Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms
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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