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When Aneurysm Meets Fistula: 3D-guided Endovascular Management Of Complex Splenic Vascular Pathology
Dora Z. Zatyko, Ponraj Chinnadurai, Adam Bardoczi, Orlando M. Diaz, Alan B. Lumsden.
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
Background:Splenic artery aneurysm (SAA) with associated splenic arteriovenous fistula (SAVF) is rare and technically challenging. Vessel tortuosity, aneurysmal compression, and turbulent high-flow shunting often preclude the use of stent grafts. In such cases, coil and liquid embolization can provide an effective, minimally invasive solution. We present successful endovascular management using neurointerventional techniques and devices, supported by advanced preoperative imaging and intraoperative cone-beam CT.
Methods:A 69-year-old woman was incidentally diagnosed with a three-centimeter splenic artery aneurysm and large splenic venous aneurysm draining into the portal system during evaluation for elevated liver enzymes. CTA demonstrated a markedly tortuous splenic artery and confirmed a high-flow SAVF. Three-dimensional reconstructions with color-coded inflow and outflow annotations were generated to guide planning and catheter navigation.Under ultrasound guidance, right common femoral access was obtained, and aortography with selective celiac angiography was performed. Cone-beam CT was utilized early to confirm catheter positioning and correlate with the inflow/outflow channels identified on preoperative reconstructions. A steerable sheath was advanced into the celiac axis, and through the splenic artery, a Raptor intermediate catheter and Red 63 catheter were positioned in the distal splenic artery at the draining vein. The Red catheter was exchanged for dual microcatheters, which were advanced into the distal splenic hilum aneurysm.Multiple Penumbra PC400 coils were deployed at the fistula site, followed by Onyx injection into the aneurysm cavity and arterial inflow under fluoroscopic guidance. Sequential angiography demonstrated progressive reduction of shunt flow and complete occlusion of the SAVF. Collateral perfusion via short gastric branches preserved partial splenic blood supply.
Results:The procedure was completed successfully with minimal blood loss and no complications. The patient tolerated the intervention well, was extubated in the operating room, and discharged home the following day in stable condition.
Conclusions:This case highlights the value of adapting neurointerventional techniques for complex visceral pathology. Dual microcatheter strategies, detachable coils, and liquid embolics enabled precise embolization of a tortuous splenic artery aneurysm with high-flow fistula. Advanced imaging, including 3D reconstructions and intraoperative cone-beam CT, provided essential roadmapping to navigate challenging anatomy. In situations where vessel tortuosity and hemodynamics preclude stent grafting, transcatheter coil and liquid embolization represent a safe and effective alternative, while careful assessment of collaterals helps preserve splenic perfusion.
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