Incidental splenic artery aneurysms: systematic literature review and single-centre study.

Endovascular management of splenic arterial aneurysms

The management of splenic artery aneurysms: Experience with 23 cases

α-1 antitrypsin deficiency and splenic artery aneurysm rupture: an association?

Theoretically, patients with alpha 1-antitrypsin deficiency may be vulnerable to the development of splenic artery aneurysms. alpha-1 antitrypsin deficiency can induce cirrhosis with portal hypertension, and resulting protease-antiprotease imbalances may exaggerate arterial wall weakness due to proteolysis of arterial structural proteins. A splenic artery aneurysm rupture 7 days after liver transplantation provoked a reassessment of the incidence of this phenomenon in a liver transplant population. Case records from three institutions and the results of a survey sent to 126 liver transplantation programs in the United Network for Organ Sharing database were reviewed. The incidence of splenic artery aneurysm rupture in the peritransplantation period, etiology of liver disease associated with this phenomenon, and recommendations regarding management of splenic artery aneurysms was assessed. Twenty-one cases of splenic artery aneurysm rupture were identified. alpha-1 antitrypsin deficiency was the most common cause of cirrhosis in the majority of identified patients who presented with splenic artery aneurysm rupture, which was associated with a mortality rate of 57%. Respondents to the survey indicated that a preoperative evaluation was warranted if a splenic artery aneurysm was suspected; however, no consensus regarding management exists. The presence and risk of rupture of splenic artery aneurysms may be greater in patients with alpha-1 antitrypsin deficiency. If identified before rupture, an aggressive approach to diagnosing and treating these aneurysms should be initiated. At present, no consensus exists regarding the management of splenic artery aneurysms.

Unruptured Intracranial Aneurysms.

Infected splenic artery aneurysm with associated splenic abscess formation secondary to bacterial endocarditis: Case report and review of the literature

We read with great interest the recent article1 describing Moon et al.'s experience with splenic artery aneurysms (SAAs) in adult living donor liver transplant recipients. The authors retrospectively reviewed 44 liver transplant recipients with SAAs out of 310 patients. Interestingly, portosystemic shunts were present in all patients, with the diameter of these collaterals being the only significant factor for the presence of SAAs. Three patients presented with a ruptured aneurysm in the postoperative period, and 2 of these had undergone splenic artery ligation at the time of transplantation. After this experience, the authors changed their policy, and they now recommend aggressive treatment of SAAs, either surgical or radiological, within 24 hours of transplantation, before or afterward. Nevertheless, other facts are also worth noting in this report. First, despite the recommendation of proximal and distal ligation of the splenic artery for a unique extrasplenic aneurysm, only proximal ligation was possible in 6 patients, and 2 of them suffered an SAA rupture. Second, 32 patients with SAAs ranging from 10.5 to 25 mm were not treated during the study period; they had no complications, and they experienced a significant reduction of the mean aneurysm diameter after 1-year of follow-up. Our experience is similar to the latter finding. From February 1996 to May 2009, 786 liver transplants were performed in our institution with whole grafts from deceased donors. In a retrospective analysis, we found 7 recipients with SAAs diagnosed during the transplant assessment. All patients had a unique SAA in the distal third of the splenic artery with a diameter ranging from 10 to 30 mm. No prophylactic treatment was indicated, and no complications occurred. After a median follow-up of 106 months (range = 5-132 months), the size of the SAAs decreased from 30 to 20 mm in 2 patients, whereas the others remained unchanged. The incidence of SAAs in our series was probably underestimated because of the retrospective analysis; however, we have had no cases of urgent reoperation or death due to SAA rupture. Although there seems to be a general consensus to treat symptomatic SAAs, asymptomatic SAAs greater than 20 mm, and those in liver transplant candidates,2, 3 this appears to be based only on reports of complicated aneurysms, whereas the natural history of untreated SAAs in transplant patients remains poorly understood. Three reports of untreated SAAs in no transplant setting were revised in a recent report, and only 1 of 191 patients suffered spontaneous rupture after a mean follow-up that ranged from 15 to 75 months.2 Nevertheless, abdominal surgery is considered to be a risk factor for SAA rupture,4 and the reported incidence of this complication is 2% to 4% in the posttransplant period.1, 3 Moreover, with respect to the treatment of SAAs in liver transplant candidates during the perioperative period, some facts must be considered: (1) splenectomy during liver transplantation might be difficult and a cause of severe intraoperative complications1; (2) distal splenic artery ligation for single extrasplenic aneurysms is usually difficult to accomplish because of technical difficulties; (3) proximal ligation alone might be enough to prevent the rupture of extrasplenic aneurysms but not the rupture of hilar and intrasplenic ones, which unfortunately are the most common1; and (4) aneurysm embolization or complete arterial embolization in hilar and multiple aneurysms seems to be very effective, although complications are not uncommon.1, 3, 5 In summary, the incidence of SAA rupture in liver transplant patients is not high, adequate surgical treatment is frequently challenging, and arterial splenic embolization is not free from complications. In this scenario, the aggressive treatment of all liver transplant candidates with SAAs is debatable. In our opinion, more studies are needed to determine the risk factors related to the rupture of SAAs in liver transplant recipients and to define a group of patients who may benefit from preventive treatment. Until then, we are very reluctant to treat all SAAs in liver transplant candidates but instead would prefer to treat them only when they are symptomatic, are greater than 30 mm, or show enlargement during a close follow-up with repeated computed tomography angiograms. Mikel Gastaca*, Alberto Ventoso*, Andrés Valdivieso*, Jorge Ortiz de Urbina*, * Hepatobiliary Surgery and Liver Transplantation Unit University Hospital of the Cross at Bilbao Baracaldo, Vizcaya, Spain.

The incidence of splenic artery aneurysm (SAA) in patients with cirrhosis ranges from 7 per cent to 17 per cent. SAA rupture after liver transplantation (LT) is reported to result in significant morbidity and mortality. We report our experience with SAA in LT candidates. From September 1995 through August 2002, 14 LT candidates were diagnosed with SAA. Twenty SAA occurred in 14 patients with an average diameter of 20 mm. Eleven patients qualified for LT; to date, seven have been transplanted. No intervention for SAA occurred prior to LT. Of the seven patients transplanted, four had SAA identified prior to LT. Three were treated at LT and are alive; the fourth had postoperative splenic artery embolization followed by splenectomy and expired on day 109 from duodenal ulcer complications. Three of seven patients had undiagnosed SAA at LT. One required emergency splenectomy for SAA rupture and is alive at 44 months. The remaining two received no treatment; one suffered a late septic death and one is alive at 15 months. No ruptures occurred in our pre-LT population, suggesting that definitive management can await LT. We recommend that all patients undergo four-phase computed tomography or magnetic resonance angiography (MRA) as part of the LT evaluation and that identified SAA be resected at transplantation.

The contemporary management of splenic artery aneurysms

Cost-effectiveness of endovascular repair, open repair, and conservative management of splenic artery aneurysms

To summarize the clinical feature of splenic artery aneurysms (SAA) in OLT recipient, and review the experience in diagnosis and management. The clinical data, results of four-phase CT scanning and CT angiography of 450 recipients, who underwent OLT from December 2001 to December 2003 were analyzed statistically. Twenty of 450 recipients were diagnosed as SAA, the incidence was about 4.4%. Nineteen of them were diagnosed by four-phase CT scanning. Fifteen patients did not receive any treatment for SAA during OLT, but two of them suffered SAA rupture after OLT, among which one died of hemorrhagic shock although emergency operations were performed. The five patients, who were performed splenectomy with SAA resection during transplantation, recovered successfully after OLT, and their grafts' function was satisfactory. Morbidity of SAA is higher in patients of liver cirrhosis. Four-phase CT scanning can diagnose SAA exactly. In the early period post-OLT, SAA rupture happens frequently, so SAA resection should be performed during transplantation.

Splenic artery aneurysms (SAAs), occurring in 7% to 17% of patients with cirrhosis, often result in catastrophic rupture after liver transplantation. We had experienced 3 cases of ruptured SAAs after adult living donor liver transplantation (LDLT), and we then performed this study to find risk factors for coexisting SAAs in liver transplant candidates with cirrhosis and to propose ideal approaches for them. Preoperative and postoperative computed tomography angiograms and axial views were reviewed for 310 adult LDLT recipients who had cirrhosis from January 2004 to August 2005. The recorded variables were the preoperative diagnosis, the presence of SAA and its characteristics, the splenic artery (SA) diameter, and the presence and size of portosystemic collaterals. Devastating SAA rupture accompanied by hypovolemic shock occurred on postoperative days 6, 82, and 8, respectively, and it was treated emergently by embolization in cases 1 and 2 and by splenectomy in case 3. Cases 1 and 3 recovered well, but case 2 died of an unrelated cause with a long hospital stay. The incidence of SAA during the study period was 14.2% (44/310), and the size was 16.6 +/- 5.7 mm. Most SAAs were single (70.6%, 31/44) and were located in the distal one-third of the SA (82.4%, 36/44). Large portosystemic collaterals demonstrating longstanding severe portal hypertension were significantly correlated with the occurrence of SAAs. Nine patients with SAAs were preventively treated by proximal ligation (n = 4) intraoperatively and by embolization (n = 5) 1 day before or after LDLT. No patient showed severe postembolization syndrome. In conclusion, a careful preoperative evaluation of SAAs by high-resolution 3-dimensional computed tomography in liver transplant candidates, especially in those showing large portosystemic collaterals, is merited. Preventive treatment should be encouraged regardless of the size in order to avoid severe morbidity and mortality related to SAA rupture, and methods such as radiological and surgical interventions need to be individualized according to the location and number of SAAs.

Management of splenic artery aneurysms: the significance of portal and essential hypertension

Splenic artery aneurysm (SAA) is a well-known complication of chronic liver disease and portal hypertension in adults. The incidence of SAA in children undergoing selective hepatic angiography prior to liver transplantation is reported as 4%, but there are few systematic studies. To investigate the SAAs detected by multidetector CT angiography (MDCTA) among children with chronic liver disease. A total of 124 children (71 girls, 53 boys; mean age 118 months; age range 5 days to 204 months) with chronic liver disease underwent MDCTA to display the vascular anatomy and any vascular complications during the pretransplantation period. Of these children, 23 also underwent coeliac angiography. The digital subtraction angiography (DSA) and MDCTA findings were compared. SAAs were detected in 13 children (10.4%); none was detectable by US. All patients had more than one aneurysm; ten patients had more than three. In all except one patient, the SAAs were located only in the intraparenchymal branches of the splenic artery; in one patient they were located in the intraparenchymal segment and in the distal third of the splenic artery. The mean size of the aneurysms was 6.5 mm (range 2.5-18 mm). All patients with aneurysms had splenomegaly and vascular collaterals. Nine of the children with SAAs had portal vein pathologies (two occlusions, two stenoses, five dilatations). A statistically significant difference existed with regard to the size of spleen (P < 0.05) and patient age (P < 0.05) between children with SAAs and children without SAAs. There was an increased risk of SAAs in patients with portal vein pathologies. In 19 patients without SAAs on MDCTA, no SAAs were seen on DSA. It is likely that the incidence of SAA in children with chronic liver disease will increase with improved survival of children with long-standing portal hypertension and chronic liver disease. MDCTA with multiplanar reconstruction is a noninvasive and effective means of imaging paediatric patients with SAAs, especially during the peritransplantation period, which is considered to be a time of significant risk for SAA rupture in this patient population.

Splenic artery aneurysms (SAAs) are the third most common forms of intra-abdominal aneurysm, and the most commonly encountered visceral aneurysms in the general population. SAAs occur more commonly in patients with portal hypertension and liver failure and, as such, are often encountered in patients undergoing high-resolution abdominal imaging as part of a work-up for liver transplantation. While rupture rates of between 2% and 10% have been reported in the literature, little is known about the natural history and behavior of these lesions in patients with liver disease. Interventional management options pose a challenge given the high anesthetic and surgical risk of such patients. This study was conducted to study the management of all SAAs diagnosed among patients presenting for a liver transplant assessment at a single center over a three-yr period. We discuss the presentation and management options, with elective and emergent presentation of SAA in patients with end-stage liver disease.