Management of splenic artery aneurysms: The significance of portal and essential hypertension

Background: Splenic artery aneurysm(s) (SAA) are rare. But the incidence an d significance of SAA among patients with portal hypertension (PHTN), espec ially among those who undergo orthotopic liver transplantation (OLT), have not been clearly delineated. Study Design: An 11-year (February 1987 to June 1998) retrospective review of our experience with treated SAA. was performed. Patient characteristics, risk factors, clinical presentation, surgical management, aneurysm charact eristics, and patient outcomes were assessed. Patients were separated accor ding to a history of PHTN for analysis. Patients were also subdivided into ruptured versus elective presentations. Results: Thirty-four patients (22 in the PHTN group) were treated for SAA d uring the study period. Sixty-two percent (21 of 34) were women; the averag e age was 50.6 years. In patients without a history of PHTN (n = 12), essen tial hypertension was a significant risk factor (p < 0.001) for development of SAA. All patients underwent surgical treatment for SAA: resection with splenectomy (n = 23), ligation with splenectomy (n = 5), ligation of SAA on ly (n = 4), and vascular reconstruction (n = 2). The average size of all tr eated SAA was 4.8 +/- 2.6 cm, ranging from 1.5 to 12 cm. Operative mortalit y after SAA rupture (n = 15) was 40%, compared with zero mortality for elec tive SAA repair (n = 19, p < 0.005). Rupture of SAA was associated with a h igher mortality in patients with PHTN compared with patients without such h istory (56% versus 17%, respectively). After a mean followup period of 46 m onths, survival after rupture was 60% in contrast to 84% after elective rep air. The majority of our patients with a history of PHTN (20 of 22) has und ergone OLT, representing 0.46% of all OLT recipients (n = 4,374) during the study period. In four patients, SAA were repaired concurrently during tran splantation. Of the 7 patients presented with rupture of SAA after OLT, 6 p atients presented within 3 to 16 days postoperatively, with a median of 6 d ays and an overall mortality of 57%. Conclusions: Essential hypertension and PHTN appear to be significant risk factors for development of SAA. Rupture of SAA. is associated with a signif icant mortality, highest among patients with PHTN. Elective repair remains a safe and effective method of treatment. The significance of SAA is recogn ized among patients undergoing liver transplantation. A decision should be made to screen and electively treat SAA found in liver transplant patients, especially if the aneurysm is larger than 1.5 cm. Awareness of the increas ed rupture risk is crucial in management during the immediate posttransplan t period. (J Am Coll Surg 1999;189:483-490. (C) 1999 by the American Colleg e of Surgeons).