AJR 2005; 185:556-557
© American Roentgen Ray Society
Treatment of Multiple Splenic Aneurysms by Coil Embolization
Kenji Ohmoto and
Shinichiro Yamamoto
Kawasaki Medical School Okayama 701-0192, Japan
We read with interest the article by Ishimaru et al.
[1] reporting a patient who
underwent N-butyl 2-cyanoacrylate injection via pancreatic
collaterals for a distal splenic aneurysm after proximal coil embolization.
However, glue embolization via peripheral anastomotic vessels may cause
end-organ infarction, such as pancreas and splenic infarction. We have managed
a patient with multiple splenic aneurysms who was safely and successfully
treated by transcatheter embolization using coils.
A 59-year-old woman with hepatitis C virus–related cirrhosis was
admitted to our hospital on April 19, 2003. She had no history of abdominal
injury or pancreatitis. Physical examination on admission showed evidence of
mild jaundice, cutaneous stigmata of chronic liver disease, and slight
hepatosplenomegaly but no ascites, peripheral edema, or hepatic
encephalopathy. Laboratory tests showed an increase of total bilirubin (2.2
mg/dL; normal, < 1.2 mg/dL) and the prothrombin time (14.2 sec; normal,
9.7–12.2 sec), although a decrease in the serum albumin level (3.2 g/dL;
normal, 3.8–4.9 g/dL) was seen, suggesting that the patient's condition
was Child-Pugh classification B. Diagnostic imaging with enhanced CT and color
Doppler sonography revealed multiple splenic aneurysms. We recommended
surgical or interventional therapy to treat her splenic aneurysms, and she
agreed to interventional treatment but refused surgery. Selective splenic
arteriography was performed and showed three aneurysms (measuring 2.4 x
2.2, 2.2 x 2.0, and 1.4 x 1.2 cm) in the splenic artery
(Fig. 2A). Subsequently,
transcatheter embolization of these aneurysms was performed using platinum
microcoils. After embolization, repeated splenic arteriography revealed
complete disappearance of the aneurysms
(Fig. 2B). The patient's
postembolization course has been satisfactory, with no adverse effects such as
splenic infarction or acute pancreatitis, and the patient is doing well at the
time of this writing.
Splenic aneurysm is a rare clinical entity but has the potential to rupture
and cause life-threatening hemorrhage. Etiology and physiopathology are not
completely understood. Multiple pregnancies and portal hypertension are the
most common conditions associated with splenic aneurysms
[2]. There have been reports
[3,
4] that the risk of rupture
depends on the size of the aneurysm. Especially in patients with aneurysms
measuring 2 cm or larger [3], a
splenic aneurysm must be treated. In our patient, all three splenic aneurysms
were successfully treated by transcatheter embolization, even though the
aneurysms were adjacent to the splenic hilus.
In conclusion, less invasive therapy involving coil embolization should be
chosen to treat splenic aneurysms, even in patients with multiple
aneurysms.
References
- Ishimaru H, Murakami T, Matsuoka Y, et al. N-butyl
2-cyanoacrylate injection via pancreatic collaterals to occlude splenic artery
distal to large splenic aneurysm after proximal coil embolization.
AJR 2004; 182:213
–215[Free Full Text]
- Hallett JW. Splenic artery aneurysms. Semin Vasc
Surg 1995; 8:321
–326[Medline]
- Trastek VF, Pairolero PC, Joyce JW, et al. Splenic artery
aneurysms. Surgery 1982;91
: 694–699[Medline]
- Mattar SG, Lumsden AB. The management of splenic artery aneurysms:
experience with 23 cases. Am J Surg 1995;169
: 580–584[CrossRef][Medline]
Reply
Hideki Ishimaru
National Nagasaki Medical Center Omura 856-8562, Japan
There is no doubt that selective coil embolization of aneurysms is the best
way to treat splenic aneurysms because the technique can preserve splenic
arterial flow [1]. If my
colleagues and I were to treat the patient presented in the letter, we would
also choose coil packing of the aneurysm in a routine fashion because the
aneurysm is not ruptured. The method is quite standard. In Figure 2B, we
consider that the contrast material filling into the proximal two aneurysms
indicates the aneurysms were still remaining and were not completely
embolized. In the future, great care should be paid to coil compaction.
The situation described in the letter by Drs. Ohmoto and Yamamoto was
different from our case in two ways. First, the splenic aneurysm was ruptured
in our case and the patient was dying as a result of hemorrhagic shock.
Second, the splenic aneurysm was quite large, and coil packing was not
preferable because it requires too much time and many coils. We had no choice
but to occlude the proximal parent artery to save our patient. However, this
procedure caused retrograde revascularization via abundant collateral vessels.
In such a case, N-butyl 2-cyanoacrylate embolization via collateral
anastomotic vessels, as described in our article, is an effective approach for
distal embolization of a visceral aneurysm. However, the technique is
exceptional, and the indication for this approach should be considered
carefully because of the possibility of end-organ ischemia.
References
- Ishimaru H, Murakami T, Matsuoka Y, et al. N-butyl
2-cyanoacrylate injection via pancreatic collaterals to occlude splenic artery
distal to large splenic aneurysm after proximal coil embolization.
AJR 2004; 182:213
–215
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