Selective use of electrolytic detachable and fiberedcoils to embolize a wide-neck giant splenic arterypseudoaneurysmRaymond K. Hung, MD,a Christopher Loh, MD,b and Leanelle Goldstein, MD,b San Jose, Calif

We report on a 55-year-old woman with recurrent chronic pancreatitis complicated by a 7-cm splenic artery pseudoan-eurysm. A therapeutic endovascular treatment was chosen because of the patient’s high surgical risk. Initial embolizationwith fibered coils succeeded in thrombosing the aneurysm lumen, but the aneurysm neck remained patent. Furtherembolization was achieved with two detachable Gugliemi Detachable Coils (GDCs) deployed across the aneurysm neck,successfully thrombosing the residual aneurysm. GDCs complement the more thrombogenic traditional fibered coils andshould be used advantageously in critical locations to embolize difficult splenic artery pseudoaneurysms. (J Vasc Surg

2005;41:889-92.)

Splenic artery aneurysms and pseudoaneurysms ac-count for 60% of all visceral aneurysms. Treatment optionsinclude surgery, and more recently, percutaneous methods.We describe the successful treatment of a giant splenicartery pseudoaneurysm using a combination of electrolyti-cally detached and fibered coils To our knowledge, there isno other case report describing the use of detachable coilsin combination with fibered coils to treat a wide-necksplenic artery pseudoaneurysm. Electrolytically detachablecoils, which are traditionally used in neurointerventionapplications, can be useful in peripheral endovascular appli-cations.

CASE REPORT

The patient was a 55-year-old woman who presentedwith abdominal pain. Her medical history is significant forchronic pancreatitis, esophageal and gastric varices, hepati-tis C, and alcohol abuse. On this admission, the patientnoted that her pain was similar to her prior exacerbations ofpancreatitis; however, she also noted the passage of darkstools. On admission, she was noted to be anemic with ahemoglobin count of 8.3, an elevated lipase level of 1796,and an amylase level of 212. Computed tomography (CT)examination showed a left upper quadrant pseudoaneu-rysm measuring approximately 4.5 � 7 � 7 cm, pancreaticcalcifications, multiple pseudocysts, and cavernous trans-formation of the portal vein (Fig 1, A and B). While in thehospital, she underwent endoscopy and colonoscopy thatconfirmed the varices but showed no site of active bleeding.A mesenteric angiogram confirmed the splenic artery pseu-doaneurysm in the distal portion of a tortuous splenic artery(Fig 2). Selective catheterization of the splenic artery was

From the Santa Clara Valley Medical Centera and the San Jose MedicalCenter.b

Competition of interest: none.Reprint requests: Raymond K. Hung, MD, Santa Clara Valley Medical

Center, 751 South Bascom Avenue, San Jose, California 95128 (e-mail:raymond.hung@hhs.co.santa-clara.ca.us).

0741-5214/$30.00Copyright © 2005 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2005.02.026

performed with a 5F Simmons 2 catheter (Torcon NBAdvantage, Cook Inc, Bloominton, IN). Because thesplenic artery was markedly tortuous, the distally locatedpseudoaneurysm could not be catheterized directly withthe 5F catheter. Irregularities of the splenic artery wereidentified and thought to be secondary to scarring from thepatient’s recurrent pancreatitis. Using a coaxial technique,and a 2.5F Renegade Microcatheter (Boston Scientific,Natick, MA), the pseudoaneurysm was selectively catheter-ized. An attempt to occlude the neck of the aneurysm wasperformed with a Tornado Embolization Microcoil (CookInc); however, because of the large neck of the pseudoan-eurysm, the coil dropped into the aneurysm sac. A decisionwas made to pack the aneurysm sac to induce thrombosis.To improve catheter stability, a 5F Simmons 3 catheter(Torcon NB Advantage) was used to select the splenicartery. A Renegade microcatheter was used to catheterizethe aneurysm sac. Twenty-one Nestor microcoils (CookInc) were packed into the aneurysm sac. As the coil packingprogressed, the visualization of the microcatheter tip waslimited because of the volume of coils. Control angiogra-phy to access aneurysm coil packing showed spasm of theaneurysm neck and residual filling of the proximal aneu-rysm. There was concern that further packing with thefibered MicroNestor microcoils would flip the catheter intothe parent splenic artery, resulting in a coil deposited in thesplenic artery. We elected at this point to stage the proce-dure; as neck vasospasm was encountered, it was postulatedthat with the introduced volume of coils there may bespontaneous thrombosis of the remaining aneurysm.

On angiographic reassessment 1 week later, continuedfilling of the proximal pseudoaneurysm was seen. Using acoaxial technique, a 2.5F Renegade microcatheter was in-troduced into the pseudoaneurysm. A single MicroNestorcoil was introduced into the proximal aspect of the pseu-doaneurysm. Control angiography through the microcath-eter showed persistent filling; however, the microcathetercould not be advanced into the filling portion of the pseu-doaneurysm because of the significant amount of coils.

Because of significant concern for coil migration into the

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JOURNAL OF VASCULAR SURGERYMay 2005890 Hung, Loh, and Goldstein

splenic artery and subsequent splenic infarction, GugliemiDetachable Coils (GDCs) were selected for coiling of theaneurysm neck. A three-dimensional GDC (Boston Scien-tific, Natick, MA) was introduced into the proximal neck ofthe pseudoaneurysm. Because the coil requires electrolyticdetachment, control angiography could be performed be-fore coil detachment to evaluate for parent artery prolapse

Fig 1. A, CT shows a large left peripancreatic 7-cm aneupseduocysts (large arrow).

Fig 2. Diagnostic splenic artery injection shows the neck of thegiant pseudoaneurysm (arrowhead).

of the coil. A second two-dimensional GDC was placed

more proximally in the neck, and a control angiogramshowed no filling of the pseudoaneurysm (Fig 3). Afterremoval of the microcatheter, angiography showed preser-vation of the native splenic artery and no further filling ofthe pseudoaneurysm.

After the embolization procedure, the patient had anuneventful recovery from pancreatitis. The initial present-ing symptoms of abdominal pain and hemosuccus pancre-atitis had completely resolved at the time of discharge fromthe hospital. A follow-up clinic visit and CT scan werescheduled, but the patient failed to meet her appointmentand was subsequently lost to further follow up.

DISCUSSION

Splenic artery aneurysms and pseudoaneurysms ac-count for 60% of all visceral aneurysms. Splenic arterypseudoaneurysms are thought to be most commonlycaused by pancreatitis and blunt trauma.1 The major risk ofsplenic artery aneurysms and pseudoaneurysms is massivehemorrhage and hemosuccus pancreatitis. Recent data sug-gest that the risk of hemorrhage ranges from 3% to 10%from splenic artery aneurysms, with the greatest risk in thelarger aneurysms.2 The reported rate of hemorrhage fromsplenic artery pseudoaneurysm is as high as 47%, of which58% are hemodynamically unstable at presentation.3

Surgical guidelines recommend resection of symptom-atic splenic artery aneurysms, asymptomatic aneurysmslarger than 2.0 cm, and all pseudoaneurysms to preventmassive hemorrhage.3 The surgical treatment is aneurysec-tomy with or without splenectomy depending on the loca-tion of the aneurysm relative to the splenic hilum. Themorbidity and mortality of surgical aneurysectomy are re-

. B, CT shows pancreatic calcifications (small arrow) and

rysm

ported to be roughly 10% and 1% to 2%, respectively.4

JOURNAL OF VASCULAR SURGERYVolume 41, Number 5 Hung, Loh, and Goldstein 891

Ligation of the pseudoaneurysm and repair of the splenicartery has been reported, but is associated with a 43% failurerate.3

More recently, percutaneous methods have been usedto treat splenic artery and other visceral pseudoaneurysms.Percutaneous transarterial embolization of splenic arterypseudoaneurysms using coils, detachable balloons, coveredstents, Gelfoam, and N-butyl cyanoacrylate has been de-scribed.5-8 Ultrasound-guided percutaneous needle place-ment into the pseudoaneurysm followed by injection ofthrombin into the pseudoaneurysm has been reported.9,10

Percutaneous covered stents are relatively new, butprovide a means of excluding the pseudoaneurysm whilepreserving flow to the splenic artery.5 In our case, the initialplans were to repair the artery with a self-expandingpolytetrafluoroethylene-covered stent, but after the initialangiogram it became evident that advancing a 7F catheterthrough the tortuous splenic artery was not feasible.

Embolization of the splenic artery distal and proximalto the aneurysm neck is a proven method for successfullytreating pseudoaneurysms provided the neck is in the prox-imal splenic artery.6 The preservation of the splenic tissue isdependent on retrograde collateral blood flow from shortgastric branches. In this patient, the aneurysm neck was inthe distal splenic artery, and hence proximal and distalembolization of the splenic artery would have likely re-sulted in significant ischemic injury to the spleen.6

Thrombin injection and N-butyl cyanoacrylate embo-lization has been successful in treating splenic arterypseudoaneurysms; however, these methods result in sacri-fice of some splenic tissue, and only treatment of muchsmaller aneurysms was discussed.7,9,10

We describe the successful treatment of a giant splenicartery pseudoaneurysm using a combination of detachableGDCs and fibered coils. To our knowledge, there is noother case report describing the use of detachable GDCs incombination with fibered coils to treat a wide-neck splenicartery pseudoaneurysm.

The GDC is an endovascular coil used primarily for thetreatment of intracranial aneurysms. The coil was first usedin people in 1990.11 The coil is made of platinum solderedto a steel pusher wire. Intra-aneurysmal thrombosis is pro-moted by the application of a low positive electric charge,which also detaches the coil from the steel pusher wirethrough a process of electrolysis. Because the coil can bedetached at a specific time, in contrast to the conventionalfibered push coils, if the coil is of an inappropriate size or isunstable in position when placed in an aneurysm, the coilcan be withdrawn into the delivery catheter and removedfrom the patient. The coils are available in a variety ofshapes and sizes. A two-dimensional coil consists of a singlehelix and is similar in configuration to the traditional fi-bered coil. A three-dimensional coil is a complex helix witha spherical configuration.

The metal coils placed in the pseudoaneurysm obscurethe aneurysm neck and splenic artery junction. BecauseGDCs can be retrieved and redeployed, we chose to place

two detachable GDCs in the neck of the pseudoaneurysm.

The GDC positions and stability were checked by angio-gram and fluoroscopy before electrolytic detachment. TheGDCs successfully completed the embolization withoutcompromising the native splenic artery. Fibered coils aremore thrombogenic than GDCs, and therefore should stillbe used initially to pack the body of the pseudoaneurysm.In addition, fibered coils are significantly less expensivethan GDCs.

CT examinations are used for follow up of the emboli-zation procedure. The recurrence of the aneurysms afterfibered-coil embolization has been reported to be as low as4%.12 The recurrence rate for intracranial aneurysmstreated solely with detachable coils has been reported to be14%.13 In this report, we anticipate recurrence of the aneu-rysm to be similar to the reported rate of recurrence usingfibered coils, based on our predominant use of fibered coils.The report shows the utility of GDC microcoils in a situa-tion in which coil stability is of critical concern. SelectiveGDC coiling in combination with fibered coils resulted in asuccessful embolization of a difficult-to-treat wide-neckgiant pseudoaneurysm. Thus, we believe that GDCs areuseful in critical locations and should be considered morefrequently in combination with traditional fibered coils.

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Fig 3. Postembolization splenic artery injection shows completethrombosis of the pseudoaneurysm. Note the precise placement ofthe GDCs within the large aneurysm neck (arrow).

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