Visceral artery aneurysms: evolving interdisciplinary management and future role of the abdominal surgeon

Abstract

Background: Visceral artery aneurysms (VAA) are rare vascular lesions. Clinically silent VAA are increasingly detected by cross-sectional imaging but some lesions are at risk for rupture with severe bleeding. The aim of the present study was to evaluate the trends in the interdisciplinary management at a tertiary center.

Methods: Patients who underwent treatment for VAA at University Hospital of Bonn between 2005 and 2018 were enrolled in this retrospective study. Demographic, clinical, VAA-specific data as well as information on therapy, early and long-term outcome were collected and statistically analyzed.

Results: Forty-two consecutive patients, 19 females and 23 males with a median age of 59 years (range 30-91 years), were diagnosed with 56 VAA. The majority were true aneurysms (N = 32; 57%), whereas 43% (N = 24) were pseudoaneurysms. The most common localization was the splenic artery (N = 18; 32%) and the average diameter was 3 cm (range 1-5 cm). Twenty-five patients (59.5%) had VAA-related symptoms such as chronic abdominal pain and hemorrhage at primary diagnosis, while the diagnosis was incidental in 17 patients (40.5%). Eleven patients (26%) underwent open surgery whereas 29 patients (69%) received an endovascular treatment. Patients with pseudoaneurysms were significantly older (P = 0.003), suffered more often from associated symptoms (P < 0.001) and required more emergency interventions (P < 0.0001) compared to those with true VAA. In the last years, the number and proportion of true VAA increased significantly (P < 0.001) while a significantly larger proportion could be managed interventionally (P = 0.017).

Conclusions: VAA are increasingly detected on imaging with lesions presenting very heterogeneously. Due to the risk of lethal rupture and in the absence of reliable prognostic markers, all the patients with VAA should be offered definite treatment. Localization, anatomy and the end-organ perfusion after intervention or operation are the most important aspects to consider when planning a treatment for VAA. For this reason, a multidisciplinary evaluation of every individual patient is necessary for an optimized outcome.

Keywords: Emergency bleeding; Hemorrhage; Interventional radiology; Open surgery; Visceral artery aneurysms.

Fig. 1

Relative frequencies of true VAA (blue) and pseudoaneuryms (green) according to their localization. SMA superior mesenteric artery, GDA gastroduodenal artery, LGA left gastric artery

Fig. 2

A 3.5-cm aneurysm of the hepatic artery before (left) and after (right) a combined radiological intervention with stenting and coiling

Fig. 3

CT scan of a 62-year-old patient with a big asymptomatic SMA aneurysm (a). Digital reconstruction of the CT scan in a (b). Intraoperative images of the same patient before (c) and (d) after isolation of 14 collateral branches. Angiography of a 37-year-old patient with an aneurysm of the gastroduodenal artery after perforation (e). Same patient in e after a successful coiling procedure (f)