6 were treated by endovascular means (coiling [N.=3] or endograft [N.=3]). Median follow-up (FU) was 21 months (4-123 months). In-hospital mortality was 0%. Median length of hospital stay was 11 days (5-28 days) after surgical and 3 days (2-71 days) after endovascular treatment. Complications included an early type I endoleak, 3 secondary open abdominal surgeries for bleeding/peritonitis after endovascular treatment of a ruptured intrahepatic aneurysm, an asymptomatic aorto-truncal bypass occlusion and aneurysm recurrence after a venous SMA interposition graft. None of the conservatively treated VAA required invasive treatment during FU.

CONCLUSIONS

Small (<20 mm) asymptomatic VAA can be managed conservatively. Whenever invasive treatment is indicated, both open and endovascular treatments can be performed with low complication rates. In order to choose the optimal therapeutic approach, anatomical features and patient comorbidities should be considered and, ideally, discussed interdisciplinarily.