Scientific letter
Fusiform Giant Splenic Artery Aneurysm
Aneurisma fusiforme gigante de arteria esplénica
Emiliano A. Rodríguez-Caulo
, Omar Araji, Nuria Miranda, Juan C. Téllez, Carlos Velázquez
Corresponding author
Servicio de Cirugía Cardiovascular, UGC Área del Corazón, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Rodríguez-Caulo, Omar Araji, Nuria Miranda, Juan C. Téllez, Carlos Velázquez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Emiliano A." "apellidos" => "Rodríguez-Caulo" "email" => array:1 [ 0 => "erodriguezcaulo@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Omar" "apellidos" => "Araji" ] 2 => array:2 [ "nombre" => "Nuria" "apellidos" => "Miranda" ] 3 => array:2 [ "nombre" => "Juan C." "apellidos" => "Téllez" ] 4 => array:2 [ "nombre" => "Carlos" "apellidos" => "Velázquez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Cardiovascular, UGC Área del Corazón, Hospital Universitario Virgen Macarena, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aneurisma fusiforme gigante de arteria esplénica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1265 "Ancho" => 719 "Tamanyo" => 198892 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Preoperative computed tomography: (A) axial image, SAA 58<span class="elsevierStyleHsp" style=""></span>mm×60<span class="elsevierStyleHsp" style=""></span>mm and (B) three-dimensional reconstruction (*: SAA).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Visceral aneurysms are relatively rare, but clinically they are relevant lesions that should be given consideration. The most common are splenic artery aneurysms (SAA), which represent about 60% of visceral aneurysms. Other more uncommon visceral locations are the hepatic artery (20%), superior mesenteric artery (5.5%), celiac trunk (4%), gastric and gastroepiploic arteries (4%), intestinal arteries (3%), pancreatic arteries (2%), gastroduodenal artery (1.5%) and very rarely in the inferior mesenteric artery (1%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition to their limited clinical presentation, visceral aneurysms are treated by cardiovascular surgeons, general surgeons, radiologists and angiologists; therefore, the overall experience of a team is never extensive and the experience of an individual surgeon may be very limited. The growing use of ultrasound and other imaging techniques has increased their detection, which is usually incidental.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case report of a 52-year-old male with diabetes, hypertension and acromegaly, who had undergone a transsphenoidal pituitary adenomectomy. He had severe aortic failure and ascending aortic aneurysms, and a calcified giant fusiform splenic aneurysm (58<span class="elsevierStyleHsp" style=""></span>mm×60<span class="elsevierStyleHsp" style=""></span>mm) was detected incidentally during computed tomography (CT, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In spite of the patient's high risk profile, we decided to carry out standard surgery. This was due to the existence of numerous preoperative factors for failure of correct endovascular exclusion, such as the large size of the neck of the aneurysm as well as excessive tortuosity of the splenic artery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">By means of a left subcostal laparotomy, the greater omentum was dissected using ligatures up to the omental sac and the aneurysm was located in the middle of the splenic artery, adjacent to the pancreas. After administering 1<span class="elsevierStyleHsp" style=""></span>mg/kg of intravenous heparin and dissecting and clamping the proximal and distal ends of the splenic artery, aneurysmectomy was carried out with later direct revascularization by means of an end-to-end anastomosis with continuous 5.0 polypropylene sutures. The final result was good and there were no complications (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was discharged on the 10th day post-op with normal platelet count (207<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>) and normal CT angiography. Six months later, he remained asymptomatic, with a normal follow-up CT angiogram.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Currently, more asymptomatic incidental cases of visceral aneurysms are being reported due to the widespread use of ultrasound and CT as imaging tests.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> They can also be detected by means of radiography, generally seen as oval calcifications. SAA are usually saccular, located proximally in 5%, mid artery in 35% and distally in 60%. In 20% of the cases, multiple locations are found, so other locations should always be screened for aneurysms.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most cases are asymptomatic, with a risk of rupture between 2 and 46%, especially in pregnant women or patients with portal hypertension.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The overall mortality for ruptured SAA is 25%–75%, while the mortality of standard surgery is 0.5%–1.5%.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Generally, the classic indications of surgery are a size larger than 2<span class="elsevierStyleHsp" style=""></span>cm, symptomatic SAA or in pregnant women or in those who desire to become pregnant (any size).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There are several methods of treatment, such as open conventional surgery, laparoscopic surgery and intravascular interventionism, using either embolizations with coils or with covered stents. The choice depends on the location and accessibility of the SAA and the general status of the patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Classic open surgery with laparotomy is a method with proven effectiveness,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> although it is relatively traumatic and presents morbidity. Laparoscopy is an excellent, less aggressive alternative, but it requires an expert surgeon.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Percutaneous endoluminal treatment has the disadvantages of difficult stent placement or embolization if the splenic artery is tortuous and the probability of recurrence or incomplete aneurysm exclusion (endoleak). We consider surgical treatment, either open or preferably laparoscopic, the best therapeutic option in patients with reasonable surgical risk. Patients with very high surgical risk or contraindication to surgery can benefit from intravascular percutaneous treatment, with excellent results as well as low morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Associated splenectomy was considered the most common therapy in the past,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but it should be avoided to preserve the hemato-immunological function of the spleen, although in the case of distal SAA it is usually necessary with the aneurysmectomy. In the case of SAA of the middle or proximal thirds, aneurysmectomy is preferred in association with revascularization whenever feasible, either by means of direct reimplantation of the splenic artery as in the present case or by using venous grafts or prostheses. In spite of the rich collateral circulation in the spleen, there have been case reports of splenic infarction and abscessification in the absence of revascularization and, given its feasibility, we believe it should be indicated whenever possible. In some cases, especially inflammatory SAA, partial pancreatectomy may be associated depending on the location.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we believe that treatment should be individualized and that conventional surgery continues to be the gold standard, but the current growth of intravascular techniques and their low associated morbidity<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> may make this situation revert in the near future, even though it is the first step in the treatment of high-risk patients with favorable anatomy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez-Caulo EA, Araji O, Miranda N, Téllez JC, Velázquez C. Aneurisma fusiforme gigante de arteria esplénica. Cir Esp. 2014;92:215–216.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1265 "Ancho" => 719 "Tamanyo" => 198892 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Preoperative computed tomography: (A) axial image, SAA 58<span class="elsevierStyleHsp" style=""></span>mm×60<span class="elsevierStyleHsp" style=""></span>mm and (B) three-dimensional reconstruction (*: SAA).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1242 "Ancho" => 721 "Tamanyo" => 188163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images: (A) SAA in the omental sac and (B) end-to-end arterial reconstruction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Splachnic artery aneurysms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 6 | 8 | 14 |
| 2024 September | 15 | 15 | 30 |
| 2024 August | 23 | 12 | 35 |
| 2024 July | 17 | 7 | 24 |
| 2024 June | 15 | 7 | 22 |
| 2024 May | 15 | 9 | 24 |
| 2024 April | 13 | 2 | 15 |
| 2024 March | 19 | 2 | 21 |
| 2024 February | 14 | 2 | 16 |
| 2024 January | 23 | 1 | 24 |
| 2023 December | 25 | 7 | 32 |
| 2023 November | 19 | 1 | 20 |
| 2023 October | 20 | 6 | 26 |
| 2023 September | 15 | 2 | 17 |
| 2023 August | 19 | 3 | 22 |
| 2023 July | 22 | 3 | 25 |
| 2023 June | 15 | 2 | 17 |
| 2023 May | 38 | 4 | 42 |
| 2023 April | 36 | 2 | 38 |
| 2023 March | 33 | 0 | 33 |
| 2023 February | 58 | 0 | 58 |
| 2023 January | 18 | 8 | 26 |
| 2022 December | 50 | 6 | 56 |
| 2022 November | 33 | 2 | 35 |
| 2022 October | 28 | 7 | 35 |
| 2022 September | 31 | 20 | 51 |
| 2022 August | 38 | 7 | 45 |
| 2022 July | 14 | 7 | 21 |
| 2022 June | 18 | 9 | 27 |
| 2022 May | 23 | 8 | 31 |
| 2022 April | 16 | 7 | 23 |
| 2022 March | 29 | 8 | 37 |
| 2022 February | 40 | 8 | 48 |
| 2022 January | 49 | 7 | 56 |
| 2021 December | 40 | 11 | 51 |
| 2021 November | 51 | 7 | 58 |
| 2021 October | 49 | 8 | 57 |
| 2021 September | 42 | 10 | 52 |
| 2021 August | 62 | 11 | 73 |
| 2021 July | 42 | 14 | 56 |
| 2021 June | 22 | 12 | 34 |
| 2021 May | 18 | 5 | 23 |
| 2021 April | 19 | 11 | 30 |
| 2021 March | 38 | 15 | 53 |
| 2021 February | 24 | 4 | 28 |
| 2021 January | 20 | 10 | 30 |
| 2020 December | 24 | 9 | 33 |
| 2020 November | 22 | 6 | 28 |
| 2020 October | 41 | 7 | 48 |
| 2020 September | 21 | 14 | 35 |
| 2020 August | 15 | 37 | 52 |
| 2020 July | 18 | 9 | 27 |
| 2020 June | 18 | 14 | 32 |
| 2020 May | 15 | 8 | 23 |
| 2020 April | 12 | 10 | 22 |
| 2020 March | 5 | 7 | 12 |
| 2020 February | 12 | 8 | 20 |
| 2020 January | 10 | 6 | 16 |
| 2019 December | 13 | 13 | 26 |
| 2019 November | 19 | 5 | 24 |
| 2019 October | 5 | 3 | 8 |
| 2019 September | 14 | 4 | 18 |
| 2019 August | 11 | 4 | 15 |
| 2019 July | 18 | 22 | 40 |
| 2019 June | 12 | 6 | 18 |
| 2019 May | 48 | 58 | 106 |
| 2019 April | 7 | 15 | 22 |
| 2019 March | 6 | 5 | 11 |
| 2019 February | 9 | 10 | 19 |
| 2019 January | 4 | 5 | 9 |
| 2018 December | 2 | 9 | 11 |
| 2018 November | 14 | 1 | 15 |
| 2018 October | 15 | 2 | 17 |
| 2018 September | 11 | 1 | 12 |
| 2018 August | 4 | 1 | 5 |
| 2018 July | 6 | 2 | 8 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 5 | 8 | 13 |
| 2018 April | 2 | 0 | 2 |
| 2018 March | 9 | 3 | 12 |
| 2018 February | 11 | 2 | 13 |
| 2018 January | 4 | 3 | 7 |
| 2017 December | 7 | 1 | 8 |
| 2017 November | 4 | 5 | 9 |
| 2017 October | 12 | 1 | 13 |
| 2017 September | 12 | 2 | 14 |
| 2017 August | 14 | 4 | 18 |
| 2017 July | 14 | 2 | 16 |
| 2017 June | 15 | 5 | 20 |
| 2017 May | 30 | 2 | 32 |
| 2017 April | 15 | 4 | 19 |
| 2017 March | 21 | 2 | 23 |
| 2017 February | 14 | 2 | 16 |
| 2017 January | 20 | 1 | 21 |
| 2016 December | 12 | 4 | 16 |
| 2016 November | 16 | 6 | 22 |
| 2016 October | 28 | 3 | 31 |
| 2016 September | 28 | 3 | 31 |
| 2016 August | 20 | 7 | 27 |
| 2016 July | 12 | 3 | 15 |
| 2016 June | 18 | 8 | 26 |
| 2016 May | 22 | 13 | 35 |
| 2016 April | 13 | 23 | 36 |
| 2016 March | 23 | 18 | 41 |
| 2016 February | 12 | 11 | 23 |
| 2016 January | 9 | 3 | 12 |
| 2015 December | 18 | 10 | 28 |
| 2015 November | 14 | 4 | 18 |
| 2015 October | 22 | 4 | 26 |
| 2015 September | 27 | 4 | 31 |
| 2015 August | 7 | 5 | 12 |
| 2015 July | 17 | 6 | 23 |
| 2015 June | 2 | 1 | 3 |
| 2015 May | 10 | 4 | 14 |
| 2015 April | 22 | 4 | 26 |
| 2015 March | 14 | 7 | 21 |
| 2015 February | 24 | 3 | 27 |
| 2015 January | 34 | 7 | 41 |
| 2014 December | 29 | 15 | 44 |
| 2014 November | 24 | 3 | 27 |
| 2014 October | 30 | 6 | 36 |
| 2014 September | 19 | 2 | 21 |
| 2014 August | 40 | 5 | 45 |
| 2014 July | 31 | 9 | 40 |
| 2014 June | 15 | 3 | 18 |
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