Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

Abstract

Visceral artery aneurysms (VAAs) are rare, usually asymptomatic and incidentally discovered during a routine radiological examination. Shared guidelines suggest their treatment in the following conditions: VAAs with diameter larger than 2 cm, or 3 times exceeding the target artery; VAAs with a progressive growth of at least 0.5 cm per year; symptomatic or ruptured VAAs. Endovascular treatment, less burdened by morbidity and mortality than surgery, is generally the preferred option. Selection of the best strategy depends on the visceral artery involved, aneurysm characteristics, the clinical scenario and the operator's experience. Tortuosity of VAAs almost always makes embolization the only technically feasible option. The present narrative review reports state of the art and new perspectives on the main endovascular and other interventional options in the treatment of VAAs. Embolization techniques and materials, use of covered and flow-diverting stents and percutaneous approaches are accurately analyzed based on the current literature. Visceral artery-related considerations and targeted approaches are also provided and discussed.

Keywords: coiling; covered stent; embolization; endovascular treatment; flow-diverting stent; visceral aneurysm.

Figure 1

Schematic illustration of available endovascular techniques and main interventional options for treatment of VAAs based on aneurysm characteristics.

Figure 2

Coil embolization. (a) Preliminary contrast-enhanced CT (white arrow) and (b) diagnostic angiography show a fusiform aneurysm of a proximal jejunal branch of the superior mesenteric artery. (c) Final angiographic control shows the complete aneurysm exclusion after coil embolization performed occluding first the efferent vessel and then the aneurysm and the afferent vessel.

Figure 3

Coil embolization. (a) Diagnostic angiography shows a saccular aneurysm with a narrow neck of the right hepatic artery (black arrow). (b) Superselective aneurysm catheterization with a microcatheter and (c) progressive coils release. (d) Final angiographic control shows the complete aneurysm exclusion after coil embolization.

Figure 3

Coil embolization. (a) Diagnostic angiography shows a saccular aneurysm with a narrow neck of the right hepatic artery (black arrow). (b) Superselective aneurysm catheterization with a microcatheter and (c) progressive coils release. (d) Final angiographic control shows the complete aneurysm exclusion after coil embolization.

Figure 4

Stent-assisted coil embolization. (a) Diagnostic angiography shows a saccular aneurysm with a wide neck of the main trunk of the superior mesenteric artery (black arrow). (b) Using a dual femoral approach, aneurysm catheterization, uncovered stent release and aneurysm coil filling are subsequently performed (c) Final angiographic control and (d) CTA MIP reconstruction both show aneurysm exclusion with stent and superior mesenteric artery patency.

Figure 4

Stent-assisted coil embolization. (a) Diagnostic angiography shows a saccular aneurysm with a wide neck of the main trunk of the superior mesenteric artery (black arrow). (b) Using a dual femoral approach, aneurysm catheterization, uncovered stent release and aneurysm coil filling are subsequently performed (c) Final angiographic control and (d) CTA MIP reconstruction both show aneurysm exclusion with stent and superior mesenteric artery patency.

Figure 5

Balloon-assisted coil embolization. (a) Diagnostic angiography shows a saccular aneurysm with a wide neck of the pancreaticoduodenal artery. (b) Using a dual femoral approach, simultaneous balloon inflation and aneurysm coil filling. (c) Final angiographic control shows aneurysm exclusion without coil migration.

Figure 6

Embolization with coils and EVOH liquid embolic agent. (a) Diagnostic angiography shows a fusiform aneurysm of the splenic artery. (b) After selective catheterization of the aneurysm, (c) a progressive embolization of the efferent vessel and the aneurysm with coils and (d) the afferent vessel with Squid (black arrows) is performed. (e) Final angiographic control shows aneurysm exclusion with splenic artery occlusion.

Figure 6

Embolization with coils and EVOH liquid embolic agent. (a) Diagnostic angiography shows a fusiform aneurysm of the splenic artery. (b) After selective catheterization of the aneurysm, (c) a progressive embolization of the efferent vessel and the aneurysm with coils and (d) the afferent vessel with Squid (black arrows) is performed. (e) Final angiographic control shows aneurysm exclusion with splenic artery occlusion.

Figure 7

Embolization with EVOH liquid embolic agent alone. (a) Diagnostic angiography shows a pseudoaneurysm of a terminal branch of the left gastric artery. (b) Selective catheterization with a microcatheter of the afferent vessel to the pseudoaneurysm. (c) Final angiographic control after Onyx infusion shows complete pseudoaneurysm occlusion.

Figure 8

Covered stent. (a) Contrast-enhanced CT (white arrow) and (b) diagnostic angiography show a ruptured aneurysm of the common hepatic artery with contrast extravasation (black arrow). (c) After a self-expandable, covered stent (Viabahn, Gore) release (black arrow), (d) the final angiographic control shows the aneurysm exclusion with no more contrast extravasation and both stent and hepatic artery patency (black arrow).

Figure 9

Flow-diverting stent. (a) Contrast-enhanced CT and (b) diagnostic angiography show an irregular aneurysm of the proper hepatic artery involving the origin of the gastroduodenal artery. (c) Flow-diverting stent (Surpass, Stryker) placement and (d) final angiographic control.