Surgical management of a proximal splenic artery aneurysm: A case report

Abstract

Introduction and importance

Splenic artery aneurysms (SAA's) pose a rare yet clinically significant challenge, characterized by the weakening and ballooning of the splenic artery, potentially leading to severe complications such as rupture and hemorrhage.

Case presentation

A 52-year-old female presenting with biliary colic. Diagnostic imaging revealed a saccular lesion closely associated with gallstones. A multidisciplinary approach guided the decision for surgery due to the size and location of the aneurysm. A bi sub costal laparotomy was performed, after the resection of the aneurysm, an arterial anastomosis with pds 5/0 suture was performed.

Clinical discussion

SAA's treatment modalities are tailored based on aneurysm localization and size. Imaging modalities such as Doppler ultrasound and CT angiography play a crucial role in accurate diagnosis, providing essential information for treatment planning. Treatment options include endovascular embolization, and surgical intervention. Traditionally open surgical techniques, including ligation of the splenic artery, aneurysmectomy, and splenectomy. Surgical treatment, especially for proximal aneurysms, is highlighted, with the presented alternative approach of resection with end-to-end anastomosis, showcasing an alternative surgical technique aimed at reducing the risk of spleen infarction.

Conclusion

SAA's are a rarity that emphasizes the need for early detection and intervention. We are urged to maintain a high index of suspicion, particularly in high-risk individuals. We report an alternative surgical technique that we hope will contributes to the expanding repertoire of approaches, calling for further research to optimize SAA management strategies in the quest for improved patient outcomes.

Highlights

• •SAAS ARE RARE BUT SIGNIFICANT CLINICAL CONDITIONS THAT CAN LEAD TO LIFE-THREATENING COMPLICATIONS.
• •IMAGING MODALITIES SUCH AS DOPPLER ULTRASOUND, CT ANGIOGRAPHY, ARE ESSENTIAL FOR DIAGNOSIS.
• •DECISION FOR INTERVENTION DEPENDS ON FACTORS SUCH AS SIZE, LOCALIZATION, AND COMPLICATIONS, WITH EARLY INTERVENTION BEING CRUCIAL TO PREVENT CATASTROPHIC HEMORRHAGE.
• •TREATMENT OPTIONS INCLUDE ENDOVASCULAR EMBOLIZATION, AND SURGICAL INTERVENTION.
• •WE HIGHLIGHTED SURGICAL TREATMENT, ESPECIALLY FOR PROXIMAL ANEURYSMS, WITH AN ALTERNATIVE APPROACH OF RESECTION WITH END-TO-END ANASTOMOSIS.

1. Introduction

Splenic artery aneurysms (SAAs) represent a rare but significant clinical entity. SAAs are characterized by the weakening and ballooning of the splenic artery, which may lead to serious complications, including rupture and hemorrhage [1]. Treatment modality can be either radiologic embolization or surgery. This case report aims to show an unusual way for the management of proximal SAAs.

This case report has been reported in line with the SCARE Criteria [2].

2. Case report

A 52 years old female with no medical history. She presented with biliary colic with no associated signs, Physical examination and biological data were normal.

A Doppler ultrasound showed gallstones associated with a saccular lesion of the splenic artery 22 ∗ 20 mm, a CT angiography confirmed the presence of a saccular cyst lesion of the splenic artery of 24 ∗ 19 ∗ 18 mm it has a close proximity to the body-caudal portion of the pancreas (Fig. 1, Fig. 2). The Lesion is located on the proximal third of the artery. After a multidisciplinary discussion the decision of surgery was made given the size of the aneurysm and its location.

Fig. 1.

CT angiography image of splenic aneurysm artery.

Fig. 2.

CT angiography image of splenic aneurysm artery.

The aneurysm was saccular with a 2.5 cm size located in proximal third portion of the splenic artery so endovascular treatment especially coil can cause coeliac embolism. Due to the potential risk of rupture we choose to perform a resection of the aneurysm with splenic artery reconstruction.

The patient underwent a bi sub costal laparotomy first able Transection of the gastro colic omentum to accesses the lesser sac therefore we identified the pancreas. The splenic artery was subsequently visualized. The artery and the aneurysm were carefully dissected after that we ligated the splenic artery proximal and distal to the aneurysm. The artery is encircled by umbilical tape to facilitate handling (Fig. 4). After the resection of the aneurysm arterial anastomosis was performed with PDS 5/0 suture (Fig. 5), time of the splenic artery was 15 min, time of intervention was 90 min. The splenic artery pulse was verified afterwards and the spleen infracts at the end of the intervention. Cholecystectomy was performed afterwards.

Fig. 4.

Splenic artery (arrow) aneurysm of splenic artery (yellow star).

Pancreas (blue star).

Fig. 5.

Splenic artery end to end anastomosis (arrow).

The specimen was showed in (Fig. 3).

Fig. 3.

Sacular splenic artery aneurysm after resection.

The patient reported being satisfied with the intervention, and the postoperative course was uneventful. Afterwards the patient was seen in post-operative consultation the patient remains asymptomatic. Currently, we have a 12 month follow-up, and the patient is still asymptomatic. We performed a Doppler ultrasound that showed a permeable splenic artery with a spleen with no signs of infracts. There was no sign of recurrence as well.

3. Discussion

This article highlights the importance of early diagnosis of splenic artery aneurysm and the cruciality of choosing the modality of treatment according to localization and size of the aneurysm.

Splenic artery aneurysm (SAA) is a rare condition that can lead to life-threatening complications if not diagnosed and managed promptly. It is the third most common type of arterial aneurysm, with small SAAs usually being asymptomatic, while giant aneurysms are more likely to cause symptoms and complications [3].Accounting for approximately 60 % of all visceral artery aneurysms [1,3]. They are more common in women, especially during pregnancy, and are frequently associated with predisposing factors such as atherosclerosis, portal hypertension, and pancreatic diseases [2,3] . Our patient doesn't have any of the surnamed risk factors.

The exact cause of SAA is uncertain, and its diagnosis can be challenging due to the nonspecific nature of the clinical presentation [1]. SAAs can rupture, leading to hypovolemic shock and high morbidity and mortality, making it a retrospective diagnosis. Timely and appropriate intervention is essential, especially among patients with comorbid diseases, to prevent life-threatening complications. The literature includes case reports of SAA rupture during pregnancy, in patients with pemphigus vulgaris, and presenting with upper gastrointestinal bleeding, highlighting the diverse clinical presentations and the importance of early recognition and management [3,5].

SAAs are relatively rare; they are often asymptomatic and incidentally discovered during imaging studies for unrelated conditions. When symptoms do occur, they can vary widely, ranging from nonspecific abdominal discomfort to life-threatening hemorrhage. Recognizing the signs and symptoms is critical for early intervention. Our patient had biliary colic due to a symptomatic gallstones we discovered incidentally the aneurysm after performed an abdominal ultrasound.

Various imaging modalities, including Doppler ultrasound, CT angiography, and magnetic resonance angiography, are employed for the accurate diagnosis of SAAs. These techniques offer precise information about the size, location, and morphology of the aneurysm that will guide our treatment.

The management of SAAs is contingent on factors such as size, location, and patient's clinical condition. Treatment options include observation, endovascular embolization, and surgical intervention. Each case should be carefully evaluated to determine the most appropriate approach. The choice of treatment depends on the size and location of the aneurysm. [1,4]

Endovascular intervention, such as stent grafting for fusiform true aneurysms and aneurysmal coiling techniques for tortuous, saccular aneurysms, has gained popularity as an alternative for managing SAAs. [1] In our case the aneurysm has a proximal localization so we cannot perform a coil embolization due to the risk of coeliac embolism.

Regarding stent grafts, it is necessary to add that they are more effective in treating fusiform true aneurysms, whereas tortuous, saccular aneurysms are typically addressed through aneurysmal coiling techniques. [7] While the successful application of stent grafts has been reported in various scenarios like traumatic arterial fistula or exclusion of peripheral aneurysms, their use in visceral vessels may not be ideal due to the challenges posed by vessel tortuosity and small diameters, which increase the risk of vessel injury. [8]

In our case surgery is mandatory du to endovascular option impossible to propose weather of coiling or for stent graft.

Traditionally, open surgical techniques have been used to treat or exclude SAAs. Surgical options include ligation of the splenic artery, ligation of the aneurysm, aneurysmectomy with or without splenectomy, and open splenectomy [4,6]. In our case the aneurysm was located in the proximal portion of the splenic artery we performed a resection of the aneurysm.

In order to minimize the risk of splenic infracts and potential splenic abscess, we have performed a new surgical technique that was not described in our review of literature regarding SAA.

Thus we performed and end to end anastomosis to guaranty an optimal vascularization of the spleen optimizing post-operative course. The choice of an end to end anastomosis over a surgical interposed graft was based only on speculation and surgeon preference due to lack of reported case comparing those two procedures in the management of SAA.

After discharge the patient underwent a Doppler ultrasound showed that reveals a permeable splenic artery (Fig. 6).

Fig. 6.

Post-operative permeable splenic artery (blue star) a normally vascularized spleen (yellow star).

To summarize the decision for intervention is based on various factors, including aneurysm size, localization, pregnancy [3], and complications. Endovascular treatment is often the first choice, especially for a medial aneurysm far from coeliac trunk [4]. If it is located in the distal portion of splenic artery a splenectomy with resection of the aneurysm is performed.

Concerning acute rupture calls for emergency surgical repair of the aneurysm, while surveillance or follow-up imaging may be recommended for aneurysms not at immediate risk of rupture [4]. Rupture of SAAs can lead to catastrophic hemorrhage. This complication carries a high mortality rate, emphasizing the significance of early diagnosis and intervention.

4. Conclusion

Splenic artery aneurysms are rare vascular anomalies that demand careful evaluation and management. Early diagnosis and intervention are pivotal in preventing potentially life-threatening complications.

Thus, we should maintain a high index of suspicion, particularly in high-risk individuals, and promptly initiate appropriate diagnostic and therapeutic measures when SAAs are suspected.

Surgical treatment is the only way of treatment for a proximal aneurysm, resection of the aneurysm either open or laparoscopic is standard we highlighted an alternative that is the resection with end to end anastomosis to reduce risk of spleen infracts.

Ethical approval

Our institutions “la Rabta Hospital” and “School of Medicine of Tunis” require no ethical approval for case series. It is required for studies on human participants. This is just a case series with written patient approval.

Funding

None.

Author contribution

Souhaib Atri: conceptualization, data curation, redaction, project manager

Elaifia Rany: conceptualization, data curation, redaction, project manager

Amine Sebai: conceptualization, redaction

Yasmine Hammami: resources, visualization

Haddad Anis: resources, visualization

Montassar Kacem: supervision, validation, visualization

Guarantor

Elaifia Rany

Research registration number

Not applicable.

Consent

Written informed consent was obtained from the patients for publication of this case series and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Conflict of interest statement

All authors declare that they have no conflicts of interest.