Management of Giant Splenic Artery Aneurysm

Journal of Vascular Surgery, 2016

Objective: Splanchnic artery aneurysms (SAAs) are uncommon, and standards for surveillance and intervention are lacking. The goal of this study was to review our 20-year experience with managing SAAs. Methods: The Research Patient Data Registry at the Massachusetts General Hospital was queried, and all patients with SAAs identified by axial imaging from 1994 to 2014 were included. Aneurysms were stratified into two cohorts: those that underwent early intervention (<6 months after lesion discovery) and those that received surveillance. Primary study end points included aneurysm growth or rupture during surveillance and patient 30-day morbidity or mortality after aneurysm repair. Results: There were 264 SAAs identified in 250 patients. In 166 patients, 176 SAAs (66.6%) were placed into the surveillance cohort; 38 SAAs (21.6%) did not have subsequent axial imaging and were considered lost to follow-up. Mean aneurysm size in the surveillance cohort at first imaging study was 16.28 mm (8-41 mm), and mean surveillance time was 36.1 months (2-155 months); 126 SAAs (91.3%) remained stable in size over time, and 8 SAAs (5.8%) required intervention for aneurysm growth after a mean of 24 months. There were no ruptures in the surveillance cohort. There were 88 SAAs (33.3%) repaired early. Mean size of SAAs that were repaired early was 31.1 mm (10-140 mm). For intact SAAs, 30-day morbidity and mortality rates after repair were 13% and 3%, respectively. In the early repair cohort, 13 SAAs (14.7%) were ruptured at presentation. The 30-day morbidity and mortality rates after rupture were 54% and 8%, respectively. Five ruptured SAAs (38%) were anatomically located in the pancreaticoduodenal arcade. On univariate analysis, pancreaticoduodenal aneurysms were strongly associated with rupture (P [ .0002). Conclusions: Small SAAs (#25 mm) are not prone to significant expansion and do not require frequent surveillance imaging. Imaging every 3 years for small SAAs is adequate. Aneurysms of the pancreaticoduodenal arcade and gastroduodenal aneurysms are more likely to rupture and therefore warrant a more aggressive interventional approach.

Case Reports in Surgery, 2012

Introduction. Visceral artery aneurysms are uncommon. Among them, splenic artery is the most common (46–60%). Most splenic artery aneurysms are asymptomatic and diagnosed incidentally, but its rupture, potentially fatal, occurs in up to 8% of cases.Presentation of Case. A female patient, 64 years old, diagnosed with a giant aneurysm of the splenic artery (approximately 6.5 cm in diameter) was successfully submitted to endovascular treatment by stent graft implantation.Discussion. Symptomatic aneurysms and those larger than 2 cm represent some of the main indications for intervention. The treatment may be by laparotomy, laparoscopy, or endovascular techniques. Among the various endovascular methods discussed in this paper, there is stent graft implantation, a method still few reported in the literature.Conclusion. Although some authors still consider the endovascular approach as an exception to the treatment of SAA, in major specialized centers these techniques have been consolidated...

Journal of the American College of Surgeons, 1999

Background: Splenic artery aneurysm(s) (SAA) are rare. But the incidence and significance of SAA among patients with portal hypertension (PHTN), especially among those who undergo orthotopic liver transplantation (OLT), have not been clearly delineated. Study Design: An 11-year (February 1987 to June 1998) retrospective review of our experience with treated SAA was performed. Patient characteristics, risk factors, clinical presentation, surgical management, aneurysm characteristics, and patient outcomes were assessed. Patients were separated according to a history of PHTN for analysis. Patients were also subdivided into ruptured versus elective presentations. Results: Thirty-four patients (22 in the PHTN group) were treated for SAA during the study period. Sixty-two percent (21 of 34) were women; the average age was 50.6 years. In patients without a history of PHTN (n‫,)21؍‬ essential hypertension was a significant risk factor (p<0.001) for development of SAA. All patients underwent surgical treatment for SAA: resection with splenectomy (n‫,)32؍‬ ligation with splenectomy (n‫,)5؍‬ ligation of SAA only (n‫,)4؍‬ and vascular reconstruction (n‫.)2؍‬ The average size of all treated SAA was 4.8؎2.6 cm, ranging from 1.5 to 12cm. Operative mortality after SAA rupture (n‫)51؍‬ was 40%, compared with zero mortality for elective SAA repair (n‫,91؍‬ p<0.005). Rupture of SAA was associated with a higher mortality in patients with PHTN compared with patients without such history (56% versus 17%, respectively). After a mean followup period of 46 months, survival after rupture was 60% in contrast to 84% after elective repair. The majority of our patients with a history of PHTN (20 of 22) has undergone OLT, representing 0.46% of all OLT recipients (n‫)473,4؍‬ during the study period. In four patients, SAA were repaired concurrently during transplantation. Of the 7 patients presented with rupture of SAA after OLT, 6 patients presented within 3 to 16 days postoperatively, with a median of 6 days and an overall mortality of 57%. Conclusions: Essential hypertension and PHTN appear to be significant risk factors for development of SAA. Rupture of SAA is associated with a significant mortality, highest among patients with PHTN. Elective repair remains a safe and effective method of treatment. The significance of SAA is recognized among patients undergoing liver transplantation. A decision should be made to screen and electively treat SAA found in liver transplant patients, especially if the aneurysm is larger than 1.5cm. Awareness of the increased rupture risk is crucial in management during the immediate posttransplant period. (

Annals of Vascular Surgery, 2021

Objective: Splanchnic artery aneurysms (SAAs) are uncommon, and standards for surveillance and intervention are lacking. The goal of this study was to review our 20-year experience with managing SAAs. Methods: The Research Patient Data Registry at the Massachusetts General Hospital was queried, and all patients with SAAs identified by axial imaging from 1994 to 2014 were included. Aneurysms were stratified into two cohorts: those that underwent early intervention (<6 months after lesion discovery) and those that received surveillance. Primary study end points included aneurysm growth or rupture during surveillance and patient 30-day morbidity or mortality after aneurysm repair. Results: There were 264 SAAs identified in 250 patients. In 166 patients, 176 SAAs (66.6%) were placed into the surveillance cohort; 38 SAAs (21.6%) did not have subsequent axial imaging and were considered lost to follow-up. Mean aneurysm size in the surveillance cohort at first imaging study was 16.28 mm (8-41 mm), and mean surveillance time was 36.1 months (2-155 months); 126 SAAs (91.3%) remained stable in size over time, and 8 SAAs (5.8%) required intervention for aneurysm growth after a mean of 24 months. There were no ruptures in the surveillance cohort. There were 88 SAAs (33.3%) repaired early. Mean size of SAAs that were repaired early was 31.1 mm (10-140 mm). For intact SAAs, 30-day morbidity and mortality rates after repair were 13% and 3%, respectively. In the early repair cohort, 13 SAAs (14.7%) were ruptured at presentation. The 30-day morbidity and mortality rates after rupture were 54% and 8%, respectively. Five ruptured SAAs (38%) were anatomically located in the pancreaticoduodenal arcade. On univariate analysis, pancreaticoduodenal aneurysms were strongly associated with rupture (P [ .0002). Conclusions: Small SAAs (#25 mm) are not prone to significant expansion and do not require frequent surveillance imaging. Imaging every 3 years for small SAAs is adequate. Aneurysms of the pancreaticoduodenal arcade and gastroduodenal aneurysms are more likely to rupture and therefore warrant a more aggressive interventional approach.

Asian Journal of Case Reports in Surgery, 2021

Splenic artery pseudo aneurysm is a rare entity. The presentation often varies so it will be a challenging case to diagnosis early and to give good outcome. It occurs due to blunt trauma abdomen, chronic pancreatitis, pseudo cyst of pancreas, liver transplantation, and peptic ulcer disease. The splenic artery aneurysm accounts for approximately 60% of all visceral arterial aneurysms. After abdominal aorta and iliac artery involvement visceral artery aneurysms arises commonly from splenic artery which is the third most common artery to involve. Even pseudoaneurysm of the splenic artery is a rare condition to occur, and fewer than 200 cases are reported in English literature till now. Case: We are presenting a one case of giant splenic artery pseudo aneurysm of size 14x8 cm with contained rupture due to alcoholic pancreatitis of pseudo aneurysm into the pseudo cyst of pancreas and managed successfully with open surgical procedure. Conclusion: The modality of treatment for the patients with giant splenic artery pseudo aneurysms with suspected rupture of the pseudo-aneurysm, is exploratory laparotomy. Early diagnosis and the modality of the treatment will give good prognosis to the patients.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2009

patients with SAA underwent laparoscopic surgery. Among these patients, 4 had splenectomy alone and 2 had splenectomy with distal pancreatectomy. The mean size of the aneurysm was 3.1 cm (range: 2 to 4 cm).

The American Journal of Surgery, 2001

Background: This retrospective study was conducted to describe the presentation, surgical treatment, and follow-up of patients with splenic artery aneurysms. Methods: From 1982 to 2000, 1,952 patients with abdominal aneurysms were referred to our department; 15 had splenic artery aneurysms. None had ruptured. All were operated on. Results: Fourteen complete and 1 partial aneurysmectomies were carried out. Arterial continuity was restored in 10, by end-to-end anastomosis, and 4 had splenectomies. In 1 patient the spleen was preserved without arterial reconstruction. There were no deaths. Morbidity was restricted to 1 patient with a limited, asymptomatic splenic infarction. Eleven patients were followed up for a mean 19.7 months. No deaths or major complications were recorded. Reconstructed splenic arteries were patent in all cases without atrophy or new cases of splenic infarction. Conclusions: Elective surgery for splenic artery aneurysms is safe. Arterial reconstruction allows good early and long-term results. In some cases splenectomy may be unavoidable.

2021

A fifty-five-year-old male, with no pathology associated and normal weight, admitted to the emergency department with sudden onset of severe epigastric pain, radiating to the back and right shoulder, abdominal hyperesthesia, started 4 hours before presentation. At the first evaluation, the patient presented signs of hypovolemic shock, such as sweating, pallor, thirst, tachycardia, and low blood pressure (pulse: 70 bpm, blood pressure: 90/50 mmHg, which decreased in 20 minutes to 70/50 mmHg). The surgical evaluation revealed signs of acute abdomen, sensitive to palpation, with signs of peritoneal irritation, Berezneagovski’s, Blumberg’s, and Mendel-Razdolski’s signs were positive. The hematological profile indicated mild anemia (Hb=11 g/dl), mild leukocytosis (14 420 U/l) with neutrophilia and lymphopenia. There were no features suggestive of pancreatitis or liver injury. The coagulation profile was within normal limits.

Annals of Vascular Surgery, 2004

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.

Journal of Vascular Surgery, 2014

Objective: True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs. Methods: A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions. Results: Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P [ .04). Conclusions: EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.