Splenic Artery Aneurysm is one of the vascular anomalies of visceral arteries. Her's seminar of visceral artery aneurysms, and in pregnancy period. Visceral aneurysms are clinically important that affect population and health socio-economical systems. - Introduction - Definition - Classifications - Causes - Risk Factors - Symptoms - Diagnosis - Management - Endovascular Surgery - Case Presentation

1. Vascular Surgery Journal Club
Visceral Aneurysm in Childbearing
Jeddah
16 January 2024
Dr. KHALID ALRAJHI
Consultant of Vascular & Endovascular Surgery
Lead of Vascular Surgery - Ministry of Health - Jazan Province
TOT General Surgery Residency - Vascular Surgery Fellowship Program, SCFHS – Saudi Arabia

2. Visceral
Arteries
Aneurysm

3. • Rare , uncommon
• incidence approximately 0.01% to 2%
• Clinically important
• Potentially lethal
• 22% present as clinical emergencies,
8.5% result in death.

4. • The etiology of such lesions, as well as their clinical behavior, seem to
differ depending on the affected visceral territory.
• some of these aneurysms are incidentally diagnosed in the absence of
symptoms, others are only noted upon rupture.

5. Prevalence of VAA

7. Clinical Presentation
• Vary from total absence of symptoms to life threatening hemorrhage and
death.
• Abdominal pain is the most common symptom of unruptured aneurysms.
• jaundice, compressive symptoms (nausea, vomiting) or gastric outlet
obstruction.
• When rupture occur, gastrointestinal hemorrhage is the most common
presentation and, depending on the location of the lesion, can occur as
hematemesis, melena, hematochezia, haemobilia or retroperitoneal
hemorrhage.
• Pain is reported in only one third of the ruptured patients.

9. Diagnostic Modalities
• US : initial screening tool. has known limitations, operator
variability is an issue. Diagnostic sensitivity 50%
• CTA : Multidetector CTA is the most commonly used and
most sensitive non-invasive modality. Multiphase
acquisitions (pre-contrast, arterial phase, venous phase, and
delayed phase images. should include both arterial and
venous phases as some aneurysms with narrow necks may
not be visible on arterial phase. Diagnostic sensitivity 67%
• MRA iodine allergy or reduced renal function.
• Angiography gold standard diagnostic imaging tool. This
technique serves both diagnostic and therapeutic purposes.
Diagnostic sensitivity 100%
Habib N, et al. Ann Surg Innov Res 2013
Yeh TS, et al. Hepatogastroenterology 1997

10. Treatment Strategies
• Open or Endovascular Approach
• Depending on: - arterial territory involved.
- clinical presentation.
- patient characteristics.
• Open or Laparoscopic: with non-neglectable
morbidity and mortality rates, open repair is the gold
standard treatment option in several situations, allowing
for successful aneurysm exclusion with minimal
compromise of collateral circulation.
• Depending on the territory affected, and treatment
options are variable, including vessel ligation, resection
and end-to-end anastomosis, re-implantation or graft
interposition.

11. Endovascular Approach
• Low morbidity and mortality.
• Complex cases and rupture situation.
• visceral arterial aneurysms are frequently hostile, mainly due to the
usually tortuous anatomy of the native artery. This poses a difficulty
not only to the navigation, but also the implantation of endovascular
material, therefore increasing the risk of distal embolization or
endoleak even rupture.
• native artery preservation

12. Aneurysm exclusion via total occlusion of the native
artery
• Coil embolization
• (aneurysms with short necks) Detachable coils provide better
control and more precise deployment than pushable coils, and as
such, should be preferred when precise deployment is essential.
• Sandwich technique
• This technique is based in the selective embolization of both the
aneurysm sac as well as the native artery, proximally and distally
to it, from where its name — “sandwich technique”
• Vascular Plug ideal for the embolization of large vessels with high
flow. In these vessels, limited control of coils can lead to coil
migration and non-target embolization.

13. Aneurysm exclusion with preservation of the native artery
• Covered stents: artery’s tortuosity allows navigation of
the stent to the desired location and proper sealing
zones are available. Their use in tortuous vessels (such
as the splenic artery) straight vessels like renal arteries,
they remain particularly useful.
• Aneurysm sac coiling selective aneurysm sac coiling.
• Coil and cage. terminal circulations such as the renal
hilus
• multilayer stents (flow diverters): Sfyroeras et al, flow
diverter stents were used to treat 100 visceral and
peripheral aneurysms with satisfactory technical
success, aneurysm thrombosis, and branch vessel
patency. However, there was a significant incidence of
stent thrombosis (8%), reinforcing the need for further
studies.

14. Splenic Artery Aneurysm in Pregnancy
an abnormal dilatation of the splenic artery with a diameter of
more than 1 centimeter.

15. • A rarely seen clinical condition, but life-threatening and are associated with a clear
risk of rupture.
• Most common visceral artery aneurysm and the third most common intra-
abdominal aneurysm.
• Mortality risk in case of rupture
during pregnancy : Maternal mortality 75 %
Fetal mortality 90-95 %
Muralidharan V. et al Aneurysms of the splenic artery - a review.
The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2010.

16. • 58 % of patients are women of
childbearing ages, and 95% of
cases are detected during
pregnancy

17. Case Report
• 32 Years old
• female Pregnant at mid 2nd trimester.
• Left hypochondrial throbbing pain / 2 weeks.
• Rebound tenderness.
• Initial Abdominal US 8 cm
• Contrast enhanced abdominal CT 7.2 cm splenic artery aneurysm
associated with splenic AVF.

19. Surgical Strategy
• General Anesthesia
• Left subcostal incision
• Hyperemic splenic vessels
• Giant fusiform splenic artery
aneurysm near splenic hilum
• High flow AVF

20. Surgical Strategy
• AVF Rupture
• Proximal splenic artery clamped
• Ruptured orifice control via Satinsky calmp, (proline 4*0)
• Splenectomy
• Hemostasis
• Suction drain
• Closure
• Fetus US by obestetrician, normal no stress.

22. • Post op ICU
• Drain removed 2nd post op day
• Transferred to ward
• Discharged home 5 post op day