Selective Spleen Embolization of Splenomegaly to Improve Thrombocytopenia Facilitating Open Aortic Aneurysm Repair: A Staged Approach.

We present an 82-year-old man with a history of hairy cell leukemia, having an 11-cm abdominal aortic aneurysm, who also had severe thrombocytopenia (about 20 000 platelets/µL) and splenomegaly at presentation. The patient had unfavorable anatomy for endovascular aneurysm repair, and therefore, an open procedure was planned. To reduce risk for perioperative bleeding and optimize patient preoperative status, a staged approach was employed. Initially, several sessions of embolization of 2 splenic artery branches were performed with the intent to decrease spleen size and to increase platelet count thus decreasing the perioperative bleeding risk. Then, after successfully increasing platelet count (280 000 PLT/µL), open repair of the aneurysm was conducted. This case demonstrates that selective splenic embolization in patients with hypersplenism and subsequent thrombocytopenia who are in need for major surgery may achieve a significant rise in platelet count and optimize patient's preoperative status in order to avoid bleeding complications.

The - Not So - Solid 5.5 cm Threshold for Abdominal Aortic Aneurysm Repair: Facts, Misinterpretations, and Future Directions.

Abdominal aortic aneurysms (AAAs) represent a focal dilation of the aorta exceeding 1.5 times its normal diameter. It is reported that 4-8% of men and 0.5-1% of women above 50 years of age bear an AAA. Rupture represents the most disastrous complication of aneurysmal disease that is accompanied by an overall mortality of 80%. Autopsy data have shown that nearly 13% of AAAs with a maximum diameter ≤5 cm were ruptured and 60% of the AAAs >5 cm in diameter never ruptured. It is therefore obvious that the "maximum diameter criterion," as a single parameter that fits all patients, is obsolete. Investigators have begun a search for more reliable rupture risk markers for AAA expansion, such as the level and change of peak wall stress or AAA geometry. Furthermore, it is becoming more and more evident that intraluminal thrombus (ILT), which is present in 75% of all AAAs, affects AAA features and promotes their expansion. Though these hemodynamic properties of AAAs are significant and seem to better describe rupture risk, they are in need of specialized equipment and software and demand time for processing making them difficult in use and unattractive to clinicians in everyday practice. In the search for the addition of other risk factors or user-friendly tools, which may predict AAA expansion and rupture, the use of the asymmetrical ILT deposition index seems appealing since it has been reported to identify AAAs that may have an increased or decreased growth rate.