Splenic Artery Aneurysms Should Be Repaired Before Liver Transplantation to Prevent Fatal Rupture
Splenic artery aneurysms (SAAs) in liver transplant candidates must be treated prior to transplantation, regardless of size, due to the high risk of post-transplant rupture and associated mortality of up to 50%. 1
Why Repair is Critical
The hemodynamic changes following liver transplantation dramatically increase rupture risk. When portal pressure normalizes after transplant, the sudden circulatory alterations create mechanical stress on pre-existing SAAs, making rupture significantly more likely in the perioperative period 1, 2. In untreated patients, post-transplant rupture occurs in approximately 4.7% of cases, with a 50% mortality rate when rupture occurs 1.
Key Risk Factors in Transplant Candidates
- Portal hypertension from cirrhosis is the primary driver of SAA formation in this population 3, 2
- SAAs occur in approximately 3.8% of liver transplant recipients 3
- Most aneurysms are located at the splenic hilum (59.2%) with 66% being solitary 3
- Duration of portal hypertension >10 years substantially increases risk 2
Treatment Algorithm
The choice between surgical ligation versus endovascular embolization depends on SAA location, number, and accessibility 3:
Surgical Ligation (Preferred for):
- Proximal splenic artery aneurysms
- Single, accessible lesions
- Can be performed at time of transplant
- Lower splenic infarction rate compared to embolization 3
Endovascular Embolization (Preferred for):
- Distal or intrahilum SAAs (80% of cases) 1
- Multiple aneurysms
- Intrasplenic locations
- Patients with prohibitive surgical risk
Treatment Outcomes and Safety
A 2025 study of 88 transplant recipients with SAAs demonstrated that aggressive pre-transplant treatment (58% surgical, 42% endovascular) resulted in zero SAA-related mortality over 53 months of follow-up 3. While splenic infarction occurred in 75% of treated patients, this complication required no additional invasive intervention and was significantly lower with surgical ligation 3.
Common Pitfall to Avoid
SAAs can be missed on standard imaging. Doppler ultrasound and venous-phase CT cannot reliably distinguish SAAs from splenic varices in patients with extensive portal collaterals 4. Dedicated arterial-phase CT angiography or hepatic angiography is essential for pre-transplant screening in patients with long-standing portal hypertension 4, 2.
Clinical Implementation
Screen all transplant candidates with:
Treat all identified SAAs before transplant, as the traditional 2 cm size threshold used in the general population does not apply to transplant candidates 1, 5. The post-transplant hemodynamic changes make even smaller aneurysms high-risk 1.