Clinical Management and Outcomes of Splenic Artery Pseudoaneurysm Complicated by Colonic Fistula After Gastrectomy: A Report of Two Cases

Summary

This report presents two rare cases of splenic artery pseudoaneurysm (SAP) with colonic fistula following gastrectomy, both successfully treated with transcatheter arterial embolization (TAE). These cases underscore the importance of early vascular imaging and coordinated multidisciplinary management in addressing postoperative gastrointestinal bleeding.

Abstract

Splenic artery pseudoaneurysm (SAP) complicated by colonic fistula is a highly uncommon but life-threatening vascular complication that may occur after upper abdominal surgery, including radical gastrectomy with D2 lymphadenectomy. The diagnosis is often delayed due to the rarity of this condition and its nonspecific presentation, especially when bleeding manifests as hematochezia rather than intraperitoneal hemorrhage. This report presents two cases of SAP with secondary colonic fistula that occurred approximately one month following laparoscopic total gastrectomy for advanced gastric cancer. Both patients presented with recurrent fresh hematochezia, left upper quadrant abdominal pain, and clinical signs of hypovolemic shock. Colonoscopy revealed bulging colonic mucosa with marked hyperemia and erosion, while contrast-enhanced abdominal CT and catheter-based digital subtraction angiography confirmed the presence of pseudoaneurysms communicating with the colon. Both patients underwent successful transcatheter arterial embolization (TAE) using a sandwich technique involving microcoils and gelatin sponge particles, which resulted in immediate hemostasis without major perioperative complications. Postoperative imaging revealed splenic infarction in both cases, but no further intervention was required, and no clinical sequelae were observed. During follow-up periods of 6-12 months, neither patient experienced rebleeding or pseudoaneurysm recurrence. These cases highlight the diagnostic challenges and the importance of early vascular imaging in postoperative gastrointestinal bleeding of obscure origin. Endovascular embolization is a safe, effective, and organ-preserving treatment strategy in such high-risk situations, especially when conventional surgery poses significant risks due to adhesions or patient comorbidities. Multidisciplinary collaboration and heightened clinical suspicion are critical for timely diagnosis and successful management.

Introduction

Splenic artery pseudoaneurysm (SAP) is a rare but potentially fatal vascular abnormality, representing less than 1% of all splanchnic artery aneurysms¹. It is defined as a breach of the arterial wall confined by the surrounding tissue, lacking the normal three-layered structure, and is thus highly prone to rupture. The majority of SAPs are associated with pancreatitis, trauma, or iatrogenic injury, especially in the context of abdominal surgical procedures involving extensive dissection near the splenic hilum².

In recent years, with the growing application of minimally invasive techniques and energy-based devices in abdominal oncology, particularly laparoscopic total gastrectomy with D2 lymphadenectomy, the incidence of delayed vascular complications such as SAP has risen³. Radical gastrectomy remains the gold standard for treating advanced gastric cancer, especially in East Asian countries, where D2 dissection is widely accepted^4,5,6. However, the technical complexity of splenic hilar lymph node dissection increases the risk of inadvertent vascular injury, infection, and localized inflammation, which may compromise the integrity of the splenic artery wall^7,8.

A particularly dangerous but under-recognized consequence of SAP is the formation of an arterial, enteric fistula, most often involving the transverse or descending colon^9,10. The resulting clinical manifestation, massive lower gastrointestinal hemorrhage, can be life-threatening¹⁰. Due to the rarity of this complication and its nonspecific early symptoms, preoperative diagnosis is often missed. Patients may present weeks after surgery with hematochezia and signs of hypovolemia, prompting an extensive and urgent diagnostic workup.

To date, literature on SAP complicated by colonic fistula is extremely limited, and standardized diagnostic and management strategies remain undefined. Conventional surgical repair is associated with high morbidity, particularly in patients who have undergone recent major surgery and present in unstable conditions. In contrast, transcatheter arterial embolization (TAE) has emerged as a minimally invasive and effective alternative that allows rapid hemostasis and preservation of splenic function¹¹. The purpose of this report is to present two rare and illustrative cases of SAP complicated by colonic fistula occurring approximately one month after laparoscopic total gastrectomy. This technique is particularly applicable in patients with a history of upper abdominal surgery, such as radical gastrectomy with D2 lymphadenectomy, who present with delayed-onset lower gastrointestinal bleeding, especially when accompanied by left upper quadrant pain and hemodynamic instability. In such scenarios, when imaging reveals vascular abnormalities near the splenic hilum, early endovascular intervention should be considered to avoid high-risk reoperation.

CASE PRESENTATION:
Case 1 involved a 68-year-old male with no significant family history or comorbidities, and no history of smoking or alcohol use. He was diagnosed with Siewert type II gastroesophageal junction adenocarcinoma (clinical stage cT3N+M0) and underwent laparoscopic total gastrectomy with D2 lymphadenectomy at the reporting institution. His early postoperative course was complicated by an esophagojejunal anastomotic leak, which was managed conservatively. On postoperative day 30, he presented with recurrent hematochezia, dizziness, hypotension (BP 82/50 mmHg), and tachycardia (HR 120 bpm). Physical examination revealed pallor, abdominal guarding in the left upper quadrant, and signs consistent with hypovolemic shock.

Case 2 involved a 72-year-old male, also without a history of tobacco or alcohol use, and with no notable family history of malignancy or vascular disease. He was diagnosed with gastric body adenocarcinoma (cT2N+M0) and underwent laparoscopic total gastrectomy with D2 lymphadenectomy. His early postoperative recovery was uneventful until postoperative day 46, when he developed abrupt-onset hematochezia, dizziness, and syncope. Physical examination showed a blood pressure of 75/48 mmHg, heart rate of 115 bpm, and marked tenderness over the left upper abdomen. Laboratory findings in both patients revealed a significant drop in hemoglobin (>30 g/L decrease from baseline).

Diagnosis, assessment, and plan

Diagnosis
Splenic artery pseudoaneurysm (SAP), a rare but serious complication after upper abdominal surgery, with a high risk of rupture and bleeding.

Assessment
Both patients developed delayed-onset, recurrent hematochezia accompanied by hemodynamic instability and left upper quadrant abdominal pain, approximately one month after laparoscopic total gastrectomy with D2 lymphadenectomy. Given the history of extensive upper abdominal surgery, anastomotic leak, and localized infection, an arterial-enteric fistula was suspected. Colonoscopy revealed bulging, hyperemic, and eroded mucosa at the splenic flexure, consistent with a bleeding focus. Contrast-enhanced CT demonstrated active extravasation from the distal splenic artery into the colon. Digital subtraction angiography (DSA) confirmed a SAP with active bleeding. Differential diagnoses such as colonic diverticular bleeding, anastomotic hemorrhage, ischemic colitis, and gastrointestinal tumor bleeding were considered but excluded based on imaging and endoscopic findings.

Plan
Emergency TAE was performed in both patients due to the high surgical risk and unstable hemodynamics. Embolization was achieved using microcoils and absorbable gelatin sponge particles. Postoperatively, patients were managed in the intensive care unit with intravenous antibiotics, parenteral nutrition, and close monitoring. Follow-up CT on day 7 confirmed complete aneurysm exclusion and splenic infarction, which remained clinically silent. No recurrent bleeding was observed during a 12-month follow-up period, indicating sustained efficacy of endovascular therapy.

Protocol

This study was conducted in accordance with the principles of the Declaration of Helsinki. Institutional approval was obtained from the Ethics Committee of Putian First Hospital. Written informed consent was obtained from both patients for the use of their clinical data and imaging in this report.

Between February and August 2024, two patients who experienced delayed lower gastrointestinal bleeding after laparoscopic total gastrectomy with D2 lymphadenectomy at the Department of Gastrointestinal Surgery, Putian First Hospital, Fujian, were diagnosed with SAP complicated by a colonic fistula. The diagnosis was established by colonoscopy, contrast-enhanced abdominal CT, and confirmatory angiography. In one case, an esophagojejunal anastomotic leak was identified on postoperative day 6 and resolved with conservative management. Both patients presented with left upper quadrant abdominal pain and recurrent episodes of hematochezia, accompanied by clinical signs of hypovolemic shock. Colonoscopy revealed extensive mucosal bulging in the colon with prominent erosions, marked hyperemia, and peripheral edema (see Figure 1). Detailed clinical data are provided in Table 1.

1. Patient selection

1. Patients who had undergone laparoscopic total gastrectomy with D2 lymph node dissection at the splenic hilum and subsequently developed delayed lower gastrointestinal bleeding suspected to be vascular in origin were included.
2. The diagnosis of SAP was confirmed by angiography following initial identification on contrast-enhanced CT or CTA.
3. Patients with non-vascular sources of bleeding, severe systemic comorbidities, coagulopathies, infections, or anatomically complex vascular variations precluding safe access were excluded.

2. Preoperative preparation and evaluation

1. A complete preoperative workup was performed, including complete blood count, liver and renal function tests, electrolytes, coagulation profile, electrocardiogram, and contrast-enhanced abdominal CT.
2. Lower gastrointestinal endoscopy was conducted to rule out tumor recurrence or anastomotic ulceration. Colonoscopy was used as the first-line tool for evaluating lower gastrointestinal bleeding and identifying mucosal clues suggestive of vascular fistula¹².
3. The morphology, location, and proximity of the pseudoaneurysm to the bowel were assessed using CT angiography or contrast-enhanced CT. CT or CTA was performed using a 64-slice or higher detector scanner, with a tube voltage of 120 kVp, 5 mm slice thickness, 1.2 pitch, and contrast-enhanced phase initiated after a 30-s delay following injection of 80-100 mL nonionic iodinated contrast agent at 3.0-3.5 mL/s via an antecubital vein. These modalities have been validated as effective tools for SAP detection and procedural planning³.
4. Patients fasted for at least 6 h prior to the procedure.
5. Two peripheral intravenous lines or a central venous access were established.
6. Intravenous somatostatin was administered at 250 µg/h using a continuous infusion pump, beginning 12 h prior to the intervention and continuing for 3-5 days postoperatively¹³. Prophylactic intravenous antibiotics (2 g every 12 h) were administered starting 24 h before the procedure and continued for 5-7 days, with adjustments based on clinical status and infection indicators¹⁴.
7. Two to four units of packed red blood cells were cross-matched based on hemoglobin level and expected blood loss, and were made available in the procedure room.
8. Multidisciplinary consultation was conducted for high-risk cases.

3. Interventional procedure

1. The patient was placed in a supine position.
2. Local or general anesthesia was administered (following institutionally approved protocols) depending on the patient's condition¹⁵.
3. Vital signs were continuously monitored.
4. The right groin was disinfected, and sterile drapes were applied.
5. The right femoral artery was punctured using the Seldinger technique.
6. A 5-F vascular sheath was introduced.
7. A 5-F angiographic catheter (Cobra or Simmons type) was advanced to the celiac trunk to perform aortography.
8. The pseudoaneurysm in the splenic artery was identified.
9. A 2.4-F microcatheter was advanced over a 0.014-inch microwire under fluoroscopic guidance into the distal splenic artery and positioned at the neck of the pseudoaneurysm.
10. Superselective angiography was performed to delineate the inflow, outflow, and neck of the lesion, using a DSA system¹⁶. The frame rate was set to 2-3 frames/s. A nonionic iodinated contrast agent was injected at 2-4 mL/s through the microcatheter to visualize the vascular architecture and aneurysm morphology.
11. Two to four detachable microcoils (2-4 mm in diameter, platinum-based, fibered or bare, compatible with 0.018-inch microcatheters) were deployed proximally and distally to the pseudoaneurysm until flow stasis was confirmed¹⁷.
    NOTE: Intermediate angiography demonstrated a significant reduction or complete cessation of arterial flow into the pseudoaneurysm sac, confirming successful embolization.
12. An absorbable gelatin sponge slurry was injected, prepared by suspending 1 mm³ sterile gelatin sponge particles (equivalent to 50 mg/mL) in iodinated contrast medium at a 1:1 volume ratio, yielding a final injection concentration of 25 mg/mL.
    NOTE: This technique was used in cases with wide-necked aneurysms or visible colonic communication¹⁷. Fluoroscopic imaging confirmed satisfactory filling of the aneurysm sac with gelatin slurry without extravasation.
13. Completion angiography was performed to confirm exclusion of the pseudoaneurysm. The final angiographic images showed complete obliteration of the pseudoaneurysm sac with no residual filling, and preserved perfusion of the distal splenic artery branches.
14. All catheters were withdrawn.
15. Manual compression was applied to the arterial puncture site for no less than 15 min or until complete hemostasis was achieved. During the first 30 min following compression, the site was closely monitored for hematoma, active bleeding, or signs of impaired distal circulation.
16. The patient was instructed to maintain strict bed rest for at least 8 h following the procedure. The punctured lower limb was kept extended and immobile during this period. Vital signs, distal pulses, and the access site were reassessed every 2 h throughout the bed rest period.
17. The patient was monitored for access site complications.

4. Postoperative management and follow-up

1. The patient was transferred to an intensive care unit or monitored ward for observation.
2. Intravenous somatostatin was maintained at 250 µg/h via continuous infusion for 3-5 days.
3. Intravenous broad-spectrum antibiotics were administered.
4. The patient was kept nil per os (NPO).
5. Nasogastric decompression was initiated.
6. Parenteral nutrition was provided for metabolic support.
7. Body temperature and white blood cell count were monitored daily.
8. Early signs of splenic infarction or abscess formation were carefully monitored.
9. Blood samples were drawn daily between 6:00 AM and 8:00 AM to assess complete blood count, C-reactive protein, liver enzymes (ALT/AST), creatinine, D-dimer, prothrombin time/international normalized ratio, and amylase in both serum and drainage fluid.
10. A contrast-enhanced CT scan was performed on postoperative day 7 to evaluate pseudoaneurysm exclusion and splenic perfusion, following published post-embolization surveillance protocols^18,19. Imaging confirmed the absence of contrast extravasation or pseudoaneurysm recurrence. No evidence of splenic infarction or ischemia was observed.
11. Colonoscopy was scheduled prior to discharge to assess fistula healing in stable patients, which is in line with recommendations from post-gastrointestinal hemorrhage management guidelines²⁰. Mucosal re-epithelialization and absence of fistulous openings were observed, confirming resolution of the colonic fistula.
12. Outpatient follow-up was scheduled at 1 month, 3 months, 6 months, and 12 months post-embolization using contrast-enhanced abdominal CT.

Results

In both cases, DSA clearly demonstrated the location, size, and morphology of the SAPs. Contrast extravasation was observed, forming round or irregular aneurysmal dilatations with opacification of the adjacent colonic lumen. Both patients underwent successful TAE, resulting in effective hemostasis without recurrence of lower gastrointestinal bleeding (See Figure 2 and Figure 3), consistent with previous reports highlighting the diagnostic value ...

Discussion

VAPA is a rare but potentially life-threatening complication after gastric cancer surgery^26,27. While gastrointestinal and intra-abdominal bleeding are common postoperative concerns familiar to most gastrointestinal surgeons, the incidence of VAPA, especially when complicated by fistula formation into the colon, remains exceedingly low and underrecognized. Previous reports, such as the 18-year retrospective study by Tessier et al.^28,<...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
2.4-Fr microcatheter with 0.014-inch microwire	Terumo	PX274F	Superselective angiography and embolization
5-Fr angiographic catheter (Cobra or Simmons type)	Cook Medical	G02170	Catheterization of celiac trunk
5-Fr vascular sheath	Terumo	RS+05J10U	Access sheath for femoral artery puncture
64-slice or higher CT scanner	GE Healthcare	Revolution EVO	Preoperative and postoperative imaging
Absorbable gelatin sponge particles (1 mm³)	Pfizer (Gelfoam)	0832-0210-01	Aneurysm sac embolization
Absorbable Hemostatic Gauze	Johnson & Johnson (Shanghai) Medical Devices Co., Ltd.	20153141908	Sterile, radiation-sterilized, single-use
Continuous infusion pump	B. Braun	8713050U	Administration of somatostatin
Detachable microcoils (2–4 mm, platinum-based)	Boston Scientific	MReye 706-35	Embolization of pseudoaneurysm
Digital Subtraction Angiography (DSA) system	Siemens Healthineers	Artis Zee	Angiographic visualization and guidance
Disposable Endoscopic Linear Cutter Stapler with Reload Cartridges	Jiangsu B. Braun Sense Medical Devices Co., Ltd.	20090021	Sterile, single-use
Electrocardiogram machine	Nihon Kohden	ECG-1250	Preoperative cardiac function evaluation
Intravenous broad-spectrum antibiotics ( 2 g q12 h)	Pfizer	0009-0340-01	Infection prevention
Nonionic iodinated contrast agent	GE Healthcare	28744-013	CT, CTA, and DSA imaging contrast
PACS imaging software	Carestream	Vue PACS	Visualization and analysis of CT/DSA images
Somatostatin (250 µg/h)	Chengdu Tiantaishan Pharmaceutical	H20000335	Bleeding control and pre/postoperative infusion
Trocar	Ethicon Endo-Surgery (Shanghai) Co., Ltd.	20152023388	Sterile, single-use