Endovascular Management of Visceral Artery Aneurysm

150 J ENDOVASC THER 2001;8:150–155 l l Endovascular Management of Visceral Artery Aneurysm Karthikeshwar Kasirajan, MD; Roy K. Greenberg, MD; Daniel Clair, MD; and Kenneth Ouriel, MD Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA l l Purpose: To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. Methods: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 6 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. Results: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 6 29.6 months. Conclusions: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel. J Endovasc Ther 2001;8:150–155 Key words: coil embolization, embolotherapy, microcoils, hepatic artery, pseudoaneurysm l l Visceral artery aneurysms (VAAs) are uncommon but potentially life-threatening vascular abnormalities. Because of the rarity of this disorder, their pathogenesis and natural history are not completely understood. Nearly 22% of all visceral artery aneurysms present Address for correspondence and reprints: Roy K. Greenberg, MD, Director of Endovascular Research, The Cleveland Clinic Foundation, Department of Vascular Surgery, Desk S-61, 9500 Euclid Avenue, Cleveland, OH 44195 USA. Fax: 216-444-9324; E-mail: [email protected] with rupture, resulting in an overall mortality of 8.5%.1 Historically, splenic artery aneurysms were the most frequently detected VAAs (60%), followed by hepatic artery aneurysms (20%).2 However, over the last decade, hepatic artery aneurysms, especially pseudoaneurysms, have become the most common.3–5 This change in the presentation of VAAs is due to an explosive increase in the use of percutaneous and laparoscopic biliary procedures, in conjunction with improved im- Q 2001 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS J ENDOVASC THER 2001;8:150–155 VISCERAL ARTERY ANEURYSM KASIRAJAN ET AL. 151 Figure 1 l (A) Pseudoaneurysms of the left hepatic and (B) gastroduodenal arteries in a 66year-old woman. (C) Both pseudoaneurysms were successfully embolized (coils visible with no flow of contrast into the aneurysms). aging modalities used to assess blunt and penetrating abdominal trauma. One half of all detected hepatic artery aneurysms are pseudoaneurysms. The vast majority of these can be managed with percutaneous transcatheter coil embolization (PTCE) techniques. 6 The purpose of this article is to evaluate our experience and assess our long-term results in the management of VAAs with PTCE techniques. METHODS A prospectively maintained computer registry at The Cleveland Clinic Foundation was interrogated to identify patients with visceral artery aneurysms treated between 1988 and 1998. Among the 58 patients with VAAs (excluding renal artery aneurysms), PTCE techniques were used in 9 patients (5 women; mean age 64 6 11 years) with 12 VAAs (8 false and 4 true). Patient demographics and treatment outcomes were evaluated by review of medical records and pre- and postprocedural angiograms. Follow-up was completed by chart reviews, telephone interviews, and assessment of radiographic studies. Systemic risk factors in the 9 patients included hypertension in 4 and multiparity in 2. Most of the cases (10, 84%) involved the hepatic artery (Fig. 1A); the other 2 were the middle colic and the gastroduodenal (Fig. 1B) arteries. Etiology of the aneurysms was iatrogenic trauma (n 5 4), pancreatitis (n 5 4), 152 VISCERAL ARTERY ANEURYSM KASIRAJAN ET AL. J ENDOVASC THER 2001;8:150–155 l l TABLE Patient Demographics and Treatment Characteristcs Age/Sex 56/M 66/F 79/M 64/F 66/F 73/F 68/F 39/M 66/M Location of Aneurysm Right hepatic Common hepatic Right hepatic Intrahepatic Left hepatic, gastroduodenal Common, left hepatic, intrahepatic Right hepatic Right hepatic Right branch of middle colic Presentation Rupture Symptomatic Hemobilia Symptomatic Symptomatic Rupture Hemobilia Rupture Rupture Technical Aneurysm Etiology Success Pseudo True Pseudo Pseudo Pseudo 3 2 True 3 3 Pseudo Pseudo Pseudo l and nonspecific (n 5 4). Iatrogenic trauma was secondary to laparoscopic cholecystectomy (n 5 2), percutaneous transhepatic cholangiography (n 5 1), and open surgical excision of a Klatskin tumor (n 5 1). Individual patient characteristics, aneurysm location, and treatment modalities are shown in the Table. The majority (6, 67%) of patients were treated for symptoms and signs of rupture; notably, 5 of the 8 pseudoaneurysms were ruptured. Technique of Superselective Catheterization and Coil Embolization The common femoral artery was the preferred site of entry for most interventions. An initial aortogram was performed using a pigtail catheter, followed by selective mesenteric vessel catheterization with either a Sos (Angiodynamics, Inc., Queensbury, NY, USA) or Cobra II (Mallinckrodt Medical, Inc., St. Louis, MO, USA) catheter. Mesenteric angiography and road-mapping guided progress into the distal vascular bed. If the vascular path to the aneurysm was easily negotiable and was located in the proximal aspect of the mesenteric circulation, a 5-F system was used throughout the procedure. However, because of the complex branching pattern and the small caliber of the distal mesenteric vasculature, superselective catheterization was frequently accomplished using a coaxial technique7 with either the Tracker 18 (Target Therapeutics, Fremont, CA, USA) or Rapid Transit (Cordis Endovascular, Miami Lakes, FL, USA) catheters. An assortment of microcoils was used. Yes No Yes No Yes Yes Yes Yes No Follow-up (mo) 19 108 30 24 33 45 21 69 65 l Saccular aneurysms were filled entirely with coils in an attempt to preserve the parent vessel, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. Since most patients were anticoagulated with heparin during the procedure, contrast flow through the aneurysm sac was not uncommon at the completion of PTCE. A computed tomographic (CT) scan was obtained within 24 hours if persistent arterial flow was noted on the completion angiogram. RESULTS Technical success was achieved in 9 (75%) of the 12 aneurysms (Fig. 1C). The 3 failures were secondary to inability to selectively catheterize the neck of the aneurysm or the feeding vessel. Among the failures, 1 patient had surgical ligation of a pseudoaneurysm arising from a branch of the middle colic artery; another underwent a saphenous vein graft replacement of a true common hepatic artery aneurysm. The final patient for whom PTCE failed had an intrahepatic artery pseudoaneurysm that has been managed medically. No procedure-related morbidity or inhospital mortality occurred. The mean length of stay was 9 days (range 1–16). None of the patients had been lost to follow-up, which ranged from 19 to 108 months (mean 46.0 6 29.6). Three patients died secondary to unrelated causes, but the other 6 were symptom free at their latest examination. Only 5 of the 9 patients had CT scans during the follow-up period; all aneurysms J ENDOVASC THER 2001;8:150–155 were thrombosed, and no evidence of continued aneurysmal enlargement or recanalization was noted. DISCUSSION Open surgical management of ruptured VAAs has been associated with mortality rates as high as 36% for splenic artery aneurysms6,8,9 and 21% for hepatic artery aneurysms.5,9 Similarly, operative mortality of visceral artery pseudoaneurysms ranges from 30% to 50%,10,11 depending on the location and etiology. Factors contributing to poor outcome include the emergent nature of the procedure, difficulty with surgical exposure, and comorbid factors that are frequently associated with this condition.12 Percutaneous techniques have been used with increasing frequency in the management of symptomatic or ruptured VAAs.4,6,13–17 In contrast to open procedures, fatalities and complications are rare.6,14,18 Salam et al.18 treated 13 patients with 16 aneurysms using PTCE. Complete aneurysm thrombosis was seen in 13 cases, with no procedural mortality and only a single complication related to common hepatic artery dissection. In a similar study, Carr et al.6 reported successful PTCE in 12 patients without any mortality. One patient had a radiologically detected splenic infarct with no clinical consequence. Baker et al.14 treated 8 ruptured VAAs (6 pseudoaneurysms) with initial coil embolization in an attempt to control bleeding. Open surgery was completely avoided in 4 patients, and 4 others underwent operative procedures on an elective basis after stabilization. No procedure-related mortalities occurred. Technical success with PTCE has been acceptable for the most part. Carr et al.6 reported a 66.7% procedural success rate that increased to 100% when a staged embolization technique was used. Salam et al.18 had an overall technical success rate of 81%, comparable to our series. Most of the failures cited in these reports were related to technical difficulties in catheterizing the aneurysm neck. Although PTCE appears to be a low-risk percutaneous alternative for the management of VAAs, it has certain disadvantages specific VISCERAL ARTERY ANEURYSM KASIRAJAN ET AL. 153 to endovascular management of aneurysms. Skepticism has been expressed regarding the prevention of pressure transmission to the aneurysm wall in connection with coil embolization techniques.19,20 Differences between these techniques and coil embolization of an abdominal aortic aneurysm may be related to the fact that VAA embolization involves blockage of feeding or outflow vessels remote from the aneurysm itself. However, long-term imaging surveillance should ensue to detect continued aneurysm growth as a result of pressurization. Unfortunately, the recurrencefree interval (representing rupture, continued enlargement, or renewed aneurysmal blood flow) is not always predictable and is clearly not uniform. Onohara et al.21 reported a patient presenting with rupture into the stomach of an embolized celiac artery pseudoaneurysm. Salam et al.18 observed 2 patients with evidence of aneurysm recanalization at 4 and 7 months, one of whom required surgical repair. Similarly, Carr et al.6 encountered 2 patients with rupture at 5 and 24 months; both of these aneurysms were managed successfully with repeat coil embolization. Only 5 of 9 patients in our series had imaging studies during follow-up, and none had evidence of continued aneurysm enlargement or recanalization. Although the majority of our patients had a pseudoaneurysm, the problem of persistent sepsis due to the presence of a foreign body (embolization coils) was not noted. However, if the patients had a persistent fever or elevated white cell count, they were maintained on intravenous antibiotics until the fever resolved and the white count normalized. No report of localized abscess or persistent sepsis secondary to coil embolization of mycotic visceral artery aneurysms has been reported. Abscess formation, when observed, is usually secondary to end-organ infarction.18 Another potential complication of coil embolization includes intraprocedural aneurysm rupture.22 Technical factors relating to coil deployment are critical when treating these friable arteries. It is important to use the least amount of force required to extrude the embolization coils. Moreover, PTCE of vessels that are the major arterial supply to a vital organ may result in end organ infarction and 154 VISCERAL ARTERY ANEURYSM KASIRAJAN ET AL. J ENDOVASC THER 2001;8:150–155 Figure 2 l Aneurysm anatomy favorable for coil embolotherapy: type I is a saccular aneurysm with a narrow neck, type II is a fusiform aneurysm with adequate collateral flow, and type III is an aneurysm of a vessel supplying an organ that has multiple arterial sources. subsequent infection.6 Whenever possible, PTCE of these vessels, such as the splenic artery, should be avoided. Favorable aneurysm morphology for PTCE (Fig. 2) includes saccular aneurysms with a narrow neck (type I), fusiform aneurysms with adequate collateral flow (type II), and aneurysms of vessels that are not the only source of arterial flow to the end organ (type III). PTCE is an attractive alternative to open surgical management of VAAs in patients at high risk for open repair, provided that the anatomical configuration of the aneurysm is favorable. Other percutaneous methods, such as the use of permanent liquid embolic material23 and covered stents, may be alternative therapeutic modalities. However, we find PTCE to be a useful means of managing the acute presentation of visceral aneurysm rupture, and it appears, on the basis of our experience, to achieve durable results. We believe that follow-up imaging is warranted to assure continued aneurysm exclusion, the absence of aneurysm growth, and, thus, protection from rupture. REFERENCES 1. Stanley JC. Abdominal visceral aneurysms. In: Haimovici H, ed. Vascular Emergencies. New York: Appleton-Century Crofts; 1981:387. 2. Stanley JC, Zelenock GB. Splanchnic artery aneurysms. In Rutherford RB, ed. Vascular Surgery. 4th ed. Philadelphia: WB Saunders; 1995: 1124. 3. Salcuni PF, Spaggiari L, Tecchio T, et al. Hepatic artery aneurysm: an ever present danger. J Cardiovasc Surg. 1995;36:595–599. 4. Lumsden AB, Mattar SG, Allen RC, et al. 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