Regarding “Giant splenic artery aneurysms: Case report and review of the literature”

Abstract

We have read with interest the article by Radu Pescarus et al. 1 The authors report an unusual case of a giant splenic artery aneurysm (SAA) treated by open surgical repair with good results and provide a review of the 12 giant SAAs published to date.They find a different pattern with respect to the small SAAs: male predominance, absence of a clear etiologic factor, situation in the middle third of the artery, and a higher presentation with rupture (25%). At the same time, the surgery in their case needed a medial visceral rotation for the artery control and splenectomy. Possible endovascular options were not considered because of the tortuosity of the artery for a stent -raft deployment and the lack of experience and likelihood of failure of coil embolization. None of the cases of the review had an endovascular repair.Recently, we reported the treatment of a ruptured giant SAA with coil embolization (Fig) . Good results were obtained, and the spleen was preserved. 2 The pattern of our case was the common one for small SAAs: female in the sixth decade of life with portal hypertension; however, the aneurysm was situated in the middle third of the artery.As Pescarus et al 3 remarked in their review, giant SAAs have a more difficult surgical exposure and Ͼ50% of the cases require splenectomy. By contrast, small aneurysms require splenectomy in Ͻ30%. This is an important issue, because after splenectomy, patients are considered immunodeficient.In the light of our experience, we believe that giant SAAs should be considered for endovascular repair as a first line of treatment if anatomically suitable. Endovascular stent-graft exclusion of SAA could be carried out if the tortuosity of the artery is not extreme. Proximal and distal coil embolization is preferable in the proximal and middle third of the artery, preserving the short gastric arteries to feed the spleen. The size of the coils should be bigger than the diameter of the distal artery to avoid spleen migration. Recurrences with embolization are not infrequent, and subsequent contrast helicoidal computed tomography scans of the abdomen should be performed to detect them.Percutaneous coil embolization with ultrasound-Doppler scan guidance has been performed in postcatheterization arterial femoral pseudoaneurysms 4 and could be considered when the giant SAA is easily accessible to puncture. This has not yet been tested, however, and requires further discussion.

Endovascular Management of Splenic Arteriovenous Fistula with Giant Venous Aneurysmal Dilatation

“…The main caveat with these endovascular techniques is that they may be impractical for long and extremely tortuous lesions, so a stent graft well not be considered as a feasible solution mostly due to hilar presence of splenic fistula and tortuousity of splenic artery. A thirty six percutaneous catheter embolization of giant aneurysms and even ruptured giant aneurysms with metal coils, balloons, and sponges has been reported with favorable results, 17) with potential complications include pain fever, embolism to other visceral arteries, abscess formation, arterial disruption, contrast nephrotoxicity, incomplete occlusion and re-canalization, despite these drawbacks, transcatheter embolization appears to have a lower incidence of serious complications compared with surgery, has a success rate of approximately 85%, and may even be considered as a first-line treatment in appropriate patients. 18) On the other hand it is less invasive, relatively low-risk, rapid procedure can be easily applied regardless location of vascular malformation and it does not necessitate splenectomy.…”

Giant splenic artery aneurysm associated with arteriovenous malformation

“…36 Percutaneous catheter embolization of giant aneurysms, and even ruptured giant aneurysms, with metal coils, balloons, and sponges has been reported with favorable results. 37,38 Recent advances in interventional radiology have led to the use of stent grafts for exclusion of visceral artery aneurysms. This technique allows preservation of a continuous arterial access to the spleen, which may be used for subsequent sequential embolization of the organ if necessary (to treat hypersplenism for example).…”

Visceral Artery Aneurysms

“…They can be located at any portion of the artery, but are commonly at the distal zones close to the splenic paranchyme. The main complication of these aneurysms is rupture, with a 2% to 10% risk that has a 20% to 30% mortality rate [Pescarus 2005;Hernandez-Lahoz 2006]. Even though treatment indications are unclear, surgery is indicated for symptomatic patients, patients with enlarging aneurysms, pregnant patients, patients anticipating pregnancy, patients with portal hypertension presenting for liver transplantation, and patients with aneurysms larger than 2 cm in diameter [Pescarus 2005].…”