Splenic aneurysms were often treated surgically in the past, but they are difficult and risky, and some high-risk patients have difficulty tolerating them.
The following is a case of complex splenic aneurysm with severe hypersplenism treated with intervention and ablation.
The patient was 72 years old, had hepatitis C, cirrhosis, and hypersplenism for many years, and later discovered hepatocellular carcinoma and complex splenic aneurysm. Later, the patient received TACE treatment for hepatocellular carcinoma at a major hospital in Shenzhen, but the iodine oil deposition was poor, and intervention for hypersplenism and splenic aneurysm was not possible because the risk was too great. Only platelet transfusion and other supportive treatments were given. Later, the patient learned that our department had many years of experience and accumulated many cases in ablation treatment of hepatocellular carcinoma and hypersplenism, so she came to our department for treatment.
In June 2014, CT scan showed hypodensity in the right hepatic gallbladder with small dot-like high-density iodine oil deposits, which was changed after external interventional embolization, and an enlarged spleen with a splenic artery aneurysm.
CT scan showed hypodensity next to the gallbladder in the right liver with small dotted high-density iodine oil deposits, which is a change after external interventional embolization.
The hepatic tumor is adjacent to the gallbladder and intestine, and the splenic artery aneurysm is located medial to the spleen.
Enlargement of the spleen is seen.
Arteriogram showed thickened splenic artery, small hepatic artery, splenic artery steal syndrome, aneurysm of splenic artery and enlarged spleen.
June 2014 PSE was performed.
The microcatheter was crossed over the splenic artery aneurysm and a small amount of gelatin sponge was injected to embolize the splenic branch artery. A microspring coil was also released to embolize the splenic artery aneurysm.
TACE plus PSE was performed in July.
Microspring coils were released distal and proximal to the splenic artery aneurysm, respectively.
A right hepatic tumor staining was seen on imaging and TACE was performed at the same time.
The liver tumor was well deposited with iodine oil after intervention, but the aneurysm blood supply was still very rich. Enhanced CT revealed a thick splenic artery and a fine hepatic artery, suggesting the presence of splenic artery steal syndrome.
After interventional treatment, the liver tumor was well deposited with iodine oil, but the blood supply of the aneurysm was still very rich. Enhanced CT shows a thick splenic artery and a small hepatic artery, suggesting the presence of splenic artery steal syndrome.
A spring coil was seen distal and proximal to the splenic artery aneurysm.
The splenic artery aneurysm is visible as a spring coil both distally and proximally.
August 2014 Microwave ablation of hepatocellular carcinoma plus microwave ablation of the spleen was performed. See Microwave needle puncture of liver tumor and ablation treatment.
Microwave needle puncture of the spleen and ablation treatment. Multiple site puncture and multiple site ablation treatment.
Microwave needle puncture of the spleen with ablative treatment. Multiple site puncture and multiple site ablation treatment.
Microwave needle puncture of the spleen and ablation treatment. Multiple loci puncture with multiple loci ablation treatment.
September 2014 On review after ablation therapy, the spleen was seen as a low-density non-enhancing area as a post-ablation change, and the foci of enhancement at the top of the liver diaphragm were dilated vascular clusters due to portal hypertension.
September 2014: On review after ablation therapy, a low-density non-enhancing area was seen in the spleen as a post-ablation change, and a focal point of reinforcement in the right liver was a dilated vascular mass due to portal hypertension.
On review after ablation treatment, the spleen was seen as a low-density non-enhancing area as a post-ablation change, and the dilated portal veins were due to portal hypertension.
In September, the right liver tumor was basically ablated, but the splenic aneurysm was still significantly enhanced.
November 2014 The splenic artery aneurysm is still significantly enhanced, and the right liver tumor appears to have small patchy enhancement near the right branch of the portal vein, which is considered to be tumor remnant.
November 2014 The splenic aneurysm remains significantly enhanced and the right hepatic tumor near the right branch of the portal vein seems to show small patchy enhancement, considering tumor remnants.
November 2014 The spleen aneurysm is still significantly strengthened, and the right liver tumor seems to have small patchy enhancement near the right branch of the portal vein, so tumor remnants are considered.
TACE plus PSE was performed again in November. On imaging, small lamellar enhancement was seen medial to the right hepatic tumor, and the splenic artery aneurysm was obviously stained.
After TACE, the residual tumor in the right liver showed crescentic deposition of iodine oil, and microspring coils were placed in the proximal splenic artery to continue strengthening embolization.
December The residual tumor of the liver was again microwave ablated plus anhydrous alcohol injection.
The lesion was very close to the dilated right branch of the portal vein and the intestine, and microwave ablation was supplemented with anhydrous alcohol injection.
The spleen was also treated with another ablation.
Multi-point puncture and multi-point ablation of the spleen.
The spleen was treated with multiple punctures and multi-point ablation.
In January 2015, the liver tumor was not enhanced, suggesting complete tumor inactivation.
January 2015 On re-review, no enhancement of the liver tumor was seen, suggesting complete tumor inactivation.
January 2015 The spleen saw lamellar hypodensity as a post-ablation change, and the splenic artery aneurysm showed a hypodense non-enhancing area, suggesting satisfactory embolization.
Patient’s lowest preoperative: WBC 0.85*10<9/L; PLT 12*10<9/L; HB 74 g/l Highest postoperative: WBC 2.93*10<9/L; PLT 70*10<9/L; HB 90 g/l Patient required assistance to walk before surgery, was bedridden most of the time, was complicated by severe herpes zoster, and was in very poor general condition.
After surgery, he could walk on his own and basically take care of himself, and now he is eating and sleeping normally. He continues to be closely followed up.
Operative comments.
The patient had hepatocellular carcinoma, severe hypersplenism and complex splenic aneurysm, and was too old and frail to undergo surgical treatment because of herpes zoster, years of cirrhosis and portal hypertension. Interventional treatment was performed at an outside hospital but with poor results.
The patient’s treatment was extremely risky, and a small mistake in one step could lead to irreversible results, so every treatment was on thin ice.
After multiple steps of treatment, the hepatocellular carcinoma was finally completely inactivated, the hypersplenism was well corrected, and the splenic aneurysm was controlled. In the process of each treatment, the patient was given liver protection, immune system improvement, good diet and exercise, and through good communication such as comfort and encouragement, the patient, who was very pessimistic, regained confidence and courage to live, and finally the patient’s physical quality was gradually improved.
This case suggests that under the premise of good communication and mutual trust between doctor and patient, if the physician has rich experience and good technical level, even very difficult cases can be successfully treated.