What is the recommended treatment for a splenic artery aneurysm?

Treatment of Splenic Artery Aneurysm

Endovascular transcatheter embolization is the first-line treatment for splenic artery aneurysms requiring intervention, with surgery reserved for failed endovascular therapy or acute rupture with hemodynamic instability. 1, 2

Treatment Indications

Absolute Indications for Intervention

• Aneurysms ≥2 cm in diameter require treatment due to rupture risk with mortality rates of 10-25% in non-pregnant patients 1, 2
• All aneurysms in pregnant women or women of childbearing age, regardless of size, as rupture during pregnancy carries maternal mortality up to 70% and fetal mortality exceeding 90% 1
  • Critically, up to 50% of aneurysms that rupture during pregnancy are <2 cm, making size criteria unreliable in this population 1
  • Risk peaks in the third trimester when splenic blood flow is maximal 1
• Growth >0.5 cm per year, even if not yet reaching 2 cm 2
• Symptomatic aneurysms presenting with chronic upper abdominal pain or signs of impending rupture 1
• Liver transplant candidates with portal hypertension 1

Observation Strategy

• Asymptomatic aneurysms <2 cm without high-risk features may be observed with periodic imaging surveillance 3
• No rupture or size increase was observed in conservatively managed patients during follow-up 4

Treatment Approach Algorithm

First-Line: Endovascular Transcatheter Embolization

Technical approach:

• Isolation technique using microcoils placed distal and proximal to the aneurysm in the afferent artery 4
• Coils can be used alone or combined with other embolic agents (vascular plugs) 2, 5
• Technical success rates range from 67-100% 1, 3

Advantages over surgery:

• Lower morbidity and mortality 2
• Shorter hospital stay (median 8 days vs 16 days for surgery) 4
• Better quality of life and most cost-effective strategy 2
• Splenic infarction is rare due to collateral supply from short gastric vessels 2
• No 30-day mortality or catheter-related complications in reported series 4

Expected outcomes:

• Primary technical success rate of 100% in experienced centers 4
• No recurrence observed during long-term follow-up (median 45 months) 4
• Comparable long-term results to conventional surgery 4

Second-Line: Surgical Treatment

Indications for surgery:

• Failed endovascular therapy 1
• Acute rupture with hemodynamic instability 1
• Ruptured aneurysms carry significant mortality, especially in pregnant women 2

Surgical options:

• Surgical ligation and splenectomy for failed endovascular treatment 1
• Laparoscopic approaches available but reserved for specific scenarios 2

Post-Procedure Management and Monitoring

Immediate Post-Procedure Care

• Monitor closely for development of abdominal pain, which may indicate complications 1, 3
• Post-embolization syndrome (persistent pain, fever, systemic symptoms) can occur but is typically self-limited 2

Follow-Up Imaging

• Post-procedure imaging is recommended to ensure complete aneurysm obliteration 6
• Cross-sectional imaging (CT angiography preferred) for detailed vascular anatomy assessment 3
• MR angiography may substitute if CT cannot be performed 3

Critical Pitfalls to Avoid

• Never delay treatment in women of childbearing age based on size criteria alone, as smaller aneurysms (<2 cm) frequently rupture during pregnancy 1
• Do not rely on size thresholds in pregnant patients—prophylactic intervention pre-conception is appropriate for known aneurysms >2-3 cm 1
• Recognize that false aneurysms (pseudoaneurysms) have greater rupture potential than true aneurysms because they grow faster 2
• Portal hypertension increases both formation and rupture risk, making liver transplant candidates high-priority for treatment 1