Contrast Enhanced Ultrasonography for the Evaluation of Coil Embolization of Splenic Artery Aneurysm

Abstract

HomeCirculationVol. 122, No. 11Contrast Enhanced Ultrasonography for the Evaluation of Coil Embolization of Splenic Artery Aneurysm Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBContrast Enhanced Ultrasonography for the Evaluation of Coil Embolization of Splenic Artery Aneurysm Fabio Piscaglia, Silvia Gualandi, Marzia Galassi, Emanuela Giampalma, Rita Golfieri and Luigi Bolondi Fabio PiscagliaFabio Piscaglia From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author , Silvia GualandiSilvia Gualandi From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author , Marzia GalassiMarzia Galassi From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author , Emanuela GiampalmaEmanuela Giampalma From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author , Rita GolfieriRita Golfieri From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author and Luigi BolondiLuigi Bolondi From the Division of Internal Medicine (F.P., S.G., M.G., L.B.) and the Radiology Unit (E.G., R.G.), Department of Digestive Disease and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Bologna, Italy. Search for more papers by this author Originally published14 Sep 2010https://doi.org/10.1161/CIRCULATIONAHA.110.955518Circulation. 2010;122:e451–e454A 65-year-old woman with compensated liver cirrhosis secondary to hepatitis C virus infection was under surveillance for early detection of hepatocellular carcinoma with ultrasonography and, due to suboptimal ultrasound feasability, at longer intervals with computed tomography (CT). During follow-up, a splenic artery aneurysm appeared and progressively increased from 18 mm to ≈30 mm in diameter over a 9-month interval. The patient had severe splenomegaly secondary to portal hypertension and hypersplenism with a low platelet count (≈30.000/mL). Percutaneous arterial embolization was proposed to the patient1 because severe portal hypertension was considered a contraindication to surgical splenectomy. Embolization was carried out, preceded by platelet infusion, using “fibered” coils and interlocking detachable coils without complications.Eight weeks later, the patient underwent abdominal CT as part of the surveillance program for hepatocellular carcinoma; no nodule with pattern of hepatocellular carcinoma was identified; at the splenic level, frank metallic artifacts were evident and prevented assessment of treatment efficacy (Figure 1) as described in previous reports from the literature with this technique.2Download figureDownload PowerPointFigure 1. CT scan of the upper abdomen at a level passing through the treated splenic aneurysm. Arrows, metallic artifacts (similar to rays departing from the coils) don’t allow adequate assessment of treatment efficacy.To investigate the splenic aneurysm status, an attempt was made with conventional ultrasound (Figure 2) and color duplex-doppler ultrasonography, which failed to provide definitive and unquestionable information about the success of the embolization. Doppler ultrasound detected aneurismal arterial signals, but this mere detection does not signify unsuccessful of treatment because the lumen of the splenic artery is expected to remain at least partially patent (Figure 3). Briefly, ultrasonography was unable to demonstrate whether the lumen of the aneurismal sac had been completely obliterated or persisted patent (and at what extent) (Figures 2 and 3). Because magnetic resonance angiography was also expected to suffer from artifacts similar to those of CT, assessment of treatment efficacy would have required digital subtraction angiography, but this is an invasive procedure with additional hazards in a patient with low platelet count. For these reasons, ultrasound was immediately integrated with contrast enhancement. Contrast enhanced ultrasound (CEUS) works at second harmonic ultrasound frequency,3 which reduces artifacts and is able to detect flowing as well as stationary microbubbles, with a sort of subtraction of background echoes (as tissues mainly produce echoes at the fundamental frequency, which is removed). CEUS was performed with a low amount of contrast agent, injected in an antecubital vein (1 mL of SonoVue, Bracco, Milan, Italy) to limit disturbance from contrast signals deriving from surrounding vessels, namely, portosystemic collaterals at the splenic hilum. CEUS clearly showed persistent patency of the peripheral parts of the aneurysm, around the metallic coils, which instead included a thrombosed core, anechoic as devoid of any contrast perfusion (Figure 4A and B; see also Movie I in the online-only Data Supplement). Such a pattern indicated an incomplete effect of the first embolization, information that was not provided by the previous CT. Based on such an examination, the patient was resubmitted to arteriography, which confirmed the findings of CEUS (Figure 5) and allowed further metallic coil deployment. Follow-up examination with CEUS 2 days later confirmed complete obliteration of the aneurysm (Figure 6A) and partial splenic infarction at the upper pole due to dislodgement of a single metallic coil (Figure 6B). Download figureDownload PowerPointFigure 2. Conventional gray scale B-mode evaluation of the spleen through a left intercostal scan. Arrows, hyperechoic dot-like structures, with ring-down artifacts, can be observed at the splenic hilum, corresponding to metallic coils that prevent adequate visualization of the lumen of the aneurysm. S, spleenDownload figureDownload PowerPointFigure 3. Left intercostal duplex-doppler ultrasound scan of the splenic region. White arrow, color duplex-doppler evaluation within the splenic aneurysm shows presence of pulsatile arterial flow (empty dotted arrow). Color duplex doppler, however, is unable to distinguish between patency of the whole aneurysm or only the main lumen of the artery (with closure of the aneurysmatic sac).Download figureDownload PowerPointFigure 4. A, Early arterial phase (14 seconds after contrast injection). The lumen of the aneurysm is clearly evident at CEUS, appearing as a semilunar hyperechoic structure (arrows), whereas the central area appears echofree (black) (arrowhead), corresponding to thrombosed portions, determined by coils deployment. S, spleen. The splenic parenchyma has been poorly reached by contrast at this time point and still remains black. At conventional B-mode ultrasound (showed in the left part of each panel in gray scale), no information can be obtained about patency of the lumen due to artifacts. B, Full arterial phase (24 seconds after injection). The splenic parenchyma (S) becomes perfused by contrast, whereas the signal intensity within the patent portions of the aneurysm has become greater. Splenic veins are still scarcely perfused due to the limited amount of contrast injected (1 mL of SonoVue).Download figureDownload PowerPointFigure 5. Percutaneous angiography. A core of thrombotic material encapsulated by metallic coils can be observed within the aneurysm (black arrow). The peripheral portions of the aneurysm are still patent and perfused (asterisks). S, spleen; B, bowel; C, catheter.Download figureDownload PowerPointFigure 6. A, CEUS 2 days after re-embolization shows absence of any perfusion within the splenic artery aneurysm (arrows). S, spleen. B, Upper portion of the spleen is nearly devoid of any contrast, indicating localized infarction due to dislodgement of a metallic coil from the aneurysm at the upper part of splenic hilum (arrowhead). S, spleen; I, infarction.The possibility of optimal assessment of coil embolization of splenic artery aneurysm was confirmed in other patients, including 1 patient who received splenic aneurysm embolization 7 years before. Also, in this case, CEUS showed a detailed evaluation of the extent of coil-induced thrombosis and size of the residual patent lumen (Figure 7). Download figureDownload PowerPointFigure 7. CEUS evaluation of thrombotic and residual patent lumen of a splenic aneurysm treated by coil embolization 5 years before in a liver transplantation patient. Left and right panels show the same image taken concurrently with and without contrast agent. Left, Conventional gray scale B-mode ultrasonography is unable to discriminate whether the lumen remained patent and at what extent. Metallic coils appear as hyperechoic structures along the outer border of the aneurysm. Right, CEUS clearly demonstrates peripheral eccentric thrombosis (semilunar anechoic structure within the left part of the aneurysm, empty arrow) determined by the coils (arrowhead), leaving a residual patent lumen of 13 mm in diameter (asterisk). S, spleen.The present images suggest that CEUS, a low-cost, noninvasive, safe technique,4 is worth attempting to assess arterial aneurysms treated by coil embolization. CEUS is recommended even if conventional ultrasonography appears technically unsatisfactory due to artifacts because second harmonic imaging can eliminate most of them, provided that the aneurysm can be preliminarily identified with ultrasonography. CEUS is able to show contrast distribution within the aneurysm, even in the presence of coils, and it might rescue cases in which adequate assessment of the aneurysm is prevented by artifacts at CT or magnetic resonance imaging, limiting unnecessary, especially invasive radiological techniques.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/122/11/e451/DC1.DisclosuresFabio Piscaglia and Luigi Bolondi received consultancy fees for giving scientific lectures during events sponsored by Bracco.FootnotesCorrespondence to Fabio Piscaglia, MD, PhD, Division of Internal Medicine, Department of Digestive Diseases and Internal Medicine, S. Orsola-Malpighi University and General Hospital, Via Albertoni 15, 40138, Bologna, Italy. E-mail [email protected]References1 Guillon R, Garcier JM, Abergel A, Mofid R, Garcia V, Chahid T, Ravel A, Pezet D, Boyer L. Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients. Cardiovasc Intervent Radiol. 2003; 26: 256–260.CrossrefMedlineGoogle Scholar2 Loffroy R, Guiu B, Cercueil JP, Lepage C, Cheynel N, Steinmetz E, Ricolfi F, Krausé D. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg. 2008; 22: 618–626.CrossrefMedlineGoogle Scholar3 Claudon M, Cosgrove D, Albrecht T, Bolondi L, Bosio M, Calliada F, Correas JM, Darge K, Dietrich C, D'Onofrio M, Evans DH, Filice C, Greiner L, Jäger K, Jong N, Leen E, Lencioni R, Lindsell D, Martegani A, Meairs S, Nolsøe C, Piscaglia F, Ricci P, Seidel G, Skjoldbye B, Solbiati L, Thorelius L, Tranquart F, Weskott HP, Whittingham T. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS). Update 2008Ultraschall Med. 2008; 29: 28–44.Google Scholar4 Main ML, Goldman JH, Grayburn PA. Ultrasound contrast agents: balancing safety versus efficacy. Expert Opin Drug Saf. 2009; 8: 49–56.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lamparski K, Procyk G, Bartnik K, Korzeniowski K, Maciąg R, Matsibora V, Sajdek M, Dryjańska A, Wnuk E, Rosiak G, Maj E, Januszewicz M, Gąsecka A, Ostrowski T, Kaszczewski P, Gałązka Z and Wojtaszek M (2023) Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography, Journal of Clinical Medicine, 10.3390/jcm12030792, 12:3, (792) Chaer R, Abularrage C, Coleman D, Eslami M, Kashyap V, Rockman C and Murad M (2020) The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms, Journal of Vascular Surgery, 10.1016/j.jvs.2020.01.039, 72:1, (3S-39S), Online publication date: 1-Jul-2020. Varghese K, Viegas M and Adhyapak S (2015) A Therapeutic Dilemma – Coronary Artery Stenting in the Setting of Thrombocytopaenia, Heart, Lung and Circulation, 10.1016/j.hlc.2015.08.002, 24:12, (e214-e216), Online publication date: 1-Dec-2015. Liu B, Zhou L, Liu M and Xie X (2014) Giant peripancreatic artery aneurysm with emphasis on contrast-enhanced ultrasound: report of two cases, Journal of Medical Ultrasonics, 10.1007/s10396-014-0572-6, 42:1, (103-108), Online publication date: 1-Jan-2015. September 14, 2010Vol 122, Issue 11 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.110.955518PMID: 20837933 Originally publishedSeptember 14, 2010 PDF download Advertisement SubjectsDiagnostic TestingImagingPeripheral Vascular Disease