WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

SPLENIC ARTERY ANEURYSM

R Beaujeux, MD, M Smith, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary

This case presents a 79-year-old patient with a history of hypertension with splenic artery aneurysm. The case is illustrated by imaging studies of the aneurysm and its treatment including 4 questions to test your knowledge.

2. Patient

79-year-old woman

3. Past history

- hypertension for 14 years;
- lower extremity venous insufficiency;
- partial thyroidectomy for benign disease;
- hysterectomy.

4. History of present illness

The patient is hospitalized for left upper quadrant pain. To evaluate the pain an abdominal ultrasonogram was performed. It demonstrated a splenic artery aneurysm.

5. Ultrasonography

Splenic ultrasonography with Doppler: abdominal ultrasound reveals the presence of splenomegaly measuring 13 cm. A splenic artery aneurysm is well visualized, measuring 2 cm in diameter.

Figure 5.a

Figure 5.b

Figure 5.c

6. Arteriography

Arteriography of celiac and superior mesenteric arteries (3D) by a femoral puncture, a selective catheterization of the splenic artery is performed. It demonstrates an opacification of a saccular aneurysm within a distal branch of the splenic artery. The artery branches from a tortuous splenic artery. The aneurysm contains a large clot.

Figure 6

7. Treatment

In this patient, in the absence of signs of a fissure or rupture and due to the symptoms of pain, it was decided to perform an embolism of the aneurysm. The artery represented less than 20% of the vascularization of the spleen and so it was decided to embolize the artery in its totality.

8. Embolization

Embolization of the artery by a femoral puncture, a selective catheterization of the splenic artery was performed. A further microcatheterization placed the catheter in contact with the clot. An embolization of the splenic artery aneurysm in the area of the clot was performed with the placement of 4 spiral rings of GDC and by injection of acrylic glue. The follow-up control angiography with visualization of the parenchyma confirmed the exclusion of the aneurysm and more than 80% conservation of the blood supply to the spleen.

Figure 8.a

Figure 8.b

Figure 8.c

9. Clinical progression

The embolism obtained good occlusion of the feeding artery of the aneurysm. During the procedure, several signs of splenic embolism were evident. For this reason a MRI was performed the following day of the embolism. There was no evidence of a perisplenic collection or splenic necrosis. The laboratory and clinical evaluation were normal and the patient was discharged in stable condition.

10. MRI

MRI 24 hours post-embolization: the MRI was performed with axial cuts in sequence with T1-weighting, followed by T2-weighting. An angio-MRI with contrast injection completed the evaluation. The exclusion of the splenic aneurysm was confirmed by the MRI. The aneurysm was completely devascularized. There were no signs of splenic necrosis nor of a perisplenic collection.

Figure 10.a

Figure 10.b

Figure 10.c

11. Quizzes

11.1. Quiz 1

Which of the following statement(s) is/are correct regarding splenic artery aneurysms?
1) They represent the most common aneurysm of the splanchnic vessels.
2) Most of them occur in men.
3) Splanchnic vessels aneurysms can be multiple in up to 40% of cases.
4) They are always symptomatic.
Correct answers:
1) They represent the most common aneurysm of the splanchnic vessels.
3) Splanchnic vessels aneurysms can be multiple in up to 40% of cases.
Splenic artery aneurysms are the most common aneurysms of the splanchnic vessels comprising 60% in most large series, followed by hepatic artery aneurysms. Most of them occur in women (2:1) and up to 40% can be multiple. They are often asymptomatic and typically diagnosed as incidental findings.

11.2. Quiz 2

Absolute indications for intervention include (please choose correct answers):
1) Elective resection or embolization for all aneurysms once the diagnosis is confirmed
2) Elective resection or embolization of all aneurysms in women contemplating childbearing
3) Emergent resection or embolization for acute rupture
4) Resection or embolization for all symptomatic aneurysms
Correct answers:
2) Elective resection or embolization of all aneurysms in women contemplating childbearing
3) Emergent resection or embolization for acute rupture
4) Resection or embolization for all symptomatic aneurysms
Splenic artery aneurysms present a bimodal distribution. The first eak is in women of childbearing age. In this setting, the aneurysms are secondary to medial degeneration of the artery wall. These aneurysms have a predilection for rupture during the 3rd trimester of pregnancy probably due to hormonal and hemodynamic changes and therefore should be electively treated surgically particularly if the patient is contemplating pregnancy. The second peak of incidence is among elderly people and here the aneurysms are manifestations of atherosclerosis. They are often calcified and asymptomatic. In this setting elective surgical resection should be reserved for symptomatic or enlarging aneurysms.

11.3. Quiz 3

The overall incidence of rupture of splenic artery aneurysms is (please choose correct answer):
1) <1%
2) 2-10%
3) 20-25%
4) > 50%
5) 100%
Correct answer:
2) 2-10%
The overall incidence of rupture of splenic artery aneurysms is 2-10%. This low incidence justifies a conservative approach for asymptomatic patients with a small aneurysm.

11.4. Quiz 4

Correct differences between splenic artery aneurysm and pseudo-aneurysms of the splenic artery include?
1) Pseudo-aneurysms are more frequently symptomatic.
2) Pseudo-aneurysms usually occur primarily.
3) Pancreatic resection is more frequently required for pseudo-aneurysms.
Correct answers:
1) Pseudo-aneurysms are more frequently symptomatic.
3) Pancreatic resection is more frequently required for pseudo-aneurysms.
Pseudo-aneurysms of the splenic artery are uniformly secondary to a retroperitoneal process, most commonly chronic pancreatitis although they have been reported in the setting of acute necrotizing pancreatitis. They are almost uniformly symptomatic and have a high propensity for rupture. Surgical therapy often involves simultaneous treatment of the underlying process and implies a distal pancreatectomy.

12. Discussion

Splenic artery aneurysms can present at all ages with a peak for females during the reproductive years and a second peak in elderly patients. If discovered during the reproductive years in females they should systematically receive treatment due to the risk of rupture during pregnancy. However if incidentally discovered in elderly patients they may be treated with simple surveillance. In these cases only an increase in size or symptoms of pain would be an indication for treatment. Embolization is the treatment of choice. In reality, if surgical intervention is necessary, the treatment of the aneurysm of the splenic artery often requires ligation of the splenic artery with a necessary resultant splenectomy. Conservative treatment is often difficult even if it represents the ideal solution with resection of the aneurysm and repair of the splenic artery. Regardless of the cause, this case illustrates the efficacy and simplicity of embolization.

13. References

de Perrot M, Berney T, Buhler L, Delgadillo X, Mentha G, Morel P. Management of bleeding pseudoaneurysms in patients with pancreatitis. Br J Surg 1999;86:29-32.
de Perrot M, Berney T, Deleaval J, Buhler L, Mentha G, Morel P. Management of true aneurysms of the pancreaticoduodenal arteries. Ann Surg 1999;229:416-20.
de Perrot M, Buhler L, Schneider PA, Mentha G, Morel P. Do aneurysms and pseudoaneurysms of the splenic artery require different surgical strategy? Hepatogastroenterology 1999;46:2028-32.
Mattar SG, Lumsden AB. The management of splenic artery aneurysms: experience with 23 cases. Am J Surg 1995;61:336-46.
Trastek VF, Pairolero PC, Joyce JW, Hollier LH, Bernatz PE. Splenic artery aneurysms. Surgery 1982;91:694-9.

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