Cost-effectiveness of endovascular repair, open repair, and conservative management of splenic artery aneurysms. J Vasc Surg. 2015;61:1432-1440. [PMID: 25827968 DOI: 10.1016/j.jvs.2014.12.064]

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 348699.

Efficacy and safety of transcatheter arterial embolization of omental artery aneurysm: A single-center experience

BACKGROUND

Omental artery aneurysm (OAA) is an extremely rare visceral artery aneurysm. Ruptured OAAs are associated with a high mortality rate. Transcatheter arterial embolization (TAE) has been used to treat OAA in recent years. However, the risk of omental ischemia due to TAE remains unclear. Therefore, this study aimed to investigate the efficacy and safety of TAE of OAA as a first-line treatment.

METHODS

Fifteen patients with true aneurysms or pseudoaneurysms who underwent OAA-TAE between 1 April 2010 and 31 December 2022 were included in this study. The technical and clinical outcomes, the incidence of omental infarction after TAE as a major complication, OAA-TAE techniques, radiological findings on computed tomography angiography and angiogram, and patient characteristics were evaluated.

RESULTS

Fifteen patients (nine men, six women; age, 69.8 ± 18.59 years) underwent TAE of OAAs (mean aneurysm size of 9.30 ± 6.10 mm) located in the right gastroepiploic (n = 9), left gastroepiploic (n = 1), and epiploic (n = 5) arteries. All patients with ruptured (n = 6) and unruptured (n = 9) OAA successfully underwent TAEs using coils, n-butyl-2-cyanoacrylate, or gelatin sponges. Hepatic artery thrombosis and coil migration were observed during the procedure; however, these adverse events were manageable. Transfusion of red blood cell units (4.66 ± 1.63 units) was required only in cases with ruptured OAAs after TAE. Additional surgery or TAE due to rupture or rerupture of OAA and omental infarction was not required during the postoperative and follow-up periods.

CONCLUSION

The OAA-TAE can effectively treat ruptured and unruptured OAAs, and the risk of omental infarction after OAA-TAE may not be high.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Evolving Diagnostic and Therapeutic Options for Visceral Artery Aneurysms

BACKGROUND

Visceral artery aneurysms (VAAs) are associated with a very high mortality rate when ruptured and may present as a surgical emergency. Due to their rarity and varying pathophysiology, literature concerning the optimal management of VAAs is limited. This review evaluates the evolving management options for VAAs with a focus on open and endovascular repair.

METHODS

A combination of databases including OVID, PubMed and Medline were used to perform a literature search. Search terms employed include 'visceral artery aneurysms', 'angiography', '3D-volumetric rendering', 'management', 'open repair' and 'endovascular repair', amongst others.

RESULTS

3D modelling in conjunction with existing diagnostic techniques, such as computed tomography and angiography, may improve diagnostic sensitivity. The literature surrounding operative management of VAAs highlights the effectiveness of endovascular repair for anatomically suitable aneurysms. Advances in endovascular technologies may expand the type and number of aneurysms amenable to catheter-based treatment approaches. For aneurysms not amenable to endovascular treatment, or those with an emergency indication, open repair remains an appropriate management choice.

CONCLUSION

Although rare, VAAs pose a high mortality risk, especially when ruptured. Practical limitations that restrict current operative approaches may be overcome by recent developments including novel neurointerventional techniques that have been applied in VAA management.

A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre

INTRODUCTION

Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management.

METHODS

Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020).

RESULTS

There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention.

CONCLUSION

In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.

Neurovascular Neck-Bridging device in treatment of wide-necked splenic artery aneurysms

We report the cases of 2 female patients, 45-year-old and 49-year-old, affected by wide-necked splenic aneurysm. We embolized the 2 lesions assisted by a new scaffolding neurovascular device, the Cascade Net, an innovative –occlusive remodeling device for temporary bridging in endovascular coil embolization of intracranial aneurysms. Visceral artery aneurysms are rare with an estimated prevalence of 2%-3% in imaging series and up to 10% in autopsy series. Most are asymptomatic and their diagnosis is occasionally. Aneurysm spontaneous rupture has been demonstrated in 2%-10% of cases and it can result in significant morbidity and mortality. Conservative management and open repair were the preferred treatment options for many years. Endovascular repair has been increasingly used since 2000; and the most widespread method of treatment has been coiling. Because of tortuosity of the parent artery, wide neck, and unfavorable locations at arterial branch points, 6% of Visceral and renal artery aneurysms VRAA cannot be adequately treated by simple coiling and requires parent artery remodeling through balloon occlusion, stent placement or parent vessel occlusion, leading to, in the latter situation, a compromised organ perfusion. Increasingly, balloon-assisted, and stent-assisted approaches as well as novel scaffolding neurovascular devices such as the Cascade Net, have allowed wide necked aneurysms to be bridged during endovascular treatment with smaller delivery system, averting parent artery occlusion and risk of distal embolization.

Noninvasive Management of Complications From Splenic Artery Aneurysm Embolization After Liver Transplant: A Case Report

Splenic artery aneurysms are more common in patients with cirrhosis than in the general population. We report the case of a patient with a history of an orthotopic liver transplant who developed an enlarging splenic artery aneurysm that was treated with splenic artery embolization. He developed extensive portal vein thrombosis and subsequently splenic abscess. Both complications were managed endovascularly, with catheter-directed thrombolysis and percutaneous drains. This case illustrates the possible complications after splenic artery embolization and demonstrates the nonsurgical options for treatment.

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BACKGROUND

Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries.

METHODS

A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY).

RESULTS

For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%.

CONCLUSION

For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.

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.

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.

The economic impact of open versus endoscope-assisted craniosynostosis surgery

OBJECTIVE

Open and endoscope-assisted repair are surgical options for sagittal craniosynostosis, with limited research evaluating each technique's immediate and long-term costs. This study investigates the cost-effectiveness of open and endoscope-assisted repair for single, sagittal suture craniosynostosis.

METHODS

The authors performed a retrospective cohort study of patients undergoing single, sagittal suture craniosynostosis repair (open in 17 cases, endoscope-assisted in 16) at less than 1 year of age at Monroe Carell Jr. Children's Hospital at Vanderbilt (MCJCHV) between August 2015 and August 2017. Follow-up data were collected/analyzed for 1 year after discharge. Surgical and follow-up costs were derived by merging MCJCHV financial data with each patient's electronic medical record (EMR) and were adjusted for inflation using the healthcare Producer Price Index. Proxy helmet costs were derived from third-party out-of-pocket helmet prices. To account for variable costs and probabilities, overall costs were calculated using TreeAge tree diagram software.

RESULTS

Open repair occurred in older patients (mean age 5.69 vs 2.96 months, p < 0.001) and required more operating room time (median 203 vs 145 minutes, p < 0.001), more ICU days (median 3 vs 1 day, p < 0.001), more hospital days (median 4 vs 1 day, p < 0.001), and more frequently required transfusion (88% vs 6% of cases). Compared to patients who underwent open surgery, patients who underwent endoscopically assisted surgery more often required postoperative orthotic helmets (100% vs 6%), had a similar number of follow-up clinic visits (median 3 vs 3 visits, p = 0.487) and CT scans (median 3 vs 2 scans), and fewer emergency department visits (median 1 vs 3 visits). The TreeAge diagram showed that, overall, open repair was 73% more expensive than endoscope-assisted repair ($31,314.10 vs $18,081.47). Sensitivity analysis identified surgical/hospital costs for open repair (mean $30,475, SEM $547) versus endoscope-assisted repair (mean $13,746, SEM $833) (p < 0.001) as the most important determinants of overall cost. Two-way sensitivity analysis comparing initial surgical/hospital costs confirmed that open repair remains significantly more expensive under even worst-case initial repair scenarios ($3254.81 minimum difference). No major surgical complications or surgical revisions occurred in either cohort.

CONCLUSIONS

The results of this study suggest that endoscope-assisted craniosynostosis repair is significantly more cost-effective than open repair, based on markedly lower costs and similar outcomes, and that the difference in initial surgical/hospital costs far outweighs the difference in subsequent costs associated with helmet therapy and outpatient management, although independent replication in a multicenter study is needed for confirmation due to practice and cost variation across institutions. Longer-term results will also be needed to examine whether cost differences are maintained.

Double aneurysm of the superior mesenteric artery: case report

Superior mesenteric artery aneurysms are rare, accounting for less than 0.5% of all intra-abdominal aneurysms. They are mainly caused by atherosclerosis and septic emboli resulting from bacterial endocarditis. Although uncommon, these aneurysms are considered dangerous because of possible complications such as rupture with hemorrhage and intestinal ischemia. Since the consequences can be very serious, early diagnosis and treatment are essential to improve outcomes. Although there is no well-defined consensus, recommended treatments include open surgery, endovascular therapy, and watchful waiting with periodic examinations. In this article we report the case of an asymptomatic 58-year-old man with an incidental and unusual finding of two superior mesenteric artery aneurysms. Since anatomy was not favorable for an endovascular approach, open surgery was performed, using a dacron graft to successfully repair the artery.

Open surgery for aneurysms of the splenic artery at the hilum of the spleen: Report of three cases

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Aneurysms of the splenic artery at the hilum of the spleen are rare.

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Endovascular or laparoscopic treatment may not be advised.

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Surgical resection through subcostal incisioni s a viable treatment.

Introduction

Aneurysms of the splenic artery (SAA) located at the hilum of the spleen are not well fit for endovascular or laparoscopic treatment. Open surgery may still be the best option of treatment.

Presentation of cases

We report the cases of 3 female patients of a mean age of 59 years (range, 45–68 years) with a hilar (n = 2) or parahilar (n = 1) SAA undergoing successful open surgical resection, through a short left subcostal access. Recovery was uneventful and mean, postoperative length of stay was 4 days (range, 3–5 days).

Discussion

Results of this report support surgical resection and splenectomy for the treatment of SAA located at the hilum of the spleen. For this particular location endovascular treatment may not be advised, as coil embolization can be followed by a massive splenic infarction precipitating the need for splenectomy, due to the exclusion of backflow from the left gastroepiploic artery through the short gastric vessels. As well, endovascular exclusion through insertion of an endograft may not be feasible due to the absence of a distal landing zone, as stent grafting requires a normal caliber artery of sufficient length on each side of the aneurysm.

Conclusion

Surgical excision and splenectomy, through a short subcostal incision, remains a viable option of treatment for hilar SAA.

Ruptured gastric artery aneurysms: two cases and emergency imaging findings

A ruptured gastric artery aneurysm is a rare but important possible cause of massive intra-abdominal or gastrointestinal haemorrhage, and carries a high risk of mortality. Although aneurysms of the gastric arteries are uncommon, emergency radiologists and clinicians should be familiar with the clinical presentation, imaging findings and pathophysiology. We present two cases of massive intra-abdominal haemorrhage and haemodynamic shock secondary to acute rupture of previously occult gastric artery aneurysm and review the relevant anatomy, imaging findings and pathophysiology of gastric and other visceral artery aneurysms. By virtue of its location in the lesser omentum, a ruptured gastric artery aneurysm may result in a typical pattern and distribution of adjacent haematoma in the upper abdomen. Our description of imaging findings highlights a characteristic epicentre of intraperitoneal haemorrhage, and its typical mass effect displacement of surrounding viscera, to aid the emergent diagnosis of gastric artery aneurysm rupture.

Endovascular Repair of 40 Visceral Artery Aneurysms and Pseudoaneurysms with the Viabahn Stent-Graft: Technical Aspects, Clinical Outcome and Mid-Term Patency

PURPOSE

Endovascular repair of true visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) with stent-grafting (SG) can simultaneously allow aneurysm exclusion and vessel preservation, minimizing the risk of ischemic complications. Our aim was to report a single-center experience on SG of visceral aneurysms, focusing on technical aspects, clinical outcome and mid-term patency.

MATERIALS AND METHODS

Consecutive patients affected by VAAs-VAPAs and submitted to endovascular treatment were retrospectively reviewed, and SG cases with the self-expandable peripheral Viabahn stent-graft were analyzed (2003-2017). Aneurysm type, patient number, SG clinical setting, procedural data, peri-procedural complications, technical success, 30-day clinical success, 30-day mortality and follow-up period (aneurysm exclusion, stent-graft patency, ischemic complications) were analyzed.

RESULTS

SG was performed in 40 patients (24 VAPAs/16 VAAs) and in 44 procedures (25 in emergency, 19 in elective treatments), via transfemoral in 37 cases (transaxillary in 7 cases). One peri-procedural complication was recorded (a splenic artery dissection successfully converted to transcatheter embolization). The overall technical and clinical success rates were, respectively, 96 and 84%, with excellent trend in elective treatments (both 100%). Overall 30-day mortality was 12.5% (septic shock after pancreatic surgery). Stent-graft thrombosis occurred in 2 patients within 3 months, with aneurysm exclusion and without ischemic complications. Stent-graft patency and aneurysm exclusion were confirmed at 6, 12 and 36 months in 18, 12 and 7 patients, respectively.

CONCLUSION

SG of VAAs and VAPAs was safe and effective, particularly in elective treatments. The Viabahn stent-graft, flexible and without shape memory, is suitable for endovascular repair of tortuous visceral arteries.

Visceral aneurysms: Old paradigms, new insights?

True visceral artery aneurysms (VAAs) are a rare entity with an incidence of 0.01-2%. The risk of rupture varies amongst the different types of VAAs and is higher for pseudo aneurysms compared with true aneurysms. Size, growth, symptoms, underlying disease, pregnancy and liver transplantation have all been associated with increased risk of rupture. Mortality rates after rupture are around 25%. The splenic artery is most commonly affected and the etiology is predominantly atherosclerosis. Open repair can be done by simple ligation or reconstruction of the artery, while endovascular options include embolization or using a stent graft. Location, collateral circulation and medical condition of the patient should all be taken into account when an intervention is planned. We compared types of treatment and searched for risk factors for rupture but unfortunately, the level of evidence found in the literature is low. Therefore, deciding when and how to treat a patient with a VAA based on the current literature, remains challenging for clinicians.

Laparoscopic approach to splenic aneurysms

Background Splenic artery aneurysm is a rare disease with possibly mortal complications. For years, the main method of treatment was excision of aneurysm with spleen. In recent years, several methods have been developed in order to salvage the spleen such endovascular techniques and aneurysmectomy. Objective The aim of our study was to determine the feasibility of laparoscopic aneurysmectomy with spleen salvage in cases of splenic artery aneurysm. Materials Analysis of prospectively gathered data containing records of patients operated laparoscopically due to diseases of the spleen in 1998-2016 in our department. Inclusion criteria were attempted laparoscopic aneurysmectomy with intent to salvage spleen. Results Out of 11 patients, seven patients underwent aneurysmectomy with spleen preservation, one patient had partial-splenectomy, two patients had intra-operative splenectomies and one patient had a re-operation on post-op day 1 with splenectomy. Re-operation with splenectomy was the only recorded complication. Conclusions Laparoscopic aneurysmectomy of SAA may be considered as a safe treatment method, with good short- and long-term results; however, a complete evaluation requires further research on a larger study group. It allows permanent treatment of SAA with maintaining spleen function.

Splenic artery aneurysm presenting as a submucosal gastric lesion: A case report

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.