Visceral Artery Aneurysms

Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review

BACKGROUND

Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs.

MATERIALS AND METHODS

A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications.

RESULTS

We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups.

CONCLUSIONS

Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.

Rupture of Hepatic Pseudoaneurysm Formed Nine Years after Carbon Ion Radiotherapy for Hepatocellular Carcinoma

An 83-year-old man with a history of carbon ion radiotherapy for hepatocellular carcinoma nine years ago presented to a primary care hospital with a fever and abdominal pain. He underwent computed tomography, which revealed the rupture of a hepatic pseudoaneurysm close to the fiducial marker for carbon ion radiotherapy and bleeding into the bile duct. He was successfully treated with transcatheter arterial embolization. Thereafter, re-rupture occurred from a site proximal to the first rupture, and this was treated similarly. It is necessary to be alert for not only tumor recurrence but also pseudoaneurysm occurrence after carbon ion radiotherapy.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm - A Case Report and Literature Review

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary.

Superior Mesenteric Artery Aneurysm Caused by Aortic Valve Endocarditis

Infectious aneurysms of the superior mesenteric artery are a rare but life-threatening condition due to the risk of visceral ischemia, sepsis, or hemorrhage. In this study, we report the case of a superior mesenteric artery aneurysm (SMAA) secondary to a bioprosthetic valve endocarditis, successfully managed with aneurysm resection and saphenous vein interposition graft. We performed an extensive PubMed-based rewiew of the literature of the last 10 years on SMAA, which include the detection of 38 articles quoting 41 SMAAs. The case histories were divided in 2 groups: 18 cases belonged to nonmycotic group A and 23 cases were included in mycotic group B. In group A, 44.4% of patients were treated surgically, whereas in group B, 90.5%. The 2 study groups significantly differed ( P = .01) in terms of surgical treatment. The surgical approach still remains the first choice of treatment in mycotic aneurysm.

Follow-up of true visceral artery aneurysm after coil embolization by three-dimensional contrast-enhanced MR angiography

PURPOSE

We aimed to evaluate the outcomes of coil embolization of true visceral artery aneurysms by three-dimensional contrast-enhanced magnetic resonance (MR) angiography.

MATERIALS AND METHODS

We used three-dimensional contrast-enhanced MR angiography, which included source images, to evaluate 23 patients (mean age, 60 years; range, 28-83 years) with true visceral artery aneurysms (splenic, n=15; hepatic, n=2; gastroduodenal, n=2; celiac, n=2; pancreaticoduodenal, n=1; gastroepiploic, n=1) who underwent coil embolization. Angiographic aneurysmal occlusion was revealed in all cases. Follow-up MR angiography was conducted with either a 1.5 or 3 Tesla system 3-25 months (mean, 18 months) after embolization. MR angiography was evaluated for aneurysmal occlusion, hemodynamic status, and complications.

RESULTS

Complete aneurysmal occlusion was determined in 22 patients (96%) on follow-up MR angiography (mean follow-up period, 18 months). Neck recanalization, which was observed at nine and 20 months after embolization, was confirmed in one of eight patients (13%) using a neck preservation technique. In this patient, a small neck recanalization covered by a coil mass was demonstrated. The complete hemodynamic status after embolization was determined in 21 patients (91%); the visualization of several collateral vessels, such as short gastric arteries, after parent artery occlusion was poor compared with that seen on digital subtraction angiography in the remaining two patients (9%). An asymptomatic localized splenic infarction was confirmed in one patient (4%).

CONCLUSION

Our study presents the follow-up results from three-dimensional contrast-enhanced MR angiography, which confirmed neck recanalization, the approximate hemodynamic status, and complications. This effective and less invasive method may be suitable for serial follow-up after coil embolization of true visceral aneurysms.

Evaluation of contrast-enhanced MR angiography in the follow-up of visceral arterial aneurysms after coil embolization

BACKGROUND

The placement of detachable coil has become the alternative method of treating visceral arterial aneurysms (VAAs). Imaging follow-up is necessary after coil embolization because of frequent incomplete occlusion.

PURPOSE

To compare contrast-enhanced magnetic resonance angiography (CE-MRA) at 3T with a reference standard of digital subtraction angiography (DSA) for the evaluation of VAAs after coil embolization.

MATERIAL AND METHODS

We treated 15 patients with VAA with coil embolization; eight had splenic artery aneurysms and seven had renal artery aneurysms. We packed the aneurysmal sac preserving native arterial circulation. For follow-up, all patients underwent CE-MRA at 3T and DSA. The results were classified according to coil occlusion: Class 1, complete occlusion; Class 2, residual neck; Class 3, aneurysmal filling.

RESULTS

CE-MRA revealed 11 complete occlusions and four residual necks. DSA follow-up showed 12 complete occlusions and three residual necks. No aneurysmal filling occurred after treatment. Comparison of CE-MRA and DSA findings showed 93% agreement (14/15). CE-MRA allowed the detection of a residual neck in one misclassified case in which DSA showed occlusion. Coil-related artifacts were minimal and did not interfere with evaluation of the occlusion status of the VAAs.

CONCLUSION

CE-MRA at 3T provides high-quality images equivalent to DSA for the evaluation of VAAs after coil embolization. We suggest that CE-MRA at 3T might be used as the primary method for follow-up of VAAs after coil embolization.

Unenhanced magnetic resonance angiography with time-spatial labeling inversion pulse for evaluating visceral artery aneurysms after endosaccular packing with detachable coils: preliminary results

The aim of this brief report is to compare unenhanced magnetic resonance (MR) angiography with time-spatial labeling inversion pulse (Time-SLIP) with conventional digital subtraction angiography (DSA) in assessing degree of saccular visceral artery aneurysm (VAA) occlusion after endosaccular packing with detachable coils. Eight patients with VAAs (five renal and three splenic artery aneurysms) were enrolled in this study. VAA occlusion rates based on Time-SLIP MR angiography were complete occlusion in four patients, neck remnants in three patients, and body filling in one patient. These findings corresponded with the DSA findings.

Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization

PURPOSE

To describe our experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and to propose indications for treating VAA by this method.

METHODS

We treated 22 patients with VAA by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. All nine splenic artery aneurysms patients presented with chronic hepatitis-C; four had hepatocellular carcinoma. Of the seven renal artery aneurysms patients, four were hypertensive and three had rheumatoid arthritis. Both pancreaticoduodenal arcade artery aneurysms patients manifested severe stenosis of the celiac axis. Our transcatheter coil embolization procedure includes coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation.

RESULTS

Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7%) of the 22 patients and the native arterial circulation was preserved. Postprocedure angiograms confirmed complete disappearance of the VAA. In four of the nine splenic artery aneurysm patients, the native arterial circulation was not preserved. In one renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in one splenic- and two renal artery aneurysms patients; the latter developed flank pain and fever after the procedure.

CONCLUSIONS

Transcatheter coil embolization is an effective alternative treatment for patients with saccular and proximal VAA. In particular, the isolation technique using coil embolization is advantageous in splenic artery aneurysm patients.