New guidelines advise on diagnosis, treatment of visceral artery aneurysms
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The Society of Vascular Surgery released clinical practice guidelines on management of visceral artery aneurysms, which are rare but can have grave consequences if they rupture.
The document covers aneurysms of the renal arteries, the splenic artery, the celiac artery, the hepatic artery and others.
“Nearly one-fourth of visceral artery aneurysms reported have presented with rupture, and the mortality rate of these diagnosed ruptures is at least 10%, probably higher,” Rabih A. Chaer, MD, professor of surgery, director of the vascular residency program and chief of vascular surgery at the University of Pittsburgh Medical Center and an author of the guidelines, said in a press release. “The mortality following ruptured celiac artery aneurysms and ruptured splenic artery aneurysms in pregnant women approaches 100%.”
Many of the recommendations concern appropriate imaging modalities, as advances in imaging have led to more frequent diagnoses of visceral artery aneurysms, and appropriate endovascular therapies.
Improved abilities
“The detailed imaging studies have allowed for an improved ability among vascular surgeons to identify asymptomatic lesions, and an enhanced potential for preoperative or preprocedural planning and elective treatment of these aneurysms,” Chaer said in the release. “Improvements in endovascular therapies have also allowed an enhanced ability for treatment of these often anatomically complex lesions with a large variety of individualized and precise catheter-based therapies.”
CT angiography is recommended to diagnose all visceral artery aneurysms, unless the patient has renal insufficiency or is at elevated risk if exposed to radiation, in which case noncontrast-enhanced MR angiography should be used, the authors wrote.
In most asymptomatic patients, treatment should be performed on radial artery aneurysms of greater than 3 cm, but urgent intervention is necessary in patients who have a rupture or develop symptoms, Chaer and colleagues wrote. They noted for asymptomatic patients, open repair is preferred, but an endovascular procedure is acceptable if the patient is at high surgical risk.
Ruptured splenic artery aneurysms should be treated urgently, and nonruptured splenic artery pseudoaneurysms should be treated due to risk for rupture, according to the authors, who also wrote that nonruptured splenic artery true aneurysms of any size should be treated in women of childbearing age, whereas nonruptured splenic artery true aneurysms of more than 3 cm should be treated in the general population.
Ruptured celiac artery aneurysms should be treated urgently, and nonruptured celiac artery pseudoaneurysms should be treated due to risk for rupture, whereas nonruptured celiac artery true aneurysms of more than 2 cm should be treated, the authors wrote.
Ruptured celiac artery aneurysms can be treated with open or endovascular repair depending on patient anatomy and clinical condition, whereas elective celiac artery aneurysm procedures should be performed with endovascular techniques if possible, Chaer and colleagues wrote.
Gastric artery and gastroepiploic artery aneurysms of any size should be treated, and the first-line treatment should be endovascular embolization, the authors wrote.
All hepatic artery pseudoaneurysms, regardless of cause, should be repaired as soon as they are diagnosed, and all symptomatic hepatic artery aneurysms should be repaired regardless of size, according to the authors.
Asymptomatic patients with hepatic artery aneurysms but no significant comorbidities should have repair if the size is more than 2 cm or grows at a rate of more than 0.5 cm per year, whereas those with significant comorbidities should have repair it the size is more than 5 cm, Chaer and colleagues wrote.
Important recommendations
“These guidelines offer important recommendations for the care of patients with aneurysms of the visceral arteries and long-awaited guidance for clinicians who treat these patients,” the authors wrote.
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