Successful resuscitation after splenic artery aneurysm rupture.

Sir,

Massive hematemesis with hemorrhagic shock without trauma and subsequent cardiac arrest is a clear life-threatening situation. Intragastric rupture of an aneurysm of the splenic artery is a rare but important differential diagnosis and urgent diagnosis, usually by computed tomography (CT), and rapid treatment, usually open surgery, are necessary.

A 48-year-old man was brought to our emergency department after he started vomiting blood and collapsed at the nearby main railway station. Despite prompt crystalloid and colloid fluid infusions, the patient's condition deteriorated as vomiting of fresh blood persisted. Soon after arrival at our shock room, the patient suffered cardiac arrest and cardiopulmonary resuscitation was started and treatment with packed red blood cells, crystalloid and colloid fluids, fresh frozen plasma, tranexamic acid and blood coagulation factors was begun.

After stabilization of the patient's condition with a palpable femoral pulse and intubation, emergency gastroscopy was performed in the resuscitation area. A diagnosis of bleeding esophageal varices was suspected because a history of alcohol abuse was suspected without identification of the source of bleeding. An intragastric rupture of a splenic artery aneurysm (SAA) was identified at CT [Figure 1]. The patient was transferred to the department of interventional radiology for endovascular occlusion of the aneurysm with front and back door coil embolization of the splenic artery [Figure 2] and the aneurysm. The patient returned home 19 days after successful resuscitation.

Figure 1

Ruptured aneurysm (A) of the splenic artery; (B) the stomach (C) is filled with fresh blood

Figure 2

Coils in the splenic artery and the calcified splenic artery aneurysm

Splenic artery aneurysms are very rare with an incidence of approximately 0.8%[1] and are the third most common abdominal artery aneurysms after aortic and iliac artery aneurysms.[2] Rupture of an SAA has often fatal consequences, with mortality rates of up to 29%[3] and even higher in pregnant women (75%),[4] who are the most frequently affected. A ruptured SAA must be managed with immediate surgical or endovascular treatment. Our case is the first reporting on a ruptured idiopathic SAA managed by an endovascular procedure alone.[5]

A ruptured SAA is associated with high mortality and must be rapidly diagnosed and treated. Endovascular intervention and coil embolization appear to be a feasible treatment and a reasonable alternative to surgery for the management of massive bleeding caused by a ruptured SAA.