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 ....

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, con....

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