Giant Splenic Artery Aneurysm

Author(s): 

Muhammad Asad, MD, FRCS, Mahalingam Sivakumar, MD, FRCS, FACS

The location on the artery of the aneurysm makes a serious difference in surgical management. If the aneurysm is located in the distal third of the artery and the aneurysm has to be resected, the patient may ultimately require a splenectomy. If the aneurysm is located in the proximal third of the artery, splenic conservation should be attempted.13 If surgery is performed, difficulties that can be encountered are the presence of a phlegmon, inability to find the plane of dissection, excessive bleeding, and inadvertent injury to the viscera. For ruptured aneurysms and pseudoaneurysms, splenectomy or splenopancreatectomy may be necessary.14,15 Dense adhesions to the surrounding structures sometimes make exclusion of the aneurysm necessary by proximal and distal ligation of the artery. Proximal control of the splenic artery in this situation is sometimes difficult.16 In cases when the aneurysm is adherent to the pancreas and no dissection plane is defined, it is reasonable to open the aneurysm and leave its posterior wall in situ.17 Pulli at al18 restored arterial continuity in 10 cases of SAA. Their series included patients who underwent surgery between 1982 and 2000, when interventional radiology was not widely available.18 Open surgery remains an option when the patient is allergic to contrast medium, when angiography has failed, or when patients with chronic renal insufficiency need urgent intervention.

Laparoscopic surgery for SAA has also been attempted but requires an operator with advanced skills.19

Endovascular interventions have been performed with increased frequency in the last decade. Stent grafts also have been used successfully.20 Pilleul and Dugougeat21 published a series of 25 transcatheter embolizations. In their series, 8 patients had complete embolization; in the remaining patients, only partial occlusion was achieved. The authors concluded that in cases of large aneurysms, embolization is likely to be incomplete.21 Davis at al22 emphasized the need for aggressive use of embolization in cases of splenic artery pseudoaneurysms that develop after blunt trauma. Their success rate was 61%.22 Endovascular interventions are also the favored approach for patients who are immunocompromised.22

Cyanoarylate glue has been successfully used in occluding aneurysms.23 Coil embolization has been used with good results in mycotic SAA and in cases of wide-mouthed aneurysms, such as the one reported here.24 Splenic infarcts can occur after embolization.25 Some authors consider that catheter embolization is best used as a temporary measure to stop bleeding from ruptured SAA, stressing the need for formal intervention at a later time. Others exclude any endovascular intervention in cases of giant SAA with extreme tortuosity. We feel that in such cases the choice of procedure should be considered individually. The skill and experience of the interventional radiologist and the availability of facilities are key factors.

Three-dimensional CT scans and colored Doppler sonography have been the favored investigational tools for the follow up of a SAA endovascular procedure.

Conclusion
Endovascular interventions should be considered as first choice in both emergency and elective treatment of SAA. Controversy and questions exist regarding the effectiveness of different types of endovascular procedures and the need for surgical interventions after successful embolization. Recanalization of the aneurysm managed by embolization is a real possibility. All such patients need a close follow up. Considering the nature of SAA and their infrequent occurrence, it is unlikely that controlled studies will ever be done.

Acknowledgement
The authors would like to thank Dr. Eugene Albu for his great help.

References: 

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