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Visceral arterial aneurysms (VAAs) are a rare entity. If left untreated, they can lead to potentially fatal rupture. A spectrum of etiologies contributes to their development; however, they are most often discovered incidentally. Computed Tomography (CT) is the imaging modality of choice for their optimal characterization and guidance for potential treatment. Management options may include watchful waiting, surgical intervention, and/or endovascular procedures.
Presentation
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Anatomy
- Of true splanchnic arterial aneurysms, the splenic artery (a. lienalis) is most commonly affected (60% of cases)
- The hepatic artery (a. hepatica) follows with 20% of cases, including the common, proper, left, and right hepatic arteries
- The remaining group consists of aneurysms of the superior mesenteric artery (AMS), inferior mesenteric artery (AMI), and their branches (e.g., gastroduodenal artery (GDA)
- False or pseudoaneurysms of the mesenteric arteries usually arise due to acute or chronic inflammation (pancreatitis is a known cause), or trauma (e.g., iatrogenic injury during hepatobiliary procedures)
- Concomitant aneurysms are found in 33-50% of VAA patients, including thoracoabdominal and iliac arteries (3-27%), other visceral arteries (4-44%), and intracranial arteries (3-4%)
Indications
Upcoming ESVS guideline (2025):
* Pancreaticoduodenal arcade aneurysms from 1.5 cm
* Other VAAs from 3 cm.
Exception:
* Pregnant women with VAA always need immediate treatment regardless of size, due to hormonal influence and increased risk of rapid growth. Ruptured splenic artery aneurysms in pregnant women have extremely high maternal (70%) and fetal (90%) mortality.
Pseudoaneurysms have a much higher rupture risk than true aneurysms and should always be discussed in an experienced multidisciplinary vascular team (vascular surgeons and interventional radiologists).
Contra Indications
- Anatomical variants and/or comorbidity should be considered
Workup
- CTA
- Multidisciplinary discussion
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Material
Essentials
- Chlorhexidine
- Standard angiography set
- Lidocaine 1% 10 ml
- Contrast
- Heparine 5.000 IE/ml
- Heparinized saline (5.000 IE/l)
- Oscor
- 0.035" Terumo Stiff guidewire
- Micorcatheter
- 0.018" Wire
- 0.014" Wire
- Embolization material like coils: pushable and detachable, plugs: micro- and macroplugs, liquid embolic agents: Glubran2 or Onyx and possibly a (covered) stent
Non Essentials
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Positioning
- Head first
- Supine
- Arms lifted
Steps
Front and back door closure:
First, occlude the "back door" (outflow) of the VAA using embolization material or devices
Once back doors are confirmed closed, embolize the "front door" (inflow/efferent vessel)
Placement of a covered stent:
A covered stent is placed through the aneurysm to maintain flow to the visceral organ distal to the aneurysm.
Packing the aneurysm:
Used in difficult cases where the back door cannot be reached with a microcatheter or when there are multiple unreachable outflow arteries
The aneurysm is packed with embolization material, followed by embolization of the inflow vessel
Often uses coils, but liquid embolics are also suitable as they fill the aneurysm slowly
Tips & Tricks
- Rupture of an untreated VAA can lead to death
- Thrombosis or embolism from a VAA with mural thrombus can lead to clinical signs of mesenteric ischemia or organ infarcts
- After stent placement, endoleaks (type 1A and 1B – proximal/distal attachment issues) can occur, similar to abdominal aneurysms
Follow up
- Initially, a CT scan will almost always be performed
- If the VAA no longer fills with contrast and ideally shrinks, ultrasound can be sufficient for further follow-up
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