Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

Delayed presentation of splenic artery pseudoaneurysm: A critical outcome of blunt abdominal trauma; A case report

INTRODUCTION AND IMPORTANCE

Blunt abdominal trauma is one of the most common reasons for emergency department visits, and spleen and splenic vasculature is involved variably in those cases. Splenic artery pseudoaneurysm formation is one complication with potentially devastating consequences. Early detection and management are of paramount importance given its potential fatality. Management includes open repair with or without splenectomy, and endovascular approach. The minimally invasive endovascular treatment offers earlier recovery, preserved splenic function, and positive outcomes. We report a case of delayed presentation of a large splenic artery pseudoaneurysm after blunt abdominal trauma, managed using endovascular intervention.

CASE PRESENTATION

A 45-year-old male presented 10 days after being involved in a pedestrian accident with blunt abdominal trauma resulting in a large splenic artery pseudoaneurysm. After multidisciplinary discussion, the decision was to take him for endovascular treatment. The patient recovered very well and was discharged two days later and followed up in an outpatient setting. Over a year, he became symptom free, and demonstrated radiological finding of shrinking pseudoaneurysm.

CLINICAL DISCUSSION

Pseudoaneurysms of visceral arteries are repaired regardless of their size per society of vascular surgery guidelines. Larger ones are at higher risk of rupture and are associated with high mortality. When discovered, treatment plans should be readily discussed, and undertaken. In our case, the patient had a 6.5 cm splenic artery pseudoaneurysm, and a multidisciplinary meeting was conducted and concluded that endovascular treatment would be the best modality to start with, with surgical option as a backup in a hybrid room setting.

CONCLUSION

Blunt abdominal trauma can present with overt symptoms of internal organ injury; however, some might be missed and need high index of suspicion and therefore further testing and imaging. Splenic artery pseudoaneurysms can expand and rupture in delayed presentation, early detection and management is of paramount importance. Endovascular treatment represents an excellent modality, with minimal invasive nature, faster recovery, and early return to daily activity with preserved splenic function.

Splenic artery pseudoaneurysm; a cause or consequence: a case report

BACKGROUND

Splenic artery pseudoaneurysm is a rare complication of recurrent pancreatitis usually presenting as an incidental finding on abdominal computed tomography.

CASE PRESENTATION

We present the case of a 66-year-old north African male with a known history of previous pancreatitis who presented with upper gastrointestinal bleeding along with recurrent epigastric pain for 3 days. Investigations did not reveal any particular pancreatitis etiology. Computed tomography of the abdomen with contrast showed splenic artery pseudoaneurysm along with findings suggestive of acute pancreatitis. Upper and lower endoscopies failed to identify gastrointestinal the bleed source. The patient underwent intervention radiology embolization of the aneurysm sac with multiple coils via right retrograde common femoral artery-celiac access. The patient was discharged with a plan for capsule endoscopy in outpatient setting.

CONCLUSION

Splenic artery pseudoaneurysm is a life-threatening complication and carries a high mortality rate if left untreated. Prompt identification through various imaging modalities, followed by urgent intervention, is crucial to avoid adverse outcomes.

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.

The Importance of Early Detection and Minimally Invasive Treatment of Pseudoaneurysms Due to Chronic Pancreatitis: Case Report

The occurrence of the pseudoaneurysm of visceral arteries in the field of chronic pancreatitis is a very rare complication that represents a life-threatening condition. The higher frequency of this complication is in the necrotic form of pancreatic inflammation, especially in patients with formed peripancreatic necrotic collections. The degradation of the arterial wall leads to bleeding and transforms these necrotic collections into a pseudoaneurysm. Urgent endovascular angioembolization is the first choice in the therapeutic approach as a valid minimally invasive solution with very satisfactory immediate and long-term outcomes. This successfully avoids open surgery, which is associated with a high mortality rate in these patients, especially in acute-on-chronic pancreatitis.

Treatment of a contained rupture of a splenic artery pseudoaneurysm with direct thrombin injection

Splenic artery pseudoaneurysm is a rare and potentially fatal condition. In the present report, we describe the case of a 50-year-old woman with chronic pancreatitis who presented with worsening abdominal pain. Computed tomography demonstrated a 3.5-cm splenic artery pseudoaneurysm of the mid-splenic artery. The patient underwent attempted endovascular repair of the pseudoaneurysm that was unsuccessful. Open conversion revealed an inaccessible splenic artery due to chronic pancreatitis that resulted in dense retroperitoneal fibrosis, and repair was achieved via direct thrombin injection under ultrasound guidance of the pseudoaneurysm and splenectomy. The patient recovered well, and computed tomography at 3 days postoperatively revealed complete thrombosis of the pseudoaneurysm.

Imaging of abdominopelvic oncologic emergencies

With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.

Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review

BACKGROUND

To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE).

METHODS

We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020).

RESULTS

Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone.

CONCLUSIONS

SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

Spontaneous Resolution of Recurrent Pancreatitis After Splenic Artery Pseudoaneurysm Stent Placement

Acute pancreatitis (AP) is a relatively common condition most often secondary to excess alcohol consumption, choledocholithiasis, medications, or hypertriglyceridemia. In rare cases, AP can result in a secondary splenic artery pseudoaneurysm (SAP). SAPs are a rare yet serious medical complication and are often under-diagnosed as they are usually asymptomatic. However, rupture and subsequent hemorrhage of SAPs pose life-threatening risks. This case involves a 72-year-old male presenting with portal vein thrombosis and recurrent episodes of AP with persistently elevated levels of lipase of no apparent etiology over a 6-month period. As patient history and pertinent test results ruled out all common causes of recurrent AP, the etiology of his AP remained unknown. After an SAP rupture and emergency treatment with an endovascular stent, the patient's recurrent AP spontaneously resolved, and lipase returned to normal levels. This case represents a yet-to-be-reported etiology of AP in which the proximal nature of the SAP with its associated inflammatory response to the pancreas resulted in intermittent AP. The lack of any other reasonable explanation for the etiology of the patient's recurrent AP along with the absence of any additional episodes after the treatment of his SAP supports this diagnosis. The findings of this case could prove useful to clinicians with patients suffering from recurrent episodes of AP with no known etiology and suggest that a potential undiagnosed SAP should be investigated further.

Managing Splenic Artery Pseudoaneurysms-An Experience from a Developing Country. A Retrospective Review

Objectives: Splenic artery pseudoaneurysm is a rare but potentially fatal condition. Early diagnosis and intervention are the key steps in the management of this condition. We have reviewed our institution's 4-year data regarding the presentation and management of this condition. Methods: We conducted a prospective review of the records of 10 patients who presented to our institute from January 2018 to December 2021 with a splenic artery pseudoaneurysm. We found one patient with a true aneurysm, whom we excluded from the study. Results: This study included seven male and two female patients with a mean age of 47.7 years. Six patients presented to the emergency department with bleeding secondary to rupture aneurysm, which is the most common reason for admission. Pancreatitis was found to be the most common cause for splenic artery pseudoaneurysm (five patients). Computed tomography angiogram remained the modality of choice for diagnosing splenic artery pseudoaneurysm. All patients were successfully managed with endovascular intervention. Conclusion: Splenic artery pseudoaneurysm is usually a rare complication of pancreatitis, which is associated with high morbidity and mortality. Timely diagnosis and intervention are the keys to successful management. Endovascular embolization should be the first-line therapy in splenic artery pseudoaneurysm.

Rare vascular complication of ESWL pseudoaneurysm of arc of Buhler

Extracorporeal shock wave lithotripsy (ESWL) is a standard treatment for nephrolithiasis. It is widely employed due to its relative safety profile when compared with other treatment options. Recognised complications include localised pain at site, steinstrasse, perinephric haematoma and ureteric obstruction. This report presents a rare non-documented complication of ESWL, pseudoaneurysm of the arc of Buhler, a branch artery of the superior mesenteric artery.

Gastrointestinal Bleeding Due to the Rupture of Splenic Artery Caused by Pancreatic Carcinoma: A Case Requiring Repeated Transcatheter Arterial Embolization in a Short Period of Time

In this report, we present a case of gastrointestinal bleeding due to splenic artery rupture, which required repeated transcatheter arterial embolization (TAE) within a short period of time. A 75-year-old man with pancreatic carcinoma was transported to our hospital with active hematemesis and vital signs consistent with shock. Contrast-enhanced computed tomography images showed a pancreatic tumor that had caused a pseudoaneurysm of the splenic artery to rupture. The pseudoaneurysm was embolized using only an N-butyl-2-cyanoacrylate (NBCA) and lipiodol mixture. However, hematemesis with signs of shock recurred 13 h later, and angiography showed rebleeding from the origin of the splenic artery. The splenic artery was subsequently embolized using an NBCA and lipiodol mixture. Repeated TAE finally controlled the hemorrhage; however, asymptomatic splenic infarction and hepatic infarction occurred due to nontarget embolization.

Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with Vascular Ehlers Danlos Syndrome

BACKGROUND

Vascular Ehlers-Danlos Syndrome (VEDS) is rare and associated with arteriopathies. The aim of this study is to investigate the presentation, operative interventions, and outcomes of splenic arterial pathology in a population of more than 1,500 individuals with genetically confirmed VEDS due to pathogenic COL3A1 variants.

METHODS

Cross-sectional analysis of 1,547 individuals was performed. The data were assembled by harmonizing data from three overlapping cohorts with genetically confirmed VEDS: the VEDS Collaborative Natural History Study (N=242), a single center cohort (N=75), and the UW Collagen Diagnostic Lab cohort (N=1,231). Duplicates were identified and removed. Patients were selected for analysis if they had splenic artery aneurysm (SAA), pseudoaneurysm, dissection, thrombosis, or rupture. Demographics, COL3A1 variants, interventions, and outcomes were analyzed. Comparisons by splenic artery rupture were made.

RESULTS

A total of 88 patients presented between 1992 and 2021 with splenic artery pathology (5.7% of the cohort, Mean age at diagnosis 37+11.1 years, 50% male). One third were diagnosed with VEDS prior to the splenic artery pathology diagnosis and 17% were diagnosed post-mortem. Most had a positive family history (61%). Most had COL3A1 variants associated with minimal normal collagen production (71.589.7%). Median follow up was 8.5 (IQR 0.9-14.7) years. Initial presentation was rupture in 47% of the cases. Splenic artery rupture overall was 51% (N=45) including 4 cases of splenic rupture. There were no major differences in VEDS related manifestations or COL3A1 variant type by rupture status. SAA was noted in 39% of the cases. Only 12 patients had splenic artery diameter documented in 12 cases with a median diameter of 12 (IQR 10.3-19.3) mm. A total of 34 (38.6%) patients underwent 40 splenic arterial interventions: 21 open surgical, 18 embolization, and 1 unknown procedure. More than one splenic artery intervention was performed in 5 (14.7%) cases. Open repair complications included arteriovenous fistula (n=1), intestinal or pancreatic injury (1 each), and four intraoperative deaths. There were no deaths or access site complications related to splenic artery embolization. Four (23.5%) developed a new SAA in the remaining splenic artery post embolization. All-cause mortality was 35% (n=31) including 22 related to a ruptured splenic artery.

CONCLUSIONS

Splenic arteriopathy in VEDS is associated with variants that affect the structure and secretion of type III collagen and frequently present with rupture. Rupture and open repair are associated with high morbidity and mortality while embolization is associated with favorable outcomes. Suggest repair considerations at SAA diameter of 15 mm. Long term follow up is indicated as secondary splenic arteriopathy can occur.

Gastrointestinal Bleeding Secondary to Splenic Artery Pseudoaneurysm: A Delayed Complication of a Lumen-Apposing Metal Stent

Lumen-apposing metal stents (LAMSs) have been widely used for drainage of peripancreatic collections. A 71-year-old woman with a history of necrotizing pancreatitis who underwent LAMS placement 3 months ago for symptomatic pancreatic fluid collection presented with hematochezia and hemodynamic instability. Computed tomographic angiography of the abdomen showed concerns for stent erosion into the splenic artery. Esophagogastroduodenoscopy revealed a large pulsating nonbleeding vessel within the LAMS. She underwent a mesenteric angiogram, which showed splenic artery pseudoaneurysm, and coil embolization was performed. Gastrointestinal bleeding secondary to pseudoaneurysm should be considered in patients with recent LAMS placement who present with signs of gastrointestinal bleeding.

Massive Haematochezia due to Splenic Artery Bleeding into the Colon: Unusual Manifestation of Advanced Pancreatic Cancer

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

Left Gastric Artery Pseudoaneurysm Complicating Chronic Calcifying Pancreatitis in a Child

A left gastric artery pseudoaneurysm is a rare complication of pancreatitis and is associated with significant morbidity and mortality. We report a 14-year-old male with severe abdominal pain and a palpable upper abdominal mass, earlier diagnosed as chronic idiopathic calcifying pancreatitis, and awaiting surgical intervention. Computed tomography showed a pseudocyst and a pseudoaneurysm in the lesser sac near the left gastric artery. The patient underwent successful angiographic coiling of the left gastric artery and definitive pancreatic surgery weeks thereafter. The early detection and interventional radiologic management of the vascular complication averted a life-threatening hemorrhage without emergency surgery in a pediatric patient.

Surgical Management of Atraumatic Rupture of Splenic Artery Aneurysm with Spleen Preservation in a Regional Australian Hospital

A 41-year-old male presented to the emergency department of a regional Australian hospital with chest and abdominal pain. He became rapidly haemodynamically unstable and was diagnosed with a ruptured splenic artery aneurysm and large volume hemoperitoneum. Due to the regional location of our small hospital, endovascular services are not available and the patient required emergency laparotomy. At laparotomy, a 2 L hemoperitoneum was evacuated, and the bleeding splenic artery aneurysm was identified and controlled. The aneurysm was approached with a unique technique via division of the gastro colic omentum to enter the lesser sac. This allowed adequate exposure of the splenic artery and proximal and distal control of the vessel was achieved. Adequate perfusion to the spleen was preserved by this surgical technique and splenectomy was therefore not required. This study details the management of this patient, details of the interoperative technique, and a discussion regarding splenic artery aneurysms. Splenic artery control and ligation without splenectomy may be considered in appropriate patients and splenectomy is therefore not always required in cases of hemodynamic instability where open surgical management is performed.

Spontaneous rupture of splenic artery pseudoaneurysm

False aneurysm or visceral artery pseudoaneurysm (VAPA) results from a tear in the vessel wall due to trauma with subsequent periarterial haematoma formation. VAPA is relatively rare, with a reported incidence of 0.1-0.2%, although the actual incidence is not known since many are asymptomatic. Splenic artery pseudoaneurysm is even more rare pathology. Only around 200 cases have been described in the literature. The case report below describes a spontaneous rupture of splenic artery pseudoaneurysm.

Massive upper gastrointestinal bleeding caused by splenic artery pseudoaneurysm rupture: A case report

BACKGROUND

Upper gastrointestinal (UGI) bleeding secondary to a ruptured splenic artery pseudoaneurysm (SAP) is a rare but life-threatening condition. Owing to the low prevalence, it remains a diagnostic and therapeutic challenge. When patients are admitted to the hospital with UGI bleeding, it is easy to overlook the cause of SAP rupture.

CASE SUMMARY

We report the case of a 65-year-old man who was admitted to our hospital with hematemesis. By endoscopic inspection and imaging examination, he was diagnosed with a ruptured SAP that caused UGI bleeding. He underwent surgery and was discharged 20 d after surgery. Now, he has good quality of life, with no incidents of hematemesis or melena.

CONCLUSION

We have documented a case of SAP rupture of unknown etiology, in which the ruptured SAP caused a gastric fistula that eventually resulted in massive UGI bleeding. Through timely diagnosis and treatment, the patient's life was saved. Therefore, even if patients with acute UGI bleeding have no previous history of pancreatic disease, abdominal trauma, etc., it is still suggested that SAP be considered as a differential diagnosis. Once SAP is found, a prompt diagnosis and urgent treatment strategy should be employed to achieve good results.

Splenic artery pseudoaneurysm resulting from gastric ulcer presenting acute upper gastrointestinal bleeding

Splenic artery pseudoaneurysm (SAP) is a rare entity, which occurs when the arterial wall is composed only of the intima and media mainly caused by pancreatitis, or abdominal trauma. Regardless of size, SAP is a high mortality disease that carries a high risk of rupture, causing abdominal pain and severe pancreatic and gastrointestinal bleeding. Here, we describe a rare case of SAP rupture caused by a large gastric ulcer due to Helicobacter pylori infection and NSAIDs use. Understanding the characteristic enhanced CT images of SAP, the complications of splenic infarction, and the therapeutic efficacy of arterial embolization is essential for the clinician to properly diagnose and treat SAP.

Spontaneous rupture of a large splenic artery aneurysm in a 59-year-old male patient with pemphigus vulgaris: a case report

Background

There is currently no information on the anatomical risk factors for splenic artery aneurysm rupture, specifically the location or size of the lesion; therefore, reporting this entity to obtain data and ultimately reduce morbidity and mortality is essential. Here we report a case of a male patient with spontaneous rupture of a large splenic artery aneurysm presenting with abdominal pain.

Case presentation

A 59-year middle-eastern male, with known pemphigus vulgaris presented with a chief complaint of headache and syncope, followed by abdominal pain along with severe metabolic acidosis. A contrast-enhanced computed tomography scan of the abdomen and pelvic showed a splenic artery aneurysm of 33 × 30 mm with a 150 × 90 mm hematoma formation around the aneurysm site. The patient underwent an operation and splenectomy, with confirmation of the diagnosis of ruptured splenic artery aneurysm.

Conclusion

It is essential to consider splenic aneurysm rupture as a second-line differential diagnosis, especially among patients with comorbid diseases, as this can lead to timely and appropriate lifesaving intervention.

Massive bleeding from gastric ulcer-induced splenic artery pseudoaneurysm successfully treated with transcatheter arterial embolization and surgery: a case report

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a routine medical emergency. The most common non-variceal cause is peptic ulcer disease, while a rare presentation is peptic ulcer-induced splenic artery pseudoaneurysm (SAP). Primary endoscopic treatment is generally attempted for UGIB; however, it sometimes fails when arterial etiology is present. In such cases, either transcatheter arterial embolization (TAE) or surgery is necessary, but the choice of treatment is controversial. We present a case that illustrates the utility of both approaches in a gastric ulcer-induced SAP.

CASE PRESENTATION

A 33-year-old male presented with hemorrhagic shock secondary to UGIB. The source of bleeding was identified as an SAP that was caused by a gastric ulcer. TAE enabled temporary bleeding control despite the patient's poor overall condition and limited blood transfusion capability. However, rebleeding occurred soon after stabilization. Ultimately, we performed proximal gastrectomy and splenic artery ligation, and the patient survived.

CONCLUSIONS

SAP is an uncommon occurrence, and angiographic information is important for correctly identifying the source of bleeding. The treatment for SAP bleeding is basically the same as for endoscopically unmanageable non-variceal UGIB, since TAE and surgery each have a different utility, depending on the situation. If surgery is performed, especially SA ligation and gastrectomy, it is important to consider the circulation of the spleen and residual stomach. Using TAE and laparotomy, we managed to save the life of the patient with massive hemorrhage under limited circumstances.

Survival following devastating penetrating gunshots polytrauma with grade 5 liver injuries requiring multiple massive transfusion protocols: A case report and review of the literature

Introduction

A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously.

Case presentation

A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well.

Discussion

High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team.

Conclusion

The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury.

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Severe hepatic injuries may require both operative management & angioembolization.

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Class 4 hemorrhagic shock often requires a massive transfusion protocol.

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Algorithms for operative/angiographic treatment of liver/spleen injuries are needed.

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Delayed hemorrhage after angioembolization for splenic pseudoaneurysm can occur.

A case of a pregnant woman with a special splenic artery aneurysm

Visceral artery aneurysm, especially splenic artery aneurysm, is rare and is usually associated with pregnancy. When such aneurysms rupture, they can be fatal, and they often require emergency surgery. This case report includes a review of the literature and describes a effective multidisciplinary approach to managing this type of aneurysm. We describe the treatment of a ruptured splenic artery aneurysm and the careful coordination of obstetric, vascular surgery, and intensive care teams. The uniqueness of this case arose from the metal embolization coil that was found to have fallen off from a recently embolized ruptured splenic artery aneurysm. The management of this ruptured splenic artery aneurysm and iatrogenic foreign body insult required a combination of multiple specialties to provide life-saving treatment. Such cases should be managed by multidisciplinary teams if institutional resources allow for it.

Fatal gastrointestinal bleeding associated with acute pancreatitis as a complication of Covid-19: a case report

Clinical manifestations of Covid-19 vary widely among patients. Recent studies suggest that up to 15% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. The location of virus-host cell receptors angiotensin-converting enzyme 2 and transmembrane serine protease 2 has an important role in the pathophysiology and presentation of disease. They are expressed in the respiratory tract, as well as other organs and tissues including exocrine and endocrine pancreatic cells. These cells are therefore a possible target for the virus, which could explain the relationship between SARS-CoV-2 infection and pancreatic injury. We report a disastrous collateral effect of the Covid-19 pandemic on a 33-year-old man with chronic renal insufficiency and asymptomatic SARS-CoV-2 infection, who developed acute pancreatitis. Inflammation progressed rapidly toward necrosis and the development of a peripancreatic pseudoaneurysm which subsequently ruptured, causing death.

Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning

Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.

Ruptured Splenic Artery Pseudoaneurysm Causing Hemorrhage Into a Pancreatic Pseudocyst

ABSTRACT

This case report describes fatal exsanguination due to splenic artery hemorrhage into a pancreatic pseudocyst with cystogastrostomy in a 46-year-old woman. The decedent had a complicated medical history including necrotizing pancreatitis, giant pseudocyst formation after cystogastrostomy procedure, and coiling of a hemorrhagic splenic artery. While hospitalized, she underwent embolization of a ruptured splenic artery pseudoaneurysm. Weeks later, she went into hemorrhagic shock and was ultimately pronounced at the hospital. Doctors suspected an upper gastrointestinal (GI) bleed as the cause of death; however, the patient was too unstable to undergo interventional radiology at the time.At autopsy, the pancreas was hemorrhagic and included a 15 × 15 × 15-cm pseudocyst, which contained a metallic stent from a cystogastrostomy. This case describes a unique co-occurrence of numerous common complications of chronic pancreatitis. There are multiple ways by which pancreatitis can cause upper and lower GI bleeds. In this case, the presence of a cystogastrostomy stent allowed for a ruptured pseudoaneurysm to hemorrhage through the pancreatic pseudocyst and into the stomach and duodenum, mimicking the presentation of a more common upper GI bleed. The pseudocyst then ruptured causing abdominal hemorrhage. The passage of hemorrhage through a cystogastrostomy stent is not described in other literature.

Life‐threatening gastrointestinal bleeding from splenic artery pseudoaneurysm due to gastric ulcer penetration treated by surgical hemostasis with resuscitative endovascular balloon occlusion of the aorta: A case report

We report the case of a patient for whom surgical hemostasis of gastrointestinal bleeding due to a splenic artery pseudoaneurysm, which developed due to gastric ulcer penetration, was achieved with resuscitative endovascular balloon occlusion of the aorta without ischemia of organs including the spleen.

Endovascular treatment of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery as a complication of chronic pancreatitis: a case report

A pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. Prompt diagnosis and appropriate treatment are of great clinical importance. We herein present an unusual case of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery that developed as a complication of chronic pancreatitis. It was detected in a timely manner and successfully treated with minimally invasive endovascular therapy.

Cross clamping of the supraceliac aorta is effective for bleeding control in ruptured giant splenic artery pseudoaneurysm when proximal and distal control of the splenic artery is not possible: a case report

Splenic artery pseudoaneurysm is the most common of all the visceral artery pseudoaneurysms. Presentation is often variable and the condition demands immediate diagnosis and management because pseudoaneurysm rupture increases morbidity and mortality. It is associated with pancreatitis and other conditions like abdominal trauma, chronic pancreatitis, pseudocyst of the pancreas, liver transplantation, and, rarely, peptic ulcer disease. We present a case of a giant splenic artery pseudoaneurysm measuring 14x8 cm. Proximal and distal control of the vessels could not be achieved during the procedure because of local adhesions and inflammation and it was necessary to cross clamp the supraceliac aorta to control bleeding.

Gastrointestinal bleeding due to pseudoaneurysms in children

Radiological embolization is the treatment of choice in adults with visceral artery pseudoaneurysm (PSA) and gastrointestinal bleeding, but pediatric data is scanty. We analyzed the etiology, clinical presentation, and outcome of radiological intervention in children with PSA of celiac (CA) or superior mesenteric artery (SMA) branches. Electronic records of children with PSA of CA or SMA branches were reviewed and data on clinical and laboratory profile, radiological intervention, and outcome was recorded. Eleven children with PSA (5 boys, 11 [7-17] years) were studied. Etiology was liver abscess (n 4), abdominal trauma (n 3), pancreatitis (n 3), and indeterminate in 1 case. Ten (91%) patients were symptomatic: abdominal pain (10, 91%), hematemesis/melena (9, 81%), and Quincke's triad (1, 9%). One child with pancreatic pseudocyst was diagnosed incidentally on imaging. Doppler ultrasound identified PSA only in 3 cases, while computed tomography angiography (CTA) picked all cases. Children with liver abscess, trauma, and unknown etiology had PSA from CA (right hepatic artery 7, left hepatic artery 1). Of the 3 pancreatitis cases, 2 had PSA from SMA (inferior pancreatico-duodenal artery and ileal branch) and 1 from CA (left gastric artery). Radiological embolization was done in 9 (81%) cases (coil 6, glue 2, both 1), without any complications or failure. One case resolved spontaneously and 1 died pre-intervention. Nine intervened cases were asymptomatic in follow-up [6 (1-24) months].Conclusion: Liver abscess, trauma, and pancreatitis are causes of PSA of CA and SMA branches in children. A majority present with gastrointestinal bleeding and are identified on CTA. Radiological embolization was safe with 100% success. What is Known: • Pseudoaneurysm of visceral artery is an uncommon cause of gastrointestinal bleeding. • Endoluminal intervention is an established and efficacious treatment modality in adults and preferred over surgery. What is New: • Liver abscess, abdominal trauma and pancreatitis are common causes of celiac artery and superior mesenteric artery branch pseudoaneurysm in children and computed tomography angiography has high sensitivity in identifying these pseudoaneurysms. • Minimally invasive radiological angio-embolization, in the hands of trained radiologists, is a safe and successful modality of treatment in children.

A rare case report of acute upper gastrointestinal hemorrhage due to splenic artery pseudoaneurysm

Splenic artery aneurysm and splenic artery pseudoaneurysm are rare vascular pathologies. The splenic artery represents the third most common site for intra-abdominal aneurysms. In contrast with true splenic artery aneurysm, splenic artery pseudoaneurysm is typically symptomatic, presenting with a range of symptoms, from abdominal pain to hemodynamic instability due to rupture. However, gastrointestinal hemorrhage is an uncommon complication of splenic artery pseudoaneurysm. We report a case of acute upper gastrointestinal hemorrhage due to splenic artery pseudoaneurysm rupture. The patient was successfully treated by endovascular intervention.

Gastric Ulcer Bleeding associated with a Left Gastric Artery Pseudoaneurysm

A left gastric artery (LGA) pseudoaneurysm is known to occur as a complication of abdominal surgery, trauma, or pancreatitis. However, an LGA pseudoaneurysm presenting with gastrointestinal bleeding is rare. A 77-year-old man complained of dizziness and three episodes of melena in the last 24 hours. He did not have a history of surgery, trauma, or pancreatitis. He underwent primary coronary intervention for unstable angina and started dual antiplatelet therapy 1 month prior. Esophagogastroduodenoscopy (EGD) revealed a 3-cm ulcer in the lesser curvature of the gastric high body with a pulsating subepithelial tumor-like lesion in the ulcer. Hemostasis was achieved endoscopically. Three days after the endoscopic hemostasis, hematemesis and hypovolemic shock occurred. Emergent angiography of the superior mesenteric artery revealed an LGA pseudoaneurysm with extravasation. Coil embolization was successfully performed. Three days after the angiographic embolization, EGD revealed improvement of the gastric ulcer, which was covered with exudate, and disappearance of the subepithelial tumor-like lesion. At the 2-month follow-up, EGD showed that the ulcer was in the healing stage.

An Unusual Case of Gastric Outlet Obstruction After Embolization of Gastroduodenal Artery Pseudoaneurysm

Gastric outlet obstruction can occur secondary to intrinsic or extrinsic pathology. Historically peptic ulcer disease was the most common cause of gastric outlet obstruction but now malignancy-associated disease process is more common. Gastric outlet obstruction from mucosal ischemia caused by embolization of gastroduodenal artery is unheard of. This is due to the extensive blood supply of the stomach. We present an unusual presentation of gastric outlet obstruction in a patient with recent embolization of pancreatitis-induced pseudoaneurysm of the gastroduodenal artery. The diagnosis was confirmed with esophagogastroduodenoscopy, computed tomography, and upper gastrointestinal series. The case was managed conservatively with a clear liquid diet and proton pump inhibitors. Repeat upper endoscopies at 1 and 6 months after presentation confirmed disease resolution. No guidelines exist on the management of such cases due to the rarity of the disease.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm

Visceral artery pseudoaneurysms are rare but potentially life-threatening. Among visceral artery pseudoaneurysm (VAPA), the superior mesenteric artery (SMA) pseudoaneurysm is the rarest type. VAPAs are usually related with infection, inflammatory disease, trauma, or arises as a postoperative complication. Early diagnosis and endovascular or surgical intervention are key in lowering the risk of intestinal infarction and death due to potentially fatal hemorrhage. A 49-year-old man presented with cough, shortness of breath, weight loss, and an incidental finding of spontaneous SMA pseudoaneurysm with localized bleed on CT angiography. An urgent endovascular embolization was performed of the pseudoaneurysm, with an adequate outcome and recovery. SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and related morbidity and mortality. Direct oral anticoagulants like apixaban (Eliquis) have also been reported to cause pseudoaneurysm formation by slow and constant bleeding, which may have contributed here as a cause of pseudoaneurysm along with infective endocarditis, which was diagnosed later after endovascular embolization. The treatment can be either an endovascular, endoscopic, or open surgical approach. 

Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Early Thrombosis of Splenic Artery Stent Graft

Splenic artery aneurysms (SAAs) are among the most common visceral aneurysms behind aortic and iliac arteries. Certain factors like aneurysm size (especially giant SAAs), hypertension (HTN), symptomatology, pregnancy, portal hypertension (pHTN), and liver transplantation increase the risk of rupture. Most often found incidentally, but when symptomatic, can present with nonspecific symptoms like nausea, vomiting, anorexia, and epigastric/left upper quadrant pain. Diagnosis can be accomplished with different modalities of CT or MRI and digital subtraction angiography (DSA) being the gold standard for diagnosis. Treatment is usually preferred for aneurysms >2 cm, symptomatic cases, and pregnant women. Various surgical/interventional procedures can be performed and selected based on the patient’s sex, age, location of the aneurysm, size of the aneurysm, and presenting complaints/complications. Endovascular techniques with or without stent-graft placement are being used more, given the minimally invasive nature of these procedures. No clear guidelines exist on initiation of dual antiplatelet therapy (DAPT), but based on guidelines from visceral arterial stenting (especially iliac arteries and renal arteries), multiple case reports/series on SAAs, we highly recommend the usage of DAPT pre- and post-stent-graft placement to improve patency.

Post-embolization outcomes of splenic artery pseudoaneurysms: A single-center experience

PURPOSE

Splenic artery pseudoaneurysms (PSA) are relatively rare but associated with high mortality/morbidity when presenting acutely. Embolization has emerged as the treatment of choice. We aim to evaluate the outcomes of embolization for the treatment of splenic artery PSAs.

METHODS

From 2007 to 2019, all patients that underwent embolization for splenic artery PSAs were included in this IRB-approved review. Evaluated outcomes included complications, morbidity/mortality rates, and 30-day white blood cell count. Student t-tests were performed to compare laboratory values before and after embolization. 5-year survival rates were estimated using Kaplan Meier methodology.

RESULTS

A retrospective analysis of 24 patients (14 males, mean age 51 ± 19 years) who underwent splenic artery PSA embolization was performed. Fifteen PSA embolizations were performed in an emergent setting. There was technical success in 23/24 patients. Etiologies included trauma (10), pancreatitis (9), post-surgical (3), and malignancy (2). Post-embolization patients had a mean length of stay of 19 days and within 30 days, 9 patients developed leukocytosis (median of 14,800/μl). The 5-year survival rate of these patients was 89% [95% CI 75% - 100%]. Post-procedure, 4 patients developed grade 2 complications. Grade 3 complications were observed in 5 patients. One (4.2%) splenic abscess was identified. Of the 19 patients with follow-up imaging, 14 patients had splenic infarcts (5 infarcts were >50% of splenic volume).

CONCLUSIONS

Splenic artery PSAs are encountered in the emergent setting and are most frequently secondary to trauma or pancreatitis. Embolization can be life-saving in these critically ill patients.

Giant splenic artery aneurysm treated surgically with spleen and pancreas preservation

Aneurysms of the splenic artery represent a rare clinical entity, even though they account for 60-70% of all visceral artery aneurysms. Splenic artery aneurysms larger than 5 cm are extremely rare, and they are considered to be giant. Possible causes of splenic artery aneurysm development include: trauma, hormonal and local hemodynamic changes in pregnancy, portal hypertension, arterial degeneration, infection and postsplenectomy occurrence. Surgical treatment of giant splenic artery aneurysms includes procedures that frequently require pancreatectomy and splenectomy. We present a case of a 10.2 cm giant splenic artery aneurysm, firmly adhered to the pancreas, which was treated surgically, with spleen and pancreas preservation. SIMILAR CASES PUBLISHED: Although many cases on treatment of giant splenic artery aneurysm have been published, the majority have described additional visceral resections associated with aneurysmectomy, which is in contrast with our report. Furthermore, aneurysms reaching 10 cm in size were extremely rare.

Hemorrhagic Shock Revealing Rupture of Splenic Artery Pseudoaneurysm Three Years After Post-Traumatic Pancreatitis

Splenic artery pseudoaneurysm (SAP) is an uncommon entity but extremely serious, given the high mortality rate if untreated. Only a limited literature reports association with post-traumatic pancreatitis. We report the case of a 30-year-old man, who was brought to the emergency department (ED) for acute confusion. His past medical history includes trauma of right hypochondriac and epigastric regions, three years ago. Three days before his admission to the hospital, he experienced abdominal pain with nausea and vomiting, without transit disorders or fever. When examined, the patient was disoriented, pale with profuse sweating, cold extremities, and a temperature of 36.3°C. Blood pressure was 75/51 mmHg, heart rate was 126 beats per minute, and oxygen saturation was 96% on room air. The abdominal exam detected generalized abdominal sensitivity. A CT angiography of the abdomen revealed hemoperitoneum of medium abundance, with extravasation of the contrast product from the splenic artery. The size of the spleen was normal with a lower polar hypodense area. In addition, a pancreas of normal size, steady outlinings, seat of bilobed cystic formation suggested a pancreatic pseudocyst. This led us to suspect a rupture of a pseudoaneurysm of the splenic artery. A laparotomy was performed and showed an estimated 2 L hemoperitoneum. Active bleeding was noted from an SAP in the mid-portion of the splenic artery, next to the pancreatic pseudocyst. Ligation of the splenic artery and splenectomy was carried out. The patient was discharged home on the 10th post-operative day. Our case highlights an uncommon cause of hemorrhagic shock, but critical to recognize. Indeed, ruptured SAP needs to be promptly detected and managed, to avoid fatal complications if left untreated.

Splenic artery pseudoaneurysm: Challenges of non-invasive and endovascular diagnosis and management

Splenic artery pseudoaneurysms (PAs) are uncommon and often occur as a complication of pancreatitis or trauma. Unlike true aneurysms, PAs are symptomatic in a majority of cases and patients can present with a constellation of non-specific symptoms. Diagnosis can be challenging due to variation in presenting features and mimicking pathologies. PAs are associated with a very high morbidity and mortality if left untreated. We present an unusual case of a 47-year-old gentleman diagnosed with a splenic artery pseudoaneurysm despite initial negative catheter angiography and discuss the challenges of splenic artery pseudoaneurysm diagnosis and management.

Splenic artery pseudoaneurysm and resultant haematosuccus pancreaticus

Splenic artery pseudoaneurysm (SAP) is a rare and dangerous diagnosis with a high risk of rupture and death. It is the most common cause of main pancreatic duct haematoma-haematosuccus pancreaticus (HP). Neither SAP nor HP have specific clinical features that allow diagnosis without cross-sectional imaging. Upper gastrointestinal haemorrhage and a history of pancreatitis should raise clinical suspicion but ultimately endoscopy and CT are required. We report a case of a 51-year-old man without clinical symptoms in whom cross-sectional imaging was undertaken for incidental severe acute anaemia. This demonstrated stigmata of chronic pancreatitis and the main pancreatic duct was distended with dense material in keeping with haematoma. The diagnosis of a SAP bleeding into the main pancreatic duct was made radiologically. A subsequent oesophago-gastro-duodenoscopy confirmed the diagnosis. The imaging appearances, pathophysiology and management are discussed.