What is the recommended evaluation and management approach for a patient with a splenic artery aneurysm, considering factors such as size, symptoms, and medical history, including conditions like hypertension and liver disease?

Splenic Artery Aneurysm Evaluation and Management

For splenic artery aneurysms ≥2.0 cm in diameter, intervention with open repair or catheter-based treatment is indicated in women of childbearing age and patients undergoing liver transplantation, and is probably indicated for all other patients regardless of gender. 1

Initial Diagnostic Evaluation

When a splenic artery aneurysm is suspected or incidentally discovered, obtain the following imaging:

• CT angiography (CTA) is the optimal imaging modality for detailed vascular anatomy, aneurysm size measurement, and treatment planning 2
• MR angiography (MRA) can substitute if CT is contraindicated 2
• Ultrasound is useful for initial detection and surveillance of known aneurysms 2

The imaging must document:

• Precise aneurysm diameter (measure at maximal dimension) 1
• Location along the splenic artery (proximal, mid, or distal/hilar) 1
• Presence of calcification (does NOT protect against rupture) 3
• Splenic artery trunk diameter (correlates with aneurysm growth risk) 4
• Evidence of portal hypertension or splenomegaly 2

Risk Stratification and Treatment Thresholds

Immediate Intervention Required (Class I)

Any symptomatic aneurysm requires repair regardless of size 1:

• Chronic upper abdominal pain radiating to left flank or back 5
• Acute rupture presentation: abdominal pain with syncope and hemodynamic instability 5

Aneurysms ≥2.0 cm in high-risk populations 1:

• Women of childbearing age (pregnant or not): Maternal mortality 70% and fetal mortality >90% if rupture occurs during pregnancy 1, 5
• Patients undergoing liver transplantation: Portal hypertension increases rupture risk 1, 5

Intervention Probably Indicated (Class IIa)

Aneurysms ≥2.0 cm in all other patients (women beyond childbearing age and men) 1:

• Rupture mortality in non-pregnant patients is 10-25% 1
• Operative mortality for elective intervention is 0% versus 38% for ruptured aneurysms 1

Surveillance Appropriate

Aneurysms <2.0 cm in asymptomatic, non-high-risk patients 5, 6:

• Monitor with ultrasound or CT imaging every 6-12 months 6
• Intervene if growth >0.5 cm per year or if aneurysm reaches 2.0 cm 6

Special Populations Requiring Aggressive Management

Pregnancy and Women of Childbearing Age

All splenic artery aneurysms in pregnant women or women of childbearing potential warrant treatment regardless of size 5:

• Up to 50% of aneurysms that rupture during pregnancy are <2.0 cm 5
• Risk is highest in third trimester when hyperdynamic circulation maximizes splenic blood flow 5
• Prophylactic intervention pre-conception is appropriate for known aneurysms >2.0 cm 5

Liver Disease and Portal Hypertension

Cirrhotic patients require heightened surveillance 4:

• SAA prevalence is 2.97% in cirrhotic patients 4
• Increased splenic artery diameter (from increased flow) correlates with aneurysm growth (R²=0.705) 4
• Portal hypertension can cause compartmented portal hypertension if aneurysm reaction prevents shunt construction 7
• Consider elective intervention based on splenic artery trunk diameter in addition to aneurysm size 4

Treatment Approach

First-Line: Endovascular Therapy

Transcatheter embolization is the primary therapeutic approach 5, 6:

• Technical success rates: 67-100% 5, 2
• Options include coil embolization alone or combined with cyanoacrylate 1
• Stent grafting is an alternative endovascular option 6

Monitor for post-procedure complications 2:

• Abdominal pain may indicate splenic infarction or abscess
• Fever is common after embolization 1

Second-Line: Open Surgical Repair

Reserve for failed endovascular therapy or anatomically unsuitable cases 5:

• Options: aneurysm ligation, resection with arterial reconstruction, or splenectomy 1
• Preserve the spleen when possible 7
• In patients with portal hypertension, avoid the aneurysm region when constructing portosystemic shunts 7

Medical Management Considerations

Blood Pressure Control

Control hypertension aggressively in all patients with aneurysms 1:

• Patients should be advised to stop smoking and offered smoking cessation interventions 1
• Beta-adrenergic blocking agents may reduce aneurysm expansion rates 1
• Interestingly, no ruptured aneurysms occurred in patients receiving beta-blockade in one series 1

Critical Pitfalls to Avoid

• Do not assume calcification protects against rupture—calcified aneurysms still rupture 3
• Do not use size criteria alone in pregnant women—50% of pregnancy ruptures occur with aneurysms <2.0 cm 5
• Do not delay intervention in symptomatic patients—mortality for ruptured aneurysms is 38% versus 0% for elective repair 1
• Do not overlook false aneurysms (pseudoaneurysms)—all should be treated regardless of size 6