We are going to discuss EOS-guided coil embolization of a splenic artery pseudoaneurysm. Authors include Vladimir Lam, Ahmed Bazarbashi, and Vladimir Kushner. We do not have any funding or relationship with industry to disclose. We describe the case of a 58-year-old male with autosomal-dominant polycystic kidney disease and end-stage renal disease. Imaging studies done in 2020 showed a 6.5-centimeter splenic artery pseudoaneurysm. The patient subsequently underwent a coiling procedure with interventional radiology in October of 2020. He then had subsequent imaging on January of 2021, which revealed persistent flow within the aneurysm sac, as well as interval increase in the size of splenic artery. Discussion with the surgical team included consideration of a distal pancreatectomy and splenectomy. There was limited role for repeat IR-guided interventions. After a multidisciplinary discussion, we decided to pursue EOS-guided coil embolization. These are CT images done two weeks prior to our procedure. Note the numerous cystic lesions in the liver and kidneys on the coronal view and the large splenic artery pseudoaneurysm measuring 6.8 by 6.0 centimeters on the axial view. This pseudoaneurysm demonstrates intrinsic flow despite presence of coils placed by radiology. Splenic ultrasound was used to identify a pseudoaneurysm measuring 5.8 by 6.0 centimeters in maximal cross-sectional diameter. The area of residual flow was identified on ultrasound and verified with Doppler flow. Under direct ultrasound guidance, the pseudoaneurysm was punctured with a 22-gauge needle and 5.018-inch tornado coils were placed into the pseudoaneurysm. At this point, the Doppler flow appeared to stop. We begin our endoscopic surveillance and note the presence of liver and kidney cysts. The splenic artery appears dilated on EOS examination. This dilation is consistent with a saccular pseudoaneurysm. The area of residual flow is identified on ultrasound. We measure the pseudoaneurysm's cross-sectional diameter. There is evidence suggesting the presence of a blood clot. We verify the area of residual flow with ultrasound and Doppler flow. We measure the pseudoaneurysm's maximal cross-sectional diameter as 5.8 by 6.0 centimeters. A 22-gauge needle is loaded with a .018-inch tornado coil and placed into the pseudoaneurysm. Doppler flow appears to show resolution of residual flow. This process is repeated four more times for a total of five tornado coils placed into the pseudoaneurysm. Here, we show placement of the final tornado coil. Endoscopic ultrasound performed three months later shows a splenic artery pseudoaneurysm 5.4 by 4.7 centimeters in maximal cross-sectional diameter. Decreased in size and with no appreciable flow on Doppler examination. All of this consistent with a successfully treated pseudoaneurysm. Our plan is to perform CT angiogram of the abdomen with contrast six months from the time of this ultrasound examination. If active flow develops, we can repeat EUS guided therapy as needed. We would like to point out that splenic artery pseudoaneurysms are rare. They can occur as a complication of autosomal dominant polycystic kidney disease, as in our patient. Pseudoaneurysms are associated with very high morbidity and mortality if left untreated. Current management options include endovascular approaches, percutaneous embolization, and surgery. Endoscopic ultrasound guided coil embolization therapy is emerging as a promising option for the treatment of gastric varices and it has been used for the management of rectal varices. We conclude that splenic artery pseudoaneurysms are rare and have very high morbidity and mortality if left untreated. EUS guided coil therapy is a feasible option in patients with splenic artery pseudoaneurysm when surgery and IR guided options are limited.

autosomal-dominant polycystic kidney disease

end-stage renal disease

splenic artery pseudoaneurysm

coiling procedure

EOS-guided coil embolization