Visceral Aneurysms

MCG Vascular Surgery – 9-12-19

Yasir Bouchi
 Giant splenic artery aneurysm

Sasank Kalipatnapu, MBBS, MS, Albert Abhinay Kota, MS, Sunil Agarwal, MBBS, MS

Journal of Vascular Surgery

Volume 69, Issue 6, (June 2019)
DOI: 10.1016/j.jvs.2019.02.039
 Case
• 44 y/o woman who presented with right upper quadrant abdominal pain of 2
months duration
• She has no significant past medical history including any
• Vasculitis
• Connective tissue disease
• Prior pancreatitis
• Physical exam revealed a pulsatile mass in the left upper quadrant
• Lipid profile was within normal limits
• CT angio showed a 12.7 x 11.9 x 11.6cm splenic artery aneurysm
• Surgical correction with ligation of the splenic artery, evacuation of the
aneurysm and ligation of outflow artery inside the sac
• Post-op course uneventful
Case

12.7 x 11.9 x 11.6cm

Case

12.7 x 11.9 x 11.6cm

Case
Aneurysms
• Abnormal dilation - > 1.5x normal diameter
• True dilation - all three layers of the vessel
• Intima
• Media
• Adventitia
• Pseudoaneurysms – does NOT involve all three layers of the vessel
• Most common true aneurysm – Infrarenal abdominal aortic aneurysm
• Most common pseudoaneurysms – femoral artery aneurysms due to
catheterization
Splanchnic Artery Aneurysms
Splenic Artery Hepatic Artery Celiac Trunk SMA Gastroepiploic Artery Intestinal Artery Pancreaticoduodenal Artery IMA

1%
3% 2%
4%

4%

6%

20% 60%
Splanchnic Artery Aneurysms
Splenic artery Aneurysms SMA
- Distal third of the artery -Proximal 5 cm
-Bifurcation distal to short gastrics
-Splenic hilum

Hepatic artery Celiac Artery

Extrahepatic (80%): -Distal to site of chronic vascular compression
-Common hepatic artery 60%
-Right hepatic artery 30%
-Left hepatic artery 10%
Intrahepatic (20%)
Splenic Artery Aneurysms Epidemiology
• 10.4% incidence based on Autopsy studies
• Patients diagnosed with SAA found a female : Male of 4:1
• More commonly in multiparous women (mean 3.5 pregnancies)
• degenerative changes in the artery wall
• hormonal changes most prominently by Relaxin
• Hypertension – 50% of patients
• Portal Hypertension – 7.8%
• A1AT deficiency and medial fibrodysplasia also associated with SAA
Splenic Artery Aneurysm

Clinical Presentation Diagnostic Studies

• Nonspecific abdominal pain • Plain X-ray
• Can be specific to the left upper • Concentric calcification in left
quadrant or epigastrium upper quadrant
• Pain can be diffuse with pain • Abdominal U/S
with rupture and shock • Cystic lesion in the left upper
quadrant
• Double rupture phenomenon –
period of unstable -> stable -> • CTA or MRA
unstable • Definitive diagnosis
Splenic Artery Aneurysm
Risk
• Rupture risk ~ 5%
• Calcification in 90% of ruptured
SAA and 84.5% of nonruptured
SAA
• Calcification associated with
decrease in size of SAA (p-0.013)
• Advised for elective repair of
SAA at 2 cm
Treatment
• Open repair
• Excision of aneurysm followed by
end to end anastomosis
• Splenectomy is indicated if
aneurysm is located in the distal
portion of the Splenic artery
• Endovascular repair
• Embolization is an option due to
adequate collateral flow from
gastric arteries, gastroduodenal
arteries, and gastroepiploic
arteries
Superior Mesenteric Artery Aneurysms
Epidemiology
• Approximately 5% of all splanchnic artery aneurysms
• Greater incidence in men
• Commonly caused by vascular disease
• Atherosclerosis
• Cystic medial disease
• Collagen vascular disease
• Extension of aortic dissection into SMA
• Disruptions of arterial wall by pancreatic enzymes from pancreatitis
Superior Mesenteric Artery Aneurysm

Clinical Presentation Diagnostic Studies

• Nonspecific abdominal pain • Abdominal U/S
• Pain can be diffuse with pain • CTA or MRA
with rupture and shock • Definitive diagnosis
• Drop in Hgb
• Bowel ischemia
Superior Mesenteric Artery Aneurysm
Risk
• Mayo clinic analyzed 22 patients
with SMAA
• 8 (38%) patients had a rupture
• 88% of ruptured patients were
male
• 48% were symptomatic
• 13 (62%) were calcified
• None of the ruptured aneurysms
were calcified
• Unclear if calcification is protective
Treatment
• Open repair
• Ligation of afferent and efferent
arteries of the aneurysm
• Bypass using either autologous
vein or prosthetic graft
• Endovascular repair
• Embolization recommended if
patient has adequate collaterals
• Monitor patient closely for signs of
bowel ischemia
Hepatic Artery Aneurysms Epidemiology
• Second most common splanchnic artery aneurysm
• Most common splanchnic artery pseudoaneurysm
• Increased incidence due to increasing number of biliary procedures, liver transplants,
and traumas
• Most hepatic artery aneurysms are due to atherosclerosis
• Commonly found in patients with HTN (72%)
• Male : Female ration 3:2
Hepatic Artery Aneurysms

Clinical Presentation Diagnostic Studies

• Ruptured hepatic Artery • Abdominal U/S
Aneurysms present with • CTA or MRA
Quincky’s triad • Definitive diagnosis
• Jaundice
• Biliary colic
• Upper GI hemorrhage
Hepatic Artery Aneurysms (HAA)
Risk
• Increased risk for rupture with
multiple hepatic artery
aneurysms
• Increased risk for rupture from non-
atherosclerotic process
• Fibromuscular dysplasia
• Polyarteritis nodosa
• Mycotic
• Mortality rates of up to 21%
Treatment
• Open repair
• Ligation can be performed if there
is flow through the portal vein
• HAA distal to the gastroduodenal
artery should have the arteries
reconstructed
• HAA proximal to that point can be
ligated
• Endovascular repair
• Embolization preferred for intra-
hepatic aneurysms
• Covered stents preferred for
proper hepatic artery
Celiac Artery Aneurysms Epidemiology
• Most commonly due to atherosclerosis
• Complication after dilation of a stenotic Celiac artery
• Due to compression from median arcuate ligament
• Associated with other aneurysms in 67% of patients
• Aortic
• Renal
• Femoral
• Popliteal
Celiac Artery Aneurysms

Clinical Presentation Diagnostic Studies

• Typically asymptomatic • Abdominal U/S
• Mimic appendicitis • CTA or MRA
• Definitive diagnosis
Celiac Artery Aneurysms
Risk
• Reported rupture risk at 10-20%
• High mortality rates
Treatment
• Open repair
• Ligation of the artery with bypass
surgery
• Resect aneurysms and reconstruct
the artery
• Endovascular repair
• In patients with normal liver
function, embolize the in and
outflow of the aneurysm
References
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