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)
679
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).
679
In patients with noncomplicated RAA of acceptable operative risk, we suggest treatment for aneurysm size >3 cm. (2 – Weak, C)
679
We recommend emergent intervention for any size RAA resulting in patient symptoms or rupture. (1 – Strong, B)
679
In patients of childbearing potential with noncomplicated RAA of acceptable operative risk, we suggest treatment regardless of size. (2 – Weak, B)
679
In patients with medically refractory hypertension and functionally important renal artery stenosis, we suggest treatment regardless of size. (2 – Weak, C)
679
We suggest daily antiplatelet therapy (ie, aspirin, 81 mg) for patients with RAA. (2 – Weak, C)
679
We suggest daily antiplatelet therapy (ie, aspirin, 81 mg) for patients with RAA. (2 – Weak, B)
679
We suggest ex vivo repair and autotransplantation for complex distal branch aneurysms over nephrectomy when it is technically feasible. (2 – Weak, B)
679
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)
679
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)
679
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)
679
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)
679
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)
679
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)
679
Splenic artery aneurysm
We recommend computed tomography angiography as the initial diagnostic tool of choice for SAAs. (1 – Strong, C)
679
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)
679
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)
679
We recommend emergent intervention for ruptured SAAs. (1 – Strong, A)
679
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)
679
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)
679
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)
679
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)
679
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)
679
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)
679
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)
679
In treatment of SAA, we suggest that the splenic artery does not routinely require preservation or revascularization. (2 – Weak, C)
679
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)
679
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)
679
We suggest screening of patients with SAAs for other intra-abdominal, intrathoracic, intracranial, and peripheral artery aneurysms. (2 – Weak, B)
679
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)
679
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)
679
Celiac artery aneurysm
We suggest computed tomography angiography (CTA) as the initial diagnostic tool of choice for CAAs. (2 – Weak, B)
679
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)
679
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)
679
We recommend emergent intervention for ruptured CAAs. (1 – Strong, A)
679
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)
679
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)
679
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)
679
In patients with ruptured CAA discovered at laparotomy, we suggest ligation if sufficient collateral circulation to the liver can be documented. (2 – Weak, C)
679
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)
679
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)
679
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)
679
We suggest screening patients with CAAs for other arterial aneurysms. (2 – Weak, B)
679
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)
679
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)
679
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).
679
We recommend the use of catheter-based angiography for all emergent cases presenting with rupture, (1 – Strong, B)
679
and electively for preoperative planning, (1 – Strong, C)
679
We recommend treatment of all gastric artery and gastroepiploic artery aneurysms of any size. (1 – Strong, B)
679
We recommend endovascular embolization for firstline treatment of gastric artery and gastroepiploic artery aneurysms. (1 – Strong, B)
679
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, C)
679
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)
679
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)
679
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)
679
In patients with HAA who are considered for intervention, we recommend mesenteric angiography for preoperative planning. (1 – Strong, B)
679
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)
679
We recommend repair of all symptomatic HAAs regardless of size. (1 – Strong, A)
679
In asymptomatic patients without significant comorbidity, we recommend repair if true HAA is >2 cm, (1 – Strong, A)
679
or if aneurysm enlarges >0.5 cm/y, (1 – Strong, C)
679
In patients with significant comorbidities, we recommend repair if HAA is >5.0 cm. (1 – Strong, B)
679
We recommend repair of HAA in patients with vasculopathy or vasculitis, regardless of size, (1 – Strong, C)
679
We recommend repair in HAA patients with positive blood cultures, (1 – Strong, C)
679
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)
679
In patients with extrahepatic aneurysms, we recommend open and endovascular techniques to maintain liver circulation. (1 – Strong, A)
679
In patients with intrahepatic aneurysms, we recommend coil embolization of the affected artery, (1 – Strong, B)
679
In patients with large intrahepatic aneurysms, we recommend resection of the involved lobe of liver to avoid significant liver necrosis, (1 – Strong, C)
679
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)
679
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)
679
We suggest annual follow-up with CTA or noncontrast-enhanced computed tomography to observe patients with asymptomatic HAA. (2 – Weak, B)
679
Superior mesenteric artery aneurysm
In patients with SMAAs, we recommend computed tomography angiography (CTA) as the diagnostic tool of choice. (1 – Strong, B)
679
We recommend mesenteric angiography to delineate anatomy in preoperative planning for SMAA repair. (1 – Strong, B)
679
We recommend repair of all true SMAAs and pseudoaneurysms as soon as the diagnosis is made regardless of size. (1 – Strong, A)
679
We suggest careful observation of SMAA because of dissection unless refractory symptoms develop. (2 – Weak, B)
679
We recommend an endovascular-first approach to all SMAAs if it is anatomically feasible. (1 – Strong, B)
679
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)
679
We suggest annual CTA to observe postsurgical patients. (2 – Weak, B)
679
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)
679
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).
679
We recommend the use of catheter-based angiography for all emergent cases presenting with rupture, (1 – Strong, B)
679
and electively for preoperative planning, (1 – Strong, C)
679
We suggest screening all patients with jejunal, ileal, and colic artery aneurysms for vasculitis with routine inflammatory markers. (2 – Weak, C)
679
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)
679
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)
679
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)
679
We suggest endovascular embolization for cases of jejunal, ileal, and colic artery aneurysm. (2 – Weak, B)
679
We suggest medical treatment of nonruptured, asymptomatic ileal, jejunal, and colic artery aneurysms associated with polyarteritis nodosa. (2 – Weak, B)
679
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)
679
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)
679
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)
679
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)
679
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).
679
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)
679
In patients with intact and ruptured aneurysms, we recommend coil embolization as the treatment of choice. (1 – Strong, B)
679
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)
679
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)
679
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)
679
In patients with nonruptured aneurysms, we suggest open surgical reconstruction if needed to preserve flow. (2 – Weak, B)
679
In patients with concomitant stenosis or occlusion, we suggest celiac artery reconstruction. (2 – Weak, B)
679
In patients with median arcuate ligament syndrome, we suggest screening for GDAA or PDAA with CTA or duplex ultrasound. (2 – Weak, C)
679
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)
679
Recommendation Grading
Overview
Title
Management of Visceral Aneurysms
Authoring Organization
Society for Vascular Surgery
Publication Month/Year
March 19, 2020
Last Updated Month/Year
October 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
These Society for Vascular Surgery Clinical Practice Guidelines describe the care of patients with aneurysms of the visceral arteries. They include evidence-based size thresholds for repair of aneurysms of the renal arteries, splenic artery, celiac artery, and hepatic artery, among others. Specific open surgical and endovascular repair strategies are also discussed. They also describe specific circumstances in which aneurysms may be repaired at smaller sizes than these size thresholds, including in women of childbearing age and false aneurysms. These Guidelines offer important recommendations for the care of patients with aneurysms of the visceral arteries and long-awaited guidance for clinicians who treat these patients.
Target Patient Population
Patients with aneurysms of the visceral arteries
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