Visceral Arterial AneurysmsEmbolotherapy

Zhang Shiyi ,MD

Vascular Surgeon and

Endovascular Surgeon

Shandong Provincial

Hospital, P.R. China

Visceral Arterial AneurysmsDefinition

Visceral arteries Celiac trunk

Hepatic artery

Gastroduodenal artery

Splenic artery

Left gastric artery

SMA

Renal arteries

VAAs

Visceral Arterial AneurysmsDefinition

VAAs include both true aneurysms and pseudoaneurysmsTrue aneurysms

Limited by all three layers of the arterial wall, which undergo progressive dilation and wall thinning.

Pseudoaneurysms (VAPAs)There is a tear of the vessel wall and a periarterial

hematoma.

Visceral Arterial AneurysmsIncidence

Visceral artery aneurysms (VAAs) are rare with a reported incidence of 0.01 to 0.2% on routine autopsies.

However, VAAs are clinically important and potentially lethal.22% of all visceral artery aneurysms present as

clinical emergencies8.5% result in death.

Celiac trunk

9×30mm Prescise , Cordis

Splenic Aneurysm

Incidence60% of all VAAsF > M, 4:1- typically in multiparous womenEtiology

Portal hypertension, PancreatitisEndocarditis, Cystic medial necrosis Iatrogenic, Collagen disease (Ehlers-Danlos)

Splenic Aneurysm

ManagementAnatomic/physiologic consideration

Splenic artery arises from celiac axis and tortuousOne of the most amenable arteries for stent graft

placementSupplying branches to the body and tail of pancreasEmbolization of SA proximal and distal to the neck

Splenic Aneurysm

Technique5F Sos or Cobra catheter combined with

microcatheterCoils embolization

>15% bigger than the vessel lumen “Sandwich” or “nest” technique necessary to ensure

a compact and occlusive embolus

Stent graft placementGood landing zone of 1-2 cm required

Splenic Aneurysm

Results of embolization100% of success rate can be achieved

It may be difficult when celiac artery is occludedRetrograde cannulation of GDA from SMAGDA may be hypertrophied if celiac artery occluded

chronicallyCoils may not be delivered easilyParticles (Gelfoam) can be used for temporary stop acute

bleed before open surgery

Splenic Aneurysm

Splenic AneurysmComplications

Nontarget emboliztion

-Pancreatic body and tail

-Splenic infarction

Increased risk of

infection

-Encaptuated bacteria

Pneumococus -Abscess/sepsis/Coils

migration

Reports in literature v.s. our results Mycotic aneurysm – most common cause in the past Traumatic and iatrogenic – most common in our study (80%) Atherosclerosis Inflammatory and vacuities

Polyarteritis nodosa Systemic lumpus erythematosus Takayasu’s arteritis Wegener’s granulomatosis Congenital arteriopathy

Marfan syndrome Ehlers-Danlos syndrome Hereditary hemorrhagic telangiectasia (HHT)

Hepatic Arterial Aneurysm Causes

Hepatic Arterial Aneurysm

The second common visceral aneurysmMore common now due to increased use of IR

procedure in the liver and improvement of imaging study.

HAP - the most common type of saccular hepatic arterial aneurysm (HAA)Comprising of 20% of all visceral aneurysm

Extrahepatic = 80%Intrahepatic = 20%

Hepatic Arterial Aneurysm

Reported mortality rate ranges from 10 – 50%HAP location

contributes to the varying

Infrequent with few reports in the current literatureRetrospective

review/Small cohorts

Hepatic Arterial Aneurysm

HAA renders a medical emergencyEarlier intervene/better clinical outcomeCorrection of coagulopathy, hydration, and fluid

resuscitation/ transfusion should be no delay in IR procedure

ICU monitoring necessary Periprocedure antibiotics

Abscess formation Hepatic ischemia Hematoma Biliary obstruction

Hepatic Arterial Aneurysm

A 41-year-old woman with hepatitis-C

S/p percutaneous liver biopsy

Presenting with severe RUQ painc positive stools, and decreased hemoglobin and hematocrit

Contrast enhanced CT scan

Mesenteric AneurysmsIncidence

Third most common VAA, but only 6%May associate with thrombosis and dissection

Presented with mesenteric ischemia or intestinal angina

Occurring frequency of other mesentericCeliac > GDA > gastric artery

No significant gender difference, typically in 60-70 years

Mesenteric Aneurysms Causes

General causes SMA aneurysms – mycotic Celiac aneurysms – cystic medial degeneration GDA – pseudoaneurysms – duodenal ulceration Gastroepiploic, pancreaticoduodenal aneurysms – pancreatitis

Other causes PAN, amphetamine abuse, and connective tissue disorders

Mesenteric Aneurysms

Risks posed by the aneurysms Ischemia

Proximal thrombosis Distal embolization

Rupture Hematoma infection –

sepsis Bowel resection

Severe ischemia

Mesenteric Aneurysms Management

Anatomic/physiologic considerationOcclusion of splenic, peripheral hepatic, and

GDA are well toleratedEmbolization of peripheral SMA and IMA may

result in ischemiastricture, and infarction of bowel.

It is unwise to place a stent graft in SMA due to potential risk of infection

Mesenteric Aneurysms

TechniqueTypically celiac and proximal SMA aneurysm

are best treated surgicallyLeft brachial artery approach may be necessary

for catheterizing celiac and SMA with acute angel from aorta

GDA can be prophylactically embolized if the origins of SMA and celiac arteries are not compromised

Mesenteric AneurysmsResults and Complications

ResultsEmbolization of SMA aneurysms appeared

to be favorableTechnical success can be reached in 70-

100%Complications

Major complicating factorBowel ischemia and infarction

Renal Artery AneurysmIncidence

Rates range (0.015 to 9.7%)Classification

Saccular/fusiformDissectionPseudoaneurym

Low rupture rate (0-14%)

典型病例张某，男， 25岁，因间断腹痛半年，加重1天入院。患者 6年前曾有下腹部钝性撞击外伤史，无明显皮肤破损，保守治疗。  CT：肠系膜上动脉瘤、肠系膜上动脉瘤分支与门静脉相通。诊断： 1.GDA假性动脉瘤 2.肠系膜上动脉 -静脉瘘

Renal Artery AneurysmCauses

Renal artery PAIatrogenic or traumatic

Other causesFMD, PAN,

amphetamine abuse, AML, and neurofibromatosis

Renal Artery AneurysmRisks posed by the aneurysms

Rupture is rarePregnant woman more prone to ruptureNon-calcified aneurysm was at risk of ruptureHighest reported rate of rupture was 14%

Many other autopsy series showed no rupture

In case of FMDDistal embolization and dissection can be seen

Malignant hypertension

Renal Artery AneurysmAnatomic/physiologic consideration

Kidney – end organInfarction is common

For patients with chronic renal failure or underline diseaseNephron-sparing

procedure is vital Super-selective

embolization

Renal Artery PA

S/p percutaneous core biopsy

presented with left flank pain

and hematuria

Renal Artery AneurysmResults and Complications

Technical successVery high when RA securely accessedVery little chance of ischemia/renal failure

ComplicationsDissection/perforation/rupture of RA

Balloon tamponade for ruptureEmergent surgery may be necessaryBalloon angioplasty for tacking down the flaps

Experience

Branchial approach-- Easier manipulations through difficult lesions

Some neurointerventional embolization techniques (stent ,catheter,wire, IDC etc) helpful to the visceral arterial aneurysms—Devices are designed to

Flexibility , pushability, Very low profile to cross the

tortuous or kink site

Visceral Arterial AneurysmsConclusion

Interventional radiologist play a major role in management of VAAsLife-threatening hemorrhage

Aggressive and emergent interventionSurgical morbidity/mortality is high

Asymptomatic lesionsTiming of tx depending on VAA size and location

Visceral Arterial AneurysmsConclusion (2)

Small lesions can be observedException, not a ruleAll splenic aneurysms in childbearing women should

be treatedHigh rupture rate

All mesenteric aneurysms should be treatedHigh complications from rupture, thrombosis, or distal

embolization

Minimally invasive embolization procedures proved to be effective and safe

Visceral Arterial AneurysmsConclusion4

Surgery is always our powerful weapon.

Individualized treatment plan is important.

谢谢