PMC6757488_01
Computed tomography of a large aneurysm of the splenic artery (SA). (A) Computed tomography showing a large aneurysm of the SA arising from the SMA. (B) Axial image of maximal diameter of SA aneurysm (SAA). (C and D) The stretched view of curved planar reconstruction images showing the (C) bifurcation of SA and (D) ostium of SAA. SMA indicates superior mesenteric artery.
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A 75-year-old man presented with an incidentally discovered large aneurysm of the splenic artery (SA), which had anomalistically arisen from the superior mesenteric artery (SMA) (Figure 1A). Computed tomography (CT) revealed saccular morphology and a maximum diameter of 60.8 mm (Figure 1B), both of which inspired invasive treatment. However, the proximal neck of SA was approximately 5 mm on the stretched view of curved planar reconstruction images of the CT (Figure 1C and D).
Angiography, coil embolization, and deployment of self-expandable stent-graft (SG). (A) Preangiogram confirmed the large aneurysm and short proximal neck. (B) Angiogram after coil embolization. (C) Start position of the SG. (D) A sequence of images during SG deployment showing deformation of the SG and dive into the splenic artery. (E) Final angiogram showing complete exclusion of the aneurysm.
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Ansel 3; Cook Medical, Bloomington, IN) was engaged to SMA via the right femoral artery. Angiography confirmed that a highly bending SA diverged from the SMA, and the aneurysm was located approximately 5 mm from the bifurcation (Figure 2A; Online Video 1). Following coil embolization (Ruby Coil COMPLEX STANDARD; Penumbra Inc., Alameda, CA; and Target coil; Stryker, Portage, MI) (Figure 2B), we tried to advance the guiding catheter. Amplatz Extra-Stiff Support guide wire (Cook Medical) was placed. Subsequently, the guiding sheath could be advanced across the bending portion of SA along the Amplatz Extra-Stiff Support guide wire. After exchanging the guide wire to 0.018-inch support wire (Thruway; Boston Scientific, Marlborough, MA), we tried to deploy the SG (VIABAHN 7.0 x 50 mm) at the ostium of the SA (Figure 2C; Online Video 2). However, the SG started to deflect as the suture was pulled and finally jumped away from the start position (Figure 2D; Online Video 3). Final angiography showed complete exclusion of the aneurysm (Figure 2E; Online Video 5).
Schema of sheath-covering technique. (A) Deliver stent-graft (SG) together with the sheath across the lesion. (B) Short pullback of the sheath. (C) Short deployment of the SG. Repeat (B) and (C) little by little (D-G).
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A second SG (VIABAHN 7.0 x 50 mm) was deployed using the sheath-covering technique, which involved alternating short deployment of the SG with short pullback of the sheath (Figure 3; Online Video 4).
One year follow-up images of abdominal ultrasound (AUS). (A) The AUS showed that the maximal diameter of splenic artery aneurysm was unchanged (approximately 60 mm). (B-D) The implanted stent-graft was patent.
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After the procedure, we planned to perform abdominal ultrasound at 1, 6, 12 months and every 12 months (Figure 4).