Portal de Periódicos da CAPES

Splanchnic Artery Aneurysms

2007; Elsevier BV; Volume: 82; Issue: 4 Linguagem: Inglês

10.4065/82.4.472

1942-5546

Shabana F. Pasha, Péter Gloviczki, Anthony W. Stanson, Patrick S. Kamath,

Vascular Anomalies and Treatments

Autopsy studies suggest that splanchnic artery aneurysms may be more frequent than abdominal aortic aneurysms. These aneurysms are important to recognize because up to 25% may be complicated by rupture, and the mortality rate after rupture is between 25% and 70%. However, little is known about the natural history and clinical presentation of splanchnic artery aneurysms. Splenic artery aneurysms are the most common of the splanchnic artery aneurysms; multiple aneurysms are present in approximately one third of patients. Hepatic artery pseudoaneurysms are more common than true aneurysms because of increasing numbers of hepatobiliary interventional procedures. The diagnosis of splanchnic artery aneurysm should be considered in any patient with abdominal pain, a pulsatile mass, or an abdominal bruit with or without associated bleeding. However, most aneurysms are asymptomatic and are detected incidentally on imaging studies. Treatment, which can be either surgical or interventional radiology-based, should be considered in all patients with symptoms related to the aneurysms, if the aneurysm is more than 2 cm in diameter, if the patient is pregnant, or if there is demonstrated growth of the aneurysm. Autopsy studies suggest that splanchnic artery aneurysms may be more frequent than abdominal aortic aneurysms. These aneurysms are important to recognize because up to 25% may be complicated by rupture, and the mortality rate after rupture is between 25% and 70%. However, little is known about the natural history and clinical presentation of splanchnic artery aneurysms. Splenic artery aneurysms are the most common of the splanchnic artery aneurysms; multiple aneurysms are present in approximately one third of patients. Hepatic artery pseudoaneurysms are more common than true aneurysms because of increasing numbers of hepatobiliary interventional procedures. The diagnosis of splanchnic artery aneurysm should be considered in any patient with abdominal pain, a pulsatile mass, or an abdominal bruit with or without associated bleeding. However, most aneurysms are asymptomatic and are detected incidentally on imaging studies. Treatment, which can be either surgical or interventional radiology-based, should be considered in all patients with symptoms related to the aneurysms, if the aneurysm is more than 2 cm in diameter, if the patient is pregnant, or if there is demonstrated growth of the aneurysm. Although abdominal aortic aneurysms are repaired more often than splanchnic artery aneurysms, autopsy studies suggest that splanchnic artery aneurysms may be more frequent than abdominal aortic aneurysms. The prevalence of these aneurysms has been estimated, on the basis of autopsy reports, to be up to 10%1Bedford PD Lodge B Aneurysm of the splenic artery.Gut. 1960; 1: 312-320Crossref PubMed Scopus (123) Google Scholar and that of abdominal aortic aneurysms, 0.5%.2Darling RC Messina CR Brewster DC Ottinger LW Autopsy study of unoperated abdominal aortic aneurysms: the case for early resection.Circulation. 1977; 56: II161-II164PubMed Google Scholar Splanchnic artery aneurysms are important to recognize because up to 25% may be complicated by rupture, and the mortality rate after rupture is between 25% and 70%. Most series have comprised fewer than 30 cases and have had limited follow-up. Little is known about the natural history and clinical presentation of splanchnic artery aneurysms. Moreover, because the diagnosis is not often considered in patients with abdominal pain, the treatment of symptomatic aneurysms is delayed. The goal of this review is to define the causes, characteristics, clinical manifestations, and complications of splanchnic artery aneurysms and to outline the diagnostic and therapeutic options currently available. Because of the limited data available on optimal management, the recommendations in this review are based on the authors' practice. The splanchnic circulation includes the celiac, superior mesenteric, and inferior mesenteric arteries, which arise from the abdominal aorta (Figure 1). The most proximal is the celiac artery, which has 3 branches: the left gastric, splenic, and common hepatic arteries. The left gastric artery supplies the fundus and proximal lesser curvature of the stomach. The splenic artery arises from the celiac artery distal to the origin of the left gastric artery. It is associated closely with the pancreas and supplies blood to the spleen, pancreas, and stomach through the short gastric and left gastroepiploic arteries. The common hepatic artery divides into the gastroduodenal and proper hepatic arteries. The gastroduodenal artery has multiple branches, including the anterior and posterior pancreaticoduodenal arcades and the right gastroepiploic artery. The gastroduodenal artery is an important source of large-vessel collateral circulation when the celiac or superior mesenteric artery is occluded proximally. The right gastric artery arises from the common hepatic or left hepatic artery and supplies the distal lesser curvature of the stomach. The proper hepatic artery usually divides into the right and left hepatic arteries, which supply the liver. The right hepatic artery may arise from the superior mesenteric artery and the left hepatic artery from the left gastric artery. The superior mesenteric artery originates from the anterior surface of the aorta 1 to 2 cm distal to the celiac trunk. The superior mesenteric artery passes posteriorly to the pancreas and anteriorly to the third part of the duodenum. It supplies the head and uncinate process of the pancreas through the inferior pancreaticoduodenal artery, the small intestine through jejunal and ileal branches, and the ascending and transverse colon through the ileocolic, right colic, and middle colic branches. The jejunal and ileal branches form anastomotic arcades in the mesentery and supply the small intestine by the vasa rectae. The inferior mesenteric artery arises from the anterior abdominal aorta 5 to 6 cm distal to the superior mesenteric artery and supplies the splenic flexure and entire descendingcolon through the left colic artery. The inferior mesenteric artery has a variable number of sigmoid branches and terminates caudally as the paired superior hemorrhoidal arteries. A true aneurysm is a permanent, localized dilatation (>1.5 times the expected diameter) of an artery that involves all 3 layers of the vessel wall. A pseudoaneurysm (“false aneurysm”) is a localized arterial disruption of the intimal and medial layers; it is lined by adventitia or perivascular tissue and caused by blunt or penetrating trauma. Fusiform aneurysms involve the entire circumference, and saccular aneurysms involve only a portion of the vessel wall. Most patients present in the sixth decade of life. Splenic artery aneurysms occur predominantly in multiparous women,3Abbas MA Stone WM Fowl RJ et al.Splenic artery aneurysms: two decades experience at Mayo Clinic.Ann Vasc Surg. 2002 Jul; 16 (Epub 2002 Jul 1.): 442-449Abstract Full Text PDF PubMed Scopus (292) Google Scholar but a male preponderance has been noted for hepatic and gastroduodenal artery aneurysms. Both sexes are affected equally with celiac and superior mesenteric artery aneurysms.4Carr SC Pearce WH Vogelzang RL McCarthy WJ Nemcek Jr, AA Yao JS Current management of visceral artery aneurysms.Surgery. 1996; 120: 627-633Abstract Full Text PDF PubMed Scopus (249) Google Scholar, 5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar Multiple aneurysms are present in approximately one third of patients.6Busuttil RW Brin BJ The diagnosis and management of visceral artery aneurysms.Surgery. 1980; 88: 619-624PubMed Google Scholar Most splanchnic artery aneurysms are asymptomatic and detected incidentally on imaging studies. The common causes and complications of splanchnic artery aneurysms are listed in Table 1. Symptomatic aneurysms present with abdominal pain or bleeding, which may be intra-abdominal or gastrointestinal. A bruit may be heard on auscultation, but an abdominal mass is rarely palpable because the aneurysms are small.TABLE 1Etiology and Complications of Splanchnic Artery Aneurysms Etiology True aneurysms Common causes ArteriosclerosisFibromuscular dysplasiaCystic medial necrosisPortal hypertensionUncommon causes Autoimmune/collagen vascular diseases Polyarteritis nodosaSystemic lupus erythematosusTakayasu arteritisEhlers-Danlos syndromeMarfan syndromeNeurofibromatosisHypertensionCongenitalα-Antitrypsin deficiencyPseudoaneurysms Common causes Inflammatory conditions PancreatitisBlunt or penetrating abdominal traumaAnastomotic pseudoaneurysm (after orthotopic liver transplantation)Percutaneous intervention of biliary tractArterial dissectionUncommon causes Infectious diseases Mycotic aneurysmsSyphilisInfective endocarditisTuberculosisComplications Intraperitoneal rupture HemoperitoneumHypovolemic shockIntrahepatic subcapsular ruptureRetroperitoneal hemorrhageGastrointestinal hemorrhage HemobiliaHemosuccus pancreaticusHerald bleedArteriovenous fistula formation Portal hypertensionAscitesVariceal bleedingObstructive jaundiceAcute mesenteric ischemia Open table in a new tab The complications of splanchnic artery aneurysms are listed in Table 1. Up to 22% of the aneurysms present with intraperitoneal rupture or gastrointestinal hemorrhage.7Stanley JC Wakefield TW Graham LM Whitehouse Jr, WM Zelenock GB Lindenauer SM Clinical importance and management of splanchnic artery aneurysms.J Vasc Surg. 1986; 3: 836-840PubMed Scopus (354) Google Scholar The reported mortality rate after intraperitoneal rupture is 21% for hepatic, 36% for splenic, and up to 100% for celiac artery aneurysms.4Carr SC Pearce WH Vogelzang RL McCarthy WJ Nemcek Jr, AA Yao JS Current management of visceral artery aneurysms.Surgery. 1996; 120: 627-633Abstract Full Text PDF PubMed Scopus (249) Google Scholar, 5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar Erosion of an aneurysm into the gastrointestinal lumen can present as sporadic gastrointestinal bleeding, the so-called herald bleed.8Otah E Cushin BJ Rozenblit GN Neff R Otah KE Cooperman AM Visceral artery pseudoaneurysms following pancreatoduodenectomy.Arch Surg. 2002; 137: 55-59Crossref PubMed Scopus (111) Google Scholar Rupture into a mesenteric vein results in a mesenteric arteriovenous fistula. In this situation, the portal venous circulation develops systemicarterial pressures, leading to portal hypertension with variceal bleeding.9Pasternak BM Cohen H Arteriovenous fistula and forward hypertension in the portal circulation.Angiology. 1978; 29: 367-373Crossref PubMed Scopus (35) Google Scholar Splanchnic artery aneurysms, if sufficiently calcified, may be found incidentally on plain radiographs of the abdomen. The diagnosis can be confirmed with computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), or angiography (Figure 2). The widespread use of US and CT has led to increased detection of asymptomatic aneurysms. Ultrasonography has a low sensitivity for small aneurysms because identification may be compromised by overlying gas and obesity. The use of CT after blunt abdominal trauma or an interventional biliary tract procedure has resulted in increased identification of false hepatic artery aneurysms.5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar Moreover, CT is useful for detecting small aneurysms and assessing anatomical details. The need for intravenous contrast limits its use in patients with renal insufficiency or severe contrast allergy. Results of MRI are similar to those of CT, and like CT, MRI allows 2- and 3-dimensional imaging of the aneurysm and vessels. The definitive diagnosis of small splanchnic artery aneurysms is made with contrast angiography, but it also can be made with high-quality CT and MRI. Angiography localizes and defines the size of the aneurysm and detects other aneurysms as well as vasculitides. It offers the advantage of therapeutic intervention. Therefore, angiography is usually performed when radiologic or surgical therapy is planned. Rarely, some splanchnic artery aneurysms appear as an extrinsic gastric impression on upper gastrointestinal endoscopy (Figure 2, C). Endoscopic US can reliably differentiate aneurysms from other extrinsic lesions such as pancreatic pseudocysts (Figure 2, D). Treatment depends on the presentation, location, and size of the aneurysm. Generally, treatment is considered even for asymptomatic patients if the diameter of the aneurysm is larger than 2 cm. Elective surgical repair is safe and effective. Patients who present with a ruptured aneurysm require rapid resuscitation and surgical or radiologic intervention. Often, emergency surgical treatment is limited to ligation of the aneurysm without arterial reconstruction. In most cases, the rich mesenteric collateral circulation prevents ischemic damage to splanchnic organs supplied by the artery distal to the ligation. Percutaneous transcatheter embolization with metallic coils has a success rate of 85%.10McDermott VG Shlansky-Goldberg R Cope C Endovascular management of splenic artery aneurysms and pseudoaneurysms.Cardiovasc Intervent Radiol. 1994; 17: 179-184Crossref PubMed Scopus (171) Google Scholar Embolization may be preferred for aneurysms difficult to manage surgically and for high-risk surgical patients.11Reidy JF Rowe PH Ellis FG Splenic artery aneurysm embolisation—the preferred technique to surgery.Clin Radiol. 1990; 41: 281-282Abstract Full Text PDF PubMed Scopus (47) Google Scholar Complications include migration of the coils (leading to organ infarction), abscess formation,11Reidy JF Rowe PH Ellis FG Splenic artery aneurysm embolisation—the preferred technique to surgery.Clin Radiol. 1990; 41: 281-282Abstract Full Text PDF PubMed Scopus (47) Google Scholar and, rarely, aneurysm rupture. The aneurysm may undergo recanalization after successful embolization.4Carr SC Pearce WH Vogelzang RL McCarthy WJ Nemcek Jr, AA Yao JS Current management of visceral artery aneurysms.Surgery. 1996; 120: 627-633Abstract Full Text PDF PubMed Scopus (249) Google Scholar Endovascular stent-graft placement is a promising treatment modality,12Arepally A Dagli M Hofmann LV Kim HS Cooper M Klein A Treatment of splenic artery aneurysm with use of a stent-graft.J Vasc Interv Radiol. 2002; 13: 631-633Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 13Larson RA Solomon J Carpenter JP Stent graft repair of visceral artery aneurysms.J Vasc Surg. 2002; 36: 1260-1263Abstract Full Text PDF PubMed Scopus (144) Google Scholar but long-term results are unknown. Etiology and Pathogenesis. Seventy-two percent of aneurysms of the splenic artery are true aneurysms. Theyare usually saccular and occur at a bifurcation in the splenic hilum.4Carr SC Pearce WH Vogelzang RL McCarthy WJ Nemcek Jr, AA Yao JS Current management of visceral artery aneurysms.Surgery. 1996; 120: 627-633Abstract Full Text PDF PubMed Scopus (249) Google Scholar Twenty percent of patients have multiple aneurysms. The more common causes are arteriosclerosis3Abbas MA Stone WM Fowl RJ et al.Splenic artery aneurysms: two decades experience at Mayo Clinic.Ann Vasc Surg. 2002 Jul; 16 (Epub 2002 Jul 1.): 442-449Abstract Full Text PDF PubMed Scopus (292) Google Scholar, 5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar and portal hypertension14Beeresha Ghotekar LH Dutta TK Verma SK Elangovan S Hepatic artery mycotic aneurysm of tubercular aetiology.J Assoc Physicians India. 2000; 48: 247-248PubMed Google Scholar; pancreatitis results in pseudoaneurysm.15Ammori BJ Madan M Alexander DJ Haemorrhagic complications of pancreatitis: presentation, diagnosis and management.Ann R Coll Surg Engl. 1998; 80: 316-325PubMed Google Scholar Less common causes include idiopathic dissection, septic emboli, essential hypertension,16Lee PC Rhee RY Gordon RY Fung JJ Webster MW Management of splenic artery aneurysms: the significance of portal and essential hypertension.J Am Coll Surg. 1999; 189: 483-490Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar polyarteritis nodosa, systemic lupus erythematosis,17Tazawa K Shimoda M Nagata T et al.Splenic artery aneurysm associated with systemic lupus erythematosus: report of a case.Surg Today. 1999; 29: 76-79Crossref PubMed Scopus (18) Google Scholar Ehlers-Danlos syndrome,18Carr SC Mahvi DM Hoch JR Archer CW Turnipseed WD Visceral artery aneurysm rupture.J Vasc Surg. 2001; 33: 806-811Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar fibromuscular dysplasia,19Messina LM Shanley CJ Visceral artery aneurysms.Surg Clin North Am. 1997; 77: 425-442Abstract Full Text Full Text PDF PubMed Scopus (343) Google Scholar and neurofibromatosis.20Ghoddousi I Kojouri K Fazel I Coeliac artery aneurysm: a case report.Cardiovasc Surg. 1996; 4: 555-556Crossref PubMed Scopus (13) Google Scholar Pseudoaneurysms of the splenic artery are most often caused by chronic pancreatitis or by trauma.21Tessier DJ Stone WM Fowl RJ et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar The incidence of splenic artery aneurysms is higher in multiparous women (average, 4.5 pregnancies)6Busuttil RW Brin BJ The diagnosis and management of visceral artery aneurysms.Surgery. 1980; 88: 619-624PubMed Google Scholar and in patients with splenomegaly or those who have undergone orthotopic liver transplantation.22Kóbori L van der Kolk MJ de Jong KP Liver Transplant Group et al.Splenic artery aneurysms in liver transplant patients.J Hepatol. 1997; 27: 890-893Abstract Full Text PDF PubMed Scopus (51) Google Scholar The increased prevalence in multiparous women may be related to increased splenic blood flow and the effects of estrogen on the elastic tissue of the tunica media.23Hallett Jr, JW Splenic artery aneurysms.Semin Vasc Surg. 1995; 8: 321-326PubMed Google Scholar Dilatation of the splenic artery resulting from increased blood flow during pregnancy likely predisposes to aneurysm formation. Similarly, increased splenic blood flow is considered the cause of splenic artery aneurysms in portal hypertension and after liver transplantation. The role of arteriosclerosis is unclear. Localized arteriosclerotic changes in aneurysms without involvement of adjacent vessels have been demonstrated. Moreover, the presence of arteriosclerosis in some but not all aneurysms of patients with multiple aneurysms suggests that arteriosclerosis is a secondary event rather than the cause of most splenic artery aneurysms. Clinical Manifestations. Most splenic artery aneurysms are smaller than 2 cm. They may be detected on plain radiographs as curvilinear calcifications in the left upper quadrant.6Busuttil RW Brin BJ The diagnosis and management of visceral artery aneurysms.Surgery. 1980; 88: 619-624PubMed Google Scholar The differential diagnosis includes tortuous splenic artery, renal artery aneurysm, calcified lymph nodes, and calcific cysts of the spleen or adrenal gland.6Busuttil RW Brin BJ The diagnosis and management of visceral artery aneurysms.Surgery. 1980; 88: 619-624PubMed Google Scholar Symptomatic patients manifest with left upper quadrant or epigastric pain that radiates to the left shoulder. Rupture of the aneurysm, which may manifest as hypovolemic shock, occurs in less than 2% of patients.24Trastek VF Pairolero PC Joyce JW Hollier LH Bernatz PE Splenic artery aneurysms.Surgery. 1982; 91: 694-699PubMed Google Scholar However, the risk of rupture is much higher for pregnant women and for aneurysms larger than 2 cm in diameter.3Abbas MA Stone WM Fowl RJ et al.Splenic artery aneurysms: two decades experience at Mayo Clinic.Ann Vasc Surg. 2002 Jul; 16 (Epub 2002 Jul 1.): 442-449Abstract Full Text PDF PubMed Scopus (292) Google Scholar, 25Holdsworth RJ Gunn A Ruptured splenic artery aneurysm in pregnancy: a review.Br J Obstet Gynaecol. 1992; 99: 595-597Crossref PubMed Scopus (96) Google Scholar More than 95% of aneurysms in pregnant women are diagnosed after rupture6Busuttil RW Brin BJ The diagnosis and management of visceral artery aneurysms.Surgery. 1980; 88: 619-624PubMed Google Scholar and are associated with a 75% maternal and 95% fetal mortality rate.25Holdsworth RJ Gunn A Ruptured splenic artery aneurysm in pregnancy: a review.Br J Obstet Gynaecol. 1992; 99: 595-597Crossref PubMed Scopus (96) Google Scholar There is no evidence that calcification of the aneurysm, normal blood pressure, or age alters the risk of rupture.7Stanley JC Wakefield TW Graham LM Whitehouse Jr, WM Zelenock GB Lindenauer SM Clinical importance and management of splanchnic artery aneurysms.J Vasc Surg. 1986; 3: 836-840PubMed Scopus (354) Google Scholar Rupture of the aneurysm into the lesser sac is manifested initially as upper abdominal pain, but the patient is hemodynamically stable as long as bleeding is confined to the lesser sac. When blood overflows into the greater intraperitoneal sac through the foramen of Winslow, diffuse abdominal pain and hypovolemic shock develop. This is termed the double-rupture phenomenon. It has been suggested that the period in which bleeding is localized in the lesser sac allows time for surgical intervention in about 25% of patients.26Wagner WH Allins AD Treiman RL et al.Ruptured visceral artery aneurysms.Ann Vasc Surg. 1997; 11: 342-347Abstract Full Text PDF PubMed Scopus (120) Google Scholar Arteriovenous fistula formation is a rare complication that leads to portal hypertension.9Pasternak BM Cohen H Arteriovenous fistula and forward hypertension in the portal circulation.Angiology. 1978; 29: 367-373Crossref PubMed Scopus (35) Google Scholar Rarely, the high flow through a splenic arteriovenous fistula causes small-bowel ischemia, the “mesenteric steal syndrome.”27Sendra F Safran DB McGee G A rare complication of splenic artery aneurysm: mesenteric steal syndrome.Arch Surg. 1995; 130: 669-672Crossref PubMed Scopus (20) Google Scholar Management. Ruptured aneurysms of the splenic artery usually are treated with splenectomy. A symptomatic aneurysm or an aneurysm of any diameter in a pregnant woman or a woman of childbearing age is considered by some to be an absolute indication for elective repair.3Abbas MA Stone WM Fowl RJ et al.Splenic artery aneurysms: two decades experience at Mayo Clinic.Ann Vasc Surg. 2002 Jul; 16 (Epub 2002 Jul 1.): 442-449Abstract Full Text PDF PubMed Scopus (292) Google Scholar Most would agree that an aneurysm larger than 2 cm is an indication for surgery; an aneurysm between 1 and 2 cm in diameter should be monitored closely with imaging studies every 6 months. Mortality after emergency surgery is as high as 40%, compared with negligible mortality after elective repair.16Lee PC Rhee RY Gordon RY Fung JJ Webster MW Management of splenic artery aneurysms: the significance of portal and essential hypertension.J Am Coll Surg. 1999; 189: 483-490Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Transcatheter embolization may be performed for all splenic artery aneurysms, except those located at the splenic hilum.11Reidy JF Rowe PH Ellis FG Splenic artery aneurysm embolisation—the preferred technique to surgery.Clin Radiol. 1990; 41: 281-282Abstract Full Text PDF PubMed Scopus (47) Google Scholar Aneurysms of the proximal splenic artery can be treated with simple ligation,28Hashizume M Ohta M Ueno K Okadome K Sugimachi K Laparoscopic ligation of splenic artery aneurysm.Surgery. 1993; 113: 352-354PubMed Google Scholar but those involving the hilum require splenectomy. Aneurysmectomy with end-to-end anastomosis is recommended for mid splenic aneurysms in a tortuous and redundant artery. Surgical repair is preferred for all symptomatic aneurysms because of the greater likelihood of success. In the presence of portal hypertension, transcatheter embolization or stent-graft placement may be preferred because the extensive collateral circulation that develops as a result of portal hypertension makes surgery more difficult.10McDermott VG Shlansky-Goldberg R Cope C Endovascular management of splenic artery aneurysms and pseudoaneurysms.Cardiovasc Intervent Radiol. 1994; 17: 179-184Crossref PubMed Scopus (171) Google Scholar, 12Arepally A Dagli M Hofmann LV Kim HS Cooper M Klein A Treatment of splenic artery aneurysm with use of a stent-graft.J Vasc Interv Radiol. 2002; 13: 631-633Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Although conservative management of splenic artery pseudoaneurysms has produced excellent results according to some reports, we recommend intervention in all cases irrespective of size or symptoms.21Tessier DJ Stone WM Fowl RJ et al.Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature.J Vasc Surg. 2003; 38: 969-974Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar Transcatheter embolization of the pseudoaneurysm is gaining popularity; however, failure does occur, especially when the pseudoaneurysm is associated with a pseudocyst of the pancreas. Splenectomy, with or without distal pancreatectomy is the current standard of treatment, with no reports of failure. Etiology. Almost 50% of hepatic artery aneurysms are pseudoaneurysms. This reflects the increased use of interventional procedures of the biliary tract and CT after blunt abdominal trauma.5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar True aneurysms occur 4 times more frequently in the extrahepatic arteries, usually involve the common hepatic artery,29Kibbler CC Cohen DL Cruicshank JK Kushwaha SS Morgan MY Dick RD Use of CAT scanning in the diagnosis and management of hepatic artery aneurysm.Gut. 1985; 26: 752-756Crossref PubMed Scopus (35) Google Scholar and are associated mainly with arteriosclerosis and acquired medial degeneration.7Stanley JC Wakefield TW Graham LM Whitehouse Jr, WM Zelenock GB Lindenauer SM Clinical importance and management of splanchnic artery aneurysms.J Vasc Surg. 1986; 3: 836-840PubMed Scopus (354) Google Scholar Mycotic aneurysms are rare (<5% of hepatic artery aneurysms). Other causes include polyarteritis nodosa,30Abbas MA Fowl RJ Stone WM et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar pancreatitis,5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar liver transplantation,31O'Driscoll D Olliff SP Olliff JF Hepatic artery aneurysm.Br J Radiol. 1999; 72: 1018-1025PubMed Google Scholar neurofibromatosis,32Hassen-Khodja R Declemy S Batt M et al.Visceral artery aneurysms in Von Recklinghausen's neurofibromatosis.J Vasc Surg. 1997; 25: 572-575Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Wegener granulomatosis,33den Bakker MA Tangkau PL Steffens TW Tjiam SL van der Loo EM Rupture of a hepatic artery aneurysm caused by Wegener's granulomatosis.Pathol Res Pract. 1997; 193: 61-66Crossref PubMed Scopus (27) Google Scholar and tuberculosis.14Beeresha Ghotekar LH Dutta TK Verma SK Elangovan S Hepatic artery mycotic aneurysm of tubercular aetiology.J Assoc Physicians India. 2000; 48: 247-248PubMed Google Scholar Clinical Manifestations. More than 50% of patients present with right upper quadrant abdominal pain that radiates to the back. Almost 20% to 30% of hepatic artery aneurysms may rupture into the peritoneal cavity and manifest as abdominal pain with hypovolemic shock.5Shanley CJ Shah NL Messina LM Common splanchnic artery aneurysms: splenic, hepatic, and celiac.Ann Vasc Surg. 1996; 10: 315-322Abstract Full Text PDF PubMed Scopus (234) Google Scholar, 30Abbas MA Fowl RJ Stone WM et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Risk factors for rupture of true aneurysms include multiple hepatic artery aneurysms and a nonatherosclerotic etiology of the aneurysm.30Abbas MA Fowl RJ Stone WM et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Gastrointestinal hemorrhage may occur from erosion of the aneurysm into the stomach or duodenum. Erosion into the biliary tract occurs in nearly 50% of patients with rupture of a hepatic artery aneurysm,26Wagner WH Allins AD Treiman RL et al.Ruptured visceral artery aneurysms.Ann Vasc Surg. 1997; 11: 342-347Abstract Full Text PDF PubMed Scopus (120) Google Scholar with one third of patients presenting with the classic triad of biliary colic, hemobilia, and obstructive jaundice.34Zachary K Geier S Pellecchia C Irwin G Jaundice secondary to hepatic artery aneurysm: radiological appearance and clinical features.Am J Gastroenterol. 1986; 81: 295-298PubMed Google Scholar Obstructive jaundice due to extrinsic compression of the biliary duct by the aneurysm and liver abscesses are uncommon complications. The diagnosis of hepatic artery aneurysm should be considered in patients with biliary colic, especially those with associated gastrointestinal bleeding (Figure 3). Management. The risk of rupture in relationship to the size of an aneurysm of the hepatic artery is unknown. When 22 patients with a mean hepatic artery diameter of 2.3 cm (range, 1.5-5 cm) were followed up for a mean of 68.4 months (range, 1-372 months), no complications were identified. Therefore, we recommend intervention only when the aneurysm is symptomatic or when risk factors for rupture (multiple aneurysms and a nonatherosclerotic etiology) are present. To prevent hepatic infarction, ligation of the affected artery or embolization of the aneurysm is best performed only if the portal vein is patent. Asymptomatic common hepatic artery aneurysms can be treated with embolization or by ligation of the aneurysm without reconstruction.35Dougherty MJ Gloviczki P Cherry Jr, KJ Bower TC Hallet JW Pairolero PC Hepatic artery aneurysms: evaluation and current management.Int Angiol. 1993; 12: 178-184PubMed Google Scholar However, vascular reconstruction is required for the treatment of proper hepatic artery aneurysms to prevent hepatic ischemia resulting from interruption of collateral circulation through the gastroduodenal and right gastric arteries.19Messina LM Shanley CJ Visceral artery aneurysms.Surg Clin North Am. 1997; 77: 425-442Abstract Full Text Full Text PDF PubMed Scopus (343) Google Scholar, 35Dougherty MJ Gloviczki P Cherry Jr, KJ Bower TC Hallet JW Pairolero PC Hepatic artery aneurysms: evaluation and current management.Int Angiol. 1993; 12: 178-184PubMed Google Scholar Embolization of the hepatic artery (Figure 3, C and D)or stent-graft placement may be used in patients at high surgical risk.13Larson RA Solomon J Carpenter JP Stent graft repair of visceral artery aneurysms.J Vasc Surg. 2002; 36: 1260-1263Abstract Full Text PDF PubMed Scopus (144) Google Scholar Etiology. The common causes of celiac artery aneurysms are arteriosclerosis and medial degeneration. Trauma, dissection, and Takayasu arteritis are other causes. Syphilitic aneurysms are now uncommon. Peripheral artery aneurysms are seen in 18% to 67% of patients with celiac artery aneurysms.36Stone WM Abbas MA Gloviczki P Fowl RJ Cherry KJ Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar Clinical Manifestations. Celiac artery aneurysms are manifested initially by epigastric pain or upper gastrointestinal hemorrhage. Worsening abdominal pain usually indicates a rapidly expanding aneurysm or rupture. Dysphagia may occur from esophageal compression.37Saliou C Kassab M Duteille F Aneurysm of the coeliac artery.Cardiovasc Surg. 1996; 4: 552-555Crossref PubMed Scopus (16) Google Scholar In earlier reports, nearly 80% of celiac artery aneurysms had ruptured by the time the patient presented, and a large number were detected at autopsy.7Stanley JC Wakefield TW Graham LM Whitehouse Jr, WM Zelenock GB Lindenauer SM Clinical importance and management of splanchnic artery aneurysms.J Vasc Surg. 1986; 3: 836-840PubMed Scopus (354) Google Scholar However, recent series have reported a lifetime risk of rupture of about 6%.36Stone WM Abbas MA Gloviczki P Fowl RJ Cherry KJ Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar Aneurysm size, calcification, and thrombus formation are not risk factors for rupture.36Stone WM Abbas MA Gloviczki P Fowl RJ Cherry KJ Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar Management. Celiac artery aneurysms can be treated with celiac ligation, followed by aortohepatic bypass or direct aortic reimplantation.20Ghoddousi I Kojouri K Fazel I Coeliac artery aneurysm: a case report.Cardiovasc Surg. 1996; 4: 555-556Crossref PubMed Scopus (13) Google Scholar In patients undergoing revascularization, prosthetic grafts have a lower risk of occlusion than saphenous vein grafts.36Stone WM Abbas MA Gloviczki P Fowl RJ Cherry KJ Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar If the aneurysm ruptures, intervention may include ligation or percutaneous transcatheter embolization. Etiology. Septic emboli account for about one third of superior mesenteric artery aneurysms, with nonhemolytic streptococci, staphylococci, and gram-negative bacteria being the organisms commonly implicated. Other causes include arteriosclerosis, polyarteritis nodosa, pancreatitis, biliary tract disease, neurofibromatosis, and trauma. Pseudoaneurysms arising from arterial dissection most frequently involve the superior mesenteric artery.38Cormier F Ferry J Artru B Wechsler B Cormier JM Dissecting aneurysms of the main trunk of the superior mesenteric artery.J Vasc Surg. 1992; 15: 424-430Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Clinical Manifestations. More than 90% of superior mesenteric artery aneurysms are symptomatic, with associated abdominal pain and gastrointestinal bleeding. Acute mesenteric ischemia may result from thromboembolism of the artery.18Carr SC Mahvi DM Hoch JR Archer CW Turnipseed WD Visceral artery aneurysm rupture.J Vasc Surg. 2001; 33: 806-811Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar Although superior mesenteric artery aneurysms are rare, up to 50% of patients present with rupture, with a mortality rate of 30%.39Shanley CJ Shah NL Messina LM Uncommon splanchnic artery aneurysms: pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and colic.Ann Vasc Surg. 1996; 10: 506-515Abstract Full Text PDF PubMed Scopus (129) Google Scholar, 40Stone WM Abbas M Cherry KJ Fowl RJ Gloviczki P Superior mesenteric artery aneurysms: is presence an indication for intervention?.J Vasc Surg. 2002; 36: 234-237Abstract Full Text PDF PubMed Scopus (153) Google Scholar β-Adrenergic blockers may have a protective effect against rupture.40Stone WM Abbas M Cherry KJ Fowl RJ Gloviczki P Superior mesenteric artery aneurysms: is presence an indication for intervention?.J Vasc Surg. 2002; 36: 234-237Abstract Full Text PDF PubMed Scopus (153) Google Scholar Management. Because of the high rate of complications, intervention is recommended for all patients at low surgical risk. Ligation of an aneurysm of a branch of a mesenteric artery should be accompanied by resection of any ischemic segment of bowel.40Stone WM Abbas M Cherry KJ Fowl RJ Gloviczki P Superior mesenteric artery aneurysms: is presence an indication for intervention?.J Vasc Surg. 2002; 36: 234-237Abstract Full Text PDF PubMed Scopus (153) Google Scholar Transcatheter embolization is safe in hemodynamically stable patients with a ruptured aneurysm. An endovascular stent-graft can be used,41McGraw JK Patzik SB Gale SS Dodd JT Boorstein JM Autogenous vein-covered stent for the endovascular management of a superior mesenteric artery pseudoaneurysm.J Vasc Interv Radiol. 1998; 9: 779-782Abstract Full Text PDF PubMed Google Scholar but it increases the risk of mesenteric ischemia. The use of β-adrenergic blockers can be considered for asymptomatic patients who are reluctant to undergo interventional procedures. Etiology. Pancreaticoduodenal and gastroduodenal artery pseudoaneurysms usually result from pancreatitis42Granke K Hollier LH Bowen JC Pancreaticoduodenal artery aneurysms: changing patterns.South Med J. 1990; 83: 918-921Crossref PubMed Scopus (43) Google Scholar but may develop after pancreatoduodenectomy.8Otah E Cushin BJ Rozenblit GN Neff R Otah KE Cooperman AM Visceral artery pseudoaneurysms following pancreatoduodenectomy.Arch Surg. 2002; 137: 55-59Crossref PubMed Scopus (111) Google Scholar True aneurysms are caused by arteriosclerosis, polyarteritis nodosa, or Takayasu arteritis and may occur with occlusion of the celiac artery.43Uher P Nyman U Ivancev K Lindh M Aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery.Abdom Imaging. 1995; 20: 470-473Crossref PubMed Scopus (43) Google Scholar Clinical Manifestations. Abdominal pain, indistinguishable from pain due to pancreatitis or pancreatic pseudocyst, is the most common presentation. After pancreatoduodenectomy, “herald” or “sentinel” bleeding from a biliary drain may indicate a pseudoaneurysm.8Otah E Cushin BJ Rozenblit GN Neff R Otah KE Cooperman AM Visceral artery pseudoaneurysms following pancreatoduodenectomy.Arch Surg. 2002; 137: 55-59Crossref PubMed Scopus (111) Google Scholar Erosion of an aneurysm of the pancreaticoduodenal artery into the pancreatic duct can manifest as hemosuccus pancreaticus, which is the presence of bleeding into the pancreatic duct. A sudden increase in the size of a pancreatic pseudocyst or a pulsatile pseudocyst indicates a communication between an aneurysm and pseudocyst and warrants prompt treatment. Management. When a pancreaticoduodenal or gastroduodenal artery aneurysm occurs close to a pseudocyst, the pseudocyst should be drained after the aneurysm is either ligated or embolized. A ruptured aneurysm is managed by resection, with or without vascular reconstruction, or by transcatheter embolization. For aneurysms associated with occlusion of the celiac axis, the median arcuate ligament may need to be resected.44Tarazov PG Ignashov AM Pavlovskij AV Novikova AS Pancreaticoduodenal artery aneurysm associated with celiac axis stenosis: combined angiographic and surgical treatment.Dig Dis Sci. 2001; 46: 1232-1235Crossref PubMed Scopus (22) Google Scholar Pancreaticoduodenal artery aneurysms can be managed with stent-graft placement.45Nyman U Svendsen P Jivegard L Klingenstierna H Risberg B Multiple pancreaticoduodenal aneurysms: treatment with superior mesenteric artery stent-graft placement and distal embolization.J Vasc Interv Radiol. 2000; 11: 1201-1205Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar There is no established cutoff for treatment of pancreaticoduodenal aneurysms; many experts consider treating all such aneurysms with either surgical ligation or endovascular exclusion. When the celiac artery is occluded, hepatic artery revascularization may be required. Splanchnic artery aneurysms, although uncommon, are important to recognize because of the risk for rupture and associated mortality. Improvements in imaging technology of CT, MRI, and angiography have led to increased detection of asymptomatic aneurysms. Because of the heterogeneity of presentation, management must be individualized according to the artery involved. Elective intervention is required for all symptomatic aneurysms and for most aneurysms larger than 2 cm in diameter to reduce the risk of rupture and hence mortality.