Figure 1. A) 64-slice CCTA (arrow). B) 3D reconstruction of CCTA (arrow). C) celiac trunk angiograp...

Figure 2. A) Tomographic segmentation. B) 3D printing of hepatic (black arrow) and gastroduodenal ar...

Figure 3. A) Cobra catheter positioned in an intraparenchymal branch of the spleen. B) Deploymentof ...

CASE REPORT

This is the case of a 66-year-old man with a past medical history of hypertension and the incidental finding of a splenic aneurysm on an abdominal computed tomography scan performed in the context of renal lithiasis. Anatomical evaluation was decided using percutaneous angiography and CCTA that revealed the presence of a giant 27/37 mm x 8 mm fusiform aneurysm located in the splenic hilum (Figure 1A and Figure B). The celiac trunk showed an anatomical variant consisting of right and left hepatic arteries (lack of common hepatic artery), left gastric artery, and gastroduodenal artery from the splenic artery (Figure 1C and Figure D). The size of the splenic artery before and after the aneurysm was between 8 mm and 10 mm according to the CT scan. Due to the anatomical complexity and for endovascular correction with a stent-graft, 3D printing was indicated based on a 64-slice CCTA with views < 1 mm (Figure 2A and Figure B). This strategy simulated the procedure in the cath lab before the definitive correction being the most appropriate angiographic projection for visualization and endovascular correction being the left anterior oblique and caudal at 40° and 20°, respectively. It also facilitated the proper selection (size and type) of the device that would eventually used (Figure 2C and Figure D).

RESOLUTION

The procedure was performed via a left radial access with a 5-Fr introducer sheath and placement of a multipurpose catheter in the abdominal aorta for control angiography. Also, via right femoral access with a 10-Fr introducer sheath to perform the procedure. Using the selected angiographic projection from 3D printing, a 5-Fr Cobra catheter mounted on a hydrophilic guidewire was placed into 1 intraparenchymal branch of the spleen after the aneurysm occurred (Figure 3A). This allowed the hydrophilic guide to be exchanged for a 0.035 in extra-support guidewire. Through the multipurpose catheter positioned in the abdominal aorta, an angiography was performed to confirm the correct position of the wire. A 8/60 mm self-expanding stent-graft (Fluency Plus®) was deployed that achieved aneurysm exclusion and splenic flow preservation (Figure 3B and Figure C). The patient progressed uneventfully and was discharged 48 hours after surgery. A follow-up CCTA 3 months after surgery confirmed aneurysm exclusion without contrast leakage (Figure 3D).

DISCUSSION

Splenic aneurysm is the third most common type of abdominal aneurysm followed by aortic and iliac aneurysms1. It amounts to 60% of all visceral aneurysms reported2. Approximately one-third of splenic aneurysms have a distal location in the artery3, and their size can be between 2 cm and 9 cm 4. They are asymptomatic in 97% of patients, making their detection incidental in imaging studies. In our case, the patient showed many of the characteristics described by the medical literature since the aneurysm was an incidental finding on the images, asymptomatic, and complex due to the anatomical variant of the celiac trunk, giant in size, and of distal location in the splenic hilum. Comprehensive understanding through imaging is crucial for successful treatment. 3D printing has been recognized and gradually added as a useful addition to the field of vascular and endovascular surgery5-7. The production of a patient-specific anatomical replica has a significant impact on the management of the patient in terms of anatomical understanding, procedural planning, endovascular navigation, and patient communication. 3D printing was extremely useful to plan aneurysm exclusion with a stenting. It allowed us to select proper guidewires, catheters, and determine the most suitable angiographic projection, thereby avoiding repeated angiographies, minimizing contrast volume, and reducing fluoroscopy time. In conclusion, 3D printing is an innovative tool to develop strategies and optimize interventional procedures, thus enabling successful treatment outcomes in complex patients.

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3. Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: Two decades’ experience at Mayo Clinic. Ann Vascular Surg 2002;16(4):442-9.

4. Al Jalbout N, Moreland AJ. Syncope in a middle-aged female: Splenic artery aneurysm revisited. Clinical Imaging 2018;52(2018):8-10.

5. Rocatello G, El Faquir N, De Santis G, et al. Patient-specific computer simulation to elucidate the role of contact pressure in the development of new conduction abnormalities after catheter-based implantation of a self-expanding aortic valve. Circ Cardiovasc Interv 2018 Feb;11(2):e005344

6. Wang DD, Eng M, Myers E, et al. Inferior and posterior: utilization of 3d print and computer aided design to spatially map optimal transseptal crossing point for left atrial appendage occlusion with the WATCHMAN device. J Am Coll Cardiol 2016;67(13 Supplement):323.

7. Alasnag M, Al-Shaibi K, Stankovic G. Computational Simulation, Bench Testing, and Modeling: Novel Tools to Strategize an Optimize Interventional Procedures. Curr Cardiovasc Imaging Rep 14, 3 (2021).

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Splenic complex aneurysm. Utility of 3D printing in endovascular interventional practice

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