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Special Feature
November 01, 2006

Image of the Month—Diagnosis

Arch Surg. 2006;141(11):1142. doi:10.1001/archsurg.141.11.1142
Answer: Splenic Artery Pseudoaneurysm

The CT scan demonstrated 2 hypodense lesions in the spleen. The most superior lesion contains prominent vessels with focus of high attenuation, which may represent active bleeding from an arteriovenous fistula, a splenic aneurysm, a splenic pseudoaneurysm, or a hemangioma. Celiac angiography showed a pseudoaneurysm of a peripheral branch of the splenic artery in the upper pole of the spleen (Figure 2) that was embolized with 3-mm coils. No residual filling was seen after embolization. The patient tolerated the procedure well and was discharged home 2 days later.

Figure 2.
Celiac artery angiogram.

Celiac artery angiogram.

Because traumatic pseudoaneurysms are rare, with only 45 reported cases,1the clinical profile of this condition is not well defined. Most traumatic splenic pseudoaneurysms result from blunt trauma. Abdominal pain is the most common symptom, although initial findings may range from an incidental radiographic finding to acute hemodynamic instability. The majority (74%) of traumatic splenic pseudoaneurysms are not present on the admission abdominal CT but diagnosed in a follow-up study performed hours to several months later. The incidence of these pseudoaneurysms correlates with the severity of splenic injury.2Only 26% of pseudoaneurysms develop following grade 1 and 2 injuries, which represent 62% of all splenic injuries. In contrast, the majority of aneurysms (71%) develop following grade 3 and 4 injuries, which account for only 36% of injuries. Grade 5 injuries (3%) rarely lead to pseudoaneurysm formation, as most patients undergo a surgical intervention.3

Almost all patients diagnosed with traumatic splenic pseudoaneurysm undergo visceral arteriography, which not only confirms the diagnosis but also provides a therapeutic option by transcatheter embolization with a 92% to 94% success rate.2,4A recently described treatment using balloon expandable or flexible self-expandable stent grafts may further improve the success of nonoperative management.5,6Unstable patients may be managed more safely in the operating room, although an increasing body of evidence suggests that transcatheter embolization can be safely used in this group of patients.2

As more and more splenic injuries are treated nonoperatively, it is important for both patients and physicians to be aware of this delayed complication of splenic trauma. Although a routine follow-up CT within 2 weeks after injury would increase the diagnosis of traumatic splenic pseudoaneurysms, it will be noncontributory in the vast majority of patients. Thus, the use of early repeat CT scanning in patients with splenic injury for the diagnosis of pseudoaneurysms should await further investigation.

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Article Information

Correspondence:Heidi Frankel, MD, Division of Burn/Trauma/Critical Care Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9158 (heidi.frankel@utsouthwestern.edu).

Accepted for Publication:November 17, 2005.

Author Contributions:Study concept and design: Frankel. Acquisition of data: Gave. Analysis and interpretation of data: Gave, Frangos, Frankel. Drafting of the manuscript: Gave, Frankel, Frangos. Critical revision of the manuscript for important intellectual content: Gave, Frangos, Frankel, Rabinovici. Study supervision: Frankel, Rabinovici.

Financial Disclosure:None reported.

References
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2.
Davis  KAFabian  TCroce  MA  et al.  Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998;441008- 1015
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Schurr  MJFabian  TCGavant  M  et al.  Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma 1995;39507- 513
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Cocanour  CSMoore  FAWare  DNMarvin  RGClark  MDuke  JH Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 1998;133619- 625
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Yoon  HKLindh  MUher  PLindblad  BIvancev  K Stent-graft repair of a splenic artery aneurysm. Cardiovasc Intervent Radiol 2001;24200- 203
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Brountzos  ENVagenas  KApostolopoulou  SCPanagiotou  ILymberopoulou  DKelekis  DA Pancreatitis-associated splenic artery pseudoaneurysm: endovascular treatment with self-expandable stent-grafts. Cardiovasc Intervent Radiol 2003;2688- 91
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