Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms

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Abstract

Purpose

To assess the feasibility and the effectiveness of endovascular treatment of visceral arteries aneurysms (VAAs) using a “multimodal approach”.

Material and methods

Twenty-five patients (mean age 60.1 years) with 29 VAAs (13 splenic, 4 hepatic, 3 gastroduodenal, 6 renal, 2 pancreatic-duodenal, 1 superior mesenteric) were considered suitable for endovascular treatment; 8/29 were ruptured. Saccular aneurysms (9/29) were treated by sac embolization with coils (in 4 cases associated with cyanoacrylate or thrombin) with preservation of artery patency. Fusiform aneurysms (6/29), were treated by an “endovascular exclusion”. In 10/29 cases, supplied by a terminal branch, we performed an embolization of the afferent artery, with coils and cyanoacrylate or thrombin. 2/29 cases were treated with a stent-graft and 2/29 cases with a percutaneous ultrasound-guided thrombin injection and coils embolization of the afferent artery. The follow-up was performed by ultrasonography and/or CT-angiography 1 week after the procedure and then after 1, 6, and 12 months and thereafter annually.

Results

In 29/29 cases we obtained an immediate exclusion. Two patient died for other reasons. Complication rate was 27.6% (7 spleen ischemia and 1 stent-graft occlusion). During the follow-up (range: 7 days–36 months, mean 18.7 months), we observed 3/29 (10.3%) cases of reperfusion in the first month, all treated successfully with a further endovascular procedure. Primary technical success was 89.7%; secondary technical success was 100%.

Conclusion

Endovascular therapy can be considered a feasible and effective approach for VAAs with good primary and secondary success rates.

Introduction

Visceral artery aneurysms (VAAs) are an uncommon vascular disease presenting an incidence of 0.01–2% [1] but they are an important, life-threatening, vascular lesion because their clinical presentation is rupture in 30–40% of cases, with a mortality rate of 25–70% [2]. However, the increasing diffusion of cross-sectional imaging (ultrasound and above all CT-angiography) has led to the diagnosis of a higher percentage (40–80%) of asymptomatic VAAs [3], [4].

When present, symptoms are pain, sentinel bleeding and hypotension [1].

The most frequent sites of VAAs are splenic (60%), hepatic (20%), superior mesenteric (5%) and celiac (4%) arteries; rarely gastroduodenal, renal, pancreatic-duodenal, jejunal, ileocolic and inferior mesenteric arteries [5].

In the past, surgery was the treatment of choice for VAAs; nevertheless the surgical approach to the VAAs is complex and presents elevated mortality and morbidity [3]. In the last few years endovascular treatment has been reported as a safe and effective alternative [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22].

We present our experience in the endovascular treatment of different VAAs by using a “multimodal approach” (different techniques and materials depending on the site and morphology of the aneurysm).

Section snippets

Materials and methods

Twenty-five patients (15 female and 10 male; mean age 62.9 years, range 34–90) with 29 VAAs (13 splenic, 4 hepatic, 3 gastroduodenal, 6 renal, 2 pancreatic-duodenal, 1 superior mesenteric) were considered suitable for endovascular treatment. The mean diameter was 2.7 cm (range 1.5–5) (Table 1).

Twenty-two were true aneurysms (12 splenic, 3 hepatic, 1 gastroduodenal, 4 renal, 1 pancreatic-duodenal, 1 superior mesenteric) and 7 pseudoaneurysm: 4 post-pancreatitis (1 splenic, 2 gastroduodenal, 1

Results

In 29/29 cases the post-procedural angiography showed complete aneurysm exclusion.

We observed 3/29 (10.3%) cases (2 gastroduodenal and 1 pancreatic-duodenal) of reperfusion during the first month after the procedure, caused by anastomosis which guarantees a rich collateral circulation. All cases were retreated successfully with a further endovascular procedure: 2 endovascular exclusions of the gastroduodenal artery (embolization of the efferent and afferent arteries) (Fig. 3d and e) and 1

Discussion

VAAs have multiple etiologies. The most frequent causes of true aneurysms are: arteriosclerosis, fibrodysplasia, connective-tissue disorders and hyperflow conditions (such as portal hypertension). Pseudoaneurysms (aneurysms where a tear of the vessel wall with successive peri-artery haematoma can be found) can be caused by trauma, iatrogenic lesions (from surgical, endoscopic or radiological interventional procedures) or from inflammatory or infectious condition [1], [5], [15]. They hold high

Conclusion

Endovascular therapy can be considered a feasible and effective approach for the treatment of visceral artery aneurysms and pseudoaneurysms both in asymptomatic patients and in emergency, with good primary and secondary success rates.

Our experience, in accordance with that reported in literature, shows that endovascular treatment has several advantages compared to surgery, in relation to its minimal invasiveness, its low complication rate and the possibility of repeating the procedure in case

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