Splenic artery aneurysm: value of color Doppler and the limitation of gray-scale ultrasonography

Splenic artery aneurysm: a diagnostic challenge in the setting of extensive portal venous collaterals

We present a 16-year-old boy with autoimmune liver disease and longstanding portal hypertension in whom a CT arteriogram demonstrated a large aneurysm arising from the distal, extra-parenchymal portion of the splenic artery. Because of its location adjacent to multiple venous collaterals, the aneurysm was indistinguishable from splenic varices on initial imaging with Doppler sonography and on portal venous-phase CT. There is an increased risk of rupture of splenic artery aneurysms in the post-liver transplant period, with high associated mortality, and therefore diagnosis of splenic artery aneurysm prior to liver transplantation is clinically important. It is quite possible that the diagnosis of splenic artery aneurysm in this case would have been missed in the absence of dedicated arterial-phase imaging. As radiologists strive to reduce radiation exposure in children, this case highlights a potential diagnostic pitfall of both Doppler sonography and venous or single-acquisition arterial/venous-phase CT angiogram in children with venous collaterals and an undiagnosed splenic artery aneurysm.

Pseudoaneurysm in a chronic pancreatitis patient: report of a case, with emphasis on contrast-enhanced sonograms

The association between pseudoaneurysm of the splenic artery and pancreatitis is now established. Rupture of an aneurysm is a lethal condition, and early diagnosis and treatment are required to prevent this hazardous life-threatening complication. In our case, early detection of pseudoaneurysm of the splenic artery enabled us to start prompt embolization, which yielded good results. Splenic infarction is known to be an important and frequent complication of transarterial embolization of splenic artery aneurysms. Thus, when performing transarterial embolization of a splenic artery aneurysm, this complication must be kept in mind and it is absolutely necessary to confirm the presence or absence of this complication after embolization of the aneurysm. In our case of pseudoaneurysm of the splenic artery due to acute aggravation of chronic pancreatitis, contrast-enhanced ultrasonography confirmed the spleen to be free from infarction. Thus, this technique is strongly recommended in such instances.

Diagnosis of an aneurysm masquerading as a pancreatic-cyst lesion at EUS

BACKGROUND

EUS-guided FNA is commonly performed for evaluating pancreatic-cyst lesions. However, not all such lesions are true cystic neoplasms of the pancreas.

OBJECTIVE

Determine the frequency at which aneurysms mimicking cysts are encountered during EUS evaluation of the pancreas.

STUDY DESIGN

Observational study.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients found to have pancreatic cyst lesions at EUS.

INTERVENTIONS

Patients with a cyst lesion in the pancreas that was suspicious for an aneurysm at EUS underwent abdominal CT imaging for a definitive diagnosis.

MAIN OUTCOME MEASURES

To determine the frequency at which aneurysms are encountered during EUS while evaluating pancreatic-cyst lesions and to describe the EUS characteristics of an underlying aneurysm.

RESULTS

Four of 413 lesions (0.97%, 95% confidence interval 0.26%-2.5%) that appeared as pancreatic cysts at EUS were diagnosed to be aneurysms: 2 were splenic artery aneurysms, 1 was an aneurysm of the gastroduodenal artery, and another was an infrarenal aortic aneurysm. The aneurysms had a characteristic donut-like appearance at EUS: a thick outer wall with a central anechoic area.

LIMITATIONS

Observational study; small sample size.

CONCLUSIONS

Aneurysms can masquerade as pancreatic-cystic lesions. Awareness of this entity is important because an inadvertent FNA during EUS may potentially lead to serious complications.

Fatal and life threatening rupture of splenic artery aneurysms in children with portal hypertension

Aneurysms of the splenic artery (SAAs) are a rare complication of portal hypertension in adults. Although the risk of rupture is small, associated mortality is high. Furthermore, circulatory changes that occur following liver transplantation (OLT) may increase the risk of SAA rupture. The incidence in children with portal hypertension is unknown and thus we present our experience with two children who had ruptured SAA, one of whom died. Although there are no accepted methods for routine screening, hepatic angiography should be considered in children with long-standing portal hypertension (more than 10 yr), in order to detect and consider resection of the aneurysms, either before or at the time of liver transplantation.

Transcatheter embolization of splanchnic aneurysms/pseudoaneurysms: early imaging allows detection of incomplete procedure

PURPOSE

The purpose of this work is to discuss results of transcatheter embolization for splanchnic aneurysms/pseudoaneurysms and to evaluate the value of color Doppler ultrasonography and CT within the first week after the procedure.

METHOD

Retrospective review of selected patients from our database with splanchnic artery aneurysms and pseudoaneurysms treated by transcatheter embolization was conducted. Patients were selected and treated in the hospital of Edouard Herriot (Lyon, France). Conventional angiography was performed by the transfemoral route in all patients. We used association of steel coils with or without hemostatic sponge after selective catheterization of the parent vessel for the embolization of the aneurysm. Color flow imaging on ultrasonography and CT scan with contrast medium injection were performed to analyze feeding arteries, treated aneurysm, and presence of complications within the first week after embolization.

RESULTS

Eighteen transcatheter embolizations were performed in 14 patients. A total of 25 ultrasonograms and/or CT scans were performed within the first week after the embolization procedure. Complete embolization in one attempt was achieved in eight patients. Imaging follow-up confirmed the absence of recurrence, recanalization, or severe complication for these patients. In one patient, a CT scan with injection of contrast medium done after the first complete procedure of embolization for mycotic pseudoaneurysm identified new aneurysms. Further embolization was done to complete the procedure. In the remaining four patients, large aneurysms were identified, with failure of transcatheter embolization. Follow-up imaging confirmed either the incomplete packing of the aneurysm or recanalization by a new feeding artery.

CONCLUSION

Imaging follow-up with ultrasonography and CT scan provides significant information after transcatheter embolization. We confirm that large visceral aneurysms are difficult to treat by embolization, with failed procedures in our series.

Splenic artery aneurysm in the 1990s

Splenic artery aneurysms (SAA), although rare, are the most common visceral artery aneurysms and are known for their potential for rupture. Pregnancy and portal hypertension have been known as major risk factors. With improved methods of diagnosis and minimally invasive therapy, management and outcome of SAA may change significantly. The purpose of this study was to analyze our institutional experience with SAA during the past decade. Charts of all patients (six women, three men; mean age, 60.5 [range: 31 to 81] years) with diagnoses of SAA from 1988 to 1999 were reviewed. Associated conditions included essential hypertension (6), portal hypertension (3), diabetes (1), intracranial aneurysm (1), and polyarteritis nodosa (1). Six patients were asymptomatic, and three had ruptured SAA. Diagnosis was made by angiography (2), computed tomography (3), ultrasonography (3), and exploratory laparotomy (1). Six patients underwent surgery (five required splenectomy), one had embolization, and two had no intervention. Three postoperative deaths occurred-two (intracranial aneurysm, myocardial infarction) in the first month, one (sepsis) in the ninth month. An association of liver disease with SAA was confirmed; however, no association with pregnancy was noted. Surgical treatment followed traditional methods, and mortality correlated with presence of severe comorbidity.