Tokuda Hospital Sofia Vascular Surgery and Angiology Department Assoc. Proff. V. Chervenkov, Dr. A. Daskalov, Dr. D. Gorcheva

Splenic artery pseudoaneurysm (SAPA) is a rare pathology. For a period of ten years only 157 cases are described in the literature. The splenic artery is the artery most commonly affected. It is followed by the hepatic artery, celiac artery, and more rarely other visceral arteries.

1. Pancreatitis in both acute and chronic forms is most frequent cause of splenic artery pseudoaneurysms due to digestion of the arterial wall by proteolytic pancreatic enzymes. 2. After splenectomy – a pseudoaneurysm is formed at the site of the ligature of a. lienalis. 3. Trauma 4. Another uncommon reason for pseudoaneurysms is a history of peptic acid disease.

1. Nonruptured SAPA  Left upper abdominal quadrant pain  Nausea  Vomitting  Epigastric pain  Back pain  Pulsatile mass

2. Ruptured SAPA  Most SAPA are asymptomatic till their acute presentation with rupture into the peritoneal cavity, retroperitoneal or in adjacent organs space (acute onset of abdominal pain, hypotension and shock).  Risk of SAPA rupture was estimated to be 10 %.  Mortality rate of a ruptured SAPA was estimated to be 25 %.

1. Echodopplersonography is usually initial investigation modality. 2. CT-angiography 3. Angiography/Arteriography are more often used as intraprocedural diagnosis. 4. MRI

A splenic artery pseudoaneurysm of any size

1. Endovascular – Arterial embolization of pseudoaneurysms are generally done using a variety of embolic agents which include coils, vascular plugs, detachable balloons and inert particles of Gelform ( gelatin sponge ). 2. Percutaneous thrombin injection under CT guidance to threat splenic artery pseudoaneurysms in patients who were not suitable for endovascular therapy has been reported. 3. Surgical - ligation and aneurysmectomy.

1. Pleural effusions that require thoracocenthesis 2. Paralytic ileus 3. Pancreatitis - likely a result of non-target embolization of the dorsal pancreatic or greater pancreatic artery 4. Postembolization syndrome which consists of fever, leukocytosis and abdominal pain 5. Transient elevation of pancreatic enzymes 6. Pancreatic abscess 7. Splenic infarction 8. Unremitting bronchopneumoniae 9. Coiling migration

1. Because of the rare nature of splenic artery pseudoaneurysms, prompt diagnosis is a challenge. 2. Pseudoaneurysm size is not a determinant of rupture. 3. Because the natural history of asymptomatic splenic artery pseudoaneurysm is unknown it is recommended that all splenic artery pseudoaneurysms should be treated, regardless of size or symptoms. 4. Pseudoaneurysm diameter is not a predictor of success or failure of transcatheter embolization. 5. Reported succees rates of these procedures vary from %.

A 58-years-old man presented with left upper quadrant abdominal pain. He had a medical history of operation for chronic pancreatitis and splenectomy – – diagnosed aneurysma spuria of the ligated a. lienalis – 1 cm in diameter – control angiography showed enlargement of the aneurysm.

The patient had history for arterial hypertension II gr. Lab: Leu , Ery – 3.68, Hb – 97.4, Hct – 0.305, Thr – 406.0, LDH – 210, creat – 144.8, urea – 9.5. Echocardiography : left ventricle hypertrophy, ejection fraction 60 %. Angiography showed 5 cm in diameter aneurysm at the end of the ligated a. lienalis.

1. Surgical : not recommended - The patient had history of previous laparotomy an year ago for chronic pancreatitis with splenectomy (hostile abdomen). 1. Endovascular – embolization.

After cannulating the right brachial artery a 6-fr sheath was placed in the celiac trunk and the splenic artery was cannulated selectively using a micro catheter.

The patient suffered no complications and was discharged 2 days later. Postprocedure computed-tomography(CT) and ultrasound (US) of the abdomen showed no evidence of continuing flow in the pseudoaneurysm.