Open repair, endovascular repair, and conservative management of true splenic artery aneurysms

Visceral Aneurysms: Systematic Review and Meta-analysis of Endovascular Versus Open Repair

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 348699.

Splenic artery aneurysm: a rare complication of autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is an important cause of renal dysfunction. It is the most common genetic disorder leading to end-stage kidney disease requiring dialysis. ADPKD is a multisystem disease and is linked to several extra renal abnormalities. Splenic artery aneurysms are rare in the general population. ADPKD is associated with cerebral artery aneurysms. However, splenic artery aneurysms are not a well-recognised complication of ADPKD. We report an unusual case of a splenic artery aneurysm found incidentally on abdominal CT imaging of a woman with known ADPKD.

Robotic resection for splenic artery aneurysm associated with neurofibromatosis type 1: a case report

BACKGROUND

Neurofibromatosis type 1 is an autosomal-dominant disease characterized by café-au-lait spots and neurofibromas, as well as various other symptoms in the bones, eyes, and nervous system. Due to its connection with vascular fragility, neurofibromatosis type 1 has been reported to be associated with vascular lesions, such as aneurysms. However, there have been few reports of abdominal visceral aneurysms associated with neurofibromatosis type 1. Furthermore, there have been no reports of robotic treatment of aneurysms associated with neurofibromatosis type 1. In this report, we describe the case of a patient with neurofibromatosis type 1 with a splenic artery aneurysm who was successfully treated with robotic surgery.

CASE PRESENTATION

This report describes a 41-year-old Asian woman with a history of neurofibromatosis type 1 who was referred to our hospital for evaluation of a 28 mm splenic artery aneurysm observed on abdominal ultrasound. The aneurysm was in the splenic hilum, and transcatheter arterial embolization was attempted; however, this was difficult due to the tortuosity of the splenic artery. Thus, we suggested minimally invasive robotic surgery for treatment and resection of the splenic artery aneurysm with preservation of the spleen. The postoperative course was uneventful, and the patient was discharged on the eighth day after surgery. At 1 year of follow-up, the patient was doing well, with no evidence of recurrence.

CONCLUSION

We encountered a rare case of splenic artery aneurysm in a patient with neurofibromatosis type 1 who was successfully treated with robotic surgery. There is no consensus on treatment modalities for neurofibromatosis-related aneurysms, and endovascular treatment is considered safe and effective; however, surgery remains an important treatment modality. Especially in patients with stable hemodynamic status, robotic surgery may be considered as definitive treatment. To our knowledge, this is the first successfully treated case of a splenic artery aneurysm in a patient with neurofibromatosis type 1.

Emergent method for management of splenic artery aneurysms rupture: A case report

INTRODUCTION AND IMPORTANCE

Although endovascular therapy is becoming more used for the treatment of splenic artery aneurysms (SAAs) instead of open surgery, there is limited information available on the emergent hybrid approach, selectively. We present our experience of hybrid therapy using an emergent endovascular balloon for inflow control and open resection.

CASE PRESENTATION

A 34-year-old woman was brought to the emergency room after it was reported that she had a pseudoaneurysm in her splenic artery at a different medical facility. The patient was hemodynamically stable. Then we underwent a combination of endovascular and open procedures, using balloon proximal control and open aneurysm resection. She was discharged from hospital on the fifth postoperative day after the operation.

CLINICAL DISCUSSION

There is no agreement on how to treat SAA patients. Endovascular procedures such as endovascular intervention are also being used, minimizing the risks of surgery and shortening the patient's hospital stay, but complications remain. We propose to try SAA's emergency hybrid strategy operation with a good prognosis and fewer complications.

CONCLUSION

It seems that, compared to open surgery alone when endovascular procedures were impossible, elective hybrid procedures are more secure and efficient in stable patients and could make the operation easier without more dissection for proximal control of splenic artery.

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.

Selection of endovascular treatment strategies and analysis of the efficacy of different locations and types of splenic artery aneurysms

PURPOSE

To analyze the selection of endovascular treatment strategies and the efficacy of various locations and types of splenic artery aneurysms (SAAs).

METHODS

Sixty-three cases of patients diagnosed with SAA from January 2016 to October 2021 were collected, and their clinical data and follow-up results were analyzed.

RESULTS

Among the 63 patients, 55 had true SAAs, and 8 had false SAAs. The average diameter of the true SAAs was 2.0 ± 0.8 cm. There were 10 cases of intra-aneurysm embolization, 24 cases of intra-aneurysm and aneurysm-bearing artery embolization, 10 cases of bare stent-assisted coil embolization, and 11 cases of stent grafts. The false SAAs had an average diameter of 2.3 ± 1.1 cm. Aneurysm-bearing artery embolization was applied in 5 cases, and stent grafts were applied in 3 cases. The incidence of complications after embolization of the aneurysm-bearing artery was higher (P < 0.01). Postembolization syndrome occurred in 10 patients; 7 patients developed splenic infarction to varying degrees, 1 patient had mildly elevated blood amylase, and 1 patient developed splenic necrosis with abscess formation, all of which improved after active treatment. The average length of hospital stay was 5.5 ± 3.2 days. The average follow-up time was 17.2 ± 16.1 months, and the aneurysm cavity of all patients was completely thrombotic.

CONCLUSION

Endovascular treatments of SAAs are safe and effective. For various locations and types of SAAs, adequate selection of treatment is necessary. Stent grafts are recommended for their safety, economy, practicality, and preservation of the physiological functions of the human body.

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.

Endovascular management of incidentally discovered splenic arteriovenous fistula resulting from ruptured splenic aneurysm: Case report and review of the literature

Splenic arteriovenous fistulas (SAVFs) are rare vascular anomalies, which have a described association with splenic artery aneurysms. Treatment options include surgical fistula excision, splenectomy, or percutaneous embolization. Here we present a unique case of endovascular repair of a splenic arteriovenous fistula (SAVFs) associated with a splenic aneurysm. A patient with past medical history of early-stage invasive lobular carcinoma was referred to our interventional radiology practice to discuss an incidentally discovered splenic "vascular malformation" discovered during magnetic resonance imaging of the abdomen and pelvis. Arteriography demonstrated smooth dilatation of the splenic artery, with a fusiform aneurysm which had fistulized to the splenic vein. There were high flows and early filling of the portal venous system. The splenic artery, immediately proximal to the aneurysm sac, was catheterized using a microsystem and embolized using coils and N-butyl cyanoacrylate. Complete occlusion of the aneurysm and resolution of the fistulous connection was achieved. The patient was discharged home the following day, without complication. Associated splenic artery aneurysms and SAVFs are rare occurrences. Timely management is necessary to prevent adverse sequelae such as aneurysm rupture, further enlargement of the aneurysmal sac, or portal hypertension. Endovascular treatment, including n-Butyl Cyanoacrylate glue and coils, offers a minimally invasive treatment option, with facile recovery and low morbidity.

Women of childbearing age have higher mortality rates following inpatient interventions for splenic artery aneurysms

INTRODUCTION

Splenic artery aneurysms (SAAs) are the most common type of splanchnic aneurysms. Current guidelines recommend repair of all SAAs in women of childbearing age since maternal mortality is high. The purpose of this study was to evaluate treatment modalities and outcomes following inpatient SAA repair in women.

METHODS

The National Inpatient Sample (NIS) database from 2012-2018 was queried. Patients with SAAs were identified utilizing International Classification of Disease (ICD) 9 and 10 codes. Childbearing age was defined as 14-49 years of age. The primary outcome was in-hospital mortality.

RESULTS

A total of 561 patients were admitted with a diagnosis of SAA between the years of 2012-2018. There were 267 (47.6%) female patients and of these 103 (38.6%) were of childbearing age. The overall in-hospital mortality rate was 2.7% (n=15). There were no differences in rates of elective admissions or type of repair (open versus endovascular) between women of childbearing age and the remainder of the cohort. However, women of childbearing age were significantly more likely to undergo a splenectomy compared to the remainder of the cohort (32.0% versus 21.4%, P=.028). Women of childbearing age had higher rates of in-hospital mortality compared to the remainder of the cohort (5.8% versus 2.0%, P=.040). Subset analysis of the women of childbearing age revealed that those undergoing a splenectomy versus no splenectomy (14.8% versus 2.6%, P=.039) and those treated in the non-elective versus elective setting (10.5% versus 0%, P=.032) had higher rates of in-hospital mortality. There was one patient with an ICD code associated with pregnancy and they survived.

CONCLUSION

Women of childbearing age had higher in-hospital mortality following inpatient interventions for SAAs with all of the deaths occurring in the non-elective setting. These data support the pursuit of aggressive elective treatment of SAAs in women of childbearing age.

Splenic artery aneurysm masked as a gastroenterology complication: A case report and literature review

INTRODUCTION AND IMPORTANCE

Splenic artery aneurysm has an insidious onset, and low incidence, most of which have no specific manifestations on the early onset and remains the most common visceral aneurysm and third most common splanchnic aneurysm as it still remains a challenge to deal with clinically by many clinicians.

CASE PRESENTATION

We report a single case of a young 21 years old girl who had no potential risk of splenic artery aneurysm on clinical presentation, for gastroenterology disease only assessment and attention in our facility. The patient born and raised on a tropical island in Southern China was clinically diagnosed with splenic artery aneurysm-associated gastroenterological complications which was presented earlier as hematemesis. The patient was considered to have received optimal critical care by our multidisciplinary team and classical features displayed within the clinical settings are worth documenting and contribute perfectly to medical literature as the patient on follow-up is now back to normal life.

CLINICAL DISCUSSION

Our patient recovered excellently on critically close follow-up since the patient had special gastroenterology associated complication features which masked the splenic artery aneurysm with very encouraging post-operative parameters or results.

CONCLUSION

The patient was considered to have received optimal multidisciplinary quaternary medical care for SAAs with gastroenterology-associated complications in our interventional cardiovascular and gastroenterology medicine department.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients: A case report and review of literature

BACKGROUND

The rupture of a splenic artery aneurysm (SAA) in pregnancy is an uncommon condition. However, it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment. Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases, the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.

CASE SUMMARY

We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy. After emergent initial resuscitation, the patient was diagnosed with a ruptured SAA through digital angiography. Immediately upon diagnosis, she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot. Next, surgery was performed to remove the hematoma under stable conditions. Although the fetus was found to be dead during resuscitation, the woman recovered without complications and was discharged 15 d postoperatively.

CONCLUSION

Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Splenic artery aneurysm rupture post-anterior cervical discectomy and fusion: Case report & literature review

Introduction and importance

Anterior cervical discectomy and fusion (ACDF) is a regular surgical procedure for correcting spinal deformities and pain relief. There are several rare complications of ACDF, one of which is postoperative hematomas. Here, we report an unexpected case of intra-abdominal hematoma after ACDF with no prior abdominal symptoms or underlying conditions identified since admission. This report will describe the events and interventions that took place for this patient.

Case description

The patient is a 44-year-old female with a history of neck pain of four-month duration. On Magnetic Resonance Imaging (MRI), a degenerative cervical disk (C5-C6) was identified. Prior surgical history is significant for a C4-C5 ACDF 3 years ago. An anterior cervical discectomy and fusion was performed and the patient was doing well relatively post-surgery. However, in less than 24 h, the patient complained of severe abdominal pain. An abdominal Computerized topography angiogram (CTA) scan revealed internal bleeding and a splenic aneurysm rupture. The patient immediately underwent an urgent laparotomy and splenectomy.

Clinical discussion

Splenic artery aneurysm incidence is rare and is detected incidentally by imaging technology in asymptomatic patients or upon rupture. Splenic artery aneurysm rupture can be spontaneous and unpredictable in previously undiagnosed patients leading to life-threatening symptoms of intra-abdominal hemorrhage.

Conclusion

Patients undergoing ACDF should be monitored closely following surgery for any complications. Physicians should consider the possibility of any signs of hematoma due to underlying conditions that are undiagnosed in order to treat accordingly.

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Unexpected case of intra-abdominal hematoma post-anterior cervical discectomy and fusion (ACDF) due to splenic artery aneurysm.

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True splenic artery aneurysms (SAA) are rare but potentially fatal, they are the third most common abdominal aneurysms.

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As much as 80% of cases of splenic artery aneurysms are asymptomatic.

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Surgical patients should be evaluated prior to operations and post-operative monitoring should be performed to prevent/treat complications.

A case of a pregnant woman with a special splenic artery aneurysm

Visceral artery aneurysm, especially splenic artery aneurysm, is rare and is usually associated with pregnancy. When such aneurysms rupture, they can be fatal, and they often require emergency surgery. This case report includes a review of the literature and describes a effective multidisciplinary approach to managing this type of aneurysm. We describe the treatment of a ruptured splenic artery aneurysm and the careful coordination of obstetric, vascular surgery, and intensive care teams. The uniqueness of this case arose from the metal embolization coil that was found to have fallen off from a recently embolized ruptured splenic artery aneurysm. The management of this ruptured splenic artery aneurysm and iatrogenic foreign body insult required a combination of multiple specialties to provide life-saving treatment. Such cases should be managed by multidisciplinary teams if institutional resources allow for it.

[Selecting the most appropriate surgical treatment of true splenic artery aneurysm]

OBJECTIVE

To analyze the results of diagnosis and treatment of true splenic artery aneurysms.

MATERIAL AND METHODS

We analyzed the results of diagnosis and treatment of 27 patients with true splenic artery aneurysm. All ones underwent surgical treatment at the Botkin Municipal Clinical Hospital between 2017 and 2021. Splenic artery aneurysm >1 cm was an indication for surgical treatment. Surgical option depended on aneurysm location. Laparoscopic splenectomy and aneurysmectomy were performed in 4 cases (14.8%), 5 (18.5%) patients underwent endovascular intervention, laparoscopic clipping was performed in 18 (66.7%) cases. Methods of surgical treatment, general and specific postoperative complications according to the Clavien-Dindo and ISGPS classifications were analyzed.

RESULTS

Laparoscopic clipping was accompanied by fewer general and specific postoperative complications. Specific complications after laparoscopic splenectomy occurred in 2 patients (BL according to the ISGPS 2016 classification). There was one case of acute pancreatitis after endovascular interventions. In long-term postoperative period, aneurysm recanalization after endovascular intervention was observed in 1 case.

CONCLUSION

Surgical treatment of splenic artery aneurysms requires a differentiated approach based on topographic and anatomical assessment of aneurysm relative to the arterial vessel.

Management of huge splenic artery aneurysm with new hybrid procedure including endovascular and open surgical approach: Case series

INTRODUCTION

Splenic artery aneurysms (SAAs) account for more than half of all visceral artery aneurysms. Small SAAs are usually asymptomatic, but giant aneurysms are more likely to cause symptoms and result in life-threatening complications; these aneurysms treatment can be challenging. Splenic artery aneurysms treatment includes laparotomy, laparoscopy, or endovascular techniques.

CASE PRESENTATION

This case series reports the details of successful management of three patients with huge splenic artery aneurysms who underwent hybrid surgery, endovascular inflow control with a balloon, and open aneurysm resection.

DISCUSSION

Although endovascular treatment options are increasingly favored, only selected aneurysms are suitable for these procedures, as marked tortuosity of the artery or SAA in the proximal splenic artery may not be suitable for endovascular management.

CONCLUSION

Open surgery escorted by endovascular techniques can be considered an ideal treatment of SAA in the proximal region of the splenic artery.

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.

Splenic Arteriovenous Fistula Accompanied by Splenic Artery Aneurysm Associated with Acute-onset Portal Hypertension and Gastrointestinal Bleeding: Case Report and Literature Review

Splenic arteriovenous fistula is an uncommon aetiology of portal hypertension, which has definitive treatment effectiveness and good prognosis. We report a case of portal hypertension and gastrointestinal bleeding in the absence of hepatic parenchymal disease in a 50 year-old woman with multiple pregnancies. Abdominal computed tomography and transabdominal arteriography recorded the presence of tortuous and aneurysmal splenic arteries and the premature filling of enlarged splenic veins, which are highly suggestive of splenic arteriovenous fistula. The above vascular abnormalities were successfully treated by transcatheter embolization. No recurrence or other complications were observed. In addition, a literature review concerning splenic arteriovenous fistula published in recent 30 years was performed to further our understanding of the management strategy on this entity.

Endovascular treatment of an asymptomatic hepatic artery aneurism: case report

We report a case of an asymptomatic, 77-year-old, male patient with arterial hypertension and no other comorbidities or risk factors for coronary disease. During a routine abdominal ultrasound examination, he was diagnosed with a hepatic vascular mass with an approximate diameter of 5 cm. Abdominal computed angiotomography was requested, showing an aneurysm of the hepatic artery, with maximum diameter of up to 5.2 cm, longest longitudinal axis of 7.2 cm, and a maximum true lumen caliber of 3.0 cm. We opted for endovascular aneurysm repair with implantation of three sequential Lifestream covered vascular stents (7x58mm, 8x58mm, and 8x37mm), successfully diverting the flow through the stents and excluding the aneurysm. The patient remains asymptomatic and free from clinical complications 2 years after the procedure. Control examinations with arterial duplex ultrasound 6 and 12 months after the procedure showed good flow through the stents with no leakage into the aneurysmal sac.

Early Thrombosis of Splenic Artery Stent Graft

Splenic artery aneurysms (SAAs) are among the most common visceral aneurysms behind aortic and iliac arteries. Certain factors like aneurysm size (especially giant SAAs), hypertension (HTN), symptomatology, pregnancy, portal hypertension (pHTN), and liver transplantation increase the risk of rupture. Most often found incidentally, but when symptomatic, can present with nonspecific symptoms like nausea, vomiting, anorexia, and epigastric/left upper quadrant pain. Diagnosis can be accomplished with different modalities of CT or MRI and digital subtraction angiography (DSA) being the gold standard for diagnosis. Treatment is usually preferred for aneurysms >2 cm, symptomatic cases, and pregnant women. Various surgical/interventional procedures can be performed and selected based on the patient’s sex, age, location of the aneurysm, size of the aneurysm, and presenting complaints/complications. Endovascular techniques with or without stent-graft placement are being used more, given the minimally invasive nature of these procedures. No clear guidelines exist on initiation of dual antiplatelet therapy (DAPT), but based on guidelines from visceral arterial stenting (especially iliac arteries and renal arteries), multiple case reports/series on SAAs, we highly recommend the usage of DAPT pre- and post-stent-graft placement to improve patency.

Neurovascular Neck-Bridging device in treatment of wide-necked splenic artery aneurysms

We report the cases of 2 female patients, 45-year-old and 49-year-old, affected by wide-necked splenic aneurysm. We embolized the 2 lesions assisted by a new scaffolding neurovascular device, the Cascade Net, an innovative –occlusive remodeling device for temporary bridging in endovascular coil embolization of intracranial aneurysms. Visceral artery aneurysms are rare with an estimated prevalence of 2%-3% in imaging series and up to 10% in autopsy series. Most are asymptomatic and their diagnosis is occasionally. Aneurysm spontaneous rupture has been demonstrated in 2%-10% of cases and it can result in significant morbidity and mortality. Conservative management and open repair were the preferred treatment options for many years. Endovascular repair has been increasingly used since 2000; and the most widespread method of treatment has been coiling. Because of tortuosity of the parent artery, wide neck, and unfavorable locations at arterial branch points, 6% of Visceral and renal artery aneurysms VRAA cannot be adequately treated by simple coiling and requires parent artery remodeling through balloon occlusion, stent placement or parent vessel occlusion, leading to, in the latter situation, a compromised organ perfusion. Increasingly, balloon-assisted, and stent-assisted approaches as well as novel scaffolding neurovascular devices such as the Cascade Net, have allowed wide necked aneurysms to be bridged during endovascular treatment with smaller delivery system, averting parent artery occlusion and risk of distal embolization.

Giant splenic artery aneurysm treated surgically with spleen and pancreas preservation

Aneurysms of the splenic artery represent a rare clinical entity, even though they account for 60-70% of all visceral artery aneurysms. Splenic artery aneurysms larger than 5 cm are extremely rare, and they are considered to be giant. Possible causes of splenic artery aneurysm development include: trauma, hormonal and local hemodynamic changes in pregnancy, portal hypertension, arterial degeneration, infection and postsplenectomy occurrence. Surgical treatment of giant splenic artery aneurysms includes procedures that frequently require pancreatectomy and splenectomy. We present a case of a 10.2 cm giant splenic artery aneurysm, firmly adhered to the pancreas, which was treated surgically, with spleen and pancreas preservation. SIMILAR CASES PUBLISHED: Although many cases on treatment of giant splenic artery aneurysm have been published, the majority have described additional visceral resections associated with aneurysmectomy, which is in contrast with our report. Furthermore, aneurysms reaching 10 cm in size were extremely rare.

Rare Cause of Syncope in a Gravid Female

CASE PRESENTATION

A 33-year-old gravid female was brought to the emergency department after she collapsed in the street. Point-of-care ultrasound showed free fluid in the abdomen and confirmed an intrauterine pregnancy. Surgical teams were consulted, and cross-sectional imaging revealed a spontaneously ruptured splenic artery aneurysm (SAA). The patient was taken expeditiously to the operating room for splenic artery ligation and subsequent splenectomy.

DISCUSSION

Ruptured SAA in pregnant patients is associated with significant mortality for both mother and fetus. Maintaining a high index of suspicion in the correct population is crucial to avoid diagnostic errors and provide definitive care with operative repair.

Giant splenic artery aneurysm presenting with massive upper gastrointestinal bleeding: A case report and review of literature

BACKGROUND

Splenic artery aneurysm (SAA) and pseudoaneurysm are rare vessel’s lesions. Pseudoaneurysm is often symptomatic and secondary to pancreatitis or trauma. True SAA is the most common aneurysm of visceral vessels. In contrast to pseudoaneurysm, SAA is usually asymptomatic until the rupture, with high mortality rate. The clinical onset of SSA’s rupture is a massive life-threatening bleeding with hemodynamic instability, usually into the free peritoneal space and more rarely into the gastrointestinal tract.

CASE SUMMARY

We describe the case of a 35-year-old male patient, with negative past medical history, who presented to the emergency department for massive upper gastrointestinal bleeding, severe anemia and hypotension. An esophagogastroduodenoscopy performed in emergency showed a gastric bulging in the greater curvature/posterior wall with a small erosion on its surface, with a visible vessel, but no active bleeding. Endoscopic injection therapy with cyanoacrylate glue was performed. Urgent contrast-enhanced computed tomography was carried out due to the clinical scenario and the unclear endoscopic aspect: The radiological examination showed a giant SAA which was adherent to posterior stomach wall, and some smaller aneurysms of the left gastric and ileocolic artery. Because of the high risk of a two-stage rupture of the giant SAA with dramatic outcome, the patient underwent immediate open surgery with aneurysmectomy, splenectomy and distal pancreatectomy with a good postoperative outcome.

CONCLUSION

The management of a ruptured giant SAA into the stomach can be successful with surgical approach.

Sarcoidosis presenting as massive splenomegaly and severe epistaxis, case report

Sarcoidosis is a multisystem disorder of unknown etiology. Extrapulmonary sarcoidosis can involve any organ, but isolated spleen involvement is rare. Diagnosis can be challenging as other etiologies may have similar presentations. A 58-year-old African American female presented with life threatening epistaxis, anemia, refractory thrombocytopenia, and massive splenomegaly. Lymphoproliferative, infectious, and autoimmune etiologies were eliminated with laboratory testing and bone marrow biopsy. The patient had multiple splenic artery aneurysms precluding an open diagnostic splenectomy. Partial splenic artery embolization was performed, which normalized the platelet count and resolved the spontaneous bleeding. This allowed diagnostic splenectomy and splenic artery repair to be safely performed. Surgical pathology demonstrated extensive non-caseating granulomas consistent with sarcoidosis. We present this case to demonstrate the omnipotent nature of sarcoidosis and a complex multi-disciplinary approach for successful diagnosis and treatment.

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Sarcoidosis rarely presents with extrapulmonary involvement leading to life-threatening clinical scenarios.

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Splenic sarcoidosis as a source of life-threatening platelet sequestration.

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Splenectomy can be used as diagnostic and therapeutic intervention in sarcoidosis.

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Partial splenic artery embolization provides safe alternative to open splenic artery aneurysm repair.

Decision-making and therapeutic options in intact splenic artery aneurysms: single-center experience and literature review

BACKGROUND

Splenic artery aneurysms are rare, potentially serious, and usually asymptomatic. Several methods are currently available to treat them, each with their own advantages and drawbacks. Therefore, its therapeutic paradigm has changed.

METHODS

We review our database of splenic aneurysms (2009-2019) and undertake an exhaustive literature review. Demographic, clinical, diagnostic, therapeutic, early and follow-up outcome data were examined. Our experience comprised: 15 patients with 19 splenic aneurysms. 11 women (average age, 59.4 years) and 4 men (average age, 61.7 years). All asymptomatic.

RESULTS

At diagnosis, aneurysms had a mean cross-sectional diameter of 3.4 cm (3.2 and 3.9 for women and men, respectively), the largest measuring 8.5 cm. Two independent aneurysms were detected in four patients. Diagnoses were always incidental to a CT scan. Treatments consisted of open surgery (2 patients), endovascular surgery (10 patients: 7 embolizations, 3 covered stent) and observation/follow-up (3 patients). The cases of open surgery (with splenectomy) were carried out without postoperative morbidity. One embolization failed (requiring subsequent open surgery) and two suffered localized splenic infarction, but without further complications. In patients treated with a covered stent, the aneurysm was always excluded, without complications. There was no 30-day or follow-up (average 26.2 months) mortality. Splenic aneurysms are diagnosed more frequently and earlier (in the asymptomatic phase), albeit incidentally, than in the past.

CONCLUSIONS

The correct indication (identifying patients at risk) and individualization of treatment, in which endovascular techniques are the first-line option, have significantly improved morbidity and mortality outcomes in our hospital.

Spontaneous Rupture of a Huge Splenic Artery Aneurysm: A Case Report

BACKGROUND Splenic artery aneurysm is uncommon in a healthy young male patient. With spontaneous rupture, it can quickly become life-threatening. Our aim is to highlight the possibility of splenic artery aneurysm among healthy young patients and its presentation as recurrent abdominal pain, while pending rupture is possible, which can present a diagnostic challenge. The rare occurrence and spontaneous rupture of a splenic artery aneurysm are often fatal outside an inpatient setting. CASE REPORT Here, we present the case of a 32-year-old patient who visited the Emergency Department with recurrent epigastric pain. While undergoing inpatient evaluation, had a spontaneous rupture of a splenic artery aneurysm with hypovolemic shock and a double-rupture phenomenon, necessitating emergency surgery. CONCLUSIONS With advances in modern imaging in recent years, the incidence of splenic aneurysm has increased 7-fold; therefore, being informed and considering it in the differential diagnosis might provide a window of opportunity and save lives.

Splenic aneurysms: natural history and treatment techniques

True splenic artery aneurysms (SAA) are a rare, but potentially fatal, pathology. They are the third most common type of abdominal aneurysm, after aneurysms of the aorta and of the iliac artery, and account for almost the all aneurysms of visceral arteries. True aneurysms account for 60% of SAA and affect four times as many women as men, generally related to increased incidental or symptomatic findings that coincide with use of ultrasonography in pregnancy. Among pregnant patients, mortality after rupture is 65-75%, with fetal mortality exceeding 90%. There are multiple etiologies and it is believed that hormonal influences and changes in portal flow during gestation play an important role in development of SAA. This review discusses their history, epidemiology, pathophysiology, and diagnosis and current treatment techniques.

Egg-shell like Calcification as a Protective Factor for Splenic Artery Aneurysm Dilatation

BACKGROUND

The purpose of this study was to evaluate the factors associated with asymptomatic splenic artery aneurysm (SAA) dilatation.

METHODS

Among patients with SAA admitted to our department from 2001 to 2018, 70 lesions in 59 patients were selected and analyzed retrospectively. There were no cases of rupture or pregnancy in the follow-up period. We defined egg-shell appearance as SAA with >75% calcification of the outer shell. We measured the dilatation rate (mm/year) and evaluated the comorbidity and anatomical factors using univariate and multiple linear regression models. Post-hoc multiple linear regression models were fitted to evaluate the possible interactions.

RESULTS

The mean age was 61.4 years (range 35-85 years), and the initial aneurysm diameter was 15.1 mm (range 3-47 mm). The mean dilatation rate was 0.26 mm/year (range 0-3.2 mm/year) during the follow-up period (average 4.6 years). Univariate analysis revealed that, portal hypertension (PHT) (P = 0.0003), egg-shell appearance (P = 0.007), and aneurysm diameter > 20 mm (P = 0.05) were significantly associated with the dilatation rate. Multivariate analysis revealed that egg-shell appearance was found to be an independent inverse risk factor of dilatation rate (P = 0.006). The multivariate analysis, including interaction terms, revealed a stronger effect of PHT and diameter >20 mm in cases with no egg-shell appearance (P = 0.08 and P = 0.05 for interactions, respectively).

CONCLUSIONS

The egg-shell appearance of SAA was an independent inverse risk factor affecting the SAA dilatation rate. The dilatation rates in the case of PHT and diameter >20 mm were restricted in the presence of the egg-shell appearance.

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.

Long-term outcomes of elective transcatheter dense coil embolization for splenic artery aneurysms: a two-center experience

Objective

This study was performed to analyze the long-term follow-up safety and efficacy of transcatheter dense coil embolization for splenic artery aneurysms.

Methods

Thirty-two patients (18 women, 14 men; age range, 23–56 years; mean age, 43.1 ± 13.6 years) who underwent dense coil embolization for treatment of splenic artery aneurysms from August 2010 to January 2018 were retrospectively reviewed. The size and location of the splenic artery aneurysms, the technical and clinical outcomes of the procedure, and the complications related to the procedure were reviewed.

Results

The technical success rate of embolization was 100% (mean aneurysm size, 29.4 ± 6.9 mm; range, 20–43 mm). Two (6.3%) patients underwent a successful repeat intervention procedure for recurrent aneurysm perfusion during follow-up (mean, 36 months; range, 6–72 months). No aneurysm ruptured during follow-up. Splenic infarction was observed in 8 of 32 (25%) patients. No patients developed major adverse events related to the procedure, such as splenic abscess or pancreatitis.

Conclusions

Percutaneous elective transcatheter dense coil embolization is safe and effective to prevent aneurysm rupture and overcome aneurysm recanalization during long-term follow-up.

Video-robotic aneurysmectomy for splenic artery aneurysm: case report and literature review

We herein report the case of a symptomatic splenic artery aneurysm (SAA) diagnosed in a 65-year-old woman. Endoluminal exclusion was considered as first option, but the potential risk of postoperative splenic infarction, postsplenectomy thrombocytosis and immunodeficiency in an otherwise healthy patient raised the possibility to carry out a surgical procedure of vascular reconstruction using the robotic device Da Vinci^® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). We performed the resection of the aneurysm and the continuity of the splenic artery was restored by end-to-end anastomosis.

Hybrid Surgery for Multiple Visceral Artery Aneurysms: A Case Report

BACKGROUND

We present a case with multiple visceral artery aneurysms that were treated with a hybrid approach involving both surgical and endovascular treatment.

CASE REPORT

The patient was a 48-year-old female. She was diagnosed with multiple visceral artery aneurysms including 2 splenic artery aneurysms, celiac artery aneurysm, and bilateral renal artery aneurysms during an examination for loss of appetite. With regard to 2 splenic artery aneurysms, the proximal aneurysm was treated surgically, whereas the peripheral aneurysm that was located deeply in the abdomen was treated with coil embolization. The celiac artery aneurysm located at the bifurcation of the common hepatic artery and splenic artery, an intracranial aneurysm clip was used. The left and right renal aneurysms were resected and renal arteries were reconstructed surgically. The postoperative course was uneventful. The pathological diagnosis of all aneurysms was segmental arterial mediolysis. The reconstructed vessels were patent without stenosis or recurrence at 1 year after the operation.

CONCLUSIONS

Hybrid treatment involving surgical resection, endovascular coil embolization, and obliteration with clips was useful in the treatment of multiple visceral artery aneurysms.

Splenic artery aneurysm in a patient of autosomal dominant polycystic kidney disease: beyond tenuous concomitance!

Splenic artery aneurysm (SAA) is rare, with risk of rupture especially if diameter is >2 cm. It is usually asymptomatic and detected incidentally on imaging either in young pregnant women or elderly cirrhotic patients. Extracranial vascular abnormalities known to be associated with autosomal dominant polycystic kidney disease (ADPKD) include ascending aortic aneurysms, dissections of coronary and vertebral arteries and rarely SAA. We describe a rare case of incidentally detected SAA in a patient with end stage renal disease due to ADPKD during evaluation of persistent gross haematuria, with no evidence of cranial or other extracranial aneurysms.

Spontaneous rupture of a splenic artery aneurysm with splenic epithelioid hemangioendothelioma: a case report

Spontaneous rupture of a splenic artery aneurysm with splenic epithelioid hemangioendothelioma is a rare condition. Splenic artery aneurysm can be complicated by rupture resulting in hypovolemic shock, which can be fatal if not treat properly. We report a case of a 50-year-old man who presented with sudden onset of left upper quadrant pain and shock. This patient underwent splenectomy with distal pancreatectomy. His pathological diagnosis showed splenic epithelioid hemangioendothelioma.

Giant Splenic Aneurysm with Arteriovenous (A-V) Shunt, Portal Hypertension, and Ascites

Patient: Male, 43

Final Diagnosis: Splenic aneurysm

Symptoms: Ascites • fever • portal hypertension

Medication: —

Clinical Procedure: —

Specialty: Surgery

Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Visceral artery aneurysms (VAAs) are a rare, but serious clinical entity as rupture confers a high rate of mortality. Data regarding the prevalence, treatment, and prognosis of VAAs is largely from case series, as true randomized trials are lacking. The incidence of VAAs has risen over the decades with advances in imaging technology, availability, and utilization. Even in the presence of symptoms, the prompt diagnosis of VAAs may be challenging as symptoms are often nonspecific and varied. Although there are no definitive treatment guidelines, asymptomatic VAAs require treatment in the following scenarios: when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplant. Similar to therapeutic trends in other vascular beds, advances in endovascular devices and techniques have driven an "endovascular first" approach for the treatment of VAAs. However, although the success rates of endovascular repair are impressive, surgical intervention is still necessary in treating centers. This paper reviews the pathophysiology, clinical features, anatomic characteristics, and management strategies required for the effective diagnosis and treatment of VAAs.

Endoscopic ultrasound-guided coil and glue for treatment of splenic artery pseudo-aneurysm: new kid on the block!

BACKGROUND AND STUDY AIMS

 Pseudoaneurysm most commonly involves the splenic artery and is conventionally treated with angioembolization or surgery. Herein we describe six patients with splenic artery pseudoaneurysm who were treated using a new technique of endoscopic ultrasound (EUS)-guided glue and coil injection.

PATIENTS AND METHODS

 Six patients (median age 36.7, range: 19 - 60, M: F = 5:1) with splenic artery pseudoaneurysm who had failed angiographic embolization underwent EUS-guided transgastric injection of coil and glue injection between July 2016 and September 2017.

RESULTS

The diameter of the splenic artery pseudoaneurysms varied from 2.5 cm to 6.5 cm . The size (8, 14 and 16 mm) and number (1 to 5) of coils and amount of glue (1 - 2 mL) injected all were greater in larger aneurysm. All six patients had complete occlusion of the pseudoaneurysm as determined by using computed tomography at 4 weeks and EUS at 12 weeks. No complication was encountered.

CONCLUSION

EUS-guided coil and glue injection for obliteration of splenic artery pseudoaneurysm is a feasible, highly effective and safe technique.

Open surgery for aneurysms of the splenic artery at the hilum of the spleen: Report of three cases

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Aneurysms of the splenic artery at the hilum of the spleen are rare.

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Endovascular or laparoscopic treatment may not be advised.

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Surgical resection through subcostal incisioni s a viable treatment.

Introduction

Aneurysms of the splenic artery (SAA) located at the hilum of the spleen are not well fit for endovascular or laparoscopic treatment. Open surgery may still be the best option of treatment.

Presentation of cases

We report the cases of 3 female patients of a mean age of 59 years (range, 45–68 years) with a hilar (n = 2) or parahilar (n = 1) SAA undergoing successful open surgical resection, through a short left subcostal access. Recovery was uneventful and mean, postoperative length of stay was 4 days (range, 3–5 days).

Discussion

Results of this report support surgical resection and splenectomy for the treatment of SAA located at the hilum of the spleen. For this particular location endovascular treatment may not be advised, as coil embolization can be followed by a massive splenic infarction precipitating the need for splenectomy, due to the exclusion of backflow from the left gastroepiploic artery through the short gastric vessels. As well, endovascular exclusion through insertion of an endograft may not be feasible due to the absence of a distal landing zone, as stent grafting requires a normal caliber artery of sufficient length on each side of the aneurysm.

Conclusion

Surgical excision and splenectomy, through a short subcostal incision, remains a viable option of treatment for hilar SAA.