Splenic artery aneurysms in pregnancy--a systematic review

Segmental arterial mediolysis leading to spontaneous rupture of splenic artery and fatal hemorrhage in pregnancy

We report an unexpected death of a 22-year-old primigravida who was admitted to the hospital with sudden abdominal pain two days before a scheduled delivery. During an emergency caesarean section due to intrauterine asphyxia, intraabdominal bleeding was observed with no apparent source of bleeding. Newly formed blood clots in the subdiaphragmatic space and arterial bleeding near the splenic hilum required a surgery on the next day. Hemorrhagic shock led to multiple organ failure on the fourth day of admission. The autopsy revealed ruptured splenic artery at the pancreatic tail and near the splenic hilum. Microscopically, different stages of segmental arterial mediolysis were observed in partially thinned and aneurysmatic artery.

The natural history and long-term follow-up of splenic artery aneurysms

OBJECTIVE

Although splenic artery aneurysms (SAAs) are the most common visceral aneurysm, there is a paucity of literature on the behavior of these entities. The objective of this study was to review the natural history of patients with SAA.

METHODS

This single-institution, retrospective analysis studied patients with SAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our institutional radiology database. Imaging, demographic, and clinical data were obtained via the electronic medical record. The growth rate was calculated for patients with radiologic follow-up.

RESULTS

The cohort consisted of 853 patients with 890 SAAs, of whom 692 were female (81.2%). There were 37 women (5.3%) of childbearing age (15-50 years). The mean age at diagnosis was 70.9 years (range: 28-100 years). Frequently observed medical comorbidities included hypertension (70.2%), hypercholesterolemia (54.7%), and prior smoking (32.2%). Imaging indications included abdominal pain (37.3%), unrelated follow-up (28.0%), and follow-up of a previously noted visceral artery aneurysm (8.6%). The mean diameter at diagnosis was 13.3 ± 6.3 mm. Anatomic locations included the splenic hilum (36.0%), distal splenic artery (30.3%), midsplenic artery (23.9%), and proximal splenic artery (9.7%). Radiographically, the majority were saccular aneurysms (72.4%) with calcifications (88.5%). One patient (38-year-old woman) was initially diagnosed at the time of rupture of a 25 mm aneurysm; this patient underwent immediate endovascular intervention with no complications. The mean clinical follow-up among 812 patients was 4.1 ± 4.0 years, and the mean radiological follow-up among 514 patients was 3.8 ± 6.8 years. Of the latter, 122 patients (23.7%) experienced growth. Aneurysm growth rates for initial sizes <10 mm (n = 123), 10 to 19 mm (n = 353), 20 to 29 mm (n = 34), and >30 mm (n = 4) were 0.166 mm/y, 0.172 mm/y, 0.383 mm/y, and 0.246 mm/y, respectively. Of the entire cohort, 27 patients (3.2%) eventually underwent intervention (81.5% endovascular), with the most common indications including size/growth criteria (70.4%) and symptom development (18.5%). On multivariate analysis, only prior tobacco use was significantly associated with aneurysm growth (P = .028).

CONCLUSIONS

The majority of SAAs in this cohort remained stable in size, with few patients requiring intervention over a mean follow-up of 4 years. Current guidelines recommending treatment of asymptomatic aneurysms >30 mm appear appropriate given their slow progression. Despite societal recommendations for intervention for all SAAs among women of childbearing age, only a minority underwent vascular surgical consultation and intervention in this series, indicating that these recommendations are likely not well known in the general medical community.

A Rare Presentation of Polyarteritis Nodosa (PAN)

Polyarteritis nodosa (PAN) is a connective tissue disease that affects arteries, causing necrotizing inflammation that can weaken the arterial walls, dilatation into aneurysms, and rupture in some cases. We present a case of a male with acute abdomen from aneurysmal rupture. The 48-year-old patient with a history of polysubstance use including cocaine and methamphetamines was admitted for acute hypoxic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia and treated with broad-spectrum antibiotics and steroids. He also reported generalized abdominal pain and discomfort, and examination revealed abdominal distension that was diffusely tender on palpation, bowel sounds intact. Laboratory workup showed a progressive drop in hemoglobin requiring blood transfusions, no coagulopathy, anion gap metabolic acidosis, and lactic acidosis. Abdominal CT showed a 2 cm lobulated saccular aneurysm involving either the left gastric artery or splenic artery, associated with an extensive moderate amount of hemoperitoneum with hematomas (largest measuring up to 8.6 cm) abutting the gastric fundus and greater curvature of the stomach, which was likely secondary to aneurysmal rupture. Additionally, several other mesenteric vessels displayed some degree of dilation. Interventional radiology (IR)-guided splenic artery embolization for splenic artery aneurysm was done, after which his hemoglobin remained stable. The patient was given vaccine recommendations since splenic artery embolization would lead to asplenia. The aneurysms were attributed to either cocaine-related aneurysms or polyarteritis nodosa with visceral artery aneurysms. He denied rashes, oral ulcers, joint pain, subcutaneous nodules, blood in the urine, history of hepatitis or syphilis. Tertiary syphilis was ruled out after the Venereal Disease Research Laboratory (VDRL) test and rapid plasma reagin (RPR) test were negative. Complement C3 and C4 levels were normal. He was treated with high-dose IV methylprednisone after infection was ruled out. Due to the severity of PAN, therapy with IV cyclophosphamide therapy 15 mg/kg once every two weeks for three doses was initiated, followed by 15 mg/kg once every three weeks for three to six months (in combination with glucocorticoids prednisone 1 mg/kg body weight with slow taper). Cyclophosphamide was given with IV hydration and mesna. The presentation of PAN can vary widely. Most commonly, individuals experience symptoms such as fatigue, weight loss, fever, and chills. However, in rare cases, patients may present with isolated abdominal pain, similar to our patient. It's crucial to note that the rupture of an aneurysm can manifest as an acute abdominal issue, potentially leading to life-threatening situations. Immediate interventions to control bleeding are imperative in such cases. The treatment of PAN has a high success rate when a combination of cyclophosphamide and steroids is administered.

Selection of endovascular treatment strategies and analysis of the efficacy of different locations and types of splenic artery aneurysms

PURPOSE

To analyze the selection of endovascular treatment strategies and the efficacy of various locations and types of splenic artery aneurysms (SAAs).

METHODS

Sixty-three cases of patients diagnosed with SAA from January 2016 to October 2021 were collected, and their clinical data and follow-up results were analyzed.

RESULTS

Among the 63 patients, 55 had true SAAs, and 8 had false SAAs. The average diameter of the true SAAs was 2.0 ± 0.8 cm. There were 10 cases of intra-aneurysm embolization, 24 cases of intra-aneurysm and aneurysm-bearing artery embolization, 10 cases of bare stent-assisted coil embolization, and 11 cases of stent grafts. The false SAAs had an average diameter of 2.3 ± 1.1 cm. Aneurysm-bearing artery embolization was applied in 5 cases, and stent grafts were applied in 3 cases. The incidence of complications after embolization of the aneurysm-bearing artery was higher (P < 0.01). Postembolization syndrome occurred in 10 patients; 7 patients developed splenic infarction to varying degrees, 1 patient had mildly elevated blood amylase, and 1 patient developed splenic necrosis with abscess formation, all of which improved after active treatment. The average length of hospital stay was 5.5 ± 3.2 days. The average follow-up time was 17.2 ± 16.1 months, and the aneurysm cavity of all patients was completely thrombotic.

CONCLUSION

Endovascular treatments of SAAs are safe and effective. For various locations and types of SAAs, adequate selection of treatment is necessary. Stent grafts are recommended for their safety, economy, practicality, and preservation of the physiological functions of the human body.

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond

Interventional radiology (IR) plays a unique and often invaluable role in the care of pregnant patients. Special considerations regarding radiation exposure and medication choice must be taken into account when evaluating a pregnant patient for an interventional procedure. In addition, the physiologic changes that occur during pregnancy can pose special challenges for an interventionalist when treating this patient population and should be appropriately recognized. Still, the majority of standard IR procedures can be safely performed in the pregnant population, often with additional precautions and proper patient education about the risks, benefits, and alternatives. In many cases, interventional radiologists can provide lifesaving and fertility-preserving alternatives to more invasive surgical intervention. The authors summarize radiation exposure effects and guidelines and medication choice during pregnancy. The physiologic changes that occur during pregnancy are discussed, with specific interest in the pathologic consequences that can be treated with IR. The authors also describe a wide variety of minimally invasive image-guided procedures offered by IR in pregnant, peripartum, or postpartum patients. The areas where IR can help in the treatment of pregnant patients include venous access, biopsies, genitourinary and biliary interventions, venous thromboembolism treatments, ectopic pregnancy management, aneurysm intervention, and management of trauma patients. IR is also involved in management during the peripartum or postpartum periods, with roles in treatment of invasive placenta spectrum, postpartum hemorrhage after vaginal delivery, and postcesarean delivery complications. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances

The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Part 1 addresses outpatient management of compensated cirrhosis: screening for hepatocellular cancer, varices and osteoporosis, vaccination and lifestyle measures. Part 2 concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. In this, the third part of the guidance, we focus on special circumstances encountered in managing people with cirrhosis, namely surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.

Nonobstetric Surgical Emergencies in Pregnancy

In this article, we discuss the major nonobstetric surgical complications that may occur in pregnancy. We highlight specific diagnostic challenges particularly with imaging modalities and radiation considerations for the fetus. Topics covered in this article include appendicitis, intestinal obstruction, gallstone disease, hepatic rupture, perforated peptic ulcer, mesenteric venous thrombosis, splenic artery aneurysm rupture, and aortic dissection.

Splenic artery aneurysm in pregnancy: A systematic review

OBJECTIVE

Splenic artery aneurysms (SAA) are associated with significant maternal and fetal mortality when ruptured in pregnancy. However, there is no consensus on the optimal obstetric management of both ruptured and asymptomatic SAA. We aimed to evaluate risk factors, presentation, investigation, and management of SAA in pregnancy and puerperium.

METHODS

MEDLINE, EMBASE, and Scopus were screened from January 2000 to October 2020 using keywords related to pregnancy and SAA. Articles on ruptured and unruptured SAA in pregnancy until 6 weeks postpartum were considered. Data were extracted by two independent reviewers. Quantitative analysis and narrative synthesis were used.

RESULTS

Seventy-five ruptured and nine unruptured SAA cases were included. Mean age was 31.1 ± 5.2 years, of which 47 (64.4%) were multiparous and 46 (54.8%) presented in their third trimester, largely with epigastric and left-sided abdominal pain. The double-rupture phenomenon of delayed blood loss and symptoms was noted in 11 (14.7%); 60 (70.7%) underwent preoperative imaging. Mean SAA size was 23.0 ± 13.6 mm. Ruptured SAA were primarily managed by laparotomy (61, 81.3%) typically with splenectomy,  and unruptured SAA by embolization or laparotomy. There was no mortality in unruptured SAA, but significant mortality on rupture (19, 25.7% maternal; 36, 50.0% fetal).

CONCLUSION

Given their predisposition and high mortality in pregnancy, it is crucial that SAAs are promptly diagnosed and managed, requiring increased obstetrician awareness.

Splenic artery aneurysm masked as a gastroenterology complication: A case report and literature review

INTRODUCTION AND IMPORTANCE

Splenic artery aneurysm has an insidious onset, and low incidence, most of which have no specific manifestations on the early onset and remains the most common visceral aneurysm and third most common splanchnic aneurysm as it still remains a challenge to deal with clinically by many clinicians.

CASE PRESENTATION

We report a single case of a young 21 years old girl who had no potential risk of splenic artery aneurysm on clinical presentation, for gastroenterology disease only assessment and attention in our facility. The patient born and raised on a tropical island in Southern China was clinically diagnosed with splenic artery aneurysm-associated gastroenterological complications which was presented earlier as hematemesis. The patient was considered to have received optimal critical care by our multidisciplinary team and classical features displayed within the clinical settings are worth documenting and contribute perfectly to medical literature as the patient on follow-up is now back to normal life.

CLINICAL DISCUSSION

Our patient recovered excellently on critically close follow-up since the patient had special gastroenterology associated complication features which masked the splenic artery aneurysm with very encouraging post-operative parameters or results.

CONCLUSION

The patient was considered to have received optimal multidisciplinary quaternary medical care for SAAs with gastroenterology-associated complications in our interventional cardiovascular and gastroenterology medicine department.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients: A case report and review of literature

BACKGROUND

The rupture of a splenic artery aneurysm (SAA) in pregnancy is an uncommon condition. However, it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment. Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases, the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.

CASE SUMMARY

We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy. After emergent initial resuscitation, the patient was diagnosed with a ruptured SAA through digital angiography. Immediately upon diagnosis, she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot. Next, surgery was performed to remove the hematoma under stable conditions. Although the fetus was found to be dead during resuscitation, the woman recovered without complications and was discharged 15 d postoperatively.

CONCLUSION

Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Splenic artery aneurysm rupture post-anterior cervical discectomy and fusion: Case report & literature review

Introduction and importance

Anterior cervical discectomy and fusion (ACDF) is a regular surgical procedure for correcting spinal deformities and pain relief. There are several rare complications of ACDF, one of which is postoperative hematomas. Here, we report an unexpected case of intra-abdominal hematoma after ACDF with no prior abdominal symptoms or underlying conditions identified since admission. This report will describe the events and interventions that took place for this patient.

Case description

The patient is a 44-year-old female with a history of neck pain of four-month duration. On Magnetic Resonance Imaging (MRI), a degenerative cervical disk (C5-C6) was identified. Prior surgical history is significant for a C4-C5 ACDF 3 years ago. An anterior cervical discectomy and fusion was performed and the patient was doing well relatively post-surgery. However, in less than 24 h, the patient complained of severe abdominal pain. An abdominal Computerized topography angiogram (CTA) scan revealed internal bleeding and a splenic aneurysm rupture. The patient immediately underwent an urgent laparotomy and splenectomy.

Clinical discussion

Splenic artery aneurysm incidence is rare and is detected incidentally by imaging technology in asymptomatic patients or upon rupture. Splenic artery aneurysm rupture can be spontaneous and unpredictable in previously undiagnosed patients leading to life-threatening symptoms of intra-abdominal hemorrhage.

Conclusion

Patients undergoing ACDF should be monitored closely following surgery for any complications. Physicians should consider the possibility of any signs of hematoma due to underlying conditions that are undiagnosed in order to treat accordingly.

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Unexpected case of intra-abdominal hematoma post-anterior cervical discectomy and fusion (ACDF) due to splenic artery aneurysm.

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True splenic artery aneurysms (SAA) are rare but potentially fatal, they are the third most common abdominal aneurysms.

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As much as 80% of cases of splenic artery aneurysms are asymptomatic.

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Surgical patients should be evaluated prior to operations and post-operative monitoring should be performed to prevent/treat complications.

Splenic artery aneurysm with extrahepatic portal venous obstruction: A case report

Introduction and importance

Case presentation

Discussion

Conclusion

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SAA with EHPVO is especially common during pregnancy.

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Albeit rare, due to its high risk of fatality, it is extremely important for clinicians to diagnose and manage it well.

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Surgery is the best modality of treatment for SAA with EHPVO with hypersplenism.

Splenic artery aneurysm rupture in pregnancy: challenges in diagnosis and the importance of multidisciplinary management

This case of acute rupture of a splenic artery aneurysm in a patient 35 weeks pregnant demonstrates the difficulties in diagnosis and importance of multidisciplinary team management for surgical emergencies in pregnancy. A women in her early 30s presented at 35 weeks pregnant with sudden onset of severe epigastric pain and shortness of breath and was found to be tachycardic with a raised lactate. Differentials included a possible vascular event or pulmonary embolism. A CT scan demonstrated free fluid and likely ruptured splenic artery aneurysm. A rapid, thorough preoperative meeting enabled us to integrate multidisciplinary care effectively. She underwent coiling of her splenic artery, which was essential to reduce further intraoperative blood loss, followed by a midline incision for caesarean section of her baby and splenectomy. She had a long stay in the intensive care unit (ITU) and complex postoperative course but was discharged after 2 months to be reunited with her baby who was in good condition.

Spontaneous rupturing of splenic artery aneurysm: Another reason for fatal syncope and shock (Case report and literature review)

Splenic artery aneurysm (SAA) is a rare condition; however, it is one of the most common intra-abdominal aneurysm. In the emergency department (ED), due to an uncommon cause of shock and syncope in SAA, it poses great diagnostic challenge for emergency physicians. Here we reported a case of spontaneous rupturing of SAA. A 47-year-old man presented to the ED for syncope and shock. As he had unstable hemodynamic, we gave him fluid resuscitation and point-of-care ultrasound (POCUS), free intraperitoneal fluid was identified on ultrasound, then hemorrhagic ascites was identified by a diagnostic abdominal paracentesis. The rare but life-threatening diagnosis of spontaneous rupturing of SAA was confirmed by contrast-enhanced Computed Tomography and surgery. Spontaneous SAA rupturing is a rare fatal condition which needs immediate diagnosis and management to achieve a favorable outcome. Though there are no risk factors, emergency physicians should consider SAA in the differential diagnosis of sudden collapse. Also, as an emergency physician, it is very important to be a master of first aid skills such as POCUS and treat patients according to the process.

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.

Next-generation sequencing in a large pedigree segregating visceral artery aneurysms suggests potential role of COL4A1/COL4A2 in disease etiology

BACKGROUND

Visceral artery aneurysms (VAAs) can be fatal if ruptured. Although a relatively rare incident, it holds a contemporary mortality rate of approximately 12%. VAAs have multiple possible causes, one of which is genetic predisposition. Here, we present a striking family with seven individuals affected by VAAs, and one individual affected by a visceral artery pseudoaneurysm.

METHODS

We exome sequenced the affected family members and the parents of the proband to find a possible underlying genetic defect. As exome sequencing did not reveal any feasible protein-coding variants, we combined whole-genome sequencing of two individuals with linkage analysis to find a plausible non-coding culprit variant. Variants were ranked by the deep learning framework DeepSEA.

RESULTS

Two of seven top-ranking variants, NC_000013.11:g.108154659C>T and NC_000013.11:g.110409638C>T, were found in all VAA-affected individuals, but not in the individual affected by the pseudoaneurysm. The second variant is in a candidate cis-regulatory element in the fourth intron of COL4A2, proximal to COL4A1.

CONCLUSIONS

As type IV collagens are essential for the stability and integrity of the vascular basement membrane and involved in vascular disease, we conclude that COL4A1 and COL4A2 are strong candidates for VAA susceptibility genes.

Revisiting the Spleen—An Imaging Review of the Common and Uncommon Splenic Pathology

The spleen is the largest lymphatic organ and is responsible for both hematological and immunological functions. Several common etiologies such as trauma, developmental variants, infectious/inflammatory conditions, and benign and malignant lesions can occur in the spleen. The role of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in diagnosing these conditions continues to evolve. The main objective of this review article is to illustrate the role of imaging in identifying the common and uncommon pathology of the spleen.

Management of pregnancy in women with cirrhosis

Although pregnancy is rare in women with cirrhosis, it is increasingly prevalent in an era of modern assisted conception techniques and improved awareness, monitoring and management of underlying liver disease. After overcoming the difficulties of subfertility and becoming pregnant, women undergo a 'high-risk' pregnancy which can be complicated by variceal haemorrhage (≤50%) and hepatic decompensation (≤25%). Management of these complications are similar to non-pregnant individuals. However, there are a few caveats to consider. These pregnancies are associated with adverse maternal and foetal outcomes, such as mortality (0%-8%) and prematurity (19%-67%) in the newborn, and mortality (0%-14%), pregnancy-induced hypertension (5%-22%) and post-partum haemorrhage (5%-45%) in the mother. Pre-pregnancy counselling, use of predictive scores and appropriate variceal screening during pregnancy can stratify patients and improve outcomes. This review focusses on the complications that can occur during pregnancy in women with cirrhosis.

Conservative Management of a Splenic Artery Aneurysm in Pregnancy: A Case Report

Splenic artery aneurysms (SAA) are a rare and life-threatening pathology. Ruptured SAA has a mortality rate of up to 25%, with increased rates of rupture in pregnancy, pseudoaneurysm, liver transplantation, portal hypertension, symptomatic SAA and diameter >2 cm. Management of SAA in pregnant women is poorly described in the literature, making treatment of these patients difficult. Furthermore, careful consideration of complications for both the mother and the foetus need to be taken into account. This case report demonstrates that conservative management with monthly surveillance MRI can be used as viable treatment option of an asymptomatic 17 mm splenic artery aneurysm in a pregnant woman.

Laparoscopic Resection of a Splenic Artery Aneurysm with Vascular Reconstruction During Pregnancy

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

A case of a patient who underwent transcatheter arterial embolization for unruptured splenic aneurysm during pregnancy

Here, we report the case of a 30-year-old female patient who underwent coil embolization for unruptured splenic artery aneurysm without any complication at 26 weeks of pregnancy with reduction in fetal radiation exposure. The patient did not suffer from rupture of splenic artery aneurysm during or after procedure. Pregnancy is a risk factor of splenic artery aneurysm rupture with a high mortality rate. Transcatheter arterial embolization at 26 weeks of pregnancy might be a better treatment alternative for a pregnant patient with splenic artery aneurysm with respect to the endurance of fetal radiation exposure to prevent aneurysm rupture.

Splenic artery aneurysm rupture during pregnancy: A case report of maternal and fetal survival

INTRODUCTION

Pregnancy has been demonstrated as a significant risk factor of splenic artery aneurysm (SAA) formation and rupture. However, prompt diagnosis of SAA rupture in a pregnant patient showing acute abdomen has been practically challenging in light of its rarity and vague initial presentation.

PRESENTATION OF CASE

A 40-year-old woman (gravida 1, para 0) at 35 weeks' gestation presented to the emergency department with upper abdominal pain and nausea. Because of fetal dysfunction, emergency caesarian section was performed by a Pfannenstiel incision. Following delivery, 400 g of hemorrhage was removed from the upper abdominal cavity. Computed tomography showed a 37-mm SAA associated with copious adjacent fluid. Although selective angiography did not demonstrate active extravasation, interventional isolation of the SAA was not performed because of multiple surrounding arteries. Relaparotomy with an upper midline incision was then performed. Sudden cardiac arrest occurred upon opening the lesser sac to irrigate clots, and cardiac massage and proximal and distal clamping of the SAA were required. Eventually, splenectomy with excision of the SAA and pancreatic tail was successfully performed, but gauze packing of the open surgical wound was required because of severe coagulopathy. Following removal of the packs and closure of the abdomen 2 days after splenectomy, the patient and infant satisfactorily recovered without sequelae.

DISCUSSION

Given continual awareness of abdominal vascular collapse during pregnancy, undelayed diagnosis and safer intervention might be achieved.

CONCLUSION

Awareness at initial presentation and multidisciplinary efforts might be essential to achieve maternal and fetal survival in SAA rupture during pregnancy.

A review of management options for splenic artery aneurysms and pseudoaneurysms

Background

A review of the management of splenic artery aneurysms (SAA). There is no general consensus as to when and what type of intervention should be chosen to treat SAAs. The aim of this study is to investigate the types of intervention for SAAs including complication, reintervention, rupture, mortality after intervention of SAA in a review.

Method

A literature search was performed using "keywords" in Medline and Embase limited to publications from 2008 to 2018. 289 articles were identified during the initial literature search. 143 articles met the eligibility criteria. 83 articles were included in the quantitative synthesis. Descriptive analysis was performed.

Results

576 patients were identified with 588 reported SAAs. The mean ± SD age was 52.6 ± 5.8 years (range 17-85). The mean ± SD size of SAA was 49.9 ± 13.2 mm (range 6-180). Types of intervention reported were endovascular treatment, open surgery, laparoscopic surgery and conservative management. Mortality rate in patients with endovascular treatment was 0.5% compared to 4.9% with open surgery. 3.4% of patients with conservative management were reported to have aneurysms that grew over time and 2.8% patients had further intervention. ANOVA test to compare mortality between open surgery, endovascular treatment and laparoscopic surgery showed there is no difference between mortality between the 3 different interventions as F (2.71) < F crit (3.02) (P = 0.07).

Conclusion

Endovascular treatment is now the first choice of treatment for SAA, but future studies are required to determine its long-term durability. By introducing a management pathway for SAA, we hope to see an improvement in managing patients. The management algorithm will require further validation through application with careful and complete follow-up of all cases to improve the pathway depending on patient outcome.

Review article: chronic liver disease and pregnancy

BACKGROUND

The prevalence of chronic liver disease in women of child bearing age is increasing, leading to a higher incidence of pregnancy in this cohort. Chronic medical conditions have a significant adverse effect on maternal morbidity and mortality. To date, reviews on this topic have been written either from a hepatology or obstetrics viewpoint, and no specific guidelines are available solely for the management of chronic liver disease in pregnancy.

AIMS

To produce a comprehensive review on the clinical management of women with chronic liver disease during pregnancy, addressing the risks of pregnancy to mother and child, how these risks can be ameliorated, and what additional considerations are required for management of chronic liver disease in pregnancy.

METHODS

Data were collected up to May 2020 from the biomedical database PubMed, national and international guidelines in gastroenterology and hepatology.

RESULTS

During pregnancy, women with cirrhosis are more likely to develop decompensated disease, worsening of portal hypertension, and to deliver premature infants.

CONCLUSIONS

The risks associated with pregnancy can be ameliorated by advanced planning, assessing risk using the model for end stage liver disease score and risk reduction through varices screening. A multidisciplinary approach is paramount in order to minimise complications and maximise the chance of a safe pregnancy and birth for mother and baby.

Decision-making and therapeutic options in intact splenic artery aneurysms: single-center experience and literature review

BACKGROUND

Splenic artery aneurysms are rare, potentially serious, and usually asymptomatic. Several methods are currently available to treat them, each with their own advantages and drawbacks. Therefore, its therapeutic paradigm has changed.

METHODS

We review our database of splenic aneurysms (2009-2019) and undertake an exhaustive literature review. Demographic, clinical, diagnostic, therapeutic, early and follow-up outcome data were examined. Our experience comprised: 15 patients with 19 splenic aneurysms. 11 women (average age, 59.4 years) and 4 men (average age, 61.7 years). All asymptomatic.

RESULTS

At diagnosis, aneurysms had a mean cross-sectional diameter of 3.4 cm (3.2 and 3.9 for women and men, respectively), the largest measuring 8.5 cm. Two independent aneurysms were detected in four patients. Diagnoses were always incidental to a CT scan. Treatments consisted of open surgery (2 patients), endovascular surgery (10 patients: 7 embolizations, 3 covered stent) and observation/follow-up (3 patients). The cases of open surgery (with splenectomy) were carried out without postoperative morbidity. One embolization failed (requiring subsequent open surgery) and two suffered localized splenic infarction, but without further complications. In patients treated with a covered stent, the aneurysm was always excluded, without complications. There was no 30-day or follow-up (average 26.2 months) mortality. Splenic aneurysms are diagnosed more frequently and earlier (in the asymptomatic phase), albeit incidentally, than in the past.

CONCLUSIONS

The correct indication (identifying patients at risk) and individualization of treatment, in which endovascular techniques are the first-line option, have significantly improved morbidity and mortality outcomes in our hospital.

Higher prevalence of splenic artery aneurysms in hereditary hemorrhagic telangiectasia: Vascular implications and risk factors

BACKGROUND

Splenic artery aneurysm (SAA) is a rare but potentially fatal condition. Rupture results in 25% mortality up to 75% in pregnant women with 95% fetal mortality. Brief reports suggest an increased risk of developing SAA in patients with HHT.

METHODS

We analyzed enhanced multidetector CT data in 186 HHT patients matched (gender and ± 5 year old) with 186 controls. We screened for SAA and recorded diameter of splenic and hepatic arteries and hepatic, pancreatic and splenic parenchymal involvements. We determined by univariate and multivariate analysis, the relationship with age, sex, genetic status, cardiovascular risk factors (CVRF) and visceral involvement.

RESULTS

SAA concerned 24.7% of HHT patients and 5.4% of controls, p<0.001. Factors associated with increased risk of SAA in HHT were female gender (p = 0.04, OR = 2.12, IC 95% = 1.03-4.50), age (p = 0.0003, OR = 1.04, 95% CI = 1.02-1.06) and pancreatic parenchymal involvement (p = 0.04, OR = 2.13, 95% CI = 1.01-4.49), but not type of mutation, hepatic or splenic parenchymal involvements, splenic size or splenic artery diameter or CVRF.

CONCLUSIONS

We found a 4.57 higher rate of SAA in HHT patients without evidence of splenic high output related disease or increased CVRF. These results suggest the presence of a vascular intrinsic involvement. It should lead to screening all HHT patients for SAA. The vasculopathy hypothesis could require a change in management as screening of all systemic arteries and even the aorta and to further research in the field.

Splenic aneurysms: natural history and treatment techniques

True splenic artery aneurysms (SAA) are a rare, but potentially fatal, pathology. They are the third most common type of abdominal aneurysm, after aneurysms of the aorta and of the iliac artery, and account for almost the all aneurysms of visceral arteries. True aneurysms account for 60% of SAA and affect four times as many women as men, generally related to increased incidental or symptomatic findings that coincide with use of ultrasonography in pregnancy. Among pregnant patients, mortality after rupture is 65-75%, with fetal mortality exceeding 90%. There are multiple etiologies and it is believed that hormonal influences and changes in portal flow during gestation play an important role in development of SAA. This review discusses their history, epidemiology, pathophysiology, and diagnosis and current treatment techniques.

Egg-shell like Calcification as a Protective Factor for Splenic Artery Aneurysm Dilatation

BACKGROUND

The purpose of this study was to evaluate the factors associated with asymptomatic splenic artery aneurysm (SAA) dilatation.

METHODS

Among patients with SAA admitted to our department from 2001 to 2018, 70 lesions in 59 patients were selected and analyzed retrospectively. There were no cases of rupture or pregnancy in the follow-up period. We defined egg-shell appearance as SAA with >75% calcification of the outer shell. We measured the dilatation rate (mm/year) and evaluated the comorbidity and anatomical factors using univariate and multiple linear regression models. Post-hoc multiple linear regression models were fitted to evaluate the possible interactions.

RESULTS

The mean age was 61.4 years (range 35-85 years), and the initial aneurysm diameter was 15.1 mm (range 3-47 mm). The mean dilatation rate was 0.26 mm/year (range 0-3.2 mm/year) during the follow-up period (average 4.6 years). Univariate analysis revealed that, portal hypertension (PHT) (P = 0.0003), egg-shell appearance (P = 0.007), and aneurysm diameter > 20 mm (P = 0.05) were significantly associated with the dilatation rate. Multivariate analysis revealed that egg-shell appearance was found to be an independent inverse risk factor of dilatation rate (P = 0.006). The multivariate analysis, including interaction terms, revealed a stronger effect of PHT and diameter >20 mm in cases with no egg-shell appearance (P = 0.08 and P = 0.05 for interactions, respectively).

CONCLUSIONS

The egg-shell appearance of SAA was an independent inverse risk factor affecting the SAA dilatation rate. The dilatation rates in the case of PHT and diameter >20 mm were restricted in the presence of the egg-shell appearance.

Current management strategies for visceral artery aneurysms: an overview

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

[Splenic artery aneurysm rupture at the end of pregnancy: a case study]

Les hémorragies lors de la grossesse peuvent être d'origine non obstétricale, la grossesse étant un terrain favorisant pour certaines étiologies du fait des modifications physiologiques qu'elle induit. Ces hémorragies non obstétricales sont rares mais sont responsables d'une mortalité materno-fœtale importante. Le pronostic dépend de la rapidité du diagnostic et d'une prise en charge multidisciplinaire. La rupture per gravidique d'un anévrysme de l'artère splénique (AAS) est une affection rare mais de pronostic redoutable. Le tableau clinique typique associant douleur abdominale, hypotension et anémie est très trompeur pour l'obstétricien qui évoque plus volontiers un hématome rétro placentaire ou une rupture utérine. Nous rapportant le cas d'une patiente enceinte ayant nécessité une laparotomie en urgence devant la découverte à l'imagerie d'une rupture d'anévrysme de l'artère splénique.

Liver Disease in Pregnancy and Transplant

PURPOSE OF REVIEW

The purpose of this review is to discuss current and new knowledge regarding liver disease in pregnancy and pregnancy post-liver transplantation.

RECENT FINDINGS

Severe liver disease associated with pregnancy is rare. Liver biopsy is rarely needed for diagnosis but is safe in selected cases. Intrahepatic cholestasis of pregnancy (ICP) with serum bile acids level > 40 μmol/L is associated with adverse fetal outcomes. Ursodeoxycholic acid should be initiated at diagnosis. Portal hypertension can worsen during pregnancy and screening endoscopy should be performed in the 2nd trimester. Maternal hepatitis B antiviral therapy can be considered in the 3rd trimester if HVB DNA > 200,000 IU/ml. Tacrolimus is the optimal immunosuppressive therapy during pregnancy post-transplantation. Preconception renal function predicts pregnancy outcome. Overall, the outcome of pregnancy post-transplantation is good but there is an increased risk of preterm delivery, low birth weight, hypertension, and pre-eclampsia. Liver disease of pregnancy can be divided into diseases unique to pregnancy, exacerbated by pregnancy or coexisting with pregnancy. Overall, the outcome of pregnancy post-liver transplantation is good.

Splenic Artery Aneurysm (SAA) Rupture in Pregnancy: A Case Report of a Rare but Life-Threatening Obstetrical Complication

This is the case of a 38 year-old Lebanese woman G2P1, history of previous cesarean section, presenting at 30+5 weeks of gestation with acute left-sided flank pain and a two-day history of chills and dysuria. In light of the clinical presentation, the patient was initially diagnosed with pyelonephritis and managed accordingly; however, her clinical status deteriorated with worsening hypotension and lethargy despite resuscitative measures and a normal abdominal ultrasound. Failure to revive the patient eventually led to a cardiac arrest for which a peri-mortem cesarean section was performed at bedside. Upon abdominal entry, an actively-bleeding ruptured splenic artery aneurysm (SAA) was identified, for which massive transfusion protocol was activated, and the patient was transferred to the operating room. The patient had a complicated postoperative course, the fetus was stillborn, and she was discharged home after 6 months of hospital stay. In view of the high mortality and morbidity associated with ruptured SAA in pregnancy, early recognition and prompt intervention are crucial for maternal and fetal benefit.

Severely Calcified True Aneurysm: A Thought-Provoking Case of Solitary Origin and Postoperative Management

Patient: Male, 70

Final Diagnosis: Splenic artery aneurysm

Symptoms: Asymptomatic

Medication: —

Clinical Procedure: Surgery and Endoscopy

Specialty: Surgery

Splenic artery aneurysms during pregnancy: An obstetric nightmare

OBJECTIVE

In this study we report our experience in the management of Splenic Artery Aneurysm (SAA), diagnosed during pregnancy.

STUDY DESIGN

The current manuscript describes three different events, treated in out our department, involving SAAs diagnosed during pregnancy. Each case presents an unusual course and a unique clinical challenge.

RESULTS

The first case is of a 25 week's gestation twin pregnancy with ruptured SAA ending in maternal and fetal death. Another case of SAA rupture presented at 27 week's gestation with consequent emergency cesarean section and splenectomy. In the last case, two SAAs were incidentally diagnosed at 25 weeks' singleton gestation. The patient was managed conservatively and delivered by an elective cesarean section at 34 weeks followed by postpartum angiographic embolization of the aneurysms.

CONCLUSIONS

Health care providers and especially obstetricians should be aware of the diagnosis of ruptured SAA in a pregnant woman with abdominal discomfort and hemodynamic deterioration. In addition, once an asymptomatic pregnant patient is diagnosed with a SAA, conservative surveillance may be allowed.

Splenic Artery Aneurysm Case Report

Splenic artery aneurysm rupture is a rare complication of pregnancy with very high maternal and fetal mortality rate. In this paper, a case of splenic artery aneurysm rupture at 34 weeks of gestation with both maternal and fetal survival is presented.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Portal hypertension in pregnancy - Concealed perils

Pregnancy in women with portal hypertension is high risk due to the danger of variceal haemorrhage, which complicates 15-34% of cases. Variceal bleeding in pregnancy to women with non-cirrhotic portal hypertension is associated with increased risk of abortion (29%) and perinatal death (33%). Pregnancy in women with cirrhosis while less common due to hypogonadism, is associated with additional potential complications of hepatic decompensation and encephalopathy (10%), hepatorenal syndrome, ascites and bacterial peritonitis. Pregnancy in women with cirrhotic portal hypertension is associated with maternal death in 1.6%, and fetal loss in 10-66%. We present a case of non-cirrhotic portal hypertension in pregnancy, discussing two other potential critical complications of portal hypertension in pregnancy, splenic artery aneurysm (SAA) and pulmonary hypertension.