Contemporary endovascular management of splenic vascular pathologies

Endovascular Strategies and Outcomes for Aberrant Splenic Artery Aneurysms

OBJECTIVES

Aberrant splenic artery aneurysms (ASAAs) located at the splenomesenteric trunk (SMT) and the celiacomesenteric trunk have a close anatomical relationship with the superior mesenteric artery (SMA). The aim of this study was to review our institutional experience of endovascular treatment for ASAAs and evaluate the long-term outcomes.

METHODS

A retrospective review of patients with ASAAs who underwent endovascular treatment between December 2006 and December 2022 was performed. The demographics of the patients, aneurysm characteristics, treatment strategies, perioperative and long-term outcomes, and complications were analyzed.

RESULTS

A total of 29 patients with ASAAs were endovascularly treated at our institution. The SMT variant occurred in the majority of the patients. All ASAAs were characterized by eccentric growth and extremely short inflow arteries. Only 1 patient's inflow artery of the aneurysm exceeded 1 cm in length. Thirteen patients were treated by coil embolization alone. Four patients received bare stent-assisted coil embolization. A combination of coil embolization and covered stent placement across the orifice of the aberrant splenic artery was performed in the remaining 12 cases. Coil migration into the SMA occurred in 2 patients during the operation. Technical success was achieved in all patients. With a median duration of 63 (34-101) months of follow-up, no intestinal ischemia, aneurysm-related death, aneurysm rupture, or sac enlargement occurred. Three cases of aneurysm sac reperfusion were observed, and 1 patient underwent reintervention with secondary embolization. Asymptomatic occlusion of the covered stent was detected in 1 patient at 2 years.

CONCLUSIONS

Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and poses a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications.

CLINICAL IMPACT

Aberrant splenic artery aneurysm (ASAA) is an extremely rare entity. This study reported a large sample size of ASAAs treated by endovascular techniques with long-term follow-up. The ASAA was characterized by an extremely short inflow artery and a close anatomical relationship with the superior mesenteric artery (SMA). Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and pose a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications.

Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with Vascular Ehlers Danlos Syndrome

BACKGROUND

Vascular Ehlers-Danlos Syndrome (VEDS) is rare and associated with arteriopathies. The aim of this study is to investigate the presentation, operative interventions, and outcomes of splenic arterial pathology in a population of more than 1,500 individuals with genetically confirmed VEDS due to pathogenic COL3A1 variants.

METHODS

Cross-sectional analysis of 1,547 individuals was performed. The data were assembled by harmonizing data from three overlapping cohorts with genetically confirmed VEDS: the VEDS Collaborative Natural History Study (N=242), a single center cohort (N=75), and the UW Collagen Diagnostic Lab cohort (N=1,231). Duplicates were identified and removed. Patients were selected for analysis if they had splenic artery aneurysm (SAA), pseudoaneurysm, dissection, thrombosis, or rupture. Demographics, COL3A1 variants, interventions, and outcomes were analyzed. Comparisons by splenic artery rupture were made.

RESULTS

A total of 88 patients presented between 1992 and 2021 with splenic artery pathology (5.7% of the cohort, Mean age at diagnosis 37+11.1 years, 50% male). One third were diagnosed with VEDS prior to the splenic artery pathology diagnosis and 17% were diagnosed post-mortem. Most had a positive family history (61%). Most had COL3A1 variants associated with minimal normal collagen production (71.589.7%). Median follow up was 8.5 (IQR 0.9-14.7) years. Initial presentation was rupture in 47% of the cases. Splenic artery rupture overall was 51% (N=45) including 4 cases of splenic rupture. There were no major differences in VEDS related manifestations or COL3A1 variant type by rupture status. SAA was noted in 39% of the cases. Only 12 patients had splenic artery diameter documented in 12 cases with a median diameter of 12 (IQR 10.3-19.3) mm. A total of 34 (38.6%) patients underwent 40 splenic arterial interventions: 21 open surgical, 18 embolization, and 1 unknown procedure. More than one splenic artery intervention was performed in 5 (14.7%) cases. Open repair complications included arteriovenous fistula (n=1), intestinal or pancreatic injury (1 each), and four intraoperative deaths. There were no deaths or access site complications related to splenic artery embolization. Four (23.5%) developed a new SAA in the remaining splenic artery post embolization. All-cause mortality was 35% (n=31) including 22 related to a ruptured splenic artery.

CONCLUSIONS

Splenic arteriopathy in VEDS is associated with variants that affect the structure and secretion of type III collagen and frequently present with rupture. Rupture and open repair are associated with high morbidity and mortality while embolization is associated with favorable outcomes. Suggest repair considerations at SAA diameter of 15 mm. Long term follow up is indicated as secondary splenic arteriopathy can occur.