Part 4/Chapter 28/7-min read

Visceral, Renal, and Splanchnic Artery Aneurysms

Visceral, renal, and splanchnic artery aneurysms require territory-specific decisions because rupture risk, pregnancy and transplant context, branch preservation, renal-function preservation, and post-treatment surveillance differ by vessel and pathology.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·7 sections · 33 references

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Planning conference: A practical planning-room conversation: anatomy, device or operative choices, surveillance, complications, and decision boundaries.

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Definition and clinical presentation

Visceral, renal, and splanchnic artery aneurysms represent an uncommon and heterogeneous group of lesions. Management relies on territory-specific criteria rather than universal diameter thresholds . Clinical assessment first classifies the lesion pathology, which dictates the rupture risk and treatment urgency:

  • True aneurysms: managed according to anatomical territory, symptoms, growth rate, and patient context .
  • Pseudoaneurysms: typically arise secondary to pancreatitis, trauma, or instrumentation; the lack of an intact arterial wall necessitates expedited treatment .
  • Infective native aneurysms: characterized by progressive arterial wall destruction with rupture risk independent of size; management requires urgent source control, antimicrobial therapy, and rapid anatomic exclusion rather than elective surveillance .

Imaging and surveillance

Diagnostic and surveillance imaging is tailored to the anatomic territory and intervention type . Contrast-enhanced computed tomography angiography is the primary diagnostic and operative planning modality. It identifies the artery of origin, sac morphology, thrombus, calcification, branch relationships, and collateral pathways required to determine whether exclusion alone is safe . Magnetic resonance angiography is utilized when iodinated contrast is contraindicated, cumulative radiation in younger patients is a concern, or metallic coil artifact renders computed tomography less reliable .

Catheter angiography provides dynamic collateral and flow assessment and is reserved for intraprocedural navigation or same-session treatment. Doppler ultrasound serves as an adjunctive follow-up tool for selected renal or splenic aneurysms but is operator-dependent and limited by body habitus .

Post-treatment surveillance monitors for specific failure modes such as residual sac perfusion, reperfusion through collaterals, endoleak, branch compromise, or graft occlusion. Surveillance intervals and modalities are protocolised at the time of intervention based on the repair type and territory .

Treatment selection and modalities

Treatment strategy is guided by the involved artery, lesion pathology, and the functional consequences of parent-vessel or branch sacrifice . Elective intervention decisions balance procedural risk against organ preservation. Size thresholds are territory-specific (SVS 2020): splenic and renal aneurysms are repaired at 3 cm or larger, or at any size in a woman of childbearing potential; celiac and hepatic aneurysms at 2 cm or larger; and superior mesenteric, gastroduodenal, and pancreaticoduodenal aneurysms at any size, given their high rupture risk. Every pseudoaneurysm is repaired regardless of size.

Visceral aneurysm management pathways

  • Asymptomatic true aneurysm

    Modifier or pathology
    Below the territory threshold (splenic/renal 3 cm; celiac/hepatic 2 cm)
    Preferred action
    Continued interval surveillance
    Citation

  • Pseudoaneurysm

    Modifier or pathology
    History of trauma, pancreatitis, or instrumentation
    Preferred action
    Expedited anatomic exclusion
    Citation

  • Symptomatic or ruptured aneurysm

    Modifier or pathology
    Pain, rupture, or hemodynamic instability
    Preferred action
    Emergency exclusion, endovascular if feasible and open if not
    Citation

  • Infective native aneurysm

    Modifier or pathology
    Suspected arterial infection
    Preferred action
    Urgent source control, antimicrobials, and anatomic exclusion
    Citation

  • Splenic artery aneurysm

    Modifier or pathology
    Pregnancy or childbearing potential
    Preferred action
    Expedited definitive treatment to prevent catastrophic rupture
    Citation

  • Favorable true aneurysm

    Modifier or pathology
    Adequate landing zones, dispensable branches, or adequate collaterals
    Preferred action
    Endovascular embolization or covered stenting
    Citation

  • Complex or hilar aneurysm

    Modifier or pathology
    Branch preservation mandatory
    Preferred action
    Open reconstruction, ex situ repair, or autotransplantation
    Citation

The decision sequence for visceral and renal aneurysm intervention follows an ordered anatomical assessment:

  1. The lesion is classified as a true aneurysm, pseudoaneurysm, or infective aneurysm to determine intervention urgency.
  2. Patient-specific rupture risks are evaluated, explicitly identifying pregnancy, childbearing potential, cirrhosis, or liver transplant candidacy.
  3. The parent artery is identified, and all dependent end-organ and collateral perfusion pathways are mapped.
  4. The necessary treatment endpoint is defined as simple aneurysm occlusion, parent vessel preservation, or complex branch reconstruction.
  5. Endovascular therapy is selected for anatomically suitable lesions where embolization or stenting maintains adequate organ perfusion.
  6. Open reconstruction, ex situ repair, or minimally invasive surgical techniques are selected when branch preservation is mandatory but endovascular options are anatomically inadequate.

Renal artery aneurysms

Renal artery aneurysm intervention is indicated to prevent rupture while preserving functional renal parenchyma; repair is warranted at 3 cm or larger, at any size in a woman of childbearing potential, and for every pseudoaneurysm (SVS 2020). The anatomic relationship between the aneurysm sac and the renal bifurcation or segmental branches dictates the repair strategy . Discrete main renal artery aneurysms with adequate landing zones are managed with covered stents or coil-assisted endovascular exclusion. Aneurysms involving the branch points or hilum generally require surgical reconstruction to protect two or more segmental arteries.

Open in situ repair is standard for accessible branch reconstructions. Ex situ repair utilizing bench reconstruction and autotransplantation is reserved for complex hilar disease where prolonged in situ warm ischemia times would compromise renal survival . Robotic and laparoscopic approaches provide minimally invasive alternatives for selected patients but rely heavily on specialized center expertise and must match the ischemic control of open techniques . Baseline renal function, blood pressure parameters, and post-procedural renal outcomes are recorded to directly evaluate the functional success of exclusion .

Splenic artery aneurysms

Splenic artery aneurysms pose specific rupture hazards dictated by patient context; repair is warranted at 3 cm or larger, at any size in pregnancy or childbearing potential, and for every pseudoaneurysm (SVS 2020). Pregnancy or childbearing potential drastically alters the tolerance for observation, as rupture during pregnancy causes catastrophic maternal and fetal mortality and mandates expedited definitive treatment . Cirrhosis, portal hypertension, and liver-transplant candidacy elevate treatment risk and alter hemodynamics, requiring tailored intervention planning .

Endovascular embolization utilizing coils or plugs is the preferred treatment for proximal or mid-splenic artery aneurysms. It relies on collateral perfusion from the short gastric and gastroepiploic arteries to maintain splenic viability . Covered stents are utilized when parent-vessel preservation is desirable and anatomy allows . Distal or hilar aneurysms present a higher risk of splenic infarction with endovascular occlusion; these are managed with laparoscopic, robotic, or open techniques including ligation, aneurysmectomy, or splenectomy . Following endovascular embolization, clinical management anticipates post-embolization pain, focal splenic infarction, occasional splenic abscess, and the requirement for surveillance imaging to monitor persistent sac filling.

Other splanchnic aneurysms

Treatment endpoints for superior mesenteric, hepatic, and celiac aneurysms depend entirely on the specific organ perfusion at risk. Celiac and hepatic aneurysms are repaired at 2 cm or larger, while superior mesenteric, gastroduodenal, and pancreaticoduodenal aneurysms are repaired at any size because of their high rupture risk (SVS 2020). Superior mesenteric artery aneurysms jeopardize bowel perfusion; embolization that sacrifices the main trunk or major jejunal branches is avoided in favor of branch-preserving covered stents or open reconstruction . Hepatic artery aneurysm management distinguishes between intrahepatic and extrahepatic disease, assessing whether arterial inflow must be reconstructed or if collateral flow is sufficient. Celiac trunk aneurysms require a defined collateral plan before complete exclusion, as interruption may compromise hepatic, gastric, splenic, or pancreatic perfusion; branch-preserving techniques are favored in suitable candidates .

Gastroduodenal and pancreaticoduodenal artery aneurysms are frequently associated with celiac artery stenosis or median arcuate ligament compression, creating high-flow collateral pathways . Endovascular embolization requires control of both inflow and outflow vessels to prevent persistent retrograde collateral flow from driving the aneurysm or causing recurrence.

Areas of controversy

The role and timing of concurrent median arcuate ligament release during the treatment of gastroduodenal and pancreaticoduodenal artery aneurysms remains unsettled . The comparative long-term superiority of robotic and laparoscopic techniques versus traditional open bench reconstruction for complex hilar renal aneurysms is not definitively established . Additionally, the long-term durability and safety of endovascular exclusion versus open surgical debridement as the definitive treatment for infective native visceral artery aneurysms remains a subject of debate .

References

  1. 1.
    The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. 2020.
    PubMed-indexed articleClinical practice guideline2020

    The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. 2020. doi:10.1016/j.jvs.2020.01.039.

    PubMedDOI
  2. 2.
    CIRSE Standards of Practice on Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms. 2024.
    DOI publisher routeClinical practice guideline2024

    CIRSE Standards of Practice on Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms. 2024. doi:10.1007/s00270-023-03620-w.

    DOI
  3. 3.
    Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment. Current treatment options in cardiovascular medicine. 2018.
    PubMed-indexed articleReview2018

    Visceral Artery Aneurysms: Diagnosis, Surveillance, and Treatment. Current treatment options in cardiovascular medicine. 2018. doi:10.1007/s11936-018-0696-x.

    PubMedDOI
  4. 4.
    Visceral artery aneurysm rupture. Journal of vascular surgery. 2001.
    PubMed-indexed article2001

    Visceral artery aneurysm rupture. Journal of vascular surgery. 2001. doi:10.1067/mva.2001.112320.

    PubMedDOI
  5. 5.
    Infective native visceral artery aneurysm (INVAA): A systematic review of etiology, treatment, and outcomes. Vascular medicine (London, England). 2025.
    PubMed-indexed articleMeta-analysis / systematic review2025

    Infective native visceral artery aneurysm (INVAA): A systematic review of etiology, treatment, and outcomes. Vascular medicine (London, England). 2025. doi:10.1177/1358863x251326537.

    PubMedDOI
  6. 6.
    ACR Appropriateness Criteria® Suspected and Known Renal or Splanchnic Artery Aneurysm. Journal of the American College of Radiology : JACR. 2026.
    PubMed-indexed articleClinical practice guideline2026

    ACR Appropriateness Criteria® Suspected and Known Renal or Splanchnic Artery Aneurysm. Journal of the American College of Radiology : JACR. 2026. doi:10.1016/j.jacr.2026.02.030.

    PubMedDOI
  7. 7.
    Follow-up of true visceral artery aneurysm after coil embolization by three-dimensional contrast-enhanced MR angiography. Diagnostic and interventional radiology (Ankara, Turkey). 2014.
    PubMed-indexed article2014

    Follow-up of true visceral artery aneurysm after coil embolization by three-dimensional contrast-enhanced MR angiography. Diagnostic and interventional radiology (Ankara, Turkey). 2014. doi:10.5152/dir.2013.13236.

    PubMedDOI
  8. 8.
    Imaging modalities used in follow-up after coil embolization of splenic artery aneurysm - a systematic review. Polish journal of radiology. 2025.
    PubMed-indexed articleMeta-analysis / systematic review2025

    Imaging modalities used in follow-up after coil embolization of splenic artery aneurysm - a systematic review. Polish journal of radiology. 2025. doi:10.5114/pjr/203730.

    PubMedDOI
  9. 9.
    Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography. Journal of clinical medicine. 2023.
    PubMed-indexed article2023

    Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography. Journal of clinical medicine. 2023. doi:10.3390/jcm12030792.

    PubMedDOI
  10. 10.
    Splenic artery aneurysm rupture: a rare but fatal cause for peripartum collapse. Journal of intensive care medicine. 2013.
    PubMed-indexed article2013

    Splenic artery aneurysm rupture: a rare but fatal cause for peripartum collapse. Journal of intensive care medicine. 2013. doi:10.1177/0885066612444257.

    PubMedDOI
  11. 11.
    Splenic artery aneurysm in pregnancy: A systematic review. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2023.
    PubMed-indexed articleMeta-analysis / systematic review2023

    Splenic artery aneurysm in pregnancy: A systematic review. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2023. doi:10.1002/ijgo.14278.

    PubMedDOI
  12. 12.
    Results of Surgical Repair of Hilar Renal Artery Aneurysm to Preserve Renal Blood Flow. Annals of vascular diseases. 2020.
    PubMed-indexed article2020

    Results of Surgical Repair of Hilar Renal Artery Aneurysm to Preserve Renal Blood Flow. Annals of vascular diseases. 2020. doi:10.3400/avd.oa.20-00020.

    PubMedDOI
  13. 13.
    Autotransplantation or In Situ Surgical Treatment of Complex Renal Artery Aneurysm: Surgical Technique and Outcomes. European urology open science. 2024.
    PubMed-indexed article2024

    Autotransplantation or In Situ Surgical Treatment of Complex Renal Artery Aneurysm: Surgical Technique and Outcomes. European urology open science. 2024. doi:10.1016/j.euros.2024.03.007.

    PubMedDOI
  14. 14.
    Reconstruction for renal artery aneurysm: operative techniques and long-term results. Journal of vascular surgery. 2003.
    PubMed-indexed article2003

    Reconstruction for renal artery aneurysm: operative techniques and long-term results. Journal of vascular surgery. 2003. doi:10.1067/mva.2003.117.

    PubMedDOI
  15. 15.
    Endovascular interventions in management of renal artery aneurysm. The British journal of radiology. 2021.
    PubMed-indexed article2021

    Endovascular interventions in management of renal artery aneurysm. The British journal of radiology. 2021. doi:10.1259/bjr.20201151.

    PubMedDOI
  16. 16.
    Kidney Autotransplantation for Renal Artery Aneurysm: Case Series and a Systematic Review. Annals of vascular surgery. 2021.
    PubMed-indexed articleMeta-analysis / systematic review2021

    Kidney Autotransplantation for Renal Artery Aneurysm: Case Series and a Systematic Review. Annals of vascular surgery. 2021. doi:10.1016/j.avsg.2021.05.039.

    PubMedDOI
  17. 17.
    Treatment of Renal Artery Aneurysm by ex situ Repair and Autotransplantation: A Nationwide Cohort Study. European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes. 2024.
    PubMed-indexed articleRegistry / cohort2024

    Treatment of Renal Artery Aneurysm by ex situ Repair and Autotransplantation: A Nationwide Cohort Study. European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes. 2024. doi:10.1159/000541814.

    PubMedDOI
  18. 18.
    Robotic Renal Artery Aneurysm Repair. European urology. 2020.
    PubMed-indexed article2020

    Robotic Renal Artery Aneurysm Repair. European urology. 2020. doi:10.1016/j.eururo.2019.06.003.

    PubMedDOI
  19. 19.
    The rise of the machines: are robots the future of renal artery aneurysm repair? A systematic review. Updates in surgery. 2024.
    PubMed-indexed articleMeta-analysis / systematic review2024

    The rise of the machines: are robots the future of renal artery aneurysm repair? A systematic review. Updates in surgery. 2024. doi:10.1007/s13304-024-01971-8.

    PubMedDOI
  20. 20.
    Robotic Surgery for Visceral and Renal Artery Aneurysms: A Systematic Review. 2024.
    DOI publisher routeMeta-analysis / systematic review2024

    Robotic Surgery for Visceral and Renal Artery Aneurysms: A Systematic Review. 2024. doi:10.3390/jcm13123385.

    DOI
  21. 21.
    Outcomes of endovascular, open surgical and autotransplantation techniques for renal artery aneurysm repair: a systematic review and meta-analysis. ANZ journal of surgery. 2023.
    PubMed-indexed articleMeta-analysis / systematic review2023

    Outcomes of endovascular, open surgical and autotransplantation techniques for renal artery aneurysm repair: a systematic review and meta-analysis. ANZ journal of surgery. 2023. doi:10.1111/ans.18628.

    PubMedDOI
  22. 22.
    Review: spontaneous rupture of splenic artery aneurysm in pregnancy. European journal of obstetrics, gynecology, and reproductive biology. 2003.
    PubMed-indexed articleReview2003

    Review: spontaneous rupture of splenic artery aneurysm in pregnancy. European journal of obstetrics, gynecology, and reproductive biology. 2003. doi:10.1016/s0301-2115(03)00094-0.

    PubMedDOI
  23. 23.
    Splenic artery aneurysm rupture in pregnancy. European journal of obstetrics, gynecology, and reproductive biology. 2009.
    PubMed-indexed article2009

    Splenic artery aneurysm rupture in pregnancy. European journal of obstetrics, gynecology, and reproductive biology. 2009. doi:10.1016/j.ejogrb.2009.05.034.

    PubMedDOI
  24. 24.
    Splenic Artery Aneurysm Management in the Cirrhotic Patient Listed for Liver Transplantation: A Systematic Review. Transplantation proceedings. 2022.
    PubMed-indexed articleMeta-analysis / systematic review2022

    Splenic Artery Aneurysm Management in the Cirrhotic Patient Listed for Liver Transplantation: A Systematic Review. Transplantation proceedings. 2022. doi:10.1016/j.transproceed.2022.01.031.

    PubMedDOI
  25. 25.
    [Splenic artery aneurysm: diagnosis and endovascular therapy]. Journal de radiologie. 2010.
    PubMed-indexed article2010

    [Splenic artery aneurysm: diagnosis and endovascular therapy]. Journal de radiologie. 2010. doi:10.1016/s0221-0363(10)70155-4.

    PubMedDOI
  26. 26.
    Endovascular and Surgical Management of Intact Splenic Artery Aneurysm. Annals of vascular surgery. 2019.
    PubMed-indexed article2019

    Endovascular and Surgical Management of Intact Splenic Artery Aneurysm. Annals of vascular surgery. 2019. doi:10.1016/j.avsg.2018.08.088.

    PubMedDOI
  27. 27.
    Endovascular Repair of a Splenic Artery Aneurysm Arising from the Superior Mesenteric Artery. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2023.
    PubMed-indexed article2023

    Endovascular Repair of a Splenic Artery Aneurysm Arising from the Superior Mesenteric Artery. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2023. doi:10.1016/j.ejvs.2023.02.006.

    PubMedDOI
  28. 28.
    Laparoscopic surgery for splenic artery aneurysm. Surgical laparoscopy, endoscopy & percutaneous techniques. 2009.
    PubMed-indexed article2009

    Laparoscopic surgery for splenic artery aneurysm. Surgical laparoscopy, endoscopy & percutaneous techniques. 2009. doi:10.1097/sle.0b013e3181a89206.

    PubMedDOI
  29. 29.
    Laparoscopic and Robotic Surgery for Splenic Artery Aneurysm: A Systematic Review. Annals of vascular surgery. 2020.
    PubMed-indexed articleMeta-analysis / systematic review2020

    Laparoscopic and Robotic Surgery for Splenic Artery Aneurysm: A Systematic Review. Annals of vascular surgery. 2020. doi:10.1016/j.avsg.2020.05.037.

    PubMedDOI
  30. 30.
    Successful Repair of Superior Mesenteric Artery Aneurysm with Reconstruction of Branches. Annals of vascular diseases. 2020.
    PubMed-indexed articleCase report2020

    Successful Repair of Superior Mesenteric Artery Aneurysm with Reconstruction of Branches. Annals of vascular diseases. 2020. doi:10.3400/avd.cr.20-00108.

    PubMedDOI
  31. 31.
    Management and outcome of true visceral and renal artery aneurysm repair. Langenbeck's archives of surgery. 2021.
    PubMed-indexed article2021

    Management and outcome of true visceral and renal artery aneurysm repair. Langenbeck's archives of surgery. 2021. doi:10.1007/s00423-021-02149-1.

    PubMedDOI
  32. 32.
    Is open repair still the gold standard in visceral artery aneurysm management? Annals of vascular surgery. 2011.
    PubMed-indexed article2011

    Is open repair still the gold standard in visceral artery aneurysm management? Annals of vascular surgery. 2011. doi:10.1016/j.avsg.2011.03.006.

    PubMedDOI
  33. 33.
    Consensus Statement on the Timing of Median Arcuate Ligament Release in Patients With Pancreaticoduodenal or Gastroduodenal Artery Aneurysms Associated With Median Arcuate Ligament Syndrome.
    PubMed-indexed articleClinical practice guideline2024
    PubMedDOI

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