Hybrid management of a patient with a giant traumatic visceral artery pseudoaneurysm

Abstract

Traumatic visceral artery pseudoaneurysms are rare and serious vascular complications with a high risk of rupture. If left untreated, they can result in significant morbidity and mortality. Current guidelines recommend treating all visceral artery pseudoaneurysms regardless of size because of these risks. We present an unusual case involving a traumatic splenic artery pseudoaneurysm diagnosed 40 years after a motor vehicle collision. This case highlights the effective management of a complex pseudoaneurysm through a hybrid technique that enabled precise definition of the pseudoaneurysm's anatomy and facilitated vascular control before open repair.

Visceral artery pseudoaneurysms are infrequent but potentially life-threatening vascular complications. They are associated most commonly with conditions such as trauma, iatrogenic injury, infection, or inflammatory processes. This condition presents a serious clinical challenge owing to the high risk of rupture if left untreated, which can lead to severe morbidity and mortality.1, 2, 3

Given the significant risk of rupture, current guidelines recommend the repair of visceral artery pseudoaneurysms regardless of their size.⁴ Advances in medical imaging and interventional techniques have enhanced the detection and treatment of visceral artery pseudoaneurysms significantly. Endovascular repair has emerged as a preferred treatment option for patients with suitable anatomical conditions. This minimally invasive approach has been associated with lower procedural morbidity compared with traditional open surgical methods. Furthermore, endovascular repair typically results in shorter hospital stays and faster recovery times, offering a considerable advantage for patient outcomes.^5,6

Given the rarity and potential severity of visceral artery pseudoaneurysms, timely diagnosis and effective management are critical. We present the successful management of a traumatic pseudoaneurysm of the splenic artery, diagnosed 40 years after a motor vehicle collision, using a hybrid approach. The patient provided written informed consent for publication of this case.

Case report

A 69-year-old woman with a history of hypertension and a remote motor vehicle collision in 1983 with severe injuries was transferred to our institution, presenting with a 5-day history of abdominal pain, nausea, and vomiting. She also reported experiencing a pulsatile abdominal mass for several years, along with food intolerance and unintended weight loss over the past couple of months. Upon examination, she presented a large, tender pulsatile abdominal mass.

Computed tomography angiography (CTA) revealed a 15-cm visceral artery pseudoaneurysm, likely arising from a branch of the splenic artery (Fig 1, A-C). owing to the size of the pseudoaneurysm and the patient's concerning symptoms, we elected to proceed with a hybrid treatment approach. First, we conducted a visceral angiogram to define the anatomy of the pseudoaneurysm accurately and achieve vascular control, followed by an open surgical repair.

Fig 1.

Preoperative computed tomography angiography (CTA) demonstrating the 15-cm visceral artery traumatic pseudoaneurysm. Note the displaced stomach (arrow). (A) Coronal view. (B) Sagittal view. (C) Aneurysm characteristics using TeraRecon 3D reconstruction software.

Operative technique

Via right femoral access, a visceral angiogram was performed and confirmed that the pseudoaneurysm arose from a branch of the splenic artery. A Van Schie 3 catheter (Cook Medical) was used to cannulate the celiac artery, and a 5F sheath was positioned at the origin of the celiac artery. Balloon occlusion of the inflow was achieved using a 7 mm × 40 mm balloon (Armada, Abbott Medical), successfully establishing vascular control (Fig 2, A). The patient was systemically heparinized. After securing the sheath and balloon in place, a midline laparotomy was performed.

Fig 2.

(A) Intraoperative image of the visceral angiogram with the balloon in place. (B) Intraoperative image of the pseudoaneurysm (C) An image of the removed thrombus.

Upon entering the abdominal cavity, a very large aneurysm was observed, with a thin wall and hematoma tracking in the most anterior aspect, signs concerning for impending rupture (Fig 2, B and C). Additionally, a significant amount of bilious/purulent fluid was identified, and cultures were obtained for analysis. The occlusive balloon was inflated, achieving vascular control, allowing safe access to the pseudoaneurysm. The pseudoaneurysm was entered, noting minimal backbleeding that was controlled with direct suture. Then, the inflow to the pseudoaneurysm was controlled by using interrupted pledgeted Prolene sutures to ligate the feeding artery. Owing to the size of the pseudoaneurysm, its close proximity to the stomach and duodenum, and the presence of fluid, raising concerns for potential erosion into the bowel or other hollow viscus, general surgery was consulted intraoperatively.

General surgery explored the abdomen carefully, focusing on the potential for stomach and duodenal erosion, with no evidence of full-thickness hollow viscus injury. An esophagogastroduodenoscopy was performed, confirming these findings. Ultimately, given the amount of thrombus removed and the relief of compression symptoms, the pseudoaneurysm sac was closed primarily, and the case was concluded without complications.

The patient's hospital course was uncomplicated. Intraoperative cultures revealed growth of Brevibacterium, leading to a consultation with infectious disease. Although they did not consider this as the cause of an active infection, they recommended a short course of antibiotic treatment. The patient was ultimately discharged on postoperative day 7 with a plan to complete a 5-day course of ciprofloxacin and metronidazole. A follow-up CTA at 3 months confirmed an aneurysm sac without blood flow (Fig 3, A and B). The patient fully regained normal function, experienced complete relief from gastrointestinal symptoms, and regained weight.

Fig 3.

(A) Preoperative computed tomography angiography (CTA) of the chest, abdomen, and pelvis axial view demonstrating the 15-cm visceral artery traumatic pseudoaneurysm. (B) Three- month follow-up CTA chest abdomen and pelvis axial view demonstrating the collapsed aneurysm sac without blood flow.

Discussion

Visceral artery pseudoaneurysms are rare but potentially life-threatening conditions that require prompt diagnosis and management owing to their high risk for rupture, which can lead to significant morbidity and mortality.1, 2, 3 These pseudoaneurysms often arise from trauma, iatrogenic injury, infection, or inflammatory processes, and can remain undetected for many years. Our case, involving a splenic artery pseudoaneurysm diagnosed 40 years after trauma, exemplifies the delayed presentation that can occur with these patients.

Given the increased risk of rupture, prompt diagnosis of visceral artery pseudoaneurysms is critical. CTA has become the preferred diagnostic tool owing to its high sensitivity and ability to aid in procedural planning.^7,8

The Society for Vascular Surgery clinical practice guidelines recommend repairing all visceral artery aneurysms, regardless of size, owing to the persistent risk of rupture.⁴ With advances in medical imaging and intervention, management strategies increasingly favor endovascular techniques. In patients with suitable anatomy, these minimally invasive procedures, such as stent graft placement or transcatheter embolization, provide significant advantages, including a lower procedural risk, shorter hospital stays, and quicker patient recovery compared with traditional open surgery.^5,6

However, in cases of complex vascular anatomy, failure to achieve successful exclusion of the pseudoaneurysm through endovascular techniques, or when significant mass effect on surrounding structures exists, open repairs remain essential. This approach is safe and effective, providing satisfactory outcomes both in the short and long term.^9,10

A hybrid approach combines the benefits of both endovascular techniques and open surgery, offering a comprehensive treatment strategy that is particularly valuable in managing complex cases. It provides a detailed understanding of the pseudoaneurysm anatomy, enables precise vascular control, and facilitates direct treatment through an open surgical approach. In our particular case, although we considered a fully endovascular approach with pseudoaneurysm embolization, the patient's significant gastrointestinal symptoms resulting from the mass effect necessitated pseudoaneurysm decompression.

These results align with the previously published literature, which indicates that, in several situations, a hybrid approach can offer significant benefits for treating these complex cases. We have previously reported our experience using a hybrid approach to achieve vascular control for the repair of infected femoral pseudoaneurysms.¹¹ Common surgical strategies to manage these patients include open exposure and control of the aneurysm, combined with endovascular exclusion using covered stents. Alternatively, embolization of inflow and outflow vessels may be performed, followed by direct surgical ligation, resection, or even debranching procedures.12, 13, 14, 15

Our case highlights one of the first reported instances of managing a delayed giant traumatic visceral artery pseudoaneurysm with a hybrid approach. Several key considerations support this strategy. First, although endovascular techniques in patients with suitable anatomy are considered the treatment of choice, a hybrid approach provides an effective alternative. In patients who can tolerate open operations, this approach offers excellent visualization of the pseudoaneurysm anatomy, obtaining vascular control, and allowing safe access to the pseudoaneurysm via an open approach to relieve patient symptoms.

Conclusions

A tailored approach was used to treat a patient with late presentation of a giant traumatic visceral pseudoaneurysm, incorporating both endovascular and open techniques. This case highlights the successful use of endovascular techniques to delineate the pseudoaneurysm's anatomy and achieve vascular control, followed by open surgery to relieve the mass effect and improve symptoms. Although endovascular approaches have lower morbidity rates, selecting the most appropriate treatment, whether open, endovascular, or a hybrid approach, requires careful consideration of the patient's specific anatomy and clinical needs. In this case, a hybrid strategy was necessary to achieve vascular control and address the compressive effects of the pseudoaneurysm on surrounding structures effectively.

Funding

None.

Disclosures

None.