Management of Visceral Aneurysms
Publication Date: March 19, 2020
Last Updated: March 14, 2022
RECOMMENDATIONS
Renal artery aneurysm
In patients who are thought to have RAAs, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
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In patients who are thought to have RAA and have increased radiation exposure risks or renal insufficiency, we recommend non-contrast-enhanced magnetic resonance angiography (MRA) to establish the diagnosis. (1 – Strong, C)
Technical remark: Non-contrast-enhanced MRA is best suited to children and women of childbearing potential or those who have contraindications to CTA or MRA contrast materials (ie, pregnancy, renal insufficiency, or gadolinium contrast material allergy).
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In patients with noncomplicated RAA of acceptable operative risk, we suggest treatment for aneurysm size >3 cm. (2 – Weak, C)
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We recommend emergent intervention for any size RAA resulting in patient symptoms or rupture. (1 – Strong, B)
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In patients of childbearing potential with noncomplicated RAA of acceptable operative risk, we suggest treatment regardless of size. (2 – Weak, B)
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In patients with medically refractory hypertension and functionally important renal artery stenosis, we suggest treatment regardless of size. (2 – Weak, C)
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We suggest daily antiplatelet therapy (ie, aspirin, 81 mg) for patients with RAA. (2 – Weak, C)
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We suggest daily antiplatelet therapy (ie, aspirin, 81 mg) for patients with RAA. (2 – Weak, B)
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We suggest ex vivo repair and autotransplantation for complex distal branch aneurysms over nephrectomy when it is technically feasible. (2 – Weak, B)
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We suggest endovascular techniques for the elective repair of anatomically appropriate RAAs to include stent graft exclusion of main RAAs in patients with poor operative risk and embolization of distal and parenchymal aneurysms. (2 – Weak, B)
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We suggest consideration of laparoscopic and robotic techniques as an interventional alternative based on institutional resources and surgeon experience with minimally invasive techniques. (2 – Weak, C)
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We suggest screening female patients of childbearing age with RAA for fibromuscular dysplasia with a focused history and one-time axial imaging study (ie, CTA or MRA) to assess for cerebrovascular, mesenteric, and iliac artery dysplasia. (2 – Weak, C)
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We suggest completion imaging after open surgical reconstruction for RAA, before hospital discharge, by way of axial imaging with CTA or MRA or arteriography in select cases, and long-term follow-up with surveillance imaging. (2 – Weak, C)
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For patients managed nonoperatively, we suggest annual surveillance imaging until two consecutive studies are stable; thereafter, surveillance imaging may be extended to every 2 to 3 years. (2 – Weak, B)
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We recommend the use of catheter-based angiography both for preoperative planning and to better delineate distal renal artery branches that may be inadequately assessed on conventional cross-sectional imaging. (1 – Strong, C)
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Splenic artery aneurysm
We recommend computed tomography angiography as the initial diagnostic tool of choice for SAAs. (1 – Strong, C)
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In patients with suspected SAAs and pre-existing renal insufficiency limiting the use of iodinated contrast material, we recommend magnetic resonance angiography to establish diagnosis. (1 – Strong, C)
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We recommend using arteriography when noninvasive studies have not sufficiently demonstrated the status of relevant collateral blood flow and when endovascular intervention is planned. (1 – Strong, B)
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We recommend emergent intervention for ruptured SAAs. (1 – Strong, A)
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We recommend treatment of nonruptured splenic artery pseudoaneurysms of any size in patients of acceptable risk because of the possibility of rupture. (1 – Strong, B)
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We recommend treating nonruptured splenic artery true aneurysms of any size in women of childbearing age because of the risk of rupture. (1 – Strong, B)
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We recommend treating nonruptured splenic artery true aneurysms >3 cm, with a demonstrable increase in size, or with associated symptoms in patients of acceptable risk because of the risk of rupture. (1 – Strong, C)
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We suggest observation over repair for small (<3 cm), stable asymptomatic splenic artery true aneurysms or those in patients with significant medical comorbidities or limited life expectancies. (2 – Weak, C)
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In patients with ruptured SAA discovered at laparotomy, we suggest treatment with ligation with or without splenectomy, depending on the aneurysm location. (2 – Weak, B)
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In patients with ruptured SAA diagnosed on preoperative imaging studies, we suggest treatment with open surgical or appropriate endovascular techniques based on the patient’s anatomy and underlying clinical condition. (2 – Weak, B)
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We suggest elective treatment of SAA using an endovascular approach if it is anatomically feasible. However, elective treatment may appropriately involve open surgical, endovascular, or laparoscopic methods of intervention, depending on the patient’s anatomy and underlying clinical condition. (2 – Weak, B)
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In treatment of SAA, we suggest that the splenic artery does not routinely require preservation or revascularization. (2 – Weak, C)
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In treatment of distal SAA adjacent to the hilum of the spleen, we suggest open surgical techniques including possible splenectomy as opposed to endovascular methods, given concern for the possibility of endorgan ischemia, including splenic infarction and pancreatitis. (2 – Weak, C)
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In pregnant women with SAA, treatment decisions should be individualized regardless of size, and the potential morbidity to both the mother and fetus should be considered. (G-U, U)
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We suggest screening of patients with SAAs for other intra-abdominal, intrathoracic, intracranial, and peripheral artery aneurysms. (2 – Weak, B)
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In patients in whom an SAA is being observed with a nonoperative or noninterventional approach, we suggest annual surveillance with computed tomography or ultrasound to assess for growth in size. (2 – Weak, B)
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After endovascular intervention for SAAs, we suggest periodic surveillance with computed tomography angiography, ultrasound, or magnetic resonance angiography to assess for the possibility of endoleak or other continued aneurysm perfusion that could lead to a continued risk of aneurysm growth or rupture. (2 – Weak, B)
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Celiac artery aneurysm
We suggest computed tomography angiography (CTA) as the initial diagnostic tool of choice for CAAs. (2 – Weak, B)
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We suggest magnetic resonance angiography in patients with suspected CAA and pre-existing renal insufficiency limiting the use of iodinated contrast material. (2 – Weak, B)
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We suggest arteriography when noninvasive studies have not sufficiently demonstrated the status of relevant collateral blood flow or when endovascular intervention is planned. (2 – Weak, C)
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We recommend emergent intervention for ruptured CAAs. (1 – Strong, A)
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We recommend treatment of nonruptured celiac artery pseudoaneurysms of any size in patients of acceptable operative risk because of the possibility of rupture. (1 – Strong, B)
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We recommend treatment of nonruptured celiac artery true aneurysms >2 cm, with a demonstrable increase in size, or with associated symptoms in patients of acceptable risk because of the risk of rupture. (1 – Strong, C)
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We suggest observation over intervention for small (<2 cm), stable asymptomatic CAAs or those in patients with significant medical comorbidities or limited life expectancy. (2 – Weak, C)
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In patients with ruptured CAA discovered at laparotomy, we suggest ligation if sufficient collateral circulation to the liver can be documented. (2 – Weak, C)
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In patients with ruptured CAA diagnosed on preoperative imaging studies who are stable, we recommend treatment with open surgical or appropriate endovascular methods based on the patient’s anatomy and underlying clinical condition. (1 – Strong, B)
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For the elective treatment of CAA, we suggest using an endovascular intervention if it is anatomically feasible. However, elective treatment may appropriately involve open surgical, endovascular, or laparoscopic methods of intervention, depending on the patient’s anatomy and underlying clinical condition. (2 – Weak, B)
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To determine the need for revascularization of the celiac artery and its branches in treating CAA, we suggest evaluating the status of the superior mesenteric artery, gastroduodenal artery, and other relevant collateral circulation, which must be carefully documented on preoperative CTA or angiography. (2 – Weak, B)
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We suggest screening patients with CAAs for other arterial aneurysms. (2 – Weak, B)
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In patients in whom a CAA is being observed with a nonoperative or non-interventional approach, we suggest annual surveillance with CTA scans to assess for growth in size. (2 – Weak, B)
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After endovascular intervention for CAAs, we suggest periodic surveillance with appropriate imaging studies to assess for the possibility of endoleak or aneurysm reperfusion that could lead to a continued risk of aneurysm growth or rupture. (2 – Weak, B)
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Gastric and gastroepiploic artery aneurysms
In patients who are thought to have gastric and gastroepiploic artery aneurysms and have high radiation exposure risks or renal insufficiency, we recommend non-contrast-enhanced magnetic resonance angiography (MRA) for diagnosis. (1 – Strong, C)
Technical remark: Non-contrast-enhanced MRA is best suited to children and women of childbearing potential or those who have contraindications to CTA or MRA contrast materials (ie, pregnancy, renal insufficiency, or gadolinium contrast material allergy).
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We recommend the use of catheter-based angiography for all emergent cases presenting with rupture, (1 – Strong, B)
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and electively for preoperative planning, (1 – Strong, C)
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We recommend treatment of all gastric artery and gastroepiploic artery aneurysms of any size. (1 – Strong, B)
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We recommend endovascular embolization for firstline treatment of gastric artery and gastroepiploic artery aneurysms. (1 – Strong, B)
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We suggest abdominal axial imaging to screen for concomitant abdominal aneurysms. (2 – Weak, B)
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We suggest one-time screening CTA (or MRA) of the head, neck, and chest for those patients with segmental arterial mediolysis. (2 – Weak, C)
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We suggest interval surveillance (ie, every 12- 24 months) with axial imaging (ie, CTA or MRA) in cases of segmental medial arteriolysis in light of reported cases of rapid arterial transformation. (2 – Weak, B)
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We suggest postembolization surveillance every 1 to 2 years with axial imaging to assess for vascular remodeling and evidence of aneurysm reperfusion. (2 – Weak, C)
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Hepatic artery aneurysm
In patients who are thought to have HAA, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
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In patients with HAA who are considered for intervention, we recommend mesenteric angiography for preoperative planning. (1 – Strong, B)
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Given the high propensity of rupture and significant antecedent mortality, we recommend that all hepatic artery pseudoaneurysms, regardless of cause, be repaired as soon as the diagnosis is made. (1 – Strong, A)
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We recommend repair of all symptomatic HAAs regardless of size. (1 – Strong, A)
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In asymptomatic patients without significant comorbidity, we recommend repair if true HAA is >2 cm, (1 – Strong, A)
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or if aneurysm enlarges >0.5 cm/y, (1 – Strong, C)
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In patients with significant comorbidities, we recommend repair if HAA is >5.0 cm. (1 – Strong, B)
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We recommend repair of HAA in patients with vasculopathy or vasculitis, regardless of size, (1 – Strong, C)
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We recommend repair in HAA patients with positive blood cultures, (1 – Strong, C)
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We recommend an endovascular-first approach to all HAAs if it is anatomically feasible (ie, if this approach maintains arterial circulation to the liver). (1 – Strong, A)
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In patients with extrahepatic aneurysms, we recommend open and endovascular techniques to maintain liver circulation. (1 – Strong, A)
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In patients with intrahepatic aneurysms, we recommend coil embolization of the affected artery, (1 – Strong, B)
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In patients with large intrahepatic aneurysms, we recommend resection of the involved lobe of liver to avoid significant liver necrosis, (1 – Strong, C)
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We suggest abdominal axial imaging to screen for concomitant intra-abdominal aneurysms in patients who did not have CTA at the time of HAA diagnosis. (2 – Weak, B)
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We suggest one-time screening CTA or magnetic resonance angiography of the head, neck, and chest for those patients with nonatherosclerotic causes of HAA. (2 – Weak, B)
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We suggest annual follow-up with CTA or noncontrast-enhanced computed tomography to observe patients with asymptomatic HAA. (2 – Weak, B)
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Superior mesenteric artery aneurysm
In patients with SMAAs, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
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We recommend mesenteric angiography to delineate anatomy in preoperative planning for SMAA repair. (1 – Strong, B)
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We recommend repair of all true SMAAs and pseudoaneurysms as soon as the diagnosis is made regardless of size. (1 – Strong, A)
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We suggest careful observation of SMAA because of dissection unless refractory symptoms develop. (2 – Weak, B)
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We recommend an endovascular-first approach to all SMAAs if it is anatomically feasible. (1 – Strong, B)
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We suggest abdominal axial imaging to screen for concomitant intra-abdominal aneurysms in patients who did not have CTA at the time of diagnosis. (2 – Weak, B)
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We suggest annual CTA to observe postsurgical patients. (2 – Weak, B)
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Jejunal, ileal, and colic artery aneurysms
In patients who are thought to have jejunal artery, ileal artery, and colic artery aneurysms, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
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In patients with high radiation exposure risks or renal insufficiency, we recommend non-contrastenhanced magnetic resonance angiography (MRA) for diagnosis. (1 – Strong, C)
Technical remark: Non-contrast-enhanced MRA is best suited to children and women of childbearing potential or those who have contraindications to CTA or MRA contrast materials (ie, pregnancy, renal insufficiency, or gadolinium contrast material allergy).
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We recommend the use of catheter-based angiography for all emergent cases presenting with rupture, (1 – Strong, B)
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and electively for preoperative planning, (1 – Strong, C)
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We suggest screening all patients with jejunal, ileal, and colic artery aneurysms for vasculitis with routine inflammatory markers. (2 – Weak, C)
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We recommend elective intervention for jejunal and ileal artery aneurysms >2 cm in maximal diameter and for all colic artery aneurysms, any size. (1 – Strong, B)
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We recommend emergent intervention for any jejunal, ileal, or colic artery aneurysm, any size, resulting in patient symptoms or rupture and all mesenteric branch vessel pseudoaneurysms. (1 – Strong, A)
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We suggest open surgical ligation or aneurysm excision for cases of jejunal, ileal, and colic artery aneurysms when laparotomy is being considered for hematoma evacuation or bowel assessment for viability. (2 – Weak, B)
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We suggest endovascular embolization for cases of jejunal, ileal, and colic artery aneurysm. (2 – Weak, B)
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We suggest medical treatment of nonruptured, asymptomatic ileal, jejunal, and colic artery aneurysms associated with polyarteritis nodosa. (2 – Weak, B)
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We suggest abdominal axial imaging to screen for concomitant abdominal aneurysms. (2 – Weak, B)
679
We suggest one-time screening CTA (or MRA) of the head, neck, and chest for those patients with segmental arterial mediolysis. (2 – Weak, B)
679
We suggest interval surveillance (ie, every 12- 24 months) with axial imaging (ie, CTA or MRA) for cases of segmental medial arteriolysis in light of reported cases of rapid arterial transformation and to monitor regression in cases of polyarteritis nodosa. (2 – Weak, B)
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We suggest postembolization surveillance every 1 to 2 years with axial imaging to assess for vascular remodeling and evidence of aneurysm reperfusion. (2 – Weak, B)
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Pancreaticoduodenal artery aneurysm (PDAA) and gastroduodenal artery aneurysm
In patients who are thought to have GDAA and PDAA, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
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In patients in whom celiac stenosis is suspected, we suggest further workup with duplex ultrasound to elucidate whether the stenosis is hemodynamically significant. (2 – Weak, C)
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In patients with high radiation exposure risks or renal insufficiency, we suggest non-contrast-enhanced magnetic resonance angiography (MRA) for diagnosis. (2 – Weak, C)
Technical remark: Non-contrast-enhanced MRA is best suited to children and women of childbearing potential or those who have contraindications to CTA or MRA contrast materials (ie, pregnancy, renal insufficiency, or gadolinium contrast material allergy).
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In patients with noncomplicated GDAA and PDAA of acceptable operative risk, we recommend treatment no matter the size of the aneurysm because of the risk of rupture. (1 – Strong, B)
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In patients with intact and ruptured aneurysms, we recommend coil embolization as the treatment of choice. (1 – Strong, B)
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In patients in whom coil embolization is not feasible, we suggest covered stenting or stent-assisted coil embolization as a treatment option in select cases of GDAA and PDAA. (2 – Weak, C)
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In patients with appropriate anatomy, we suggest transcatheter embolization with liquid embolic agents as a treatment option for both GDAA and PDAA. (2 – Weak, C)
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In patients with suitable anatomy, we suggest flowdiverting, multilayered stents as a treatment option for GDAA and PDAA, although these have not been adequately studied to be recommended as a primary treatment modality. (2 – Weak, C)
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In patients with nonruptured aneurysms, we suggest open surgical reconstruction if needed to preserve flow. (2 – Weak, B)
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In patients with concomitant stenosis or occlusion, we suggest celiac artery reconstruction. (2 – Weak, B)
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In patients with median arcuate ligament syndrome, we suggest screening for GDAA or PDAA with CTA or duplex ultrasound. (2 – Weak, C)
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In patients status post treatment of GDAA and PDAA, we recommend follow-up imaging after endovascular treatment of GDAA and PDAA to rule out persistent flow through the aneurysm sac. (1 – Strong, B)
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Recommendation Grading
Overview
Title
Management of Visceral Aneurysms
Authoring Organization
Society for Vascular Surgery
Publication Month/Year
March 19, 2020
Last Updated Month/Year
August 30, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant, social worker, surgical technologist
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D000783 - Aneurysm, D017542 - Aneurysm, Ruptured
Keywords
Splenic artery aneurysm, celiac artery aneurysm, Vascular surgery, Visceral aneurysms, Gastric and gastroepiploic artery aneurysms, Hepatic artery aneurysms, Superior mesentric artery aneurysm , Renal artery aneurysm, Distal parenchymal
Source Citation
Chaer RA, Abularrage CJ, Coleman DM, Eslami MH, Kashyap VS, Rockman C, Murad MH. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg. 2020 Jul;72(1S):3S-39S. doi: 10.1016/j.jvs.2020.01.039. Epub 2020 Mar 20. PMID: 32201007.
Supplemental Methodology Resources
Methodology
Number of Source Documents
240
Literature Search Start Date
January 1, 1980
Literature Search End Date
March 27, 2017
Specialties Involved
Cardiology, Emergency Medicine, Vascular Surgery, Interventional Cardiology, Cardiology