Splenic aneurysms: natural history and treatment techniques

Long-term Outcome Comparison of 2 Techniques for Embolization of Splenic Artery Aneurysms

PURPOSE

The aim of the study is to analyze our single-center experience in endovascular treatment of splenic artery aneurysms (SAAs) with transcatheter coil embolization, comparing long-term outcomes of packing and sandwich techniques.

MATERIALS AND METHODS

Between January 2010 and December 2021, 28 patients with certain diagnosis of non-ruptured asymptomatic SAA were treated with 2 different embolization techniques (packing, n=10, and sandwich, n=18). Early outcomes assessed were technical success, overall mortality, mean hospital stay, post-embolization syndrome rate, and freedom from splenectomy rate. Estimated 5-year outcomes in terms of freedom from sac reperfusion, and freedom from reintervention were evaluated and compared between the 2 different embolization techniques.

RESULTS

The mean SAA diameter was 2.8±0.8 cm. Overall technical success rate was 100%. Intraoperative and 30-day mortality rates were 0 in both groups. One patient in the sandwich group required a postoperative splenectomy. The mean follow-up period was 58.3±44.5 months. Estimated overall 5-year survival was 86.7%. Five-year freedom from sac reperfusion was 100% in the sandwich group, and 85.7% in the packing group, with no difference between the 2 groups (p=0.131), whereas freedom from reintervention was 100% in the sandwich group, and 75% in the packing group with a statistically significant difference (p=0.049; log-rank=3.750).

CONCLUSIONS

Embolization of SAAs seemed to be safe and effective with 100% of technical success rate and good perioperative results. Both sandwich and packing techniques yielded promising results also in the long-term period.

CLINICAL IMPACT

Transcatheter coil embolization of splenic artery aneurysms seems to be a safe and effective procedure with a 100% technical success and satisfactory perioperative outcomes. Sandwich and packing techniques offer good results in the long-term period. Freedom from reintervention seems to be optimal and comparable between the 2 techniques.

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.

A case of splenic artery pseudoaneurysm rupture presenting as rectal bleeding in a regional hospital

Splenic artery pseudoaneurysm is a rare phenomenon most associated with chronic pancreatitis or previous trauma. Complications can include erosion and rupture into local structures, a situation that carries a reported mortality of 10–40%. A 58-year-old male with chronic alcoholic pancreatitis and a known splenic artery pseudoaneurysm presented to the emergency department of a regional hospital with rectal bleeding and sepsis. Computed tomography revealed a peri-splenic mass communicating with the splenic flexure. The patient was taken for an emergency splenectomy and left hemicolectomy and was confirmed to have rupture of the splenic artery aneurysm into the large bowel. This case presented with comparable features reported in the literature and demonstrates that access to emergency specialist surgical services in a regional setting offers the capability to manage rare, life threatening surgical emergencies.

Multiple Incidental Unruptured Splenic Artery Aneurysms Following Severe Trauma

Splenic artery aneurysm is a relatively rare, potentially life-threatening condition due to its high potential for rupture. We report a case of two incidentally found unruptured splenic artery aneurysms in a 39 year-old female victim of severe trauma resulting from a motor vehicle accident (MVA). Management by coiling of the splenic artery aneurysm and embolization to the entire segment distal to it was successfully performed for this patient.

Vascular Remodeling and Immune Cell Infiltration in Splenic Artery Aneurysms

Rupture of splenic artery aneurysms (SAAs) is associated with a high mortality rate. The aim of this study was to identify the features of SAAs. Tissue sections from SAAs were compared to nonaneurysmal splenic arteries using various stains. The presence of intraluminal thrombus (ILT), vascular smooth muscle cells (VSMCs), cluster of differentiation (CD)-68+ phagocytes, myeloperoxidase+ neutrophils, CD3+, and CD20+ adaptive immune cells were studied using immunofluorescence microscopy. Analysis of SAAs revealed the presence of atherosclerotic lesions, calcifications, and ILT. Splenic artery aneurysms were characterized by a profound vascular remodeling with a dramatic loss of VSMCs, elastin degradation, adventitial fibrosis associated with enhanced apoptosis, and increased matrix metalloproteinase 9 expression. We observed an infiltration of immune cells comprising macrophages, neutrophils, T, and B cells. The T and B cells were found in the adventitial layer of SAAs, but their organization into tertiary lymphoid organs was halted. We failed to detect germinal centers even in the most organized T/B cell follicles and these lymphoid clusters lacked lymphoid stromal cells. This detailed histopathological characterization of the vascular remodeling during SAA showed that lymphoid neogenesis was incomplete, suggesting that critical mediators of their development must be missing.