From the Guidelines
The best management option for a 56-year-old patient with a history of acute pancreatitis who has a 2.5 cm calcified splenic artery aneurysm is splenectomy with removal of the affected artery (option C). This is because the aneurysm is large (≥2 cm) and calcified, which increases the rupture risk, and the patient has a history of pancreatitis, a known risk factor for both aneurysm formation and rupture 1. Some key points to consider in this case include:
- The size of the aneurysm: aneurysms larger than 2 cm carry a significant rupture risk of 10-25%, with mortality rates of 25-70% if rupture occurs 1.
- The presence of calcification: this indicates chronic disease and potential wall weakening, further increasing the rupture risk.
- The history of pancreatitis: this is a known risk factor for both aneurysm formation and rupture.
- The potential consequences of rupture: these can be severe, with high mortality rates, and include the "double rupture phenomenon" where an initial small bleed is followed by a major rupture with rapid intra-abdominal bleeding and haemorrhagic shock 1. Splenectomy with removal of the affected artery (option C) would be the most definitive treatment in this scenario, as it eliminates both the aneurysm and the risk of collateral vessel formation that could lead to recurrence 1. Following splenectomy, the patient would require appropriate vaccinations against encapsulated organisms and lifelong antibiotic prophylaxis to prevent overwhelming post-splenectomy infection. Observation (option A) is not appropriate given the high rupture risk, and ligation of the aneurysm (option B) may not be as effective in preventing recurrence as splenectomy with removal of the affected artery.
From the Research
Management Options for Splenic Aneurysm
- The patient has a history of acute pancreatitis and presents with a splenic aneurysm of 2.5cm with calcification.
- Considering the size of the aneurysm and its potential for rupture, management options should be carefully evaluated.
- According to the study by 2, splenic artery pseudoaneurysm is rare and usually a complication of pancreatitis or trauma, and the authors recommend repair of all splenic artery pseudoaneurysms.
Treatment Approaches
- The study by 3 presents a case of a ruptured splenic artery aneurysm as a complication of acute pancreatitis, where the patient underwent immediate surgery with excision of the pseudoaneurysm, spleen, and part of the pancreatic tail.
- Another approach is transcatheter embolization, as reported in the study by 4, where a 49-year-old male with recurrent pancreatitis and a splenic artery pseudoaneurysm underwent successful embolization with complete resolution of symptoms.
- Splenectomy with removal of the affected artery is also a possible management option, as mentioned in the study by 2, where 4 patients underwent splenectomy and distal pancreatectomy.
Best Management Option
- Based on the available evidence, the best management option for the patient with a 2.5cm splenic aneurysm and calcification would be either splenectomy with removal of the affected artery or transcatheter embolization, considering the patient's history of acute pancreatitis and the size of the aneurysm.
- However, the final decision should be made by a specialist tertiary center, taking into account the patient's overall condition and the potential risks and benefits of each management option, as suggested by the study by 5.