DOI:10.2214/AJR.07.2210
AJR 2007; 189:641-647
© American Roentgen Ray Society
MDCT and 3D CT Angiography of Splanchnic Artery Aneurysms
Karen M. Horton1,
Christopher Smith1 and
Elliot K. Fishman1
1 All authors: The Russell H. Morgan Department of Radiology and Radiological
Science, Johns Hopkins Medical Institutions, 601 N Caroline St., Rm. 3253,
Baltimore, MD 21287.
Received December 6, 2006;
accepted after revision March 28, 2007.
Address correspondence to K. M. Horton.
CME
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. The purpose of this article is to review our experience
with the use of MDCT and 3D imaging in the detection and management of
patients with both symptomatic and asymptomatic splanchnic artery
aneurysms.
CONCLUSION. Although splanchnic artery aneurysms are relatively
rare, they are being diagnosed with increased frequency given the widespread
availability of MDCT and 3D imaging capabilities. It is important that these
aneurysms be diagnosed accurately because they can carry a high morbidity and
mortality, even in asymptomatic patients.
Keywords: aneurysm • angiography • CT • mesenteric vasculature • 3D imaging
Splanchnic artery aneurysms are rare, with an incidence of 0.01–0.2%
in routine autopsies [1]. The
distribution of aneurysms is as follows: splenic artery, 60%; hepatic artery,
20%; superior mesenteric artery, 5.5%; celiac artery, 4%; pancreatic arteries,
2%; and gastroduodenal artery, 1.5%
[2,
3].
Splanchnic artery aneurysms are clinically significant and can rupture,
causing abdominal pain and bleeding. Rupture is associated with a high rate of
morbidity and mortality
[4–6].
These autopsy statistics suggest that asymptomatic cases largely remain
undiagnosed. Therefore, splanchnic artery aneurysms may be more common than
previously suspected.
Splanchnic artery aneurysms were traditionally diagnosed with catheter
angiography. However, with increased use of noninvasive cross-sectional
imaging with MR and CT, both of which allow 3D imaging of the aorta and its
branches, these aneurysms may be detected with greater frequency and in
asymptomatic patients [6]. The
treatment depends on the location, type, and size of the aneurysm and the
medical condition of the patient
[6].
This article will focus on our experience with the use of MDCT and 3D
imaging in the detection and management of patients with both symptomatic and
asymptomatic splanchnic artery aneurysms.
MDCT and CT Angiography Technique
CT has undergone considerable improvement over the past several years. The
introduction of 64-MDCT now allows submillimeter imaging and the creation of
isotropic data sets. This, along with significant advancements in 3D imaging
software, now makes it possible to obtain high-resolution images of the
abdominal aorta and its branches. In the past, patients with suspected
vascular disease and aneurysms would need conventional angiography. However,
today CT can be used initially as a primary vascular imaging technique.
If a splanchnic artery aneurysm is suspected clinically, a dedicated
examination of the abdominal aorta and its branches should be performed. At
our institution, approximately 120 mL of nonionic IV contrast material is
injected at a rapid rate of 3–5 mL/s through a large-caliber peripheral
catheter. Arterial phase images are obtained approximately 30 seconds after
the start of the injection. Venous phase images may also be helpful in
selected cases and can be acquired approximately 60 seconds after the start of
the injection. This dual-phase imaging allows excellent visualization of the
splanchnic arteries and veins.
Thin collimation is essential to maintain high resolution in all imaging
planes. At this time, we use our 64-MDCT scanner and the 0.6-mm collimator
setting. This allows creation of 0.75-mm slices that are reconstructed every
0.5 mm for 3D imaging. Because of the complexity of the mesenteric
vasculature, multiplanar reconstruction and preferably volume-rendered 3D
imaging are necessary to completely visualize all of the branches. The choice
of the 3D rendering algorithm is crucial in this clinical setting. There are
currently three main rendering algorithms available: shaded surface, volume
rendering, and maximum intensity projection (MIP). Shaded-surface rendering is
the most basic algorithm but is of limited value for evaluating the abdominal
vasculature. Shaded-surface rendering only allows visualization of the surface
of the aneurysm and therefore includes no information about intraluminal
thrombus. MIP is a projection algorithm that displays the brightest voxel
along a ray. It can be useful to accentuate small vessels but requires either
thin slabs or extensive bone editing. Volume rendering allows the brightness,
opacity, window width, and level to be adjusted in real time to accentuate
either the wall of the aneurysm, the intraluminal contrast, or adjacent soft
tissues. Therefore, usually a combination of volume rendering and MIP is the
most valuable for this clinical indication. Also, current software allows easy
bone removal, which is especially helpful when using MIP.
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Fig. 1B —54-year-old woman with history of autoimmune hepatitis. Axial
oblique maximum-intensity-projection (MIP) image shows aneurysm
(arrow) arising from distal splenic artery. Narrow neck of aneurysm
is nicely displayed, which is important in planning therapy.
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Fig. 2A —45-year-old man who presented for evaluation of acute back
pain and underwent contrast-enhanced CT. Patient had remote history of
pancreatitis. Axial image shows 2.0-cm splenic artery pseudoaneurysm
(arrow). There was also small amount of associated hemorrhage (not
shown).
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Fig. 2B —45-year-old man who presented for evaluation of acute back
pain and underwent contrast-enhanced CT. Patient had remote history of
pancreatitis. Coronal maximum-intensity-projection (MIP) image after bone
removal nicely depicts 2.0-cm pseudoaneurysm (arrow) arising from
splenic artery.
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Because the splanchnic vasculature is complicated, it is usually necessary
to use a variety of imaging planes. For visualization of the proximal portion
of the celiac axis, superior mesenteric artery, and inferior mesenteric
artery, usually a sagittal projection is most helpful. However, to adequately
visualize the complicated vascular branching of these vessels, usually coronal
or coronal oblique planes are needed
[7]. This can be performed
easily in real time using the new advanced 3D imaging software. Comprehensive
3D evaluation of the arteries and veins can usually be performed in 5 minutes.
At our institution, the radiologists perform the postprocessing
themselves.
Splanchnic Artery Aneurysms
The splenic artery is the most common location for splanchnic artery
aneurysms, accounting for up to 60% of cases. Splenic artery aneurysms (Figs.
1A,
1B,
2A,
2B,
3A,
3B, and
3C) are also the third most
common intraabdominal aneurysm after aneurysms of the abdominal aorta and
iliac arteries [8,
9]. Although once thought to be
relatively rare, splenic artery aneurysms are being diagnosed with greater
frequency, likely related to the increasing routine use of cross-sectional
imaging examinations [2]. The
true prevalence is not known and estimates vary from 0.2% to 10.4%
[1,
10].
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Fig. 3A —64-year-old woman with history of congestive heart failure
who underwent contrast-enhanced CT for evaluation of abdominal pain. Axial
contrast-enhanced MDCT image shows 1.8-cm aneurysm (arrow) with
calcified rim arising from splenic artery.
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Fig. 3B —64-year-old woman with history of congestive heart failure
who underwent contrast-enhanced CT for evaluation of abdominal pain.
Three-dimensional volume-rendered image clearly depicts aneurysm
(arrow).
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Fig. 3C —64-year-old woman with history of congestive heart failure
who underwent contrast-enhanced CT for evaluation of abdominal pain. Coronal
maximum-intensity-projection (MIP) image shows calcified nature of splenic
aneurysm (arrow) but fails to define residual contrast-filled
lumen.
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Splenic artery aneurysms are up to four times more common in women than in
men [11]. In women, there is a
definite association between splenic artery aneurysms, pregnancy, and
multiparity [12]. Although
splenic artery aneurysms are more common in women, they are more likely to
rupture in men [11]. The exact
cause of splenic artery aneurysms is still unknown. It is not thought to be a
result of atherosclerotic disease, although atherosclerosis may be present as
a secondary process [2,
9]. Most splenic artery
aneurysms are true aneurysms, meaning they contain all the normal layers of
the vessel wall.
Most true splenic artery aneurysms are asymptomatic and are diagnosed
incidentally on cross-sectional imaging studies
[11]. However, the risk of
rupture is estimated to be between 2% and 3%
[9,
13]. The risk of rupture
increases with pregnancy, with portal hypertension, and after liver
transplantation [14]. Most
asymptomatic patients with aneurysms of less than 2 cm do well without
intervention. Symptomatic aneurysms usually present acutely with pain,
bleeding, and hypotension. Symptomatic splenic artery aneurysms are treated
with either surgical repair or transcatheter embolization
[11]. In addition, the
literature supports the treatment of asymptomatic splenic artery aneurysms of
more than 2 cm in patients with acceptable operative risks and in patients
whose life expectancies are greater than 2 years
[9,
11].
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Fig. 4A —73-year-old man with long medical history and multiple
medical problems who presented for evaluation of abdominal pain and underwent
contrast-enhanced CT. Coronal CT image shows large 8.0-cm aneurysm arising
from hepatic artery that partially fills with contrast material. In addition,
aneurysm is partially thrombosed and has associated rim of calcification.
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Fig. 4B —73-year-old man with long medical history and multiple
medical problems who presented for evaluation of abdominal pain and underwent
contrast-enhanced CT. Coronal volume-rendered image again shows large hepatic
artery aneurysm and better defines its relationship with hepatic artery
(arrow).
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Indications for intervention include the presence of symptoms, pregnancy,
or planning to become pregnant. Other indications include increasing size of
the aneurysm or diameter greater than 2 cm. The risk of elective removal or
resection is extremely low and has minimal morbidity. In most cases, the
spleen can be preserved. Splenectomy is only necessary for aneurysms found in
the hilum of the spleen or during emergency situations.
Splenic artery pseudoaneurysms are histologically different and are
typically the result of pancreatitis, trauma, surgery, or peptic ulcer disease
[15]. These aneurysms do not
have the normal layers of the vascular wall and are therefore more fragile.
Most are reported as a complication of pancreatitis and are thought to result
from destruction of the vessel wall by pancreatic enzymes
[16]. Patients with splenic
artery pseudoaneurysms are usually symptomatic, with abdominal pain,
gastrointestinal bleeding, or hemorrhagic pancreatitis. The risk of rupture is
higher than with true splenic artery aneurysms and is estimated to be higher
than 35% in some series [17,
18]. Mortality is extremely
high, as high as 90% if left untreated
[18]. Due to the high risk of
rupture of splenic pseudoaneurysms, early intervention is essential.
Traditionally, it consisted of surgery. However, recently there have been
reported successes with endovascular coils, balloons, particles and gelatin
foam, and percutaneous thrombin injections
[18].
Hepatic Artery Aneurysms
Hepatic artery aneurysms (Figs.
4A,
4B,
5A,
5B, and
5C) have historically
represented approximately 20% of all splanchnic artery aneurysms
[2,
3]. A review of the literature
from 1985 to 1995 suggests that hepatic artery aneurysms are more common than
previously thought and could represent up to 40% of splanchnic artery
aneurysms [19]. This increased
incidence is thought to be related to the increasing use of invasive
diagnostic and therapeutic approaches in the liver and biliary tree, which can
result in the development of intrahepatic artery pseudoaneurysms
[19]. Hepatic artery aneurysms
occur more frequently in men than in women
[3].
Most patients with hepatic artery aneurysms are asymptomatic until rupture;
therefore, it is extremely important to be able to identify these lesions on
cross-sectional imaging studies
[20]. Symptoms include
abdominal pain, gastrointestinal hemorrhage, and hemobilia. The most common
pathologic finding is medial degeneration, although secondary atherosclerosis
is present in 30% of cases
[21]. The risk factors for
rupture are difficult to define, and the literature varies in the rate of
rupture risk between 20% and 80%
[3,
22–24].
After rupture, there is a high mortality rate.
Treatment of hepatic artery aneurysms varies. Historically, they have been
treated surgically, although more recently, endovascular techniques have
become more frequent. The size, morphology, and location of the aneurysm can
help guide treatment [20]. For
example, intrahepatic lesions can be embolized with coils, microspheres, or
glue. At the level of the common hepatic artery, embolization or surgical
ligation can be performed. Often, identification of involvement of the
gastroduodenal artery is important. For example, if the aneurysm involves the
origin of the gastroduodenal artery, surgery may be easier than a percutaneous
approach. Saccular aneurysms with a good neck can be treated with
embolization. Saccular or fusiform aneurysms without a good neck require
surgical intervention.
Diagnosis of perihepatic aneurysms can be made with CT or MRI, including 3D
imaging. Doppler sonography has also been used for diagnosis and follow-up of
these patients [2].
Superior Mesenteric Artery Aneurysms
Superior mesenteric artery aneurysms (Figs.
6A,
6B,
6C,
7A, and
7B) are the third most common
type of splanchnic artery aneurysms, accounting for approximately 5.5%
[3]. Most aneurysms of the
superior mesenteric artery occur within the proximal segment, usually within
the first 5 cm from the origin and can be either saccular or fusiform
[3]. Again, these aneurysms can
be classified as true aneurysms or pseudoaneurysms. True aneurysms are less
common than pseudoaneurysms.
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Fig. 6A —58-year-old man with history of superior mesenteric artery
dissection with repair by stent placement. Patient underwent contrast-enhanced
CT for follow-up of dissection and stent repair. Axial oblique multiplanar
reconstruction (MPR) image clearly shows large 5.0-cm pseudoaneurysm arising
immediately distal to stent in superior mesenteric artery. Pseudoaneurysm is
partially thrombosed and also contains thin rim of calcification.
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Fig. 6B —58-year-old man with history of superior mesenteric artery
dissection with repair by stent placement. Patient underwent contrast-enhanced
CT for follow-up of dissection and stent repair. Coronal MPR image shows large
partially thrombosed superior mesenteric artery pseudoaneurysm.
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Fig. 6C —58-year-old man with history of superior mesenteric artery
dissection with repair by stent placement. Patient underwent contrast-enhanced
CT for follow-up of dissection and stent repair. Three-dimensional sagittal
volume-rendered image shows superior mesenteric artery stent and
contrast-filled lumen of pseudoaneurysm arising from false lumen of superior
mesenteric artery dissection. Larger surrounding thrombus within aneurysm is
not seen.
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Fig. 7A —49-year-old man who presented with abdominal pain and
underwent contrast-enhanced CT for evaluation. Axial contrast-enhanced MDCT
image shows partially thrombosed aneurysm (arrow) arising from mid to
distal portion of superior mesenteric artery.
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Fig. 7B —49-year-old man who presented with abdominal pain and
underwent contrast-enhanced CT for evaluation. Coronal volume-rendered CT
angiography image better defines location of aneurysm (arrow) in mid
to distal superior mesenteric artery. Also seen is focal extension of contrast
material, likely into thrombus. This was thought to be suggestive of
vasculitis and patient improved symptomatically after treatment with
steroids.
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Endocarditis is thought to be the main cause for the development of up to
33% of superior mesenteric artery pseudoaneurysms. Other causes have been
proposed, including atherosclerotic disease or pancreatitis. Most
pseudoaneurysms are detected in symptomatic patients who present with pain.
Complications include mesenteric ischemia, thrombosis of the superior
mesenteric artery, or rupture causing massive and often fatal hemorrhage. True
superior mesenteric artery aneurysms are less common than pseudoaneurysms and
are likely related to atherosclerotic disease or connective tissue
diseases.
In the past, treatment consisted of surgical ligation after sufficient
collateral vessels had been defined
[3]. More recently,
transcatheter embolization of the superior mesenteric artery aneurysm has been
used, especially in the saccular variant or in aneurysms of the first branch
of the superior mesenteric artery in which adequate collateral vessels are
present. Stent-graft placement has also been used to treat patients with
superior mesenteric artery pseudoaneurysms
[25].
CT angiography plays an important role in diagnosing these patients because
not only can it detect the presence of the aneurysm, but it can also provide
vascular maps for defining adequate collateral flow before surgical or
percutaneous treatment is attempted.
Celiac Artery Aneurysms
Celiac artery aneurysms (Figs.
8A and
8B) are rare, accounting for
only approximately 4% of splanchnic aneurysms. Celiac artery aneurysm was
first described at autopsy in 1830. The diagnosis of celiac artery aneurysm
has increased, most likely related to advancements in diagnostic imaging
techniques [1,
26,
27]. Celiac artery aneurysms
typically occur in the sixth decade of life
[3]. The risk of rupture is
reported to be 13%, and after rupture, the mortality rate is up to almost 100%
[1,
5,
19].
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Fig. 8A —61-year-old man with history of bladder cancer who underwent
CT for further evaluation of possible lesion in left kidney suggested on prior
excretory urography. Three-dimensional sagittal volume-rendered image further
shows celiac artery aneurysm (arrow).
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Fig. 8B —61-year-old man with history of bladder cancer who underwent
CT for further evaluation of possible lesion in left kidney suggested on prior
excretory urography. Three-dimensional volume-rendered axial image viewed from
superior perspective shows celiac artery aneurysm and also clearly depicts
relationship of aneurysm with celiac arterial branches.
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The most common cause of celiac artery aneurysm is thought to be medial
degeneration, although atherosclerotic disease has also been found in up to
30% of patients [28].
Traumatic causes and mycotic infection (tuberculosis and syphilis) have been
reported but are exceedingly rare
[5,
29]. The diagnosis is being
made more frequently in asymptomatic patients. However, when patients are
symptomatic, they typically present with abdominal pain and signs of impending
rupture [21,
28]. In patients with rupture,
gastrointestinal or intraabdominal bleeding is common.
Elective repair of detected celiac artery aneurysm decreases the mortality
rate to 5% [27]. Surgical
repair is indicated for symptomatic aneurysms, aneurysms larger than 3 cm, or
in patients in whom the aneurysm is enlarging rapidly
[30].
Pancreaticoduodenal Artery Aneurysms
Pancreaticoduodenal artery aneurysms (Figs.
9A and
9B) are uncommon, usually
representing approximately 2% of all visceral artery aneurysms
[2,
3]. The exact incidence is
difficult to determine because the literature sometimes confuses both true
pancreatic duodenal artery aneurysms and pseudoaneurysms of the pancreatic
duodenal artery related to adjacent inflammation, most commonly pancreatitis.
In a study of true pancreaticoduodenal artery aneurysms by Moore et al.
[31], a male prominence was
noted.
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Fig. 9A —61-year-old man with history of recent lumbar spinal surgery
who presented with signs of intraperitoneal hemorrhage and pancreatitis. Axial
contrast-enhanced MDCT image shows 4 x 4 cm pseudoaneurysm in region of
pancreas. There is contrast opacification of residual 1.2 x 0.8 cm
lumen.
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Fig. 9B —61-year-old man with history of recent lumbar spinal surgery
who presented with signs of intraperitoneal hemorrhage and pancreatitis.
Coronal volume-rendered image shows aneurysm sac (small arrows) and
patent lumen (large arrow). Pseudoaneurysm was confirmed by
conventional angiography to be arising from branch of pancreaticoduodenal
artery.
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Patients can present with nonspecific symptoms such as abdominal pain or,
rarely, a palpable mass. Rupture of these aneurysms is common. In the study by
Moore et al. [31], 62% of the
pancreaticoduodenal aneurysms were ruptured at presentation, resulting in a
morality rate of 21%. Risk of rupture is not necessarily related to size.
Therefore, once the diagnosis is made, definitive treatment is required. When
a pancreaticoduodenal artery aneurysm ruptures, it often leads to
retroperitoneal hemorrhage. In the study by Moore et al., it was also noted
that there was a significant incidence of associated occlusive disease
involving the celiac axis in patients with pancreaticoduodenal artery
aneurysms. It is thought that because of the occlusive disease of the celiac
axis, this may result in increased flow through peripancreatic vessels, which
serve as collateral flow from the superior mesenteric artery. This increased
flow may play a role in the development of these aneurysms. However, aneurysms
of the pancreaticoduodenal artery have also been known to occur in patients
without stenosis of the celiac axis.
In addition, there is an association between pancreaticoduodenal artery
aneurysms and aneurysms of other splanchnic vessels, including aortic and
intracranial aneurysms. This suggests the possibility of a systemic cause as
an underlying factor.
Emergent surgical repair and treatment are usually needed in patients who
present with rupture. Surgery is often difficult in this setting because
extensive collateralization is typically present and makes hemostasis
difficult. At surgery, ligation or embolization of the aneurysm is typically
performed. Today, percutaneous embolization is used more frequently and is
considered the treatment of choice in most patients. These patients will
obviously require follow-up. Intravascular coils, gelatin foam, glue, ethanol,
and balloons have all been used successfully.
Gastroduodenal Artery Aneurysms
Gastroduodenal artery aneurysms (Figs.
10A and
10B) are the least common of
all the splanchnic artery aneurysms. They typically represent less than 2% of
all splanchnic artery aneurysms
[3]. Typically, these are
pseudoaneurysms developing in patients with pancreatitis. Patients are most
commonly symptomatic because of the association with pancreatitis
[21,
22]. Gastroduodenal artery
aneurysms can be detected in asymptomatic patients incidentally or in patients
who present after rupture and bleeding. Rupture of the aneurysm occurs in up
to 25% of cases, with a high mortality rate of 25–75%.
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Fig. 10A —59-year-old man with history of cirrhosis and prostate cancer
who underwent CT for follow-up evaluation. Axial contrast-enhanced MDCT image
shows 1.2-cm contrast-filled aneurysm (arrow) inferior in relation to
pancreatic head in region of gastroduodenal artery.
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Fig. 10B —59-year-old man with history of cirrhosis and prostate cancer
who underwent CT for follow-up evaluation. Coronal 3D volume-rendered image
further defines gastroduodenal artery aneurysm (arrow).
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Preoperative diagnosis of gastroduodenal artery aneurysms can be difficult.
If suspected, either CT angiography or conventional angiography can be
performed to confirm the diagnosis and to establish the size and morphology of
the lesion. This is very helpful when planning either surgical or percutaneous
therapies. If gastroduodenal artery aneurysms are detected incidentally and in
relatively asymptomatic patients, treatment is somewhat controversial.
However, because of the relatively high risk of rupture, aggressive surgical
repair may be justifiable.
Conclusions
Splanchnic artery aneurysms are rare but can be clinically significant,
especially in the setting of rupture, with a high associated morbidity and
mortality. Autopsy series suggest that asymptomatic cases largely remain
undiagnosed and may be more common than previously suspected. Catheter
angiography has been the traditional means of diagnosis. However, 3D imaging
with CT and CT angiography, which allows visualization of the aorta and its
branches, may detect splanchnic artery aneurysms with greater frequency in
symptomatic and in asymptomatic patients. As discussed previously, the
treatment depends on the location, type, and size of the aneurysm and the
medical condition of the patient.
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