Invited commentary

Abstract

The authors report their experience with the treatment of complex splenic artery aneurysms complete with a new classification scheme: type I, rupture or impending rupture; type II, at the origin of the splenic artery; and type III, aberrant splenic artery originating from the splenomesenteric or celiacomesenteric trunk. They used a variety of techniques, including combinations of occluding the inflow artery, the inflow collaterals, the aneurysm itself, and the outflow artery using either embolic coils or a covered stent. The choice of specific technique was dictated by the clinical presentation in terms of hemodynamic stability and the anatomy of the lesion. Their overall outcomes with these complex aneurysms was spectacular in terms of the technical success (96%), complications (none), and longer term success (96% at a mean follow-up of 34 months). Based on these results, they concluded that endovascular treatment appeared to be feasible, safe, and effective in the management of complex splenic artery aneurysms. Overall, I would like to commend the authors for their contribution and applaud them for their excellent results. The technical descriptions in the text, figures, and discussion along with the descriptions of the procedures in the tables are valuable and should serve as a nice resource. The required technical skill appears to be within the range of most experienced endovascular surgeons, although it is important to point out that these complex splenic artery aneurysms are quite rare and accounted for only 16% (24/154) of the total number of splenic aneurysms encountered by the authors during the 10-year study period. The indication for the procedures was fairly standard, although I remain unconvinced that all bland, 2-cm splenic artery aneurysms need to be fixed, particularly in elderly patients. It would be nice to have better guidance in terms of the natural history of these small aneurysms, although this was not the focus of the manuscript. The variety of techniques used to exclude the aneurysms reflects the anatomic complexity of the lesions. Despite the common themes, the various approaches were tailored to the specific lesion and required some creativity and insight on behalf of the endovascular surgeon. I am not certain that the classification scheme will be readily adopted, given the low incidence of these lesions, and it is not clear that the type I lesions should be considered different from the more common splenic artery aneurysms in the mid or distal segment of the artery, despite the obvious difference that they had ruptured or that rupture was deemed to be imminent, because the endovascular approach is typically the same. The longer term results must be interpreted with some caution, given the limited follow-up and the inherent challenges of imaging splenic artery aneurysms packed with metallic coils using computed tomography. Although the aneurysms did not appear to increase in size during follow-up, not all of them may have been successfully excluded. I would also underscore the study limitations highlighted by the authors that included the small sample size and retrospective design with its inherent selection bias. However, the authors have clearly demonstrated that these complex splenic artery aneurysms can be treated with standard endovascular therapies with excellent results, and I suspect that the treatment algorithms and outcomes can be reproduced by other experienced endovascular surgeons. Strategies for endovascular treatment of complicated splenic artery aneurysmsJournal of Vascular SurgeryVol. 68Issue 3PreviewEndovascular treatment (ET) is being increasingly used for splenic artery aneurysms (SAAs), but systematic treatment strategies have not been defined. We set out to investigate the optimal strategies for ET of complicated SAAs (CSAAs). Full-Text PDF Open Archive