When is repair of a splenic artery aneurysm recommended?

Splenic Artery Aneurysm Repair Recommendations

Repair of splenic artery aneurysms is strongly recommended for aneurysms measuring 2.0 cm or larger in diameter, particularly in women of childbearing age, pregnant women, and patients undergoing liver transplantation due to high risk of rupture and associated mortality. 1

Size-Based Recommendations

• Open repair or catheter-based intervention is indicated for splenic artery aneurysms measuring 2.0 cm or larger in women of childbearing age who are not pregnant and in patients of either gender undergoing liver transplantation 1
• Open repair or catheter-based intervention is probably indicated for splenic artery aneurysms 2.0 cm or larger in women beyond childbearing age and in men 1
• Smaller aneurysms (<2.0 cm) in low-risk patients may be monitored with regular imaging surveillance 2

High-Risk Patient Groups

Pregnancy

• Pregnant women with splenic artery aneurysms are at significantly increased risk of rupture 1
• Rupture during pregnancy is associated with maternal mortality of 15.6% to 90% and fetal mortality of 21.9% to 70% 1
• Notably, 50% of lesions that rupture during pregnancy are smaller than 2.0 cm, suggesting a lower threshold for intervention may be appropriate in this population 1

Portal Hypertension

• Splenic artery aneurysms are more common in patients with portal hypertension 1
• These patients have an increased risk of rupture compared to the general population 2

Liver Transplantation

• Patients undergoing liver transplantation with splenic artery aneurysms should undergo repair regardless of size 1

Symptomatic Aneurysms

• All symptomatic splenic artery aneurysms should be repaired regardless of size 2
• Approximately 20% of patients present with chronic upper abdominal pain or acute rupture 1
• The mortality rate for ruptured splenic artery aneurysms in non-pregnant patients ranges from 10% to 25% 1

Treatment Options

• Endovascular therapy (embolization or stent grafting) should be the primary therapeutic approach for most patients 2, 3
• Surgical options include:
  • Aneurysmectomy with or without splenectomy 3
  • Laparoscopic approaches in select cases 4
• All false aneurysms (pseudoaneurysms) should be treated regardless of size 2

Surveillance Recommendations

• Patients with small (<2.0 cm) splenic artery aneurysms who are managed conservatively require regular imaging to monitor for growth 2
• Any documented growth of the aneurysm should prompt consideration for intervention 5

Special Considerations

• Prophylactic screening should be considered for patients with multiple risk factors, such as pregnancy in liver transplant recipients 2
• Endovascular treatment has shown good outcomes with lower morbidity compared to open surgical approaches in appropriately selected patients 6, 3

Pitfalls and Caveats

• The natural history of splenic artery aneurysms during pregnancy is not well established due to limited data 1
• Many case reports document rupture of aneurysms ≥2.0 cm during pregnancy 1
• While 2.0 cm is the generally accepted threshold for intervention, clinicians should recognize that rupture can occur in smaller aneurysms, particularly in high-risk groups 1
• Increasing use of abdominal imaging has led to more incidental findings of asymptomatic splenic artery aneurysms, requiring careful risk-benefit assessment 2