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Technical Innovation |
1 Department of Radiology, M/C 931, University of Illinois Medical Center at
Chicago, 1740 W. Taylor St., Chicago, IL 60612.
2 Department of Transplant Surgery, University of Illinois Medical Center at
Chicago, Chicago, IL 60612.
Received March 4, 2002;
accepted after revision April 9, 2002.
Address correspondence to C. A. Owens.
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We describe the case of a large hilar splenic artery aneurysm complicated by a wide aneurysmal neck found in a patient awaiting a liver transplantation. To preserve splenic function and reduce the risk of aneurysmal rupture, we used a remodeling technique to isolate and embolize the aneurysm with Guglielmi detachable coils (Target Therapeutics, Fremont, CA).
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Using a right transfemoral artery approach, we placed a 5-French catheter (Cobra 2; Cook, Bloomington, IN) through a 5-French introducer sheath (Cordis, Miami, FL) and positioned the catheter in the main splenic artery. Splenic arteriograms were obtained with the patient in various positions. The arteriograms identified a small branch artery emerging from the base of the aneurysm (Fig. 1A). Computer-assisted measurements of the main splenic artery, branch artery, and aneurysm were obtained using a standard software package (Neurostar; Seimens, Erlangen, Germany) found in our angiography suite. An attempt was made to occlude the aneurysm using appropriately sized Guglielmi detachable coils deployed through a coaxially placed 3-French Tracker-18 catheter with double markers (Target Therapeutics). After coils were deposited in the small branch artery extending from the base of the aneurysm, we abandoned further attempts to embolize the aneurysm when additional Guglielmi detachable coils protruded into the lumen of the main branch artery.
The 5-French catheter and the sheath were replaced with a 90-cm-long, 8-French guiding catheter (Cordis) that was positioned in the main splenic artery. A 9-French double rotating Y connector with an adjustable valve was attached to the end of the guiding catheter to allow side-by-side placement of a turbo Tracker-18 catheter and a nondetachable silicone balloon microcatheter (Endeavor; Target Therapeutics). A 5000-U bolus of heparin was administered to the patient to prevent thrombosis during temporary arterial occlusion. The Tracker-18 catheter was placed in the aneurysm, after which the nondetachable silicone balloon microcatheter was positioned across the neck of the aneurysm and inflated with diluted contrast material, causing temporary occlusion of the aneurysmal neck. With the neck of the aneurysm protected, we deposited Guglielmi detachable coils in the lumen of the aneurysm (Fig. 1B). Road-mapping was used during deployment. Before detachment of each coil, the balloon was deflated to test the stability of the coil in the aneurysm. Whenever the coil protruded across the neck of the aneurysm, the coil was retrieved and another deployment was attempted using either the Tracker-18 catheter placed in a different position in the aneurysm or a smaller coil.
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Complete occlusion of the aneurysm was achieved after 12 Guglielmi detachable coils of sequentially decreasing lengths (10-30 cm) and helical diameters (4-16 mm) were deployed. Repeated arteriography was performed during and at completion of embolization, confirming patency of the major branch artery and occlusion of the densely packed aneurysm (Fig. 1C).
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The remainder of the patient's hospitalization was uneventful and without clinical or laboratory evidence of splenic infarction. Three weeks after embolization, the patient underwent a successful liver transplantation. Intraoperative examination of the spleen revealed a normal splenic capsule and no gross evidence of splenic infarction. The patient's perioperative and postoperative courses were unremarkable. At 12 months after the liver transplantation, the patient showed no signs or symptoms of splenic infarction or aneurysmal rupture.
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Rupture of splenic artery aneurysms after liver transplantation has been well documented [1, 2, 4]. The reduction of portal vein resistance after liver transplantation increases splenic artery blood flow and thereby the risk of aneurysmal rupture. Gitlin et al. [5] showed a 44% increase in splenic blood flow after surgical portocaval shunts were placed. This increase was seen despite a decrease in splenic size, and the increase remained unchanged after several years of follow-up (1-14 years). A similar increase in splenic blood flow after liver transplantation may account for the reported postoperative rupture of splenic artery aneurysms and the appearance of new aneurysms after transplantion surgery [1, 2, 4]. Treatment of these aneurysms by ligation of the splenic artery has been recommended at the time of liver transplantation, when the size of the aneurysm is greater than 10 mm in diameter and is isolated to the main splenic artery [1, 2, 4]. As in our patient, hilar aneurysms account for 87% of splenic artery aneurysms found in transplantation patients and require splenectomy if they are not treated by endovascular means [4].
Our decision to embolize the hilar aneurysm was complicated by the presence of a wide aneurysmal neck. The use of the remodeling technique to treat wide-neck or poorly shaped aneurysms was first described by Moret et al. [6]. This technique has been shown to be highly effective in the endovascular treatment of intracranial aneurysms [7]. By temporally occluding the neck of the aneurysm during deployment of the Guglielmi detachable coil, the operator can then create a basket of coils in the aneurysm. Filling of the basket is achieved by successive deployment of Guglielmi detachable coils with a shorter length and smaller helical size until the aneurysm is occluded. The balloon occlusion catheter prevents migration of the coils across the neck of the aneurysm by providing a temporary barricade during deployment.
Our choice to selectively embolize the aneurysm during temporary occlusion of the aneurysmal neck proved to be effective at preserving the patency of the adjacent branch artery and minimizing the risk of splenic infarction. Alternative surgical therapies to treat the aneurysm could result in a loss of time and additional blood loss during the planned transplantation surgery. A splenectomy would pose the additional risk of severe infection to an already immunosuppressed liver recipient [8].
Further studies are needed to determine the proper workup and treatment of asymptomatic splenic artery aneurysms in patients who plan to undergo a liver transplantation or portosystemic shunt procedure. Researchers have shown the effectiveness of the remodeling technique in the treatment of wide-neck intracranial aneurysms [7]. We anticipate that the use of this technique in the treatment of visceral aneurysms, as in our patient, will be equally successful.
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