Prospective randomized comparison of open versus laparoscopic management of splenic artery aneurysms: a 10-year study

Visceral Aneurysms: Systematic Review and Meta-analysis of Endovascular Versus Open Repair

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 348699.

Treatment Strategy for Splenic Artery Aneurysms and Novel Classification Based on Imaging

OBJECTIVE

The incidence of splenic artery aneurysms (SAAs) has increased with advancements in imaging techniques, necessitating a comprehensive classification to guide treatment strategies. This study aims to propose a novel classification system for SAAs based on aneurysm characteristics and to review treatment outcomes at our center.

METHODS

This retrospective study included 113 SAAs patients admitted at Peking Union Medical College Hospital from January 2019 to December 2023, assessed using computed tomography angiography (CTA) or digital subtraction angiography (DSA). A new classification system was devised based on the aneurysms' location, morphology, integrity, and parent artery anatomy. Treatment strategies were determined based on these characteristics, with interventions ranging from endovascular therapy to laparoscopic and open surgery. Patients were followed up post-intervention to assess mortality, complications, reinterventions, and aneurysm-related outcomes.

RESULTS

The study cohort of 113 patients with 127 SAAs had a predominance of female patients (63.7%) and a mean age of 52.7 years. The SAAs were classified into five types, with Type I being the most common. The intervention techniques varied across types, with sac embolization, covered stent implantation, and artery embolization being the most frequently employed. The overall technical success rate was 94.7%, with perioperative complication and reintervention rates of 25% and 0.9%, respectively, and no deaths within 30 days post-intervention. The median follow-up duration was 21 months, with overall complications rate of 3.5% and no aneurysm-related complications or deaths.

CONCLUSIONS

The proposed classification system effectively guides the selection of treatment strategies for SAAs, incorporating key anatomical and morphological features. This system facilitated high technical success and low complication rates, underscoring the importance of tailored techniques in managing SAAs. Further research is necessary to validate this classification system and optimize treatment algorithms.

Laparoscopic Resection of a Gastroduodenal Artery Aneurysm

Gastroduodenal artery aneurysm is a rare condition generally diagnosed incidentally. Once detected, it cannot be ignored due to the high risk for rupture. Endovascular intervention may be a method of effectively treating this condition. We describe elective laparoscopic surgical excision of gastroduodenal artery aneurysm along with cholecystectomy safely performed in an elderly woman.

Splenic artery aneurysm in obstetric patients: a series of four cases with different clinical presentation and outcome

OBJECTIVE

To describe four consecutive cases of splenic artery aneurysm with different clinical patterns of presentation among obstetric patients.

METHOD

A series of four cases of splenic artery aneurysm diagnosed in pregnant or post-partum women at our University center between January 1998 and December 2020. Clinical and radiological data were retrospectively obtained by reviewing paper and electronic medical records after acquiring patient's consent.

RESULTS

One case was completely asymptomatic and incidentally identified at the beginning of pregnancy, thus allowing for multidisciplinary treatment. The other three cases were unknown: two manifested with maternal collapse due to aneurysm rupture in the third trimester of gestation, whereas one presented with acute abdominal pain during the post-partum period and was successfully managed before rupture occurred.

CONCLUSION

Although being extremely rare, SAA rupture in obstetric patients can be associated with dramatic consequences. Since early suspicion and prompt intervention are essential to avoid fatal outcomes, promotion of knowledge of all the potential clinical patterns of presentation of SAA rupture among obstetric patients is mandatory.

Multiple Splenic Artery Aneurysms: A Case Report and Review of the Literature

Background: Multiple splenic artery aneurysms (MSAAs) are rare and there are few reports about their treatment. We herein present a rare case of MSAAs treated with splenectomy combined with endovascular embolization.

Methods: A 51-year-old female patient was incidentally diagnosed with MSAAs. Splenectomy combined with endovascular embolization was the chosen treatment.

Outcomes: The patient recovered uneventfully and was discharged from the hospital 5 days after splenectomy. The patient has been doing well during the 27-months of follow-up.

Conclusion: Combined with the experience of the previous literature, we think splenectomy combined with endovascular embolization is a safe, reliable and minimally invasive treatment for some selected multiple SAAs, depending on several patient parameters, such as the age, sex, aneurysm dimension, aneurysm location, complications, and severity of the clinical findings.

Endovascular Treatment of Giant Visceral Aneurysms: An Overview

Giant visceral aneurysms (or pseudoaneurysms) are aneurysmal lesions of the splanchnic vessels that are larger than 5 cm in diameter. As with other visceral aneurysms, treatment may be either surgical or endovascular. Both treatments face challenges given the anatomical complexity of such lesions. However, in the era of novel tools and techniques that have been developed in this field, an increasing number of giant visceral aneurysms can now be treated using endovascular approaches. The purpose of this article is to offer an overview of the most current techniques and trends in the endovascular treatment of giant visceral artery aneurysms.

Giant splenic artery aneurysm presenting with massive upper gastrointestinal bleeding: A case report and review of literature

BACKGROUND

Splenic artery aneurysm (SAA) and pseudoaneurysm are rare vessel’s lesions. Pseudoaneurysm is often symptomatic and secondary to pancreatitis or trauma. True SAA is the most common aneurysm of visceral vessels. In contrast to pseudoaneurysm, SAA is usually asymptomatic until the rupture, with high mortality rate. The clinical onset of SSA’s rupture is a massive life-threatening bleeding with hemodynamic instability, usually into the free peritoneal space and more rarely into the gastrointestinal tract.

CASE SUMMARY

We describe the case of a 35-year-old male patient, with negative past medical history, who presented to the emergency department for massive upper gastrointestinal bleeding, severe anemia and hypotension. An esophagogastroduodenoscopy performed in emergency showed a gastric bulging in the greater curvature/posterior wall with a small erosion on its surface, with a visible vessel, but no active bleeding. Endoscopic injection therapy with cyanoacrylate glue was performed. Urgent contrast-enhanced computed tomography was carried out due to the clinical scenario and the unclear endoscopic aspect: The radiological examination showed a giant SAA which was adherent to posterior stomach wall, and some smaller aneurysms of the left gastric and ileocolic artery. Because of the high risk of a two-stage rupture of the giant SAA with dramatic outcome, the patient underwent immediate open surgery with aneurysmectomy, splenectomy and distal pancreatectomy with a good postoperative outcome.

CONCLUSION

The management of a ruptured giant SAA into the stomach can be successful with surgical approach.

A systematic review on clinical features and management of true giant splenic artery aneurysms

BACKGROUND

True giant splenic artery aneurysms (GSAAs) >5 cm are rare and present unique therapeutic challenges. The aim of this study was to evaluate the anatomic and clinical characteristics of these lesions and the current surgical and endovascular techniques available for their treatment.

METHODS

A systematic review of the literature from 2004 to 2018 and the personal experience of the authors with management of GSAAs are presented. A total of 92 GSAA cases were reviewed. Analyses were performed on anatomic and clinical features and management modalities and outcomes of GSAA, including reintervention, morbidity, and mortality.

RESULTS

GSAA presented at a mean age of 56.1 ± 17.3 years, with no sex predilection; 73% were symptomatic at presentation. Abdominal pain was the presenting symptom in >50% of cases; 34% percent were ruptured, with an overall mortality rate of 12.5%. This group often presented with gastrointestinal bleeding or hemodynamic collapse. The aneurysms were almost evenly distributed across the splenic artery and were not uncommonly associated with arteriovenous fistula formation (8.7%). There were 88 patients who had surgical (53.4%), endovascular (44.3%), or combination (2.3%) therapy. The most commonly performed procedure was aneurysmectomy and splenectomy with or without additional resection. Overall, surgical treatment had a lower morbidity (P = .041) than endovascular therapy and comparable reintervention and mortality rates.

CONCLUSIONS

GSAAs are uncommon vascular lesions, with distinct clinical features and aneurysm characteristics. Considering their high risk of rupture, timely diagnosis and management are essential to attain a satisfactory outcome. Surgery remains the standard treatment of these lesions. Endovascular intervention is a viable alternative in high-risk patients, particularly those with lesions <10 cm or with anomalous origin.

Video-robotic aneurysmectomy for splenic artery aneurysm: case report and literature review

We herein report the case of a symptomatic splenic artery aneurysm (SAA) diagnosed in a 65-year-old woman. Endoluminal exclusion was considered as first option, but the potential risk of postoperative splenic infarction, postsplenectomy thrombocytosis and immunodeficiency in an otherwise healthy patient raised the possibility to carry out a surgical procedure of vascular reconstruction using the robotic device Da Vinci^® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). We performed the resection of the aneurysm and the continuity of the splenic artery was restored by end-to-end anastomosis.

Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment

Visceral artery aneurysms (VAAs) are a rare, but serious clinical entity as rupture confers a high rate of mortality. Data regarding the prevalence, treatment, and prognosis of VAAs is largely from case series, as true randomized trials are lacking. The incidence of VAAs has risen over the decades with advances in imaging technology, availability, and utilization. Even in the presence of symptoms, the prompt diagnosis of VAAs may be challenging as symptoms are often nonspecific and varied. Although there are no definitive treatment guidelines, asymptomatic VAAs require treatment in the following scenarios: when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplant. Similar to therapeutic trends in other vascular beds, advances in endovascular devices and techniques have driven an "endovascular first" approach for the treatment of VAAs. However, although the success rates of endovascular repair are impressive, surgical intervention is still necessary in treating centers. This paper reviews the pathophysiology, clinical features, anatomic characteristics, and management strategies required for the effective diagnosis and treatment of VAAs.

Laparoscopic Resection of a Middle Colic Artery Aneurysm

We report herein the successful laparoscopic resection of an asymptomatic 3-cm middle colic artery aneurysm in a young woman. Endovascular treatment represents nowadays the first-line option facing visceral artery aneurysm, but in this case, embolization was excluded because of hostile anatomy. Advantages of laparoscopic approach were the safe resection of the aneurysm with immediate evaluation of the bowel tolerance and the possibility of a histological examination of the arterial wall, without the disadvantages of laparotomy.

Vascular Diseases of the Spleen: A Review

Vascular diseases of the spleen are relatively uncommon in the clinical practice. However, the reported incidence has been progressively increasing, probably due to advances in the imaging modalities used to detect them. This disease condition often presents with non-specific clinical manifestations, but can be associated with significant morbidity and mortality. This review article aims to provide updated clinical information on the different vascular diseases of the splenic vasculature-splenic vein thrombosis, splenic vein aneurysm, splenic artery aneurysm, splenic arteriovenous fistula, and spontaneous splenorenal shunt-in order to aid clinicians in early diagnosis and management.

Treatment of distal splenic artery aneurysm by laparoscopic aneurysmectomy with end-to-end anastomosis: A case report

RATIONALE

Splenic artery aneurysm (SAA) is the most common visceral artery aneurysm, while most SAAs are treated by endovascular or open procedures.

PATIENT CONCERNS

Here we present a case of SAA treated by laparoscopic aneurysmectomy with end-to-end anastomosis.

DIAGNOSES

A 40-year-old woman was incidentally found to have an asymptomatic distal SAA. CT scan revealed the SAA to be located at the hilum of the spleen, with a maximal diameter of 2.7 cm.

INTERVENTIONS

To prevent sudden rupture, the patient received laparoscopic aneurysmectomy. During the operation, end-to-end anastomosis was also performed since a tortuous proximal splenic artery prevented delivery of the stent graft.

OUTCOMES

The patient was ambulated 12 hours after surgery and discharged 5 days later. Postoperative recovery was smooth without hemorrhage, infarction, infection, or splenic artery thrombosis. At 10-month follow-up,no hemorrhage, aneurysm recurrence, spleen infarction, splenic artery stenosis, or thrombosis had occurred.

LESSONS

Patients with distal SAA can be treated by laparoscopic aneurysmectomy with end-to-end anastomosis to preserve the spleen. The laparoscopic procedure is safe and feasible in the selected patients.

Open repair, endovascular repair, and conservative management of true splenic artery aneurysms

OBJECTIVE

True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs.

METHODS

A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions.

RESULTS

Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P = .04).

CONCLUSIONS

EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.

Laparoscopic ligation of proximal splenic artery aneurysm with splenic function preservation

Splenic artery aneurysm is one of the most common visceral aneurysms, and patients with this type of aneurysm often present without symptoms. However, when rupture occurs, it can be a catastrophic event. Although most of these aneurysms can be treated with percutaneous embolization, some located in uncommon parts of the splenic artery may make this approach impossible. We present a patient with an aneurysm in the proximal splenic artery, close to the celiac trunk, which was treated by laparoscopic ligation only, without resection of the aneurysm, and with long-term preservation of splenic function.