Endovascular management of giant visceral artery aneurysms

Abstract

Endovascular management of small visceral artery aneurysms is an established treatment with satisfactory outcomes. However, when size exceeds 5 cm visceral aneurysms are considered as "giant" (giant visceral artery aneurysms or GVAAs) and management is significantly more complex. Between August 2007 and June 2019 eleven cases of GVAAs that were endovascularly treated were retrospectively reviewed and included in this single center study. Mean size was 80 mm (± 26.3 mm) x 46 mm (+ \-11.8 mm). Nine of the lesions were true aneurysms, and two were pseudoaneurysms. In 8 patients, the lesion was causing compression symptoms in the surrounding organs, one patient developed a contained rupture while 2 patients were completely asymptomatic. However, all patients were hemodynamically stable at the time of treatment. Technical success was defined as immediate complete exclusion of the aneurysmal sac, and clinical success as complete relief from clinical symptoms. Follow-up was performed with CT angiography, ultrasound and clinical examination. Mean follow-up was 45 months (range 6-84). Technical and clinical success were both 91%. Complications were one lack of control of contained rupture that was subsequently operated, one case of self-limiting non-target spleen embolization and one case of splenic abscess. Three patients died, one due to the contained rupture 15 days after procedure, the other two for other causes and occurred during the long-term follow-up. This series suggests that endovascular treatment of giant visceral artery aneurysms and pseudoaneuryms is a valid minimally invasive solution with very satisfactory immediate and long-term outcomes unless the aneurysm is already ruptured. A variety of endovascular tools may be required for successful treatment.

Figure 1

(a) Volume rendering contrast enhanced CT confirming the presence of multilobed fusiform splenic artery GVAA measuring 88 × 140 mm (arrow). (b) Angiogram confirmed the CT findings. (c) Selective catheterization of the distal splenic artery of “back door” of the aneurysm. (d,e) Endovascular exclusion was obtained by transcatheter “sandwich” embolization with Tornado coils (Cook Medical, Bloomington, Indiana, USA) and Jackson coils (Cook Medical, Bloomington, Indiana, USA) of the distal and proximal tract of the main artery and packing of the sac. Furthermore, inflow was totally stopped using a 8 mm detachable vascular plug (Amplatzer Plug, AGA, Plymouth, USA) in the proximal neck of the aneurysm. (f) Angiogram from the coeliac axis confirming satisfactory exclusion of the GAA.

Figure 2

(a) CT scan in arterial phase demonstrated a 95 × 36 mm GAA of the splenic artery. (b) Curved reconstruction shows the complete extension of the aneurysm and the thrombosed part of the sack. (c) Angiogram confirming the aneurismal dilatation and allowing treatment planning. (d,e) Endovascular treatment was performed by positioning three overlapping covered stents (Viabahn; Gore, Falstaff, AZ) measuring in order from distal to proximal: 10 × 100 mm, 10 × 50 mm and 11 × 50 mm f) Angio-CT with curved reconstruction shows patency of the splenic artery with aneurysm complete exclusion.