Technical considerations of endovascular management of true visceral artery aneurysms

Abstract

Background: True visceral artery aneurysms are potentially complex to treat but with advances in technology and increasing interventional radiology expertise over the past decade are now increasingly the domain of the interventional radiologist. BODY: The interventional approach is based on localization of the aneurysm and identification of the anatomical determinants to treat these lesions to prevent aneurysm rupture. Several different endovascular techniques are available and should be selected carefully, dependent on the aneurysm morphology. Standard endovascular treatment options include stent-graft placement and trans-arterial embolisation. Different strategies are divided into parent artery preservation and parent artery sacrifice techniques. Endovascular device innovations now include multilayer flow-diverting stents, double-layer micromesh stents, double-lumen balloons and microvascular plugs and are also associated with high rates of technical success.

Conclusion: Complex techniques such as stent-assisted coiling and balloon-remodeling techniques are useful techniques and require advanced embolisation skills and are further described.

Keywords: Arterial embolisation; Mesenteric; Renal; Visceral aneurysm.

Fig. 1

Diagram of Indications of Management of VAAs based on the Society of Vascular Surgery Clinical Practice Guidelines (Chaer et al. 2020)

Fig. 2

Diagram of stent-assisted coiling and balloon remodelling

Fig. 3

Diagram of the Rundback Classification (Chung et al. 2016)

Fig. 4

Left renal artery aneurysm (Rundback type 2) managed by stent assisted coiling

Fig. 5

Splenic artery aneurysm managed by front and back door embolisation using vascular plug for the front door and coils for the back door. A Axial arterial phase post contrast CT showing 5.5 cm main artery SAA. B Coeliac angiogram confirms the SAA. C Embolisation using vascular plug for the front door and coils for the back door. D 2 months follow up arterial phase post contrast CT confirming exclusion of the aneurysm from the circulation with less than 20% infarction of the splenic parenchyma without clinical significance

Fig. 6

Management of a true CHA aneurysm with stent-grafts and GDA embolisation. A Angiography confirmed the presence of a large aneurysm arising from the proximal proper hepatic artery extending to the bifurcation of the proper hepatic artery. B The gastroduodenal artery arising from the proximal aspect of the aneurysm was embolised with coils. C and D Two Viabahn stent grafts were placed extending from the right hepatic artery proximally to the origin of the coeliac trunk and completion angiography showed an excellent result with exclusion of the hepatic artery aneurysm. E Complete aneurysmal exclusion from the circulation on final angiogram. F On the 30 month follow up, the hepatic artery stents appeared occluded, however there are hepatic collaterals noted from the left gastric artery with patent portal vein. The hepatic artery aneurysm remains occluded

Fig. 7

Embolisation of GDA aneurysm by sandwich occlusion technique with micro coils. A GDA aneurysm on selective angiogram of the celiac axis with associated replaced right hepatic artery arising from the GDA at the neck of the aneurysm. B Embolisation of the front and back doors of the GDA aneurysm as well as the replaced right hepatic artery using 4, 5 and 6 mm detachable 0.018 coils