Chapter 85 - Splanchnic artery aneurysms Flashcards by Gary Yang

First reported repair of splanchnic artery aneurysm

Kehr 1903

Ligation of proper hepatic artery aneurysm

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Paul 1951 on splanchnic artery aneurysms

Ligation and revascularization of traumatic hepatic artery aneurysm

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Debakey and Cooley 1953 on splanchnic artery aneurysm

Repair of mycotic SMA

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Definition of splanchnic artery aneurysms

Aneurysms affecting celiac, SMA, IMA and branches

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Splanchnic aneurysm Association with aortic, renal, iliac or LE, cerebral aneurysms

33%

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Incidence of splanchnic aneurysm

0.1-2%

10% in elderly

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Distribution of types of splanchnic aneurysm by prevalence

Splenic 60%
Hepatic artery 20%
SMA 6%
Celiac 4%
Gastric artery 4%
Jejunal/ileal/colic 4%
PDA 2%
GDA 1.5%
IMA < 1%

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Causes of splanchnic aneurysms

1) atherosclerosis
2) medial degeneration
3) collagen vascular disease
4) FMD
5) infection/inflammatory
6) iatrogenic

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Risk factors for splanchnic aneurysm

1) multiparity
2) portal hypertension
3) post transplant
4) celiac occlusive disease (GDA/PDA aneurysms)

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Multiple splanchnic aneurysm potential systemic causes

1) von Recklinghausen disease
2) Ehlers-Danlos syndrome
3) periarteritis nodosa
4) Behcet disease
5) systemic arteritis
6) endocarditis with septic emboli
7) connective tissue disorders
8) excessive use of acetaminophen

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Vaccination for post-splenectomy

1) Pneumococcal
2) Meningococcal
3) Haemophilus influenzae B

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Splanchnic arteries that can be ligated in emergency

Splenic with splenectomy
proximal hepatic artery
PDA
gastric artery

SMA and celiac will need reconstruction or bowel resection of dead portions

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Criteria to observe splanchnic artery aneurysms

1) less than 2cm
2) asymptomatic
3) minimal or no growth

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Criteria to intervene on splanchnic artery aneurysms

1) women of child bearing age or are pregnant
2) pseudoaneurysms
3) SMA, GDA, PDA aneurysms

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Methods of endovascular treatment of splanchnic aneurysm

1) nitinol coil, cyanoacrylate glue
2) particles or Gelfoam
3) covered stents
4) flow diverting stents
5) thrombin or ethyl alcohol injection

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Down sides of endovascular treatment of splanchnic aneurysms

1) access related complication
2) contrast
3) end-organ embolization
4) higher rate of failure
5) prolonged surveillance

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Mortality after endovascular treatment

8.3%

All related to emergent intervention with hemodynamic instability

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Techniques for embolizing splanchnic aneurysms

End branches can be glued directly

For mid segments, distal coil, then glue or more coil, and proximal coil plug

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Flow diverting stents

Non-covered stents geared to redirect flow away from the aneurysm itself without occluding branch vessels

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Incidence of splenic artery aneurysm in general population

0.78%
Female:male 4:1

occur at younger age than other splanchnic aneurysms but still affects elderly more

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Average size of splenic aneurysm at diagnosis and size at symptom onset

2cm at diagnosis

3cm with symptoms

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Local of splenic aneurysm along splenic artery

1) Saccular

2) mid- or distal splenic artery and at bifurcations

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Giant splenic artery aneurysm

> 10 cm more often in men

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Cause of splenic artery aneurysm

1) atherosclerosis
2) FMD
3) arteritis

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Parity association with splenic aneurysm

1) hormone, FMD, wall stress? etiology unclear 2) 50% of female with >6 preg have splenic aneurysm 3) 80% of female with splenic aneurysm had > 4.5 pregnancies

Incidence of splenic aneurysm in patients with portal HTN or cirrhosis waiting for liver transplant

10-50%

Causes of splenic artery PSEUDOaneurysm

1) trauma 2) infection 3) pancreatitis (diggest splenic artery)

Hemosuccus pancreaticus

rupture of visceral aneurysm into main pancreatic duct

% of splenic artery aneurysm rupture on presentation

10%

Rate of rupture of splenic artery aneurysm not during pregnancy

Pregnancy rupture of splenic artery accounts for this % of all ruptures

50%

double rupture phenomenon of splenic artery aneurysm rupture

First into the lesser sac tamponade up to 4 days then free rupture into peritoneum

Mortality associated with splenic artery aneurysm rupture

10-25%

Mortality for maternal and fetal during splenic artery aneurysm rupture

75% mom | 95% fetus

Rupture in pregnancy when does it occur

third trimester

Prevalence of splenic artery aneurysm in pregnant women

0.1%

How prevalent is portal hypertension in splenic artery aneurysm ruptures

20%

Indication to treat splenic artery aneurysms

1) Ruptures 2) symptomatic 3) women childbearing age 4) pseudoaneurysms 5) size > 2cm

Rate of splenic artery aneurysm growth

Most 90% do not grow | those that grow grow at 0.06-0.2 mm/year

Collateral to supply spleen without splenic artery

Short gastric vessels

Hepatic artery aneurysms first described by

Wilson 1809 | ligated it in 1903

Hepatic artery aneurysms as a % of all splanchnic aneurysms

20%

Incidence of hepatic artery aneurysm

0.4%

Distribution of the hepatic artery aneurysms

Extrahepatic vasculature 75-80% Extraparenchymal liver space 20% Exlusively intrahepatic 5%

Distribution of hepatic artery aneurysm along the extrahepatic vasculature

1) CHA 63% 2) Right hepatic 28% 3) Left hepatic 5% 4) bilateral hepatic 4%

Association of hepatic artery aneurysm with sex and pregnancy

Male:Female 3:2 No association with pregnancy

Mean age of occurence without trauma of hepatic artery aneurysms

60 years

Most common cause of hepatic artery aneurysm

Atherosclerosis 30%

Comorbidities associated with hepatic artery aneurysm

1) HTN 2) arterial dysplasia 3) medial degeneration 4) trauma 5) polyarteritis nodosa 6) biliary disease

Rate of other splanchnic and nonsplanchnic aneurysms in the presence of hepatic artery aneurysm

20% splenic artery aneurysm | 40% nonsplanchnic mostly aortic

Quincke's triad

Rupture of hepatic aneurysm into bile ducts: 1) hemobilia 2) jaundice 3) RUQ pain

Mortality of hepatic artery aneurysm rupture

20-70%

Treatment of hepatic parenchyma aneurysms

Embolization and hepatic resection or lobectomy

Consequence of ligating right hepatic artery

Gallbladder necrosis

SMA aneurysm incidence

1 in 12000-19000

Where along SMA do aneurysms occur

first 5 cm

Causes of SMA aneurysms

1) Mycotic 60% 2) atherosclerosis 3) connective tissue disease 4) PAN 5) pancreatitis 6) trauma

Rupture rates for SMA aneurysms and mortality rate

Rupture 38-50% | Mortality 30-90%

Most common organism for mycotic SMA aneurysm

Streptococcus 47% | Staphylococcus 28%

SMA aneurysm symptoms

1) abdominal pain 2) nausea/vomiting 3) GI bleeding

mortality of SMA surgical repsair

15%

Indication to repair SMA aneurysms

1) Size > 2.5 cm 2) pseudoaneurysms 3) mycotic aneurysms

Celiac aneurysm as percentage of all splanchnic aneurysms

Prevalence of celiac aneurysms

1 in 8000

Celiac aneurysm with concomitant splanchnic aneurysm or AAA

40% other splanchnic | 20% AAA

Causes of celiac artery aneurysms

1) Atherosclerosis | 2) infection 20%

Epidemiology of celiac artery aneurysms

1) male | 2) 50-60's of age

Celiac artery aneurysm rate of rupture and subsequent mortality

10-20% rupture 50% mortality if ruptured

Factors associated with celiac artery aneurysm rupture

none found

Consensus size for celiac artery aneurysm repair

2.5 cm

Rate of gastric and gastroepiploic aneurysms of all splanchnic artery aneurysms

Causes of gastric/gastroepiploic aneurysms

1) Atherosclerosis 30% 2) trauma 25% 3) infection 15%

Epidemiology of gastric/gastroepiploic aneurysms

1) male | 2) age 60-70

Ratio of aneurysms in the left/right gastric (lesser curvature) vs gastroepiploic (greater curvature)

10:1, more in gastric

Clinical presentation of gastric/gastroepiploic aneurysm

Rupture 90%

Mortality after rupture of gastric/gastroepiploic aneurysm

70%

GDA and PDA aneurysms as % of all sphlanchnic aneurysms

2% PDA | 1.5% GDA

Ferguson 1895 on splanchnic aneurysms

First description of superior PDA aneurysm

Causes of GDA/PDA aneurysms

1) pancreatic pathology 2) celiac stenosis/occlusion 3) abdominal trauma 4) iatrogenic injury

Epidemiology of GDA/PDA aneurysms

Male: female 4:1 | 60's age

Size of GDA/PDA aneurysm that predispose rupture

no evidence

% of patients with GDA/PDA aneurysms that present with rupture

65-75%

Mortality after GDA/PDA rupture

30-40%

Rate of IMA branch aneurysms of all splanchnic aneurysms

Causes of IMA branch aneurysms

1) inflammation and infection accounts 1/3

IMA branch aneurysm epidemiology

5:1 male : female

Mortality after mesenteric branch aneurysm rupture

20%

Most common location of visceral venous aneurysms

1) main portal vein 2) junction of SMV and splenic vein 3) hepatic hilus

Chapter 85 - Splanchnic artery aneurysms Flashcards

(88 cards)