Unusual case of haemorrhagic shock

1. Unusual case of haemorrhagic shock Joint Hospital Surgical Grand Round Ruttonjee Hospital Travis Chan

2. 59/M • PMHx • Hypertension • Hyperlipidaemia • History of open appendicectomy • c/o sudden onset epigastric pain with radiation to back

3. At AED • Developed shock with BP 55/35mmHg • Pulse 110/min • Physical examination • No fever • Pallor • Abdomen: tenderness over epigastrium • PR: empty, no blood • BP 110/60mmHg after 2Liter IV fluid

4. Basic investigation in AED • Fast scan • Free fluid in Morrison pouch • 8cm pulsatile mass over epigastrium • CXR: clear, no free gas • AXR: no dilated bowel • First DDx: Ruptured AAA

5. Contrast CT Aortogram

6. Emergency Laparotomy • 300ml haemoperitonium • 8cm aneurysm in mid segment of splenic artery • Splenic artery proximal and distal ligation • Aneurysm excised • Spleen viable at the end of procedure • Pathology: True Aneurysm

7. Splenic artery aneurysm • 3rd commonest Intra-abdominal aneurysm • Definition: diameter > 1cm • Most are saccular • Prevalence ~0.1%; Mean age: 58 • Commoner in Female (F:M ratio is 4:1) Beaussier, J Med Clin Pharm,1770 Samer et al American journal of surgery, 1995 Gautam et al , AJR, 2007 Hogendoorn et al, J Vasc Surg, 2014

8. Splenic artery aneurysm • Etiology: Unknown • Association • Portal hypertension/cirrhosis • Arterial fibrodysplasia • Collagen vascular disease • Liver transplant • Multiple pregnancy • Atherosclerosis is not underlying cause Beaussier, J Med Clin Pharm,1770 Samer et al American journal of surgery, 1995 Gautam et al , AJR, 2007 Hogendoorn et al, J Vasc Surg, 2014

9. Splenic artery aneurysm • Presentation • Asymptomatic  Incidental finding in CT scan • Pulsatile abdominal mass • Abdominal pain • complication • Fistula: GIB • Rupture • Rupture risk increased with: • Pregnancy • Portal hypertension • Size >2cm Beaussier, J Med Clin Pharm,1770 Samer et al American journal of surgery, 1995 Gautam et al , AJR, 2007 Hogendoorn et al, J Vasc Surg, 2014

10. Management • Observation • Asymptomatic aneurysm with size <2cm • Operation (open surgery / minimally invasive surgery) • Endovascular intervention

11. Indication for intervention • Symptomatic aneurysm with any size • Asymptomatic aneurysm with size > 2cm • Asymptomatic aneurysm with size < 2cm • Female anticipating pregnancy Samer G. et al, American journal of surgery, 1995 Saltzberg et al, Ann Vasc Surg 2005 Gautam A et al, AJR, 2007 Frankhauser et al, J Vasc Surg 2011 Hogendoorn et al, J Vasc Surg, 2014

12. Surgical operation • Gold standard before era of interventional radiology • Strategies • Proximal and distal ligation • Resection of aneurysm • Reconstruction • Splenectomy

13. Is splenectomy essential in operation for splenic artery aneurysm?

14. Risk after splenectomy • Infection/sepsis • Encapsulated organism (e.g. Strep. Pneumoniae, H Influenza, meningiococci) • Overwhelming post-splenectomy infection (OPSI) • Thrombocytosis

15. Location of Aneurysm • Proximal: 16% • Middle: 30% • Distal/Hilar: 54% Hogendoorn et al, J Vasc Surg, 2014

16. Surgical strategies • Proximal/middle: Ligation + Resection +/- reconstruction +/- Splenectomy • Assess the spleen at the end of procedure • Collateral from short gastric artery • Distal: Ligation + splenectomy Pulli et al, J vasc Surg ,2008 Piereabissa et al, J vasc Surg 2009

17. Laparoscopic approach? Pietrabissa et al, J Vasc Surg, 2009 Moriyama et al, MIT 2012

18. Endovascular intervention • Embolization • Stent-Graft repair

19. Embolization • Complication • Failure • Access site bleeding/haematoma/thrombosis • Post embolization syndrome (up to 30%) • Recurrence Tulsyan et al, J Vasc Surg 2006 Hogendoorn et al, J Vasc Surg, 2014

20. Stent-Graft repair • Preserve the blood flow to end organ • Limitation • Anatomy • Tortuosity • Complication • Procedure failure • Stent thrombosis/occlusion • Endoleak Fankhauser et al, J Vasc Surg 2010

21. Surgical vs endovascular? Hogendoorn et al, J Vasc Surg, 2014

22. Surgical vs endovascular Hogendoorn et al, J Vasc Surg, 2014

23. Surgical vs endovascular Hogendoorn et al, J Vasc Surg, 2014

24. Conclusion • Splenic artery aneurysm is not common but occasionally seen as incidental finding • Indication for intervention • Symptomatic • Asymptomatic , Diameter > 2cm • Female anticipating pregnancy • Splenectomy may not be necessary • Location of aneurysm is important

25. Conclusion • Surgical management • Higher mortality rate • Lower complication and reintervention rate • Laparoscopic approach is an option • Endovascular management • Limited by anatomy • Lower mortality rate • Higher minor complication and reintervention rate • Trend of management is shifting to endovascular approach

26. Conclusion • Elective cases • Endovascular approach is suggested • Ruptured splenic artery aneurysm • Successful cases managed by endovascular approach • No evidence to conclude EV is better • Open surgical approach is still suggested in unstable patient

27. Reference • Etezadi V, Gandhi RT, Benenati JF, Rochon P, Gordon M, Benenati MJ, et al. Endovascular treatment of visceral and renal artery aneurysms. J Vasc Interv Radiol 2011;22:1246-53. • Beaussier M. Sur un anervrisme de l’artere splenique dont les parois se sont ossifiées. J Med Clin Pharm Paris 1770;32:157. • Fankhauser GT, Stone WM, Naidu SG, Oderich GS, Ricotta JJ, Bjarnason H, et al. The minimally invasive management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2011;53: 966-70. • Gabelmann A, Görich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9:38-47. • Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83. • Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg 2008;48:334-42. • Saltzberg SS, Maldonado TS, Lamparello PJ, Cayne NS,NalbandianMM, Rosen RJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg 2005;19:507-15. • Mattar SG, Lumsden AB. The management of splenic artery aneurysms: experience with 23 cases. Am J Surg 1995;169:580-4. • Pietrabissa A, Ferrari M, Berchiolli R, Morelli L, Pugliese L, Ferrari V, et al. Laparoscopic treatment of splenic artery aneurysms. J Vasc Surg 2009;50:275-9. • Hogendoorn W, Lavida A, Hunink MG, Moll FL, Geroulakos G, Muhs BE, et al. Open repair, endovascular repair, and conservative management of true splenic artery aneurysms. J Vasc Surg 2014;60: 1667-76.e1. • Hideki Moriyama, Norihiki Ishikawa, Masahiko Kawaguchi, Noriyuki Inaki, Go Watanbe: Laparoscopic approaches for splenic artery aneurysms. Minimally invasive Therapy. 2012;21:362-365 • Deron J Tessier, MD, William M. Stone et al. Clinical features and management of splenic artery pseudoaneurysm: Case series and cumulative review of literature. J Vasc Surg 2003;38:969-73

28. Thank you

29. Post-op FU CT

30. Post-op FU CT

31. Post Embolization Syndrome • Common side effect after embolization • E.g. TACE, Embolization of uterine fibroid • Occurs 24-72 hours after embolization • Symptom • Fever • Abdominal pain • Nausea/Vomiting • Flu like symptoms • Management • Symptomatic treatment

32. Splenic Artery Aneurysm

33. Splenic Artery Aneurysm