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Treatment of visceral artery aneurysm and pseudoaneurysm

Treatment of visceral artery aneurysm and pseudoaneurysm
Literature review current through: Jan 2024.
This topic last updated: Sep 30, 2022.

INTRODUCTION — The indications for treating specific visceral artery aneurysms depend upon the natural history of disease for the specific site. In general, all visceral artery pseudoaneurysms (VAPAs), symptomatic visceral artery aneurysms (VAAs), and many asymptomatic VAAs (those meeting criteria) require treatment to reduce the risk of death associated with rupture [1]. (See "Overview of visceral artery aneurysm and pseudoaneurysm", section on 'Management'.)

There has been a steady increase in the use of an endovascular approach for aneurysmal disease at other sites, and although all VAAs/VAPAs can technically be treated using endovascular techniques, an open approach may remain the optimal strategy, particularly among those who require emergency repair. Endovascular intervention is an excellent approach in the elective setting, particularly for patients who are poor risk surgical candidates.

The specific treatment of VAAs (open or endovascular) will be reviewed here. The clinical features, diagnosis, and management of VAA are reviewed separately. (See "Overview of visceral artery aneurysm and pseudoaneurysm".)

The clinical features, diagnosis, and management of renal artery aneurysm are presented separately. (See "Renal artery aneurysm".)

APPROACH TO TREATMENT — The goal of treatment of visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) consists of excluding the aneurysm sac from the systemic circulation while ideally preserving distal blood flow. If this cannot be accomplished, the aneurysm can be occluded. Either can be accomplished using an open surgical or endovascular approach. The choice for an individual patient needs to take into account the clinical presentation, site of the aneurysm (vascular bed), location within the affected artery (proximal versus distal, main trunk branch vessel), associated risk factors, and local expertise [2]. (See 'Endovascular intervention' below and 'Open surgery' below.)

For either approach, it is necessary to evaluate the specific anatomy of involved visceral vessel before determining the appropriate treatment [3,4]. (See 'Specific aneurysm sites' below and 'Endovascular intervention' below and 'Open surgery' below.)

For VAA/VAPA affecting vessels that supply an end organ with multiple sources of flow (native or collateral), the aneurysm can be ligated surgically or embolized percutaneously.

For VAA/VAPA affecting vessels that supply an end organ that does not have multiple sources of flow (native or collateral), blood flow to the organ will need to be preserved either through the aneurysm lumen using a stent or stent-graft, or surgical revascularization (eg, bypass).

Open versus endovascular — Although all VAAs and VAPAs can technically be managed using endovascular techniques, open surgical repair and reconstruction may remain the optimal strategy for some VAAs/VAPAs, particularly among those who are hemodynamically unstable and require emergency repair [5]. Compared with endovascular interventions, open surgery has the advantage of durability, reduced need for follow-up studies, and mortality rates as low as 0.5 percent in elective repairs [6-11]. Patients with emergency indications and those with significant comorbidities are at increased risk for complications and poor outcomes [6]. In the emergency setting, open exploration, control of hemorrhage, and ligation of the aneurysm without vascular reconstruction is expeditious and may be preferred. Endovascular treatment may be an option for rupture in selected patients who remain hemodynamically stable, particularly poor risk surgical candidates due to comorbidities, in the setting of a hostile abdomen, or when the aneurysm is not easily accessible. However, overall outcomes using an endovascular approach in the emergency setting have been less desired, though some case reports may suggest the contrary [12-14]. Endovascular treatment reduces perioperative cardiovascular complications and the duration of hospitalization compared with an open surgical approach but is associated with increased rates of reintervention [4,15]. In some series, endovascular treatment of VAA/VAPA has been associated with morbidity rates up to 25 percent, related mainly to transient postembolization syndrome, and incomplete aneurysm exclusion, which remains at risk for rupture [16]. In the Mayo Clinic case series of minimally invasive management, all the deaths that occurred were among those undergoing emergency repair [17]. This poor outcome was confirmed in another large series that reported a perioperative (30 day) mortality of 8.3 percent, in which all deaths occurred in patients requiring urgent or emergency intervention. There were no mortalities on those undergoing elective intervention [18].

The endovascular approach has a more prominent role in the elective setting, for which reported morbidity and mortality rates in the short term are low. With ongoing refinements in catheters, techniques (eg, access, embolization techniques [19]), and devices (eg, stent grafts, multilayer fluid modulating stents [20]), the endovascular approach has evolved to become the preferred initial treatment approach for anatomically suited VAA/VAPA. The main advantages of the endovascular approach are its reduced invasiveness, less postoperative pain, decreased wound complications, decreased length of hospital stay, quicker return to normal activities, and improved quality of life in the short term [5,6,15,21,22]. However, further studies are needed to determine the longer-term durability of endovascular treatment [23-25]. Cost effectiveness related to endovascular devices may also have a bearing on the approach to treatment [5].

The following illustrate overall outcomes of VAA management using open and endovascular approaches.

A large retrospective case series of 185 aneurysms (64 percent VAPA and 36 percent VAA, 46 percent performed for bleeding as an indication) reported a 98 percent technical success rate using an endovascular approach [17]. Overall periprocedural (30 day) and aneurysm-related mortality rates were 6.2 and 3.4 percent, respectively.

Another large series reported a 98 percent success rate with endovascular intervention using mainly coil embolization for aneurysm exclusion [18]. The periprocedural (30 day) mortality rate was 8.3 percent, with no mortality for patients undergoing elective intervention.

In a comparison series of 94 patients with VAA/VAPA, a 100 percent technical success was reported [9]. Morbidity and mortality with the open approach were 9.4 and 1.3 percent, respectively. The endovascular group had similar morbidity (10 percent) and no mortality.

Event rates differ for open and endovascular management for each anatomical site [4].

ENDOVASCULAR INTERVENTION — Options for endovascular intervention include embolization to occlude the vessel, or endovascular stenting or stent-grafting, which preserves flow through the aneurysm [23,26]. These endovascular interventions are accomplished using catheter-based technologies that access the common femoral artery in the groin, or the brachial artery. A brachial artery approach may provide easier access if the visceral vessel has a marked downward trajectory. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures".)

Prior to endovascular intervention, anatomic suitability must be determined to evaluate the collateral flow, which determines the approach; adequacy of potential seal zones for stent-grafting; potential for kinking of the artery; and accessibility of proximal vessels for placement of the delivery sheath.

Once the vessel is accessed with a sheath, a guiding catheter aids in cannulating the specific visceral vessel for the introduction of the small catheter that is used to deliver embolizing agents (eg, coils, hemostatic particles, glue, thrombin, polyvinyl alcohol), vascular occluding plug(s), or a vascular stent (multilayer fluid modulating, stent-graft) to exclude the aneurysm [6,19,27]. (See "Surgical and endovascular techniques for mesenteric revascularization".)

For aneurysms (saccular or fusiform) affecting vessels that supply an end organ with multiple sources of flow or good collateral flow, percutaneous embolization with coils or glue (N-butyl cyanoacrylate) is particularly appropriate [18,19,28]. Glue has a high rate of technical and clinical success with low recurrence rates [19]. True visceral artery aneurysms (VAAs) with good end organ circulation can be treated with coil packing; however, large saccular aneurysms may have poor long-term outcomes with coil embolization as the coils may dislodge and/or migrate. When using an endovascular approach to treat visceral artery pseudoaneurysm (VAPA), in general, proximal and distal coil embolization should be used.

For aneurysms affecting vessels that supply an end organ that does not have good collateral flow, blood flow through the aneurysm lumen needs to be preserved. For the specific anatomic site, the risk of stent thrombosis or restenosis resulting in occlusion and potential end organ ischemia needs to be taken into consideration. Either a stent-graft or multilayer fluid modulating (bare) stent can be used.

For stent or stent-graft deployment, the vessel needs to be of sufficient length to attain proper fixation, which should be at least 5 mm of normal artery proximally and distally. Excessive vessel tortuosity also may not permit stent-graft deployment.

An alternative is a multilayer fluid modulating (bare) stent, which has a spatial three-dimensional design that slows and laminates blood flow inside an aneurysm, allowing an organized thrombus to form [20]. The aneurysm sac naturally thromboses because the flow velocity is reduced [6]. Several studies have documented the feasibility and outcomes using multilayer stents in VAA at different sites [12,29,30]. In a systematic review that included 10 cohort studies, the pooled rate of total aneurysm thrombosis at a mean of 14.1 months follow-up was 89.8 percent (95% CI 84.3-95.3) and primary stent patency rate was estimated at 87.9 percent (95% CI 81.0-94.8) [31].

Reported complications of endovascular therapy include access-related problems such as groin hematomas, pseudoaneurysms, and arterial thrombosis, which can occur during any percutaneous intervention. Procedure-specific complications include distal thromboembolism, nontarget vessel embolization, coil migration, end organ infarction, and intraprocedural aneurysm rupture [32]. Stent thrombosis and occlusion are concerns; however, no consensus exists regarding the use of antithrombotic or antiplatelet agents. Other downsides include higher reintervention rates, incomplete exclusion, unknown long-term durability, and need for repeated imaging [6].

OPEN SURGERY — Traditional open surgical management involves an abdominal incision and mobilization of the organs to expose and ligate/excise the aneurysm, with or without vascular reconstruction depending on the status of collaterals, and when indicated, with end organ resection (eg, splenectomy, bowel resection). Minimally invasive open surgical approaches use small incisions to gain abdominal access for a laparoscope and other instruments for laparoscopic or robotic-assisted aneurysm clipping [33]. The ease of open surgical access to the aneurysm depends upon the location of the aneurysm, previous surgeries, and the acuteness of the presentation. Open surgical repair in a hostile anatomic environment (eg, in the setting of pancreatitis, sepsis, or multiple previous surgeries) can be technically challenging and is associated with high rates of morbidity and mortality. Nonetheless, in a large retrospective review of contemporary outcomes with open repair, there was acceptable mortality and morbidity with elective repair of various visceral aneurysms [11]. However, the mortality and complication rates rose significantly with open surgical management of ruptured visceral aneurysms. (See "Surgical and endovascular techniques for mesenteric revascularization".)

SPECIFIC ANEURYSM SITES — The approach to treatment of splenic, hepatic, and mesenteric artery aneurysms and pseudoaneurysms is reviewed briefly below. Our recommendations are consistent with The Society for Vascular Surgery (SVS) clinical practice guidelines on the management of visceral aneurysms [34]. Aneurysms involving the pancreaticoduodenal [31], gastroduodenal, and inferior mesenteric arteries are approached using similar principles. Endovascular coil embolization is particularly useful in these settings, for which open operative exposure may be difficult and arterial reconstruction is not necessarily required [31].

Splenic — Treatment options for splenic artery aneurysms (SAAs) include open surgical repair, percutaneous intervention with either embolization coils or covered stents, and laparoscopic excision or clipping. Among these, percutaneous intervention of SAA has become increasingly popular due to its high technical success rates and low morbidity [2,18,21,28,35].

SAAs are often ideal for coil embolization because of the collateral supply from the short gastric arteries. Reported success rates range from 90 to 100 percent [18,21,35]. For proximal and midvessel SAA, stent-grafts can be used to maintain perfusion in the main artery; however, tortuosity of the artery can complicate stent-graft placement and deployment [35,36]. Selective splenic artery catheterization and coil embolization of the aneurysm sac are generally recommended for high-risk patients with aneurysm rupture [36].

As with endovascular treatment, the location of the aneurysm, as well as its presentation, generally dictates the type of open procedure that is performed. Resection with end-end repair can be performed in many cases, especially with proximal and midvessel SAA, owing to the redundancy and tortuosity of the artery [7]. This allows for splenic preservation, which has important implications for the immune system. Splenectomy is performed more commonly in the setting of aneurysm rupture and may be necessary for aneurysms involving the splenic hilum [7,10,37].

Complications of SAA coil embolization include splenic infarct and reperfusion of the aneurysm, which occurs in 5 to 20 percent of patients [35,38]. Splenic infarcts are common occurrences in patients with portal hypertension or hilar SAA [27] but usually are successfully treated with pain control [13,18,35,39]. In reported series, splenic infarcts occurred in 25 to 40 percent of the patients treated, but no patient required any further treatment [13,18,38]. To evaluate for reperfusion of the aneurysm, annual follow-up with computed tomography (CT) or magnetic resonance imaging (MRI) is necessary [38].

Hepatic — Endovascular treatment is emerging as the preferred treatment of hepatic artery aneurysms (HAAs). Open surgical repair for rupture is associated with extremely high rates of morbidity and mortality [1].

For intrahepatic aneurysms, percutaneous embolization is always the first-line treatment owing to the complicated nature of open repair [32]. Exclusion of these lesions essentially consists of selective endovascular embolization of the "feeding" arteries proximal to the HAA after the outflow tract has been plugged. Different options can be used, including coils, glue, stents, and detachable silicone balloons, depending on the pathology. With either the open or endovascular intervention, ligation or coil embolization of the hepatic artery can be safely performed if the portal vein is patent [28,35,40,41].

Endovascular approaches appear to have particular utility in the treatment of hepatic artery pseudoaneurysms (HAPAs), for which previous abdominal surgery and medical comorbidity are prominent features [28,35,40]. In unruptured HAPA caused by pancreatitis, percutaneous occlusion is successful in 88 to 100 percent of cases. Good results are also obtained with embolization of ruptured HAA/HAPA, but repeated embolization is necessary in 30 to 40 percent of patients [40]. In a large series, technical success for coil embolization of HAA was 80 percent, and failures were attributed to an inability to cannulate the aneurysm neck [28]. Rare reports of hepatic necrosis are probably the result of inadequate catheter placement or embolization, particularly when the portal vein is occluded. In a small series of 12 hepatic artery embolizations, there was no evidence of hepatic ischemia after aneurysm ablation using either coils or glue [18]. Stent-graft repair may be desirable in patients with baseline hepatic insufficiency, or in aneurysms involving the proper hepatic artery to maintain antegrade perfusion.

Open surgical procedures include ligation, ligation with bypass, partial hepatic resection, and in rare instances, hepatectomy and orthotopic liver transplantation [1,14,35]. Aneurysms involving the proper hepatic artery require vascular reconstruction, whereas common HAA may be managed without reconstruction if collateral flow through the gastroduodenal artery is adequate [7,40-42]. Complications of open surgical repair include graft thrombosis, bile leak, and intra-abdominal abscess or sepsis [1,35].

Mesenteric — Open surgical intervention has been the predominant approach to managing superior mesenteric artery (SMA) aneurysms. For proximal aneurysms, exposure may require a medical visceral rotation, whereas for more distal aneurysms, operative exposure is anterior through the mesentery [43]. Complex or extensive aneurysms may require staged, open repair [44]. Ligation of vessels that enter and exit the aneurysm without reconstruction is feasible in the management of these aneurysms. Collaterals from the celiac and inferior mesenteric arteries are usually sufficient to prevent intestinal ischemia [43,45]. Prior to ligation, a test occlusion with intraoperative assessment of bowel viability can be performed [43]. Other open surgical approaches include endoaneurysmorrhaphy, or ligation and arterial bypass using a prosthetic graft or with vein in the setting of infection.

Embolization of the SMA aneurysm sac is particularly suitable for hemodynamically stable patients and is becoming the more popular approach [39,45]. In general, literature on these techniques is limited to very small series or case reports [28]; thus, long-term outcomes are difficult to assess.

Celiac — Traditional open repair can be performed through a transabdominal route and may require medial visceral rotation to access the proximal celiac artery [43]. Simple artery ligation can be performed in the absence of liver pathology but is sometimes accompanied by hepatic ischemia [46]. Another approach is aneurysm excision (aneurysmectomy) with arterial reconstruction using the supraceliac aorta as an inflow source [43].

Endovascular management of celiac artery aneurysm (CAA) has been described and may be appropriate in high-risk patients without liver dysfunction and without disease of the collateral circulation including the SMA and gastroduodenal arteries [18,21,47]. A retrospective series reported an 89 percent success rate in the treatment of CAA with the endovascular approach using coil embolization or stent grafting [35].

Complications specifically related to endovascular aneurysm exclusion of the celiac artery do not appear to commonly involve organ ischemia [18,21]. Late coil migration leading to fatal gastrointestinal hemorrhage has been described [48]. Complications such as ischemic gastric ulcers, gangrenous cholecystitis, liver abscess, and exacerbation of cirrhosis have also been reported [49].

Pancreaticoduodenal — Endovascular intervention is the preferred initial treatment for pancreaticoduodenal aneurysms [50-54], but the need for reintervention rates is high regardless of treatment approach. The role for hepatic revascularization remains uncertain [55], but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo interventions. In one review, 18 of 24 aneurysms (75 percent) were successfully managed with primary endovascular repair (coil embolization with or without celiac stent), whereas endovascular therapy failed in two (8 percent) and required open repair [52]. Four aneurysms (17 percent) were treated with primary open repair. Overall, 30-day morbidity and mortality after aneurysm repair were 29 and 4 percent, respectively.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Aortic and other peripheral aneurysms" and "Society guideline links: Intestinal ischemia".)

SUMMARY AND RECOMMENDATIONS

All visceral artery pseudoaneurysms (VAPAs), symptomatic visceral artery aneurysms (VAAs), and some asymptomatic VAAs that meet criteria for elective repair require treatment to reduce the risk of rupture. The indications for treatment depend upon the natural history of aneurysmal disease. (See 'Introduction' above and "Overview of visceral artery aneurysm and pseudoaneurysm", section on 'Management'.)

The goal of treatment of VAA and VAPA is ideally to exclude the aneurysm sac from the systemic circulation while preserving distal blood flow; however, if this cannot be accomplished, the aneurysm can be occluded. Either can be accomplished using an open surgical or endovascular approach. (See 'Approach to treatment' above.)

For VAA/VAPA affecting vessels that supply an end organ with multiple sources of flow (native or collateral), the aneurysm can be ligated surgically or embolized percutaneously.

For VAA/VAPA affecting vessels that supply an end organ that does not have multiple sources of flow (native or collateral), blood flow to the organ will need to be preserved either through the aneurysm lumen using a graft or stent graft, or surgical revascularization (eg, bypass).

For patients with ruptured VAA/VAPA, an open approach is often required for rapid control of hemorrhage. However, the ease of open surgical access to the aneurysm depends upon the location of the aneurysm; some difficult-to-access vessels may be better handled with an endovascular approach (eg, pancreaticoduodenal aneurysm). Ligation of the artery proximal and distal to the aneurysm is often adequate. Perfusion to the end organ should be assessed to determine whether or not revascularization is needed. (See 'Open versus endovascular' above and 'Open surgery' above.)

For elective repair of VAA/VAPA, a percutaneous approach is becoming the first-line treatment for VAAs/VAPAs that are anatomically suitable. The percutaneous approach has high technical success rates and is associated with decreased lengths of hospital stay. (See 'Open versus endovascular' above and 'Endovascular intervention' above.)

Our approach to specific sites and their outcomes are discussed above for each type of VAA/VAPA. (See 'Specific aneurysm sites' above.)

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References

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