Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review

Abstract

Background: Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs.

Materials and methods: A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications.

Results: We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups.

Conclusions: Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.

Keywords: aneurysm rupture; ruptured splenic aneurysms; shock during pregnancy; splanchnic aneurysms; splenectomy; splenic artery aneurysms and pseudoaneurysms; transarterial artery embolization; visceral aneurysms.

Figure 1

Axial view of a huge, ruptured SAA. A: anterior; P: posterior.

Figure 2

Ruptured SAA in coronal view.

Figure 3

Selective intraoperative angiography showing a ruptured SAA.

Figure 4

Proximal coil embolization of the splenic artery.

Figure 5

Proximal and distal embolization of the SA.

Figure 6

Final angiogram showing successful aneurysm exclusion.

Figure 7

Coil removal after laparotomy.

Figure 8

SAA excision.

Figure 9

Selection flow-chart of the reports included in the review.

Figure 10

Records of r-SAA repair between 1990 and 2023.