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Another complication of cirrhosis

Cleveland Clinic Journal of Medicine. 2017 September;84(9):701-706 | 10.3949/ccjm.84a.16084
September 1, 2017|Cleveland Clinic Journal of Medicine
Houriya Ayoubieh, MD;Eyas Alkhalili, MD
Author and Disclosure Information

Houriya Ayoubieh, MD
Assistant Professor, Department of Hospital Medicine, University of New Mexico, Albuquerque

Eyas Alkhalili, MD
Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD

Address: Houriya Ayoubieh, MD, Assistant Professor, Department of Hospital Medicine, University of New Mexico, 915 Camino De Salud NE, MSC10 5550, 1 University of New Mexico, Albuquerque, NM 87131; h.ayoubieh@gmail.com

TREATMENT OF SPLENIC ARTERY ANEURYSM

4. Which of the following is false regarding treatment of splenic artery aneurysms?

  • Aneurysms larger than 2 cm and those that are expanding require repair
  • Treatment should be offered if the patient has symptoms attributable to the aneurysm
  • Asymptomatic aneurysms in pregnant women can be followed with watchful waiting
  • Minimally invasive therapies such as percutaneous embolization may be a good option in poor operative candidates

Asymptomatic aneurysms in pregnant women should not be followed with watchful waiting—they should be repaired, as rupture carries a maternal mortality rate of 75% and a fetal mortality rate of 95%.34

Complications of splenic artery aneurysm depend on the type of aneurysm and its predisposing factors. Indications for treatment of true aneurysms include:

  • Symptoms attributable to the aneurysm (hence, the second answer choice above is true)
  • Diameter 2  cm or greater or enlarging diameter (hence, the first answer choice is true)
  • Women of childbearing age in anticipation of pregnancy
  • Need for surgical intervention such as portocaval shunt and liver transplant.

Conservative management is associated with a late mortality risk of 4.9%.2 Interventional options include percutaneous embolization or stenting; or laparotomy with splenic artery ligation or excision with or without splenectomy.1,28,35–37

Endovascular and open surgical repair have both been used to treat splenic artery aneurysms. The method used depends on the patient’s surgical history and aneurysm anatomy such as splenic artery tortuosity hindering passage of a catheter. Open surgery is associated with longer intraoperative time and length of hospital stay and higher rates of 30-day mortality and perioperative morbidity.38–41 With endovascular repair, the complication of persistent or recurrent flow occurs in 3% to 5% of cases by 30 days; hence, postprocedural surveillance is recommended.42–44 Endovascular repair has a higher reintervention rate but may still be more cost-effective than open surgical repair.

Because patients with cirrhosis have a higher risk of surgical complications,45 elective endovascular treatment may be an option for patients with aneurysms at high risk of rupturing. Endovascular treatment of visceral aneurysms is associated with complications such as postembolization syndrome (fever, abdominal pain, pleural effusion, and pancreatitis), access site hematoma, splenic infarction, and persistent abdominal pain.42

Patients with cirrhosis as the cause of splenic artery aneurysm tend to need longer hospitalization after endovascular treatment, but there is insufficient evidence to suggest that they are at higher risk of other complications.37

CASE CONTINUED: SPLENIC ARTERY EMBOLIZATION

Figure 2. Angiography before treatment demonstrates splenic aneurysm (large arrow) with extravasation (small arrow).

The patient undergoes emergency splenic artery embolization, performed by an interventional radiology team (Figure 2 and Figure 3). Over the next few days, her mental status improves and her abdominal pain resolves. Her hemoglobin level remains stable after the procedure.

Figure 3. Angiography after embolization demonstrates coils in the embolized aneurysm without extravasation.
She is discharged home on day 5 but comes back 5 days later with recurrent abdominal pain. CT of the abdomen and pelvis with contrast shows a hematoma and hemoperitoneum with bleeding originating near the previously embolized splenic artery aneurysm and splenic infarction.

The surgical and interventional radiology teams discuss the risk of repeat intervention with the patient and her family, who prefer a nonoperative approach. She is managed supportively in the intensive care unit and is finally discharged home in stable condition and is scheduled for outpatient follow-up.

SUSPECT THIS FATAL CONDITION

The low prevalence of ruptured splenic artery aneurysm may lead physicians to attribute septic shock to spontaneous bacterial peritonitis or hemorrhagic shock from gastroesophageal varices in patients with cirrhosis, but a high index of suspicion and early recognition of this rare disease can lead to timely diagnosis and treatment of this highly fatal complication.

KEY POINTS

  • Splenic artery aneurysm is a common complication of cirrhosis, often diagnosed incidentally.
  • Elective embolization should be considered for asymptomatic splenic artery aneurysms larger than 2 cm in diameter, clinically symptomatic aneurysms, women of childbearing age, and patients who are candidates for liver transplant.
  • Although splenic artery aneurysm rupture is rare, it has a high mortality rate and warrants a high index of suspicion to institute prompt specialized intervention.
  • We recommend that physicians consider splenic artery aneurysm rupture in their differential diagnoses in patients with liver cirrhosis presenting with abdominal pain, altered mental status, and hemodynamic shock.

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