Endoscopy 2021; 53(05): E194-E195
DOI: 10.1055/a-1216-0670
E-Videos

Successful treatment by novel endoscopic ultrasound-guided devascularization for refractory splenic artery aneurysm associated with portal hypertension

Hongtan Chen
1  Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
,
Feng Li
2  Department of Gastroenterology, Christus Trinity Mother Frances Hospital and Clinic, Tyler, Texas, USA
,
Fenming Zhang
1  Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
,
Jianan Guo
1  Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
,
Chunhui Nie
3  Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
,
Junhui Sun
3  Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
,
Guoqiang Xu
1  Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
› Author Affiliations
 

Splenic artery aneurysm carries significant risk of rupture and life-threatening hemorrhage [1]. Therapy utilizing digital subtraction angiography (DSA) with embolization is usually safe and effective; however, incomplete occlusion can occur and frequently requires surgical repair [2]. We report the case of refractory splenic artery aneurysm associated with portal hypertension that was successfully treated by a novel endoscopic ultrasound (EUS)-guided devascularization technique.

A 64-year-old woman with chronic hepatitis B presented with epigastric abdominal pain for 4 months. Esophagogastroduodenoscopy showed isolated gastric varix in the fundus. Computed tomography revealed splenic artery aneurysm and cirrhosis with portal hypertension ([Fig. 1]). Embolization via DSA was performed successfully, as confirmed by selective splenic arteriography. One week later, a 2-cm residual aneurysm cavity was detected by EUS ([Fig. 2]). After EUS-guided obliteration of gastric varices, which hamper transgastric puncture to the aneurysm, a standard 22-gauge fine-needle aspiration needle was inserted into the aneurysmal neck, and a preloaded 0.018-inch fibered interlock detachable coil (F-IDC; 2 D 12 mm, 30 cm; Boston Scientific, Marlborough, Massachusetts, USA) was slowly pushed out of the needle tip into the residual aneurysmal cavity. After confirming that the aneurysmal neck was adequately coiled, the delivery wire was removed. EUS showed the direction of inflow had changed and the velocity had slowed down. Then, 3 mL lauromacrogol was injected into the aneurysmal sac; inflow slowed down further. Rapid injection of 0.5 mL tissue glue followed by 2 mL lauromacrogol generated a hyperechoic clot in the aneurysmal neck, with cessation of inflow ([Video 1]). EUS with Color Doppler confirmed complete occlusion of the original aneurysm at the 8-week and 16-week follow-ups ([Fig. 3]).

Zoom Image
Fig. 1 Computed tomography revealed splenic artery aneurysm and cirrhosis with portal hypertension.
Zoom Image
Fig. 2 Endoscopic ultrasound images. a A thick walled anechoic residual cavity with multiple hyperechoic coils was detected. b Color Doppler revealed the inflow from tortuous splenic artery. c Color Doppler showed the inflow and the retractable flow streams from the sac wall.

Video 1 Successful treatment by novel endoscopic ultrasound-guided devascularization for refractory splenic artery aneurysm associated with portal hypertension.


Quality:
Zoom Image
Fig. 3 Endoscopic ultrasound revealed complete occlusion of the aneurysm at the 16-week follow-up.

Angiographic re-embolization of an aneurysm may not be feasible because of small vessel caliber [3]. The key to successful management of refractory aneurysm is selective devascularization of high-velocity blood inflow from the neck of the sac leading to the endoleak, rather than direct deployment of excess coils in the sac with risk of erosion and migration of coils [4] [5]. With more powerful embolization effect and more control in selecting embolization sites, F-IDCs are the preferred treatment modality for vascular lesions with high blood flow that require highly precise embolization. Though not reported in the past, F-IDCs can be used successfully for EUS-guided aneurysm embolization. We therefore considered the EUS-guided selective devascularization with F-IDC, glue, and lauromacrogol to be a valuable therapeutic alternative for refractory cases with both splenic artery aneurysm and gastric varices.

Endoscopy_UCTN_Code_TTT_1AS_2AC

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Guoqiang Xu, MD, PhD
Department of Gastroenterology
The First Affiliated Hospital
College of Medicine, Zhejiang University
79 Qingchun Road
Hangzhou
China, 310003   
Fax: +86-571-87236730   

Publication History

Publication Date:
02 September 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomography revealed splenic artery aneurysm and cirrhosis with portal hypertension.
Zoom Image
Fig. 2 Endoscopic ultrasound images. a A thick walled anechoic residual cavity with multiple hyperechoic coils was detected. b Color Doppler revealed the inflow from tortuous splenic artery. c Color Doppler showed the inflow and the retractable flow streams from the sac wall.
Zoom Image
Fig. 3 Endoscopic ultrasound revealed complete occlusion of the aneurysm at the 16-week follow-up.