- Email: [email protected]
Endovascular Treatment of Splenic and Renal Aneurysms
Endovascular Treatment of Splenic and Renal Aneurysms M.J. Vallina-Victorero Vazquez,1 F. Vaquero Lorenzo,1 A. Alvarez Salgado,1 M. J. Ramos Gallo,1 M. Vicente Santiago,1 I. M. Lojo Rocamonde,2 and L. J. Alvarez Fernandez,1 Gijon and La Corun˜a, Spain
Four cases (three women and one man) of embolization of visceral artery aneurysms are presented, of which two affected the splenic artery and two the renal artery. The two renal aneurysms were related to hypertension; one of the splenic aneurysms was diagnosed in the context of hypertension, and the other affected a woman of a fertile age. Microguides, microcatheters, and Guglielmi platinum coils, liberated by electrolysis, with different lengths and characteristics, were used. Also, one of the renal aneurysm cases was related to the placing of a stent due to the existence of a stenosis of the renal artery adjacent to the aneurysmatic neck. Immediate occlusion of the aneurysm was achieved in the four cases. Evaluation with nuclear magnetic resonance angiography carried out 3 months later confirmed the sealing of the aneurysm and the patency of the native artery. Currently available devices provide a good therapeutic option for the embolization of visceral aneurysms with low morbidity and mortality rates.
Visceral artery aneurysms are diagnosed in <1% of the overall population.1 The most frequent ones are those that affect the splenic artery (SAA), which reach percentages of 60-71%, while renal artery aneurysms (RAAs) make up 15-22% of visceral aneurysms.2 Nowadays, the diagnosis of both pathologies is supported by noninvasive methods, such as duplex scanning, multislice computed tomographic (CT) scan, and nuclear magnetic resonance angiography (MRA), with results similar to those obtained with angiography.3 Although little is known of the natural history of SAAs, the high mortality rate related to their rupture makes it advisable to treat women of a fertile age, patients who are going to be submitted to a liver
1 Department of Angiology and Vascular and Endovascular Surgery, Cabuen˜es Hospital, Gijon, Spain. 2 Department of Angiology and Vascular and Endovascular Surgery, Santa Teresa Polyclinic, La Corun˜a, Spain.
Correspondence to: Manuel Javier Vallina-Victorero Vazquez, MD, Department of Angiology and Vascular and Endovascular Surgery, Cabuen˜es Hospital, Cabuen˜es s/n, 33394 Gijon, Asturias, Spain, Email: [email protected] Ann Vasc Surg 2009; 23: 258.e13-258.e17 DOI: 10.1016/j.avsg.2008.05.018 Ó Annals of Vascular Surgery Inc. Published online: November 5, 2008
transplant, if the aneurysm is symptomatic or shows a contained rupture, as well as pseudoaneurysms and aneurysms >2 cm.4 In the past, open surgery was used for aneurysm exclusion, grafting, or ligature of the splenic artery associated with splenectomy, with mortality rates around 1%. Development of endovascular techniques made it possible to use selective embolization of the aneurysm, to place a stent or endoprosthesis, and even to use combined procedures with simultaneous stenting and embolization.5 Treating true RAA is indicated due to their possible complications, including vascular renal hypertension, thrombosis and renal embolism, renal infarction, and rupture.6 Although the risk of local complications is low and rupture is infrequent,2 there is a relatively high percentage of RAAs related to hypertension, as in the two cases we are presenting. The endovascular treatment techniques for these pathologies have progressively replaced surgery in the past few years, mainly because they are less invasive.2 We present four cases of endovascular treatment of visceral aneurysms, of which two affect the splenic artery and two the renal artery. For embolization, Guglielmi coils liberated by electrolysis were used. Little has been published on the use of this material for endovascular treatment of RAA and SAA.1-3,7 258.e13
258.e14 Case reports
Annals of Vascular Surgery
CASE REPORTS Case 1 A 77-year-old housewife with a past history of human coronary virus Hepatitis C Virus (HCV) + chronic hepatopathy, portal hypertension, and thrombopenia secondary to hypersplenism was admitted because of an episode of abdominal pain. Abdominal CT showed a saccular SAA with a major diameter of 3 cm, located near the hilum. Due to her high risk for surgery, classified on the American Society of Anesthesiologists (ASA) scale as IV by the Anesthesiology Department, we scheduled her for endovascular treatment. Preservation of perfusion of the spleen was considered mandatory in order to ensure the compensation of her portal hypertension condition through collaterality. Initially, an attempt was made to place a nitinol stent with polytetrafluoroethylene (PTFE) covering (Viabahn; W. L. Gore, Flagstaff, AZ). However, the tortuousness of the artery distal to the SAA prevented the progression of a rigid guidewire for support and navigation of the device. Therefore, after catheterization of the proximal splenic artery using a double bend renal 0.038-inch catheter (Imager RDC, 5F; Boston Scientific, Watertown, MA), a soft-tipped microguide (Transend EX Floppy 0.014 inch, 205 cm, platinum; Boston Scientific) was advanced through it (Turbo tracker-18, 150 cm, 3F; Boston Scientific). Once the microcatheter was placed inside the aneurysm (Fig. 1), eight Guglielmi detachable coils (GDCs) were deployed using the electrolysis system (Boston Scientific) with different lengths and calibers. Once the technique was over and after checking the angiograph, which showed that there was no aneurysm and that the splenic artery was patent (Fig. 2), all the material was withdrawn and the puncture site was sealed. Follow-up at 3 months with MRA confirmed that the aneurysm had been correctly embolized, with a small asymptomatic splenic infarction. Case 2 A 34-year-old female bus driver had a past history including smoking of one pack of cigarettes a day and a C-section after her only pregnancy. She regularly took contraceptive drugs. Due to an episode of acute abdominal pain, ultrasound and CT exams were performed, which led to the diagnosis of a saccular SAA, with a maximum size around 2 cm and a narrow neck <4 mm, located in the middle part of the arterial course. The indication for treatment was justified by the patient’s fertile age and her wish to become pregnant soon. Considering she
Fig. 1. Turbo tracker 18 micro-catheter within the aneurysm in the case 1, which introduced through the Double Bend Renal Catheter.
Fig. 2. Angiography for check in the seal of aneurysm in case 1. It shows the line dimensional gulielmi coils and the patency of the splenic artery. The contrast is injected through the Double Bend Renal Catheter.
had already had a cesarean and in an attempt to keep the abdominal wall safe to avoid possible complications of a future pregnancy, she was offered endovascular repair. Both the technique and devices were identical to those used in the previous case. Ten Guglielmi coils (360 GDC, two measuring 12 mm x 30 cm, two measuring 8 mm x 20 cm, four measuring 3 mm x 8 cm and two measuring 2 mm x 8 cm) were finally placed. The arteriogram at the end of the procedure confirmed the complete sealing of the aneurysm, with a normal aspect of the splenic artery. These findings remained, while no other complications were shown at the MRA carried out 3 months later.
Vol. 23, No. 2, March 2009
Fig. 3. The 0.018 Thruway guidewire within the left renal artery distal from the neck of the aneurysm to the cases, which is introduced through the SF Double Bend Renal Catheter.
Case 3 A 23-year-old male had a long past history of hypertension. During the study of his hypertension, a saccular aneurysm of the left renal artery with a maximum diameter of 1.5 cm and a narrow neck was diagnosed by duplex scanning and later confirmed with an angio-CT. A mild stenosis of the renal artery was detected at the aneurysm exit area, perhaps as a result of its compression. In this case, repair was indicated in order to treat the hypertension cause, probably related to the RAA and the artery’s adjacent stenosis. The renal artery was gained with the same catheter as in the previous cases, and a rigid guidewire (Fig. 3) measuring 0.018 inches by 300 cm long (Thruway, Boston Scientific) was advanced up to the aneurysm site. The wire offered the necessary support for delivering an expandable metallic, monorail stent with a balloon measuring 5 x 15 mm (Express Vascular SD, Boston Scientific). Finally, a microcatheter was advanced through one of the stent mesh orifices to the aneurysm sac. Two 360 GDCs, 16 mm x 40 cm, were introduced, and another two fibrated, thrombogenic GDCs measuring 2 x 6 mm (Fig. 4), with complete sealing of the aneurysm and correction of the renal artery stenosis, were used. At discharge, the patient was put on an oral treatment of 100 mg of salicylic acetic acid every 24 hr along with 75 mg of clopidogrel every 24 hr for 1 month. After 3 months, clinical exam showed normal blood pressure and atomic resolution microscopy (MRI)
Case reports 258.e15
Fig. 4. The stent deployed in the renosis adjacent to the aneurysm neck, with the three dimensional and fibered coils that have allowed semi aneurysm.
confirmed the correct technical result. confirmed the correct technical result. Case 4 A 59-year-old woman with a past history of hypertension and dyslipidemia was admitted for a left adrenal adenoma. A 3 cm saccular aneurysm located at the hilum of a tortuous right renal artery was observed on the CT scan. Under suspicion of hypertension related to RAA, endovascular repair was indicated. Despite the use of different projections, the neck of the aneurysm was poorly imaged because of overlapping of the adjacent vascular structures. In order to ensure the accuracy of the procedure, a 6F (RDC, Boston Scientific) catheter guide was advanced through a 6F introducer. An unsuccessful attempt was made to canalize some distal artery to the aneurysm using a double bend renal and 4F multipurpose catheters. Finally, a microcatheter was placed inside the aneurysm sac, supported by the same guide. After delivering the first 360 GDCs, angiography performed during the procedure showed persistent filling up of the aneurysm sac, requiring an increased number of coils up to eight for complete sealing of the aneurysm (Fig. 5), which remained 3 months later as shown at the ARM exam (Fig. 6).
DISCUSSION Endovascular treatment of visceral aneurysms is an alternative to surgery. Recently, this technical option has increased with the use of devices that
258.e16 Case reports
Fig. 5. Angiography for checking the procedure in case 4, which shows the sealing of aneurysm with Guglielmi coils and the patency of the native renal artery with good perfusion of the right kidney.
Fig. 6. ARM for monitoring the case 3 to 4 months. It confirms the sealing of the anuerysm and the patency of the native renal artery.
were initially designed for the treatment of intracranial aneurysms, such as the microguides, microcatheters, and the Guglielmi platinum coils. In the series published in the last few years, rates of success that range 89.7-98% have been reported.8-11 Although these techniques are not exempt from major complications like extensive splenic infarctions or pancreatitis, which can appear in up to 22.2% of the procedures,9 different authors agree that endovascular treatment of visceral artery aneurysms is feasible and effective, with good primary and secondary patency and low morbidity and mortality rates.8-13 A major concern related to the use of
Annals of Vascular Surgery
coils is that it may preclude the follow-up with CT scan due to image artifacts.11 RAAs located at the bifurcation or in the hilum as well as those with a wide neck were traditionally considered to be more complicated to manage with this type of technique.7 The use of Guglielmi three-dimensional coils has facilitated treatment under these situations. Sometimes, their application is combined with a stent with the technique described by Moret et al.,7,14 consisting of inflation of a balloon at the neck of the aneurysm to prevent migration of embolic material to the arterial lumen. Due to their length (sometimes up to 40 cm), three-dimensional coils allow controlled liberation with complete occlusion of the aneurysm in comparison to other available devices, limiting the chance of distal migration of the embolic material or its protrusion into the arterial lumen with the resulting complications. On the other hand, the microguides and microcatheters are very easy to handle and offer good navigability features, which allow relatively fast and simple catheterization of aneurysms, even through the stent mesh. In the four cases presented here, embolization was indicated, due to the saccular nature of the aneurysms, although in one of the cases endografting was initially attempted in order to seal a wide neck at the aneurysm entrance (case 1). However, its hilar location and the tortuousness of the artery prevented the distal canalization. Finally, application of the above-mentioned reconstruction technique permitted us to solve the problem. An attempt was made to minimize these risks with the 360 three-dimensional GDCs, and we finally managed to correctly seal the aneurysm sac without compromising the spleen’s viability. Case 2 was easier as the aneurysm was in the middle area of the artery and the neck was narrow. Therefore, catheterization of the neck and sealing were completed with the delivery of three-dimensional GDCs, along with other fibrated ones. In case 3, the procedure was simple and uneventful as the aneurysm was located in the middle segment of the renal artery and the neck was relatively narrow. After placing the stent in the stenotic portion, catheterization of the aneurysm sac through the stent mesh orifices was quickly performed and the final result was satisfactory. Case 4 presented more problems due to the location of the aneurysm at the hilum and the great tortuousness of the artery. After multiple attempts with different catheters and guides, it was nearly impossible both to clearly differentiate the image of the aneurysm from the adjacent arteries and to catheterize a distal artery. For that reason, embolization had to be done without a stent. However, since the
Vol. 23, No. 2, March 2009
aneurysm was very large, it was possible to introduce the microcatheter into the sac and to place sufficiently long three-dimensional coils in order to completely seal the aneurysm. Follow-up with duplex scanning and MRA after 3 months showed persistent sealing of the aneurysms, and no complications were observed apart from the above-mentioned splenic infarction of case 1. It is important to point out again that the image artifacts impeded the imaging of these coils with CT scan.11 In conclusion, currently available endovascular devices provide a good therapeutic alternative for the treatment of visceral aneurysms, with low morbidity and mortality rates. REFERENCES 1. Cheng T-C, hau-Bin Chou A, Chang P-Y, Lee C-C. Splenic artery aneurysm successfully treated by transarterial embolization: a case report. Chin J Radiol 2006;31:189-193. 2. Klein GE, Szolar DH, Breinl E, Raith J, Schreyer HH. Endovascular treatment of renal artery aneurysms with conventional non-detachable microcoils and Guglielmi detachable coils. Br J Urol 1997;79:852-860. 3. Damascelli B, Bartorelli AL, Ticha V, Trabattoni D, Lanocita R. Large renal artery aneurysm treated with Guglielmi detachable coils: procedural and 4-year follow-up results. Cadiovasc Intevent Radio 2008; 31(Suppl 2):S88-91. 4. Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: two decades experience at Mayo Clinic. Ann Vasc Surg 2002;16:442-449.
Case reports 258.e17
5. Bercelli SA. Hepatic and splenic artery aneurysms. Semin Vasc Surg 2005;18:196-201. 6. Hupp T, Allenberg JR, Post K, Roeren T, Meier M, Clorius JH. Renal artery aneurysm: surgical indications and results. Eur J Vasc Surg 1992;6:477-486. 7. Dib M, Sedat J, Ch Raffaelli, Petit I, Robertson WG, Jaeger Ph. Endovascular treatment of a wide-neck renal artery bifurcation aneurysm. J Vasc Interv Radiol 2003;14: 1461-1464. 8. Gabelmann A, Go¨rich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002; 9:38-47. 9. Saltzberg SS, Maldonado TS, Lamparello PJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg 2005;19:507-515. 10. Lagana D, Carrafiello G, Mangini M, et al. Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Eur J Radiol 2006;59:104111. 11. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-283. 12. Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular management of visceral artery aneurysm. J Endovasc Ther 2001;8:150-155. 13. Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004;18:695-703. 14. Moret J, Cognard C, Weill A, Castaings L, Rey A. Reconstruction technique in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. A propos of 56 cases. J Neuroradiol 1997;24: 30-44.
Four cases (three women and one man) of embolization of visceral artery aneurysms are presented, of which two affected the splenic artery and two the renal artery. The two renal aneurysms were related to hypertension; one of the splenic aneurysms was diagnosed in the context of hypertension, and the other affected a woman of a fertile age. Microguides, microcatheters, and Guglielmi platinum coils, liberated by electrolysis, with different lengths and characteristics, were used. Also, one of the renal aneurysm cases was related to the placing of a stent due to the existence of a stenosis of the renal artery adjacent to the aneurysmatic neck. Immediate occlusion of the aneurysm was achieved in the four cases. Evaluation with nuclear magnetic resonance angiography carried out 3 months later confirmed the sealing of the aneurysm and the patency of the native artery. Currently available devices provide a good therapeutic option for the embolization of visceral aneurysms with low morbidity and mortality rates.
Visceral artery aneurysms are diagnosed in <1% of the overall population.1 The most frequent ones are those that affect the splenic artery (SAA), which reach percentages of 60-71%, while renal artery aneurysms (RAAs) make up 15-22% of visceral aneurysms.2 Nowadays, the diagnosis of both pathologies is supported by noninvasive methods, such as duplex scanning, multislice computed tomographic (CT) scan, and nuclear magnetic resonance angiography (MRA), with results similar to those obtained with angiography.3 Although little is known of the natural history of SAAs, the high mortality rate related to their rupture makes it advisable to treat women of a fertile age, patients who are going to be submitted to a liver
1 Department of Angiology and Vascular and Endovascular Surgery, Cabuen˜es Hospital, Gijon, Spain. 2 Department of Angiology and Vascular and Endovascular Surgery, Santa Teresa Polyclinic, La Corun˜a, Spain.
Correspondence to: Manuel Javier Vallina-Victorero Vazquez, MD, Department of Angiology and Vascular and Endovascular Surgery, Cabuen˜es Hospital, Cabuen˜es s/n, 33394 Gijon, Asturias, Spain, Email: [email protected] Ann Vasc Surg 2009; 23: 258.e13-258.e17 DOI: 10.1016/j.avsg.2008.05.018 Ó Annals of Vascular Surgery Inc. Published online: November 5, 2008
transplant, if the aneurysm is symptomatic or shows a contained rupture, as well as pseudoaneurysms and aneurysms >2 cm.4 In the past, open surgery was used for aneurysm exclusion, grafting, or ligature of the splenic artery associated with splenectomy, with mortality rates around 1%. Development of endovascular techniques made it possible to use selective embolization of the aneurysm, to place a stent or endoprosthesis, and even to use combined procedures with simultaneous stenting and embolization.5 Treating true RAA is indicated due to their possible complications, including vascular renal hypertension, thrombosis and renal embolism, renal infarction, and rupture.6 Although the risk of local complications is low and rupture is infrequent,2 there is a relatively high percentage of RAAs related to hypertension, as in the two cases we are presenting. The endovascular treatment techniques for these pathologies have progressively replaced surgery in the past few years, mainly because they are less invasive.2 We present four cases of endovascular treatment of visceral aneurysms, of which two affect the splenic artery and two the renal artery. For embolization, Guglielmi coils liberated by electrolysis were used. Little has been published on the use of this material for endovascular treatment of RAA and SAA.1-3,7 258.e13
258.e14 Case reports
Annals of Vascular Surgery
CASE REPORTS Case 1 A 77-year-old housewife with a past history of human coronary virus Hepatitis C Virus (HCV) + chronic hepatopathy, portal hypertension, and thrombopenia secondary to hypersplenism was admitted because of an episode of abdominal pain. Abdominal CT showed a saccular SAA with a major diameter of 3 cm, located near the hilum. Due to her high risk for surgery, classified on the American Society of Anesthesiologists (ASA) scale as IV by the Anesthesiology Department, we scheduled her for endovascular treatment. Preservation of perfusion of the spleen was considered mandatory in order to ensure the compensation of her portal hypertension condition through collaterality. Initially, an attempt was made to place a nitinol stent with polytetrafluoroethylene (PTFE) covering (Viabahn; W. L. Gore, Flagstaff, AZ). However, the tortuousness of the artery distal to the SAA prevented the progression of a rigid guidewire for support and navigation of the device. Therefore, after catheterization of the proximal splenic artery using a double bend renal 0.038-inch catheter (Imager RDC, 5F; Boston Scientific, Watertown, MA), a soft-tipped microguide (Transend EX Floppy 0.014 inch, 205 cm, platinum; Boston Scientific) was advanced through it (Turbo tracker-18, 150 cm, 3F; Boston Scientific). Once the microcatheter was placed inside the aneurysm (Fig. 1), eight Guglielmi detachable coils (GDCs) were deployed using the electrolysis system (Boston Scientific) with different lengths and calibers. Once the technique was over and after checking the angiograph, which showed that there was no aneurysm and that the splenic artery was patent (Fig. 2), all the material was withdrawn and the puncture site was sealed. Follow-up at 3 months with MRA confirmed that the aneurysm had been correctly embolized, with a small asymptomatic splenic infarction. Case 2 A 34-year-old female bus driver had a past history including smoking of one pack of cigarettes a day and a C-section after her only pregnancy. She regularly took contraceptive drugs. Due to an episode of acute abdominal pain, ultrasound and CT exams were performed, which led to the diagnosis of a saccular SAA, with a maximum size around 2 cm and a narrow neck <4 mm, located in the middle part of the arterial course. The indication for treatment was justified by the patient’s fertile age and her wish to become pregnant soon. Considering she
Fig. 1. Turbo tracker 18 micro-catheter within the aneurysm in the case 1, which introduced through the Double Bend Renal Catheter.
Fig. 2. Angiography for check in the seal of aneurysm in case 1. It shows the line dimensional gulielmi coils and the patency of the splenic artery. The contrast is injected through the Double Bend Renal Catheter.
had already had a cesarean and in an attempt to keep the abdominal wall safe to avoid possible complications of a future pregnancy, she was offered endovascular repair. Both the technique and devices were identical to those used in the previous case. Ten Guglielmi coils (360 GDC, two measuring 12 mm x 30 cm, two measuring 8 mm x 20 cm, four measuring 3 mm x 8 cm and two measuring 2 mm x 8 cm) were finally placed. The arteriogram at the end of the procedure confirmed the complete sealing of the aneurysm, with a normal aspect of the splenic artery. These findings remained, while no other complications were shown at the MRA carried out 3 months later.
Vol. 23, No. 2, March 2009
Fig. 3. The 0.018 Thruway guidewire within the left renal artery distal from the neck of the aneurysm to the cases, which is introduced through the SF Double Bend Renal Catheter.
Case 3 A 23-year-old male had a long past history of hypertension. During the study of his hypertension, a saccular aneurysm of the left renal artery with a maximum diameter of 1.5 cm and a narrow neck was diagnosed by duplex scanning and later confirmed with an angio-CT. A mild stenosis of the renal artery was detected at the aneurysm exit area, perhaps as a result of its compression. In this case, repair was indicated in order to treat the hypertension cause, probably related to the RAA and the artery’s adjacent stenosis. The renal artery was gained with the same catheter as in the previous cases, and a rigid guidewire (Fig. 3) measuring 0.018 inches by 300 cm long (Thruway, Boston Scientific) was advanced up to the aneurysm site. The wire offered the necessary support for delivering an expandable metallic, monorail stent with a balloon measuring 5 x 15 mm (Express Vascular SD, Boston Scientific). Finally, a microcatheter was advanced through one of the stent mesh orifices to the aneurysm sac. Two 360 GDCs, 16 mm x 40 cm, were introduced, and another two fibrated, thrombogenic GDCs measuring 2 x 6 mm (Fig. 4), with complete sealing of the aneurysm and correction of the renal artery stenosis, were used. At discharge, the patient was put on an oral treatment of 100 mg of salicylic acetic acid every 24 hr along with 75 mg of clopidogrel every 24 hr for 1 month. After 3 months, clinical exam showed normal blood pressure and atomic resolution microscopy (MRI)
Case reports 258.e15
Fig. 4. The stent deployed in the renosis adjacent to the aneurysm neck, with the three dimensional and fibered coils that have allowed semi aneurysm.
confirmed the correct technical result. confirmed the correct technical result. Case 4 A 59-year-old woman with a past history of hypertension and dyslipidemia was admitted for a left adrenal adenoma. A 3 cm saccular aneurysm located at the hilum of a tortuous right renal artery was observed on the CT scan. Under suspicion of hypertension related to RAA, endovascular repair was indicated. Despite the use of different projections, the neck of the aneurysm was poorly imaged because of overlapping of the adjacent vascular structures. In order to ensure the accuracy of the procedure, a 6F (RDC, Boston Scientific) catheter guide was advanced through a 6F introducer. An unsuccessful attempt was made to canalize some distal artery to the aneurysm using a double bend renal and 4F multipurpose catheters. Finally, a microcatheter was placed inside the aneurysm sac, supported by the same guide. After delivering the first 360 GDCs, angiography performed during the procedure showed persistent filling up of the aneurysm sac, requiring an increased number of coils up to eight for complete sealing of the aneurysm (Fig. 5), which remained 3 months later as shown at the ARM exam (Fig. 6).
DISCUSSION Endovascular treatment of visceral aneurysms is an alternative to surgery. Recently, this technical option has increased with the use of devices that
258.e16 Case reports
Fig. 5. Angiography for checking the procedure in case 4, which shows the sealing of aneurysm with Guglielmi coils and the patency of the native renal artery with good perfusion of the right kidney.
Fig. 6. ARM for monitoring the case 3 to 4 months. It confirms the sealing of the anuerysm and the patency of the native renal artery.
were initially designed for the treatment of intracranial aneurysms, such as the microguides, microcatheters, and the Guglielmi platinum coils. In the series published in the last few years, rates of success that range 89.7-98% have been reported.8-11 Although these techniques are not exempt from major complications like extensive splenic infarctions or pancreatitis, which can appear in up to 22.2% of the procedures,9 different authors agree that endovascular treatment of visceral artery aneurysms is feasible and effective, with good primary and secondary patency and low morbidity and mortality rates.8-13 A major concern related to the use of
Annals of Vascular Surgery
coils is that it may preclude the follow-up with CT scan due to image artifacts.11 RAAs located at the bifurcation or in the hilum as well as those with a wide neck were traditionally considered to be more complicated to manage with this type of technique.7 The use of Guglielmi three-dimensional coils has facilitated treatment under these situations. Sometimes, their application is combined with a stent with the technique described by Moret et al.,7,14 consisting of inflation of a balloon at the neck of the aneurysm to prevent migration of embolic material to the arterial lumen. Due to their length (sometimes up to 40 cm), three-dimensional coils allow controlled liberation with complete occlusion of the aneurysm in comparison to other available devices, limiting the chance of distal migration of the embolic material or its protrusion into the arterial lumen with the resulting complications. On the other hand, the microguides and microcatheters are very easy to handle and offer good navigability features, which allow relatively fast and simple catheterization of aneurysms, even through the stent mesh. In the four cases presented here, embolization was indicated, due to the saccular nature of the aneurysms, although in one of the cases endografting was initially attempted in order to seal a wide neck at the aneurysm entrance (case 1). However, its hilar location and the tortuousness of the artery prevented the distal canalization. Finally, application of the above-mentioned reconstruction technique permitted us to solve the problem. An attempt was made to minimize these risks with the 360 three-dimensional GDCs, and we finally managed to correctly seal the aneurysm sac without compromising the spleen’s viability. Case 2 was easier as the aneurysm was in the middle area of the artery and the neck was narrow. Therefore, catheterization of the neck and sealing were completed with the delivery of three-dimensional GDCs, along with other fibrated ones. In case 3, the procedure was simple and uneventful as the aneurysm was located in the middle segment of the renal artery and the neck was relatively narrow. After placing the stent in the stenotic portion, catheterization of the aneurysm sac through the stent mesh orifices was quickly performed and the final result was satisfactory. Case 4 presented more problems due to the location of the aneurysm at the hilum and the great tortuousness of the artery. After multiple attempts with different catheters and guides, it was nearly impossible both to clearly differentiate the image of the aneurysm from the adjacent arteries and to catheterize a distal artery. For that reason, embolization had to be done without a stent. However, since the
Vol. 23, No. 2, March 2009
aneurysm was very large, it was possible to introduce the microcatheter into the sac and to place sufficiently long three-dimensional coils in order to completely seal the aneurysm. Follow-up with duplex scanning and MRA after 3 months showed persistent sealing of the aneurysms, and no complications were observed apart from the above-mentioned splenic infarction of case 1. It is important to point out again that the image artifacts impeded the imaging of these coils with CT scan.11 In conclusion, currently available endovascular devices provide a good therapeutic alternative for the treatment of visceral aneurysms, with low morbidity and mortality rates. REFERENCES 1. Cheng T-C, hau-Bin Chou A, Chang P-Y, Lee C-C. Splenic artery aneurysm successfully treated by transarterial embolization: a case report. Chin J Radiol 2006;31:189-193. 2. Klein GE, Szolar DH, Breinl E, Raith J, Schreyer HH. Endovascular treatment of renal artery aneurysms with conventional non-detachable microcoils and Guglielmi detachable coils. Br J Urol 1997;79:852-860. 3. Damascelli B, Bartorelli AL, Ticha V, Trabattoni D, Lanocita R. Large renal artery aneurysm treated with Guglielmi detachable coils: procedural and 4-year follow-up results. Cadiovasc Intevent Radio 2008; 31(Suppl 2):S88-91. 4. Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: two decades experience at Mayo Clinic. Ann Vasc Surg 2002;16:442-449.
Case reports 258.e17
5. Bercelli SA. Hepatic and splenic artery aneurysms. Semin Vasc Surg 2005;18:196-201. 6. Hupp T, Allenberg JR, Post K, Roeren T, Meier M, Clorius JH. Renal artery aneurysm: surgical indications and results. Eur J Vasc Surg 1992;6:477-486. 7. Dib M, Sedat J, Ch Raffaelli, Petit I, Robertson WG, Jaeger Ph. Endovascular treatment of a wide-neck renal artery bifurcation aneurysm. J Vasc Interv Radiol 2003;14: 1461-1464. 8. Gabelmann A, Go¨rich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002; 9:38-47. 9. Saltzberg SS, Maldonado TS, Lamparello PJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg 2005;19:507-515. 10. Lagana D, Carrafiello G, Mangini M, et al. Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Eur J Radiol 2006;59:104111. 11. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-283. 12. Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular management of visceral artery aneurysm. J Endovasc Ther 2001;8:150-155. 13. Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004;18:695-703. 14. Moret J, Cognard C, Weill A, Castaings L, Rey A. Reconstruction technique in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. A propos of 56 cases. J Neuroradiol 1997;24: 30-44.