DOI:10.2214/AJR.06.0343
AJR 2006; 187:W548-W549
© American Roentgen Ray Society
Splenic Arteriovenous Fistula with Pseudoaneurysm as a Complication of Splenectomy
James E. Silberzweig,
Darian Matissen and
Azita S. Khorsandi
St. Luke's-Roosevelt Hospital Center New York, NY 10019
Beth Israel Medical Center New York, NY 10019
WEB—This is a Web exclusive article.
Keywords: angiography • arteriovenous fistula • pseudoaneurysm • spleen • splenectomy
The formation of a splenic artery pseudoaneurysm with an associated
arteriovenous fistula is a rare complication after surgical splenectomy
[1,
2]. We present a patient with a
large splenic artery pseudoaneurysm and arteriovenous fistula 10 years after
splenectomy for immune thrombocytopenic purpura (ITP). The pseudoaneurysm and
arteriovenous fistula were successfully treated using percutaneous
transarterial coil embolization.
A 54-year-old woman with a history of splenectomy for ITP in 1994 and
hysterectomy for fibroids presented with a complaint of left abdominal pain.
The abdominal pain started approximately 7 years after her operation and was
described as intermittent and "gnawing" in character.
In March 2002, an abdominal sonogram obtained for a complaint of abdominal
pain showed a cystic mass in the left upper quadrant in the splenic fossa. No
further evaluation was performed at that time. CT of the abdomen in March 2004
revealed a 7-cm distal splenic artery pseudoaneurysm with associated
arteriovenous fistula to the splenic vein
(Fig. 1A). The imaging studies
showed no evidence of portal hypertension. Liver function test results were
normal.
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Fig. 1A —54-year-old woman with history of splenectomy for immune
thrombocytopenic purpura in 1994 and hysterectomy for fibroids presented with
complaint of left abdominal pain. Abdominal pain started approximately 7 years
after her operation and was described as intermittent and
"gnawing" in character. Abdominal CT image shows distal splenic
artery pseudoaneurysm with splenic vein fistula.
|
|
Arteriograms (Figs. 1B and
1C) were obtained, and
percutaneous transarterial coil embolization of the splenic artery was
performed. Initially, a 12-mm-diameter, 14-cm-long coil (Nester coil, Cook)
was deployed within the splenic artery. The coil migrated from the splenic
artery distally into the pseudoaneurysm immediately after deployment. Multiple
10-mm-diameter conventional platinum embolization coils were then deployed
within the splenic artery proximal to the initial splenic artery dilatation.
Completion arteriogram showed no flow within the splenic artery beyond the
embolization coils (Fig. 1D).
There was no opacification of the aneurysm or splenic vein. An abdominal CT
scan obtained 1 day after the embolization procedure showed that the migrated
coil was located within the splenic vein. Routine follow-up abdominal CT
performed 13 months after embolization showed total regression of the
pseudoaneurysm (Fig. 1E).
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Fig. 1B —54-year-old woman with history of splenectomy for immune
thrombocytopenic purpura in 1994 and hysterectomy for fibroids presented with
complaint of left abdominal pain. Abdominal pain started approximately 7 years
after her operation and was described as intermittent and
"gnawing" in character. Abdominal aortogram (B) and venous
phase of splenic arteriogram (C) show progressively tortuous and
enlarging splenic artery feeding large pseudoaneurysm with communication to
splenic vein.
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Fig. 1C —54-year-old woman with history of splenectomy for immune
thrombocytopenic purpura in 1994 and hysterectomy for fibroids presented with
complaint of left abdominal pain. Abdominal pain started approximately 7 years
after her operation and was described as intermittent and
"gnawing" in character. Abdominal aortogram (B) and venous
phase of splenic arteriogram (C) show progressively tortuous and
enlarging splenic artery feeding large pseudoaneurysm with communication to
splenic vein.
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|
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Fig. 1D —54-year-old woman with history of splenectomy for immune
thrombocytopenic purpura in 1994 and hysterectomy for fibroids presented with
complaint of left abdominal pain. Abdominal pain started approximately 7 years
after her operation and was described as intermittent and
"gnawing" in character. Completion arteriogram shows there is no
flow within splenic artery beyond embolization coils.
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Fig. 1E —54-year-old woman with history of splenectomy for immune
thrombocytopenic purpura in 1994 and hysterectomy for fibroids presented with
complaint of left abdominal pain. Abdominal pain started approximately 7 years
after her operation and was described as intermittent and
"gnawing" in character. Abdominal CT scan obtained 13 months after
embolization (A-D) shows total regression of pseudoaneurysm and
fistula.
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|
The major risk of splenic artery aneurysms and pseudoaneurysms is rupture.
The reported risk of splenic artery aneurysm rupture is 3-10% and that of
splenic artery pseudoaneurysm rupture is up to 37% of patients
[3]. The mortality rate after
rupture has been estimated at 10-25%
[3]. Untreated splenic
arteriovenous fistulas may induce portal hypertension
[2].
Splenic arteriovenous fistula formation is a rare complication after
splenectomy. Arteriovenous fistulas have been identified after splenectomy for
portal hypertension, trauma, splenic injury during a vagotomy and
pyloroplasty, staging splenectomy for Hodgkin's disease, and laparoscopic
splenectomy [1,
2,
4-6].
One possible cause of iatrogenic splenic arteriovenous fistula formation
has been thought to be the use of mass ligation of the arteries and veins
during splenectomy. Fistula formation is thought to be due to the presence of
small communications that enlarge when the arterial pressure within the
ligated vessels increases. Formation of the fistula can be avoided by separate
ligation of the splenic artery and vein when splenectomy is performed
[1].
Treatment of symptomatic splenic artery aneurysms, asymptomatic aneurysms
larger than 2 cm, and all pseudoaneurysms is recommended
[3]. Traditionally, management
of splenic artery aneurysms and splenic artery pseudoaneurysms has been
surgical, with ligation or resection of the aneurysmal arterial segment with
or without splenectomy. Recently, an endovascular treatment approach has
become accepted as an alternative to surgical intervention
[3].
Diagnosis and treatment of splenic pseudoaneurysms and arteriovenous
fistulas are essential to eliminate the associated risks of portal
hypertension and rupture.
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