Endovascular management of visceral artery aneurysms: When to watch, when to intervene?

Abstract

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.

Pseudoaneurysm Endovascular Treatment of a Middle Colic Arterial Branch in a Patient with an Intermittent Digestive Hemorrhage from an Obscure Source: Case Report

“…According to guidelines, the treatment of a true visceral aneurysm is recommended when its diameter is >2 cm or three times larger than the respective normal artery [11,15]. The treatment is also recommended in cases of rapid expansion >0.5 cm/year, symptoms, pregnant women, or those who are fertile, and patients submitted to hepatic transplant [11,14,16].…”

Spontaneous haemorrhage from a left gastric artery aneurysm as a cause of acute abdominal pain

“…Covered stents may be considered for VAA treatment if flow has to be maintained through the vessel. 5 Good characterisation and location of the lesion on imaging can help aid choice of technique. 5 In the case presented, coil embolisation of the left gastric artery was suitable, because of the good collateral blood supply in this region.…”

“…5 Good characterisation and location of the lesion on imaging can help aid choice of technique. 5 In the case presented, coil embolisation of the left gastric artery was suitable, because of the good collateral blood supply in this region. Post-intervention all-cause 30-day mortality has been reported between 6.2% and 6.7%.…”

“…For most splenic artery aneurysms, the threshold for intervention is a minimum diameter of 2 cm. 2,5 In this case, the patient continues to remain under surveillance for the two splenic artery aneurysms, as both were smaller than this minimum threshold. Confirmation of a connective tissue disorder, such as Ehlers-Danlos, would prompt more urgent treatment of smaller aneurysms, because of the increased risk of aneurysm rupture.…”

“…Confirmation of a connective tissue disorder, such as Ehlers-Danlos, would prompt more urgent treatment of smaller aneurysms, because of the increased risk of aneurysm rupture. 5 The patient is currently under investigation for connective tissue disorders, which may alter her longterm management if a new diagnosis is made.…”