The therapeutic challenge of giant splenic artery aneurysm: a case repport / O desafio terapêutico do aneurisma gigante da artéria esplênica: um relato de caso

ABSTRACT Giant splenic artery aneurysm is a rare condition that represents an eminent life threatening for the patient, requiring, therefore, urgent surgical correction. A 61-year-old woman, former smoker, hypertensive, hypercholesterolemic and multipara sought our service because of a large tumor in the mesogastrium, which was an abdominal ultrasound finding. Despite the size of the tumor, the patient was asymptomatic. The angiotomography and the magnetic resonance image of the abdomen were suggestive of giant splenic artery aneurysm with more than 10cm in diameter that was confirmed by an angiography. She underwent surgery, open splenectomy, and partial aneurysmectomy. The approach of the celiac artery, which was ligated, was only possible with medialvisceral rotation because there was no possibility to view it through the anterior access. The histopathological test of aneurysmatic wall revealed atheroma plaques in the intima. The patient progressed without complications and she was discharged cured. In general, giant splenic artery aneurysms are symptomatic, however, as in the case we report, it may be asymptomatic and found in abdominal imaging exam. Although less invasive Interventional methods exist, such as laparoscopy and endovascular techniques, they were considered inappropriate in this case. Conventional open surgery should be the therapy of choice for a giant splenic artery aneurysm.

RESUMO O aneurisma gigante da artéria esplênica constitui condição rara, que representa risco de vida iminente para o paciente, necessitando, consequentemente, de correção cirúrgica urgente. Mulher de 61 anos, ex-fumante, hipertensa, com hipercolesterolêmica e multípara nos procurou por apresentar grande tumor no mesogástrio, achado de ultrassonografia abdominal. Apesar das dimensões do tumor, era assintomática. Angiotomografia e ressonância magnética de abdômen sugeriam tratar-se de aneurisma gigante de artéria esplênica com mais de 10cm de diâmetro, confirmado por angiografia. Foi submetida a tratamento cirúrgico aberto, tendo sido realizadas esplenectomia e aneurismectomia parcial. A abordagem do tronco celíaco, que foi ligado, só foi possível com rotação visceral medial, pois não havia possibilidade de visualizá-lo pela via anterior. O exame anatomopatológico da parede do saco aneurismático revelou placas de ateroma na íntima. A paciente evoluiu sem intercorrências e teve alta hospitalar curada. Aneurismas da artéria esplênica de dimensões avantajadas, em geral, são sintomáticos, porém, como no caso em questão, podem ser assintomáticos e descobertos em exame de imagem do abdômen. Apesar de existirem métodos intervencionistas menos invasivos, como laparoscopia e técnicas endovasculares, eles não foram considerados adequados neste caso. Diante de um aneurisma gigante de artéria esplênica, a conduta terapêutica de eleição é a cirurgia convencional aberta.

Analysis of 36 patients with type B aortic intramural hematoma: clinical presentations, treatments and outcomes in a single center / 中国医师杂志

Objective To review the clinical manifestation,diagnosis method,misdiagnosis,risk factors,treatments and prognosis of Stanford B aortic intramural hematoma (IMHB).Methods All of the Stanford B aortic IMHB patients admitted in Wuhan Union hospital from January 2008 to December 2013 were analyzed.The clinical manifestation,diagnosis method,misdiagnosis,managements and prognosis were studied.Furthermore,the effect and long-term survival of different therapies were compared,including medical treatment and endovascular repair.The statistics was performed with SPSS 16.0.Results There were 36 B aortic IMHB patients,and the percent of male patients was 72.22％.The mean age of IMHB was 60.19 ± 11.12.Most patients complained of acute chest and back pain,accompanied with hypertension.Twenty-eight patients (77.78％) received medication therapy,among them,there were 5 patients died of aortic rupture; eight patients (22.22％) received endovascular surgery,one died of cerebral hemorrhage (12.5％).No difference was found between medication therapy and endovascular surgery (17.86％ vs 12.5％,P ＞0.05).Conclusions For simple type B aortic IMHB patients,medication therapy and a dynamic monitoring of full aortic CT angiography was recommended,and for pejorative patients the endovascular treatment should be taken actively.

Endovascular Stent-Graft Placement and Secondary Intervention for Abdominal Aortic Aneurysm in a Patient who had a Previously Inserted Iliac Stent

Endovascular repair of abdominal aortic aneurysm is associated with low morbidity and mortality rates when compared to open surgery, and this can be used in patients who are at a high risk for open surgical repair. Also, secondary intervention is an important for achieving intermediate and long term success of endovascular repair of abdominal aortic aneurysm as this can resolve complications. We report here on endovascular stent-graft placement and a secondary interventional procedure in the abdominal aortic aneurysm of a patient who had a previously inserted iliac stent.

Unruptured Aneurysms with Cranial Nerve Symptoms: Efficacy of Endosaccular Guglielmi Detachable Coil Treatment

OBJECTIVE: To evaluate the efficacy of endosaccular Guglielmi detachable coil (GDC) treatment of unruptured aneurysms causing cranial nerve (CN) symptoms. MATERIALS AND METHODS: Among a database of 218 patients whose aneurysms were treated using GDC, seven patients met the criteria for unruptured aneurysms presenting with symptoms and signs of CN palsy. Changes in CN symptoms before and after GDC treatment were reviewed. RESULTS: Aneurysms were located in the internal carotid-posterior communicating artery (n=3), the basilar bifurcation (n=1) and the cavernous internal carotid artery (n=3). CN symptoms included ptosis (n=6), mydriasis (n=2), and extraocular muscle (EOM) disorder (CN III: n=4; CN VI: n=3). Overall, improvement or resolution of CN symptoms after treatment was noted in five patients. CN symptoms in cases involving small (< or =10 mm) and intradural aneurysms tended to respond better to GDC treatment. Ptosis was the initial symptom to show improvement, while EOM dysfunction responded least favourably. CONCLUSION: GDC coil packing appears to be an appropriate treatment method for the relief of CN symptoms associated with intracranial aneurysms.

Stent Assisted Coil Embolization of a Dissecting Aneurysm of the Vertebral Artery: A Case Involving a Patient with Hypoplasia of the Contralateral Vertebral Artery

A dissecting aneurysm of the vertebral artery may be treated conservatively, surgically, or using an endovascular approach. Proximal clipping, wrapping or trapping are surgical treatment methods, and endovascular treatment with coils and balloons is performed where a dissecting aneurysm is located near the midline or the appropriate surgical manipulation is difficult. As the contralateral vertebral artery of this patient was hypoplastic, the stent-assisted coil embolization technique was employed to preserve the ipsilateral vertebral artery. We describe a clinical case of dissecting aneurysm of the vertebral artery occurring in a patient in whom a hypoplastic contralateral vertebral artery was successfully treated.

Usefulness of "Double-catheter" Technique in GDC Treatment of Intracranial Wide-necked Aneurysm

Purpose: To describe two different methods of "double-catheter" techniques for the treatment of wide-necked intracranial aneurysms. MATERIALS AND METHODS: Using two microcatheters simultaneously, we treated two wide-necked ophthalmic aneurysms and one wide-necked basilar bifurcation aneurysm. In the two cases of ophthalmic aneurysms, the two microcatheters were placed in the aneurysm sac, thus allowing two coils to be braced across the aneurysmal neck before either was detached. In the case of the basilar bifurcation aneurysm, a microcatheter was placed in the posterior cerebral artery (PCA), and another within the aneurysm lumen. When making the first frame with a GDC, we tried to ensure that the frame of the coil and the microcatheter in the PCA did not over-lap. Then, through the microcatheter positioned at the PCA, angiography was performed and flow pattern and dye-disappearance time were evaluated. Subsequent coils were introduced, but in order to preserve PCA flow, not beyond the frame of the first coil. RESULTS: All three aneurysms were successfully embolized without parent artery compromise and the patients were discharged in good neurological condition. CONCLUSION: The "double-catheter" technique can provide a valuable option for treating wide-necked aneurysms, especially when 'balloon remodeling' is not feasible and/or the relationship between the aneurysmal neck and adjacent parent artery cannot be ascertained.

GDC Embolization of Wide-necked Cerebral Aneurysms Using Balloon-Assisted Technique

PURPOSE: The main factor limiting endovascular treatment of intracranial aneurysms is the shape of the a-neurysmal sac, especially the width of the neck. We describe an early experience and technical aspects of treating wide-necked cerebral aneurysm using a Guglielmi detachable coil (GDC) and simultaneous application of a temporary balloon. MATERIALS AND METHODS: Four cases of unruptured wide-necked cerebral aneurysm were treated with GDC, with simultaneous application of a temporary balloon. Patients were aged between 29 and 49 years. On admission, clinical presentation was subarachnoid hemorrhage (SAH) in all cases. Hunt and Hess grade was II in two cases, III in one case, and traumatic SAH in one case. In all patients angiography revealed an asymptomatic a-neurysm after rupture of another aneurysm or traumatic SAH. The aneurysms were occluded with GDC-10, and a Cirrus balloon occlusion system was used simultaneously. All procedures were performed under endo-tracheal general anesthesia and systemic heparinization. RESULTS: All cases were treated successfully, without parent artery compromise. The occlusion rate at the end of the procedure was total in three cases and subtotal in one. In one case a heparin-related hematoma occurred during post-procedural treatment and the patient eventually expired. One patient underwent follow-up angiography after 6 months, and the coil was not changed. CONCLUSION: An aneurysm may not be completely occluded, but with regard to coil compaction and parent artery preservation, the technique is an attractive alternative.

Clinical Application of Stent-Graft Using Gianturco Stent and Poly-tetra-fluoro ethylene (PTFE) in AorticAneurysm

PURPOSE: To evaluate the effectiveness of treatment of aortic aneurysm with endoluminal stent-grafts usingGianturco stent and poly-tetra-fluoro ethylene (PTFE). MATERIALS AND METHODS: In ten patients with aorticaneurysm, eleven procedures were performed using tubular (n=7) or bifurcated (n=4) Gianturco Z-stents covered withPTFE to treat aortic disease (six atherosclerotic aortic aneurysms, four pseudoaneurysms of abdominal aorta inthree patients with Behcet's disease, and one penetrating atherosclerotic ulcer). Spiral CT angiography was usedfor follow-up from 14 days to 31 months (mean, 12 months). The effectiveness of stent-grafts was evaluated duringfollow-up. RESULTS: In all cases, implantation of stent-grafts was technically successful ; in five, perigraftleakage was detected on completion of aortography. On initial post-procedural CT images obtained 4 - 24 days afterinsertion of the stent-graft, complete thrombosis of the aneurysm was seen in seven cases and perigraft leakage infour. Two of the four cases in which leakage was seen on initial CT improved spontaneously during follow-up.Procedure-related thromboembolism occurred in one case, which was managed by thrombolytic therapy without residualsequelae. During follow-up CT, the size of aortic aneurysms of atherosclerotic disease did not change. Thepseudoaneurysms of Behcet's disease decreased and eventually completely disappeared, with only residual periaorticsoft tissue. CONCLUSION: For the treatment of aortie diseases, stent grafting using a Gianturco stent and PTFE isclinically feasible, safe, and effective.

Endovascular Treatment of Abdominal Aortic Aneurysm by Bifurcated Stent Graft

PURPOSE: To evaluate the effectiveness and safety of endoluminal bifurcated stent graft for the treatment of AAA. MATERIALS AND METHODS: Between August 1997 and August 1998, 20 patients with AAA underwent treatment involving the use of a bifurcated stent graft. Fourteen in whom the aneurysm involved only bifurcation and six patients in whom the common iliac arteries were involved. For one patient, a stent with a short proximal neck measuring 12 mm was used. The stent graft was inserted by means of a unilateral surgical femoral arteriotomy. After the procedure, follow up involving CT and aortography was performed between month 3 and month 12. RESULTS: The primary success rate with the first trial was 79 percent (15 of 19 patients), and the overall success rate was 84 percent; one perigraft leak was successfully corrected. In one case, technical failure occurred due to a tortuous iliac vessel and spasm. Procedure-related complications occurred in 16% of patients (3 of 19), one of whom died due to acute renal failure following a contrast overdose. CONCLUSION: Endovascular treatment of infrarenal AAA by means of a bifurcated stent graft was effective and safe. In particular, if the proximal neck measured more than 1cm, any AAA could be treated using bifurcated stent graft. Further investigation of the outcome and complications arising during long-term follow-up are needed, however.

Endovascular Treatment of 20 Acutely Ruptured Cerebral Aneurysms with Detachable Coils

PURPOSE: To evaluate the preliminary results of endovascular coil treatment of acutely ruptured aneurysms. MATERIALS AND METHODS: Between August 1995 and December 1997, 18 patients with 20 ruptured aneurysms weretreated. They were classified as Hunt and Hess grade I (n=3), grade II (n=1), grade III (n=3), grade IV (n=10) orgrade V (n=1). Endovascular treatment was performed at mean 5.2 (range, 1-18) days. The first aneurysm was treatedwith mechanical detachable spirals (MDS) and the others with Guglielmi detachable coils (GDC). Aneurysm size wascategorized as small (n=17) or large (n=3). Ten aneurysms were located in the anterior circulation, and ten in theposterior circulation. Using the Glasgow outcome scale (GOS), clinical outcome was evaluated 5 to 27 months aftertreatment in 11 patients. Three patients had already died. RESULTS: In 14 of the 18 patients (16 of 20 aneurysms: 80%), treatment was successful. Four aneurysms failed due to unsuccessful catheter placement (n=2), smallaneurysm (n=1) or occlusion of the parent vessel (n=1). Total occlusion was observed in 13 aneurysms; 95-99%, orsubtotal occlusion, in two, and less than 95%, or incomplete occlusion, in one. Technical complications includedpassing of wire (n=1) and unintentional parent artery occlusion (n=1). There was a 7.1%(1/14) morbidity rate, butno mortality related to the technique. Six patients with Hunt and Hess grade I-III had good clinical outcome (3with GOS 1, and 2 with GOS 2). Four of the nine patients who were grade IV-V showed clinical improvement (GOS 3);two patients were clinically unchanged (GOS 4), and three died from the severity of primary hemorrhage. CONCLUSION: Endovascular coil treatment is a reasonable alternative for patients who are not candidates forconventional surgical treatment or in whom such treatment has failed.

Evaluation of Results and Radiologic Follow-up in Detachable Balloon Occlusion Thera py of the Internal CarotidArtery Aneurysms

PURPOSE: The author has studied the clinical results of CT and MR findings of proximal carotid artery occlusion using detachable balloons in the treatement of unclippable internal carotid (IC) aneurysms. MATERIALS AND METHODS: From 1987 to 1995, twenty-eight patients with IC aneurysms were treated by proximal arteryocclusion with detachable balloons. Of these patients, 4 had aneurysms arising from the supraclinoid portion ofthe IC artery, 23 had aneuryms arising from cavernous portion of the IC artery, and one had aneurysm arising fromcervical portion of the IC artery. Of the 28 patients, 7 patients without CT or MR examinations were excluded inthis study. The mean follow-up period was 18.6 months. The causes of aneurysm formation were spontaneous in 17cases and traumatic in 4 cases. RESULTS: Of 20 patients with aneurysms arising from supraclinoid and cavernousportion of the IC artery, 16 patients (80%) had cranial nerve symptoms by mass effect. Five patients had epistaxis(3 patient), carotid cavernous fistula (1 patient) or subarachnoid hemorrhage (1 patient) due to aneurysmrupture. Two patients, each with aneuryms arising from supraclinoid and cervical portion of carotid artery had 9thand 12th cranial nerve symptom. There were three instances of complication after permanent occlusion; two patientshad subarachnoid and intracerebral hemorrhage by aneurysm rupture and expired. One patient had ischemia ofposterior cerebral artery teritorry after one day. Delayed ischemic event did not occur during the follow-upperiod. All aneurysms of the carotid artery below the level of ophthalmic artery presented radiographic proof ofcomplete thrombosis within two months. However, complete thrombosis of aneurysm was considerably delayed in twoaneurysms arising from the supraclinoid portion of the carotid artery. In long-term follow-up study, complete-lythrombosed aneurysms decreased in size slowly. But incompletely thrombosed aneurysms did not decrease in size fora long time and began to contract after formation of complete thrombosis. All three traumatic pseudoaneurymscharacteristically decreased in size rapidly, comparing with spontaneous aneurysms. CONCLUSION: In conclusion,proximal IC balloon occlusion for unclippable IC aneurysms is a convenient, safe, and effective way of producinganeurysm obliteration. Longer-term follow-up study is needed for incompletely thrombosed aneuryms after balloonocclusion of the proximal IC artery.

Changes of Incompletely Embolized Aneurysm with Tungsten Coils: An Experimental Study in Dogs

PURPOSE: To evaluate changes of residual aneurysms according to the size of aneurysmal neck andthrombogenicity of a tungsten coil after incomplete embolization of experimental lateral aneurysms. MATERIALS AND METHODS: Eleven experimental lateral aneurysms with different aneurysmal neck size were created in the commoncarotid arteries of mongrel dogs. They were then divided into narrow-neck(n=3), wide-neck(n=6) and spontaneouslythrombosed control(n=2) groups. After confirmation of aneurysmal patency, incomplete embolizations of varyingdegrees (about 30% to near total occlusion) were performed using 5mm-diameter tungsten coils. Angiography wasperformed immediately before and after, and one and six weeks after embolizations. The size of residual aneurysmwas measured on each angiogram. After the last angiography, embolized aneurysms were excised and examined underlight and electron microscopes. RESULTS: On angiograms obtained 6 weeks after embolization, all residual narrowneck aneurysms were completely occluded, whereas in those with a wide-neck, therre was either no change (n=4) or aslight increase in size(n=2). On light microscopy, all narrow-neck aneurysms showed total organized fibrosis whileall control aneurysms and half those with a wide neck showed unorganized thrombi. The embolized group showed ahigher degree of organization in the aneurysmal cavity than did the control group. Neointima formation was seen inall embolized aneurysms, but no aneurysm showed foreign body reaction. On electron microscopy, uniform thicknessof plasma coatings was noted on the surface of the tungsten coils. CONCLUSION: A wide-neck residual aneurysm maypersist or increase in size, while one with a narrow-neck can be thrombosed after incomplete embolization withtungsten coils in a lateral aneurym. Careful consideration might be necessary in the embolization of wide-neckaneurysms. With plasma coatings on its surface and organized fibrosis, tungsten coil can be an useful forembolization of an aneurysm.

Percutaneous Transcatheter Embolization of Extensive Congenital Arteriovenous Malformation Combined withAneurysms in the Chest Wall: A case report

Congenital arteriovenous malformation (AVM) usually involves the head, extremities and internal organs, but isuncommon in the chest wall. It is, moreover, rarely combined with aneurysms. It can be cured by surgery, but isoften difficult to treat. The purpose of this study is to report a case of extensive AVM involving the rightlateral chest wall combined with multiple aneurysms, which was successfully treated by transcatheter embolizationusing several embolic materials.

Significance of Transcatheter Arterial Embolization in the Treatment of Pseudoaneurysm ComplicatingPancreatitis

PURPOSE: To evaluate the significance of transcatheter arterial embolization(TAE) of pseudoaneurysmcomplicating pancreatitis. MATERIALS AND METHODS: This study was based on a retrospective analysis of eightcases, in which TAE for the control of pseudoaneurysm complicating pancreatitis was attempted. All patients weremales, and were aged between 35 and 65(mean, 47) years. Seven had a history of episodes of chronic pancreatitisand one case was the result of acute pancreatitis. All patients underwent diagnostic angiography andsuperselective embolization. RESULTS: Arteries in which pseudoaneurysm had occurred were the gastroduodenal(n=5), inferior pancreaticoduodenal (n=1), superior mesenteric artery root (n=1), and the celiac axis (n=1). Sixcases were treated successfully without complications, but in two, embolization failed due to a wide aneurysmalneck arising from the superior mesenteric artery root and celiac axis. In four successful cases, pseudoaneurysmswere completely resolved within three to six months of embolization. One of the other two remained as apseudocyst, while in the other, also a pseudocyst, surgery was performed. CONCLUSION: Because TAE in patientswith pseudoaneurysm complicating pancreatitis has a high success rate, and also leads to absolute resorption of apseudocyst, TAE is the preferred pre-surgical treatment mode.

Transcatheter Arterial Embolization of the Pseudoaneurysm and Aneurysm: The Usefulness and Therapeutic Effect according to Embolic Materials

PURPOSE: To evaluate therapeutic effect according to embolic materials, and the usefulness of transcatheter arterial embolization (TAE) in the treatment of pseudoaneurysm and aneurysm. MATERIALS AND METHODS: We evaluated 12 patients who since 1987 had suffered arterial pseudoaneurysm or aneurysm. Ten were males and two were females, and their ages ranged from 10 months to 67 years (mean 34 years). The arteries involved were the superficial temporal (n=3), the renal (n=3), the hepatic (n=2), the gastroduodenal (n=2), the persistent sciatic (n=1), and the superior gluteal artery (n=1). All patients underwent diagnostic arteriography and TAE with gelfoam particles, coil, and detachable balloon, or a combination of these. Follow-up, of between three and 74 months duration, involved computed tomography, angiography, ultrasound, and the evaluation of clinical symptoms. RESULTS: All patients were treated successfully with TAE and there was no recurrence during the follow-up. Seven patients (58.3%) were treated only coils; the site of their aneurysm or pseudoaneurysm was the superficial temporal (n=2), the renal (n=2), the gastroduodenal (n=2), or the superior gluteal artery (n=1). Four patients (33.3%) with a small pseudoaneuysm arising from the distal branch of a small artery-the hepatic (n=2), the superficial temporal (n=1), or the renal (n=1)-were treated with gelfoam particles, and a pseudoaneurysm of the hepatic artery too small for the insertion of a coil was embolized completely with gelfoam particles. A detachable balloon was used in one case with a huge pseudoaneurysm arising from the persistent sciatic artery, in which embolization with a large coil was not effective. CONCLUSION: TAE is safe and effective in the treatment of arterial pseudoaneurysm and aneurysm. Coil was the preferred material, but for a small pseudoaneurysm arising from the distal branch of a small artery, gelfoam was preferred . For the embolization of a huge pseudoaneurysm, a adtachable balloon was useful.

Splanchnic Artery Pseudoaneurysm: Transcatheter Embolization

PURPOSE: To evaluate the therapeutic effect and difficulty of embolization of pseudaneurysm of the splanchnic artery. MATERIALS AND METHODS: Between February 1988 and June 1996, we employed transcatheter embolization to treat a total of eleven patients with splanchnic artery pseudoaneurysm by transcatheter embolization. Eight were males and three were females ; their ages ranged from four to 70 years (mean 44). Three patients had previously been operated on, three had undergone biopsy, and on three, percutaneous transhepatic biliary drainage had been performed ; one had been involved in a traffic accident and one had suffered a gun-shot wound. All patients underwent diagnostic angiography and superselective embolization using a 3F microcatheter. We used Gelfoam with microcoil four times, microcoil twice, Gelfoam once, Gelfoam with ethanol once, a detachable balloon once, and Ivalon once. RESULTS: Arteries in which pseudoaneurysm had occurred were as follows: renal, four, hepatic, three; gastroduodenal, two ; superior mesenteric, one. Nine patients underwent one session of procedure and two underwent two session. Nine patients (82%) were treated successfully and without complication by embolization. Two patients failed to embolize due to vascular spasm and tortuosity in one and a wide aneurysmal neck in the other ; one of these died six days later and the other was operated on. CONCLUSION: Although there are therapeutic difficulties in cases of vascular spasm, tortuosity, or a wide aneurysmal neck, embolization of pseudoaneurysm of the splanchnic artery is a safe and effective life-saving procedure.