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Splanchnic Artery Aneurysms. Katherine B. Harrington Vascular Surgery Conference May 15, 2006. Splanchnic Artery Aneurysms. Uncommon, but clinically important 22% present emergently, with an overall mortality of 8.5%.

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splanchnic artery aneurysms

Splanchnic Artery Aneurysms

Katherine B. Harrington

Vascular Surgery Conference

May 15, 2006

splanchnic artery aneurysms2
Splanchnic Artery Aneurysms
  • Uncommon, but clinically important
  • 22% present emergently, with an overall mortality of 8.5%.
  • Incidence is increasing as imaging improves, but distribution is constant.
  • One-third will have associated nonvisceral aneurysms as well- aortic, renal, iliac, lower extremity, and cerebral.
splanchnic aneurysm treatment
Splanchnic Aneurysm Treatment
  • Although noninvasive imaging is improving, selective arteriography is the mainstay for planning therapy.
  • Surgery is still considered the gold standard especially for emergent rupture but both prophalactic and post-rupture catheterization are gaining in popularity.
  • Consistent long term results are lacking e.g:

-Study 1: 92% early success rate, 4% mortality at 1 month, and only 1 recurrence at 4 years.

vs.

-Study 2: 57% early success rate, convert to open in 20%.

  • Catheter based interventions more appropriate for those aneurysms involving solid organs, e.g. those embedded in hepatic or pancreatic tissue with well formed collaterals.
splenic artery aneurysms
Splenic Artery Aneurysms
  • Incidence:

-Necropsy series vary between

0.098% to 10.4%.

-0.78% on review of abdominal

arteriographic studies.

-Female to male ratio of 4:1.

  • Pathophysiology:

-Saccular macroaneurysms secondary to acquired derangements of vessel wall: elastic fiber fragmentation, loss of smooth muscle, and internal elastic lamina disruption.

-Occur most often at bifurcations.

-Multiple in 20% of patients.

splenic aneurysms risk factors
Splenic Aneurysms: Risk Factors
  • Fibromuscular Dysplasia:
    • Those with renal dysplasia are 6x more likely to have splenic aneurysm.
  • Portal Hypertension with Splenomeglay:
    • Splenic Aneurysms found in 10-30% of patients.
    • Often multiple aneurysms.
  • Multiple Pregnancies:
    • 40-45% of female patients in case series were grand multiparous
    • Thought to be secondary to both hormonal effects and increased splenic arteriovenous shunting during pregnancy.
  • Other:
    • Nearby inflammation: e.g. chronic pancreatitis -> false aneurysms.
    • Mycotic aneurysms from endocarditis from IVDA.
    • Trauma.
splenic aneurysms presentation
Splenic Aneurysms: Presentation
  • History:
    • 17-20% symptomatic with vague LUQ pain with occasional radiation.
    • 3-9.6% Rupture: Normally bleeds into lesser sac with CV collapse.
      • 25% of ruptures get “Double rupture phenomenon” when blood escapes lesser sac confinement. Provides window for treatment.
      • Ruptures can also present as GI bleeding or arteriovenous fistulas.
  • Exam:
    • -- Bruit rare.
    • Normally under 2cm, so rarely
    • palpable pulsatile mass.
  • Imaging/Labs:
    • Often found incidentally with
    • CT/MRI/Arteriography.
    • 70% will have curvilinear, signet
    • ring calcification on Xray.
    • MMP-9 for monitoring progression.
splenic aneurysm treatment indications
Splenic Aneurysm: Treatment Indications
  • Indications for Treatment:
    • Symptomatic Aneurysms
    • Aneurysms > 2 cm.
    • OLT patients: mortality post rupture >50%.
    • Pregnant patients or those who want to conceive:
      • Maternal mortality post rupture –70%, fetus- 75%.
  • Not associated with increased risk for rupture:
    • Calcifications
    • Age >60
    • Hypertension.
splenic aneurysms treatment options
Splenic Aneurysms: Treatment Options
  • Aneurysmectomy, Aneursymorraphy, Simple ligation-exclusion without arterial reconstruction. Restoration of splenic artery continuity is rarely indicated.
  • Endovascular Coiling-still with unsure failure rates, risk of splenic infarction.
  • Stent Grafting- rare when splenic flow is needed for other theraputic reason like mesocaval shunting.
splenic aneurysm treatment
Splenic Aneurysm: Treatment
  • Proximal Aneurysms:
    • Excise Gastrohepatic ligament.
    • Expose through lesser sac.
    • Ligate entering and exiting vessels.
    • Those not embedded in pancreatic tissue are excised.
  • Mid-Splenic Aneurysms:
    • Generally associated with pancreatitis- generally false aneurysms.
    • Clamp proximal splenic artery.
    • Ligate arteries with prolene from within aneurysmal sac to reduce infection.
    • Placement of external drains in associated psuedocysts.
    • May need distal pancreatectomy.
  • Peri-Hilar:
    • Conventionally treated by splenectomy.
    • Now simple suture obliteration, aneurysmorraphy, or excision recommended.
hepatic artery aneurysms
Hepatic Artery Aneurysms
  • Incidence:
    • 20% of splanchnic aneurysms.
    • 1/3 associated with splenic aneurysms.
    • Male: Female 2:1.
    • Most common in patients in their 50s.
    • Normally solitary
    • Average >3.5 cm. Those >2cm tend to be saccular.
    • 80% Extrahepatic, 20% intrahepatic.
      • Common hepatic: 63%
      • Right hepatic: 28%
      • Left Hepatic 5%
      • Right and Left hepatic: 4%.
hepatic artery aneurysms11
Hepatic Artery Aneurysms
  • Etiology:
    • Medial degeneration- 24%.
    • False aneurysms secondary to trauma- 22%
    • Infectious (IVDA)- 10%
    • Oral amphetamine use- ?
    • Periarterial inflammation, e.g. cholecystitis or pancreatitis- rare.
hepatic aneurysms presentation
Hepatic Aneurysms: Presentation
  • Most likely asymptomatic.
  • Can present as RUQ or epigastric pain +/- radiation to the back not associated with meals.
  • Manifest as extrahepatic bile duct obstruction when large aneurysms compress biliary tree.
  • Pulsatile masses and bruits rare.
  • Rupture risk ~20-44%. Mortality > 35%.
  • Rupture: into hepatobiliary tract and peritoneal cavity with equal frequency.
    • Rupture into bile ducts produces hematobilia- colic pain, massive GI bleeding with hematemesis, jaundice, and fevers are common. More common with traumatic intrahepatic false aneurysms.
    • Rupture into peritoneal cavity produced acute abdomen, CV colapse. More likely in PAN associated aneurysms.
hepatic aneurysms treatment
Hepatic Aneurysms: Treatment
  • Common Hepatic Artery:
    • Extensive collaterals allow aneurysmectomy or exclusion without reconstruction.
    • However, 5 minute occlusion trial recommended to confirm flow to prevent necrosis.
    • Those with already existing parenchymal disease may need reconstruction.
hepatic aneurysms treatment14
Hepatic Aneurysms: Treatment
  • Proper Hepatic Artery and Extrahepatic branches:
    • Requires revascularization.
    • Subcostal or vertical midline incision.
    • Care should be taken to avoid common bile duct injury near the proximal hepatic artery near the gastroduodenal artery and pancreaticoduodenal artery.
hepatic aneurysm repair options
Hepatic Aneurysm: Repair options
  • Aneurysmorrhaphy with or without vein patch closure, especially for traumatic false aneurysms.
  • Resection and reconstruction for fusiform or saccular with interpostion grafts using autogenous saphenous vein. Use spatulation of the artery and vein graft to produce ovoid anastomoses.
  • Aortohepatic bypass when interpostion not possible:
    • Extended Kocher manuver, medial viseral rotation.
    • Vein graft from aorta behind duodenum to porta hepatis.
    • Spatulated vein to artery with end-to-end anastomosis.
  • Liver parenchymal resection for intrahepatic aneurysms nonamenable to resection.
  • Endovascular coiling especially for traumatic- but with 42% recanulization reported.
superior mesenteric artery aneurysms
Superior Mesenteric Artery Aneurysms
  • 5.5% of all splanchnic aneurysms.
  • Affects men and women equally.
  • Affects the first 5cm of the SMA.
  • Most often infectious in etiology: Nonhemolytic Strep- related to Left sided endocarditis.
  • Dissecting aneurysms are rare, but more common than in other visceral aneurysms.
  • Trauma- rare cause.
sma aneurysm presentation
SMA Aneurysm: Presentation
  • Most are symptomatic
  • Intermittent upper abdominal pain progressing to constant epigastric pain.
  • Half of patients have a tender pulsatile mass that is not rigidly fixed.
  • Dissection or propagation can cause intestinal angina.
  • 40% Rupture rate.
sma aneurysm treatment
SMA Aneurysm: Treatment
  • Aneursymorrhaphy or simple ligation without reconstruction is acceptible, but try temporary occlusion of SMA with assesment of bowel viability.
  • Aneursymectomy hazardous secondary to surrounding SMV and pancreas.
  • Distal lesions through transmesenteric route. Proximal lesions visualized through retroperitoneal.
  • Interpostition graft or aortomesenteric bypass after exclusion is rarely accomplished/done.
  • Transcatherter occulsion used, but stent-grafts generally not favored secondary to high infectious etiology percentage.
celiac artery aneurysms
Celiac Artery Aneurysms
  • Equal sex predilection. 50’s.
  • Mostly medial degeneration related. Trauma and infection rare.
  • Most are asymptomatic.
  • Bruits heard frequently, and palpable puslatile mass in 30%.
  • Risk of rupture 13%. Normally intraperitoneal.
celiac aneurysms treatment
Celiac Aneurysms: Treatment
  • Aneursymectomy with aortoceliac bypass with graft originating from supraceliac aorta, or aneurysmectomy with primary reanastomosis.
  • OR celiac axis ligation. Do not use with liver dx.
  • Abdominal route, medial visceral rotation, transection of crus and median arcuate ligament to expose celiac. If celiac is particularly large may need a thoracoabdominal approach.
gastric and gastroepiploic aneurysms
Gastric and Gastroepiploic Aneurysms
  • Likely etiology medial degeneration.
  • Often solitary
  • Gastric artery aneurysms are 10x more common than gastroepiploic.
  • Men:Women 3:1. 50s and 60s.
  • Over 90% present as ruptures with 70% with serious GI bleeding. Very few admit to preceding symptomatology.
gastric and gastroepiploic aneurysms treatment
Gastric and Gastroepiploic Aneurysms- Treatment
  • Treatment directed at stopping the hemorrhage- approximately 70% mortality post-rupture.
  • Ligation with or without excision of aneurysm is appropriate for extraintestinal lesions.
  • Intramural aneurysms and those bleeding into the GI tract should be excised with the portions of associated gastric tissue.
jejunal ileal and colic aneurysms24
Jejunal, Ileal, and Colic Aneurysms
  • Pathogenesis poorly understood.
  • Equal sex distribution. 60s.
  • Most are solitary, mms to 1cm.
  • Multiple lesions seen with immunologic injury, septic emboli, or necrotizing vasculitides.
  • Rarely symptomatic.
  • Jejunal rupture rare, colic rupture more common.
  • 20% rupture mortality.
jejunal ileal and colic aneurysms treatment
Jejunal, Ileal, and Colic Aneurysms:Treatment
  • Arterial ligation, aneurysmectomy, and resection of affected bowel if blood supply is compromised.
gastroduodenal pancreaticoduodenal and pancreatic aneurysms
Gastroduodenal, Pancreaticoduodenal, and Pancreatic Aneurysms
  • Gastroduodenal aneurysms are 1.5% of splanchnic aneurysms and pancreaticoduodenal and pancreatic are 2%.
  • Men:Female is 4:1.
  • Etiology: Periarterial inflammation, actual vascular necrosis, and erosion by expanding pancreatic psuedocysts. False aneurysms more common.
  • 60% present as rupture, with a 49% mortality.
  • Most are symptomatic with epigastric pain radiating to back, because most are pancreatitis related.
  • 75% tend to have GI bleeding into stomach or duodenum.
gastroduodenal pancreaticoduodenal and pancreatic aneurysms27
Gastroduodenal, Pancreaticoduodenal, and Pancreatic Aneurysms
  • Treatment: Pancreaticoduodenal and pancreatic artery aneurysms are more difficult to treat secondary to their small size and being embedded in the pancreas. Intraoperative arteriography is useful.
  • Suture ligature of entering and exiting vessels without extra-aneurysmal dissection is appropriate.
  • Those involving pancreatic tissue should place appropriate drains and/or resection pancreatic tissue as needed.
  • Transcatheter embolization has been described, but may only serve as a temporizing step.
  • Stent-grafting of the SMA which occludes the pancreaticoduodenal has also been described.