Endovascular Treatment of Visceral Artery Aneurysms: Data Analysis of the DeGIR/DGNR Quality Management System

Abstract

Purpose

Visceral artery aneurysms (VAA) are rare, and data on their occurrence and treatment are often outdated or heterogeneous. The objective of this study is to provide a comprehensive overview of features and interventional treatment options for VAA.

Materials and Methods

We analyzed demographic, procedural, and clinical data on VAA from 2018 to 2022 based on data derived from the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) registry regarding demographic details, aneurysm characteristics, treatment processes, and outcomes such as technical success, complication rates, and radiation exposure. Group comparisons between aneurysm locations and types were calculated as dependent variables as well as occurrence of incomplete embolization, complication rates, technical success, duration of intervention, and dose-area-product (DAP).

Results

In total 647 patients were enrolled. The mean age was 66 years, with 68.5% male. The most affected arteries were splenic (27.5%) and renal (21.3%). True aneurysms were most common (56.7%). Technical success was 91.2%, while primary incomplete embolization occurred in 47.3%. Complications were observed in 4.8%, with a 0.2% mortality. Mean intervention duration was 67 min, mean fluoroscopic time was 36 min and mean DAP was 9560 cGycm². There were no significant differences in primary incomplete embolization, complication rate, correct placement of embolization material, duration, and DAP based on aneurysm location. Aneurysm types showed a significant difference in incomplete embolization, with dissections having the highest rates and longest durations of intervention and highest DAP.

Conclusion

The analysis of DeGIR quality management data reveals consistently high technical success and low complication rates in endovascular treatment of VAA. Dissecting aneurysms exhibit the highest rates in incomplete embolization, requiring the longest interventions and increased radiation. Enhancing the DeGIR registry with follow-up features would benefit assessing VAA occlusion rates. The data provide a comprehensive nationwide overview of how interventional radiology can impact treatment strategy.

Key Points

• Visceral artery aneurysms represent a rare entity

• The DeGIR registry provides extensive data about rare endovascular treatments of visceral artery aneurysms

• Endovascular treatment of visceral aneurysms is feasible and safe

• Dissecting aneurysms are associated with the highest rates of primary incomplete embolization and the longest interventional durations

Citation Format

• Weiss D, Jannusch K, Wilms LM et al. Endovascular Treatment of Visceral Artery Aneurysms: Data Analysis of the DeGIR/DGNR Quality Management System. Rofo 2025; DOI 10.1055/a-2513-1135

Zusammenfassung

Ziel

Viszeralarterienaneurysmen (VAA) sind selten, und die Daten zu ihrem Auftreten und ihrer Behandlung sind oft veraltet oder heterogen. Das Ziel dieser Analyse ist es, einen umfassenden Überblick über interventionelle Behandlungsoptionen und Eigenschaften der VAA zu bieten.

Material und Methoden

Es wurden prozedurale und klinische Daten zu VAA von 2018 bis 2022 analysiert. Die Daten stammen aus dem Deutschen Register für Interventionelle Radiologie und Minimalinvasive Therapie (DeGIR) und umfassen demografische Details, Merkmale der Aneurysmen, Behandlungsprozesse und Ergebnisse wie dem technischen Erfolg, Komplikationsraten und die Strahlenexposition. Gruppenvergleiche zwischen Aneurysmalokalisationen und -typen als abhängige Variablen sowie dem Auftreten von einer primären unvollständigen Embolisation, Komplikationsraten, technischem Erfolg, Interventionsdauer und Dosisflächenprodukt (DFP) wurden berechnet.

Ergebnisse

Es wurden 647 Patienten eingeschlossen. Das Durchschnittsalter betrug 66 Jahre, mit 68,5% Männern. Am häufigsten betroffen waren die Milz- (27,5%) und die Nierenarterien (21,3%). Wahre Aneurysmen waren am häufigsten (56,7%). Der technische Erfolg betrug 91,2%, während eine primäre unvollständige Embolisation bei 47,3% auftraten. Komplikationen traten bei 4,8% auf, mit einer Mortalitätsrate von 0,2%. Die durchschnittliche Interventionsdauer betrug 67 Minuten, die durchschnittliche Fluoroskopiezeit 36 Minuten und das DFP durchschnittlich 9560 cGycm². Es gab keine signifikanten Unterschiede in primärer unvollständiger Embolisation, Komplikationsrate, korrekter Platzierung von Embolisationsmaterial, Dauer und DFP basierend auf der Aneurysmalokalisation. Aneurysmatypen zeigten einen signifikanten Unterschied im Auftreten einer primären unvollständigen Embolisation, wobei Dissektionen die höchste Rate und die längsten Interventionen sowie das höchste DFP aufwiesen.

Schlussfolgerung

Die endovaskuläre Behandlung von VAA zeigt hohe technische Erfolgs- und niedrige Komplikationsraten. Dissezierende Aneurysmen zeigten insgesamt die höchste Rate an einer primären unvollständigen Embolisation, erforderten längere Interventionen und dadurch eine erhöhte Strahlenbelastung. Die Erweiterung des DeGIR-Registers um Follow-up-Daten würde dazu beitragen, die Okklusionsraten von VAA besser zu beurteilen. Die Daten zeigen einen umfassenden nationalen Überblick darüber, wie die interventionelle Radiologie die Behandlungsstrategie beeinflussen kann.

Kernaussagen

• Viszeralarterienaneurysmen sind eine seltene Entität.

• Das DeGIR-Register liefert umfangreiche Daten zu seltenen endovaskulären Behandlungen von viszeralen Arterienaneurysmen.

• Die endovaskuläre Behandlung von viszeralen Aneurysmen ist machbar und sicher.

• Dissezierende Aneurysmen haben die höchste Rate an einer primären unvollständigen Embolisation und längste Interventionsdauern.

Keywords

DeGIR registry data - module b - aneurysm - endovascular treatment - stent - coil

Introduction

Visceral aneurysms represent a relatively rare entity with an incidence of under 0.1% and are often detected incidentally or when they become symptomatic due to their size and the resulting pain or compression of adjacent structures or a bleeding event [1] [2]. Various etiologies and forms of visceral aneurysms are known, e.g. dissective, true, or pseudoaneurysms. Due to the low incidence, therapy recommendations are also limited and depend on specific factors such as the general constitution of the patient and morphological and clinical criteria of the aneurysm itself, such as aneurysm size, form and wall configuration, growth and location [3] [4] [5].

In addition to a surgical approach, endovascular minimally invasive treatment has gained importance in the treatment of visceral aneurysms [6] [7]. Common interventional techniques in this context involve coiling, potentially stent or balloon assisted, as well as stent graft implantation. Furthermore, flow-diversion is another, more recent treatment option regarding visceral aneurysms [8] [9].

Recruiting a significant number of patients with rare diseases can be challenging. The database of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) together with the German Society for Neuroradiology (DGNR) is a great utility to fulfill the need of data for such rare diseases [10]. Hence, data are collected nationwide, enabling an overview to be made about diseases with relatively low patient numbers and providing an overview of the various treatment options and frequencies.

This study aimed to provide a systematic overview of endovascular visceral aneurysm treatment in Germany and Austria between 2018 and 2022. In addition, the aim was to compare different types of aneurysms in terms of their technical success and complication rates.

Materials and Methods

This retrospective multicenter study involving 141 interventional centers extracted and analyzed procedural and clinical data from the DeGIR registry related to the treatment of visceral aneurysms between 2018 and 2022. Anonymized records from Module B (vascular closure procedures, subcategory “visceral aneurysms”) were retrieved for this purpose. The selection criteria for attributes such as aneurysm characteristics, treatment options, and complications are predefined through an input interface. In cases where data were incomplete or inconsistent, the authors used their judgment, either excluding implausible data from the survey or choosing not to assess individual categories (see appendix). This module includes both mandatory variables (e.g. the treated vessel or the size of the aneurysm) and optional variables (e.g. the choice of material). The latter are significantly fewer in number but can lead to incomplete datasets. Additionally, new parameters are occasionally added over the years, which can also contribute to incomplete datasets in the overall retrospective view [11].

The data were analyzed without disclosing or attributing them to specific manufacturers. The study encompassed a comprehensive examination of demographic data, aneurysm features, and treatment process data. Additionally, technical success, complication rates, and radiation exposure were thoroughly scrutinized to provide a comprehensive understanding of the outcomes. Furthermore, the complications were classified according to the Society of Interventional Radiology classification: these correspond to categories A) no further therapy or consequence, B) nominal therapy, no consequences, C) therapy necessary, hospitalization under 48 hours, D) major therapy required, prolonged hospitalization, E) permanent adverse sequelae, and F) death. Categories A and B correspond to minor complications, while categories C to F correspond to major complications [12].

Statistical analysis was carried out using the SPSS software (Statistical Package for Social Science, version 28, IBM, Armonk, New York, USA). Means with standard deviation or median values with interquartile range (IQR) were employed for continuous values. Multiple group comparisons were conducted with the Kruskal-Wallis test for non-parametric variables and with an analysis of variance (ANOVA), a statistical test to compare arithmetic means across groups, including testing for normal distribution and homogeneity of variance, for parametric dependent variables, respectively. In instances where the Kruskal-Wallis test yielded a statistically significant result, post-hoc Dunn-Bonferroni tests were computed, and for ANOVA, post-hoc Tukey tests were calculated to detect differences in subgroups.

The first subgroup analysis included aneurysm location as the independent variable, while the second subgroup analysis considered aneurysm type as the independent variable. Non-parametric variables included general anesthesia (GA), arterial access route, correct placement of embolization material, and the occurrence of a “primary endoleak”. In the broader context, it would be more appropriate to use the term “incomplete embolization” instead of “primary endoleak”. It is important to note that the term “incomplete embolization” refers to the immediate post-interventional outcome. This should not be misunderstood as a technical failure, as it is well known that, in many cases, a complete closure of the aneurysm occurs over time due to increasing flow stasis within the aneurysmal sac. This is influenced by various factors, such as flow dynamics, external and internal factors affecting blood coagulation (e.g. the administration of heparin), as well as the choice of embolization device. This phenomenon is regularly examined, particularly in neurointerventional studies [13] [14].

This terminology will be adopted moving forward. Parametric dependent variables were the duration of the intervention, defined as: incision/puncture to suture/closure and dose area product (DAP) for each analysis.

Results

We have evaluated the records of the DeGIR registry for endovascular treatment of visceral aneurysms, regarding demographic, anatomical, and morphological as well as procedural and radiation data.

Patients

A total of 647 patients (78 (2018), 72 (2019), 68 (2020), 208 (2021) and 221 (2022)) were enrolled based on the registry ([Fig. 1]). The mean age of patients was 66 years (14–96 ±14) with 68.5% (n=443) male and 31.5% (n=204) female. Of all the examinations conducted, 15.3% (n=99) were emergency examinations and 84.7% (n=548) were planned examinations during routine working hours ([Table 1]).

Fig. 1 Number of endovascular treatments of abdominal and visceral aneurysms between 2018–2022 in Germany and Austria per year.

Table 1 Baseline characteristics.

	Total (n=647)	Elective treatment (n=548)	Emergency (n=99)
SMA = superior mesenteric artery, IMA = inferior mesenteric artery
Age (years)	66 (14–96 ± 14)	66 (14–96 ± 14)	66 (19–89 ± 16)
Female sex	204 (31.5%)	175 (31.9%)	29 (29.3%)
Aneurysm location
Splenic artery	178 (27.5%)	163 (29.7%)	15 (15.2%)
Renal artery	138 (21.3%)	122 (22.3%)	16 (16.2%)
Hepatic artery	108 (16.7%)	79 (14.4%)	29 (29.3%)
Celiac trunk	52 (8.0%)	51 (9.3%)	1 (1.0%)
SMA	52 (8.0%)	43 (7.8%)	9 (9.1%)
IMA	40 (6.2%)	39 (7.1%)	1 (1.0%)
Gastroduodenal artery	36 (5.6%)	23 (4.2%)	36 (5.6%)
Other	43 (6.6%)	28 (5.1%)	13 (13.1%)
Aneurysm sizes
<20 mm	401 (62.0%)	330 (60.2%)	71 (71.7%)
<30 mm	163 (25.2%)	147 (26.8%)	16 (16.2%)
30–50 mm	55 (8.5%)	45 (8.2%)	10 (10.1%)
50–70 mm	20 (3.1%)	18 (3.3%)	2 (2.0%)
70–90 mm	8 (1.2%)	8 (1.5%)	0 (0.0%)
>90 mm	0 (0.0%)	0 (0.0%)	0 (0.0%)
Aneurysm types
true aneurysms	367 (62.0%)	340 (62.0%)	27 (27.3%)
pseudoaneurysms	150 (23.2%)	118 (21.5%)	32 (32.3%)
dissections	59 (9.1%)	45 (8.2%)	14 (14.1%)
localized perforations	33 (5.1%)	20 (3.6%)	13 (13.1%)
free perforations	27 (4.2%)	16 (2.9%)	11 (11.1%)
infectious (mycotic)	6 (0.9%)	4 (0.7%)	2 (2.0%)
non-infectious	5 (0.8%)	5 (0.9%)	0 (0.0%)
Treatment features
Technical success	590 (91.2%)	493 (90.0%)	97 (98.0%)
Complication rate	31 (4.8%)	30 (5.5%)	1 (1.0%)
General anesthesia	199 (30.8%)	151 (27.6%)	48 (48.5%)

Vessel and aneurysm characteristics

Location site: The occurrence of visceral aneurysms can manifest in various arterial locations. In our study, the two most commonly affected arteries were the splenic artery (n=178, 27.5%) and the renal artery (n=138, 21.3%). Beyond these, other arteries included in our analysis were the hepatic artery, the celiac trunk, the superior and inferior mesenteric artery, and the gastroduodenal artery. Arteries less frequently impacted were collectively categorized under the term “Other” ([Fig. 2]).

Fig. 2 Distribution of endovascular treatments of visceral aneurysms between 2018–2022 in Germany per affected vessel. The splenic artery was affected in 178 patients (27.5%), the renal artery in 138 patients (21.3%), and the hepatic artery in 108 patients (16.7%). Additionally, the celiac trunk and the superior mesenteric artery were affected in 52 patients each (8.0%), the inferior mesenteric artery in 40 patients (6.2%), and the gastroduodenal artery in 36 patients (5.6%). In 43 patients (6.6%), “other” vessels were affected.

Aneurysm types: Aneurysm types were systematically categorized to provide a comprehensive overview of the varied presentations. These categories included true aneurysms, pseudoaneurysms, dissections, free and localized perforations, and non-infectious as well as infectious (mycotic) aneurysms ([Fig. 3]). The most common types were true aneurysms (n=367, 56.7%) followed by pseudoaneurysms (n=150, 23.2%).

Fig. 3 Distribution of aneurysm types. Aneurysm types were categorized into true aneurysms (n=367, 56.7%), pseudoaneurysms (n=150, 23.2%), dissections (n=59, 9.1%), free (n=27, 4.2%) and localized (n=33, 5.1%) perforations, and non-infectious (n=5, 0.8%) as well as infectious (mycotic) (n=6, 0.9%) aneurysms.

Aneurysm sizes: Aneurysm sizes were categorized into six subgroups in the DeGIR registry: <20 mm (n=401, 62.0%), <30 mm (n=163, 25.2%), 30–50 mm (n=55, 8.5%), 50–70 mm (n=20, 3.1%), 70–90 mm (n=8, 1.2%), and >90 mm (n=0, 0.0%). The majority of aneurysms were smaller, with <20 mm being the most prevalent category, while larger aneurysms (70–90 mm and >90 mm) were less common in the studied patient cohort.

Procedural characteristics and radiation exposure

Anesthesia types: Various anesthesia approaches were observed. Most patients were treated with local anesthesia alone (n=386, 59.7%). 199 (30.8%) patients were treated under general anesthesia (GA), 48 (7.4%) patients under analgesia. Given the potential for multiple responses, it is also possible to code for local anesthesia, additionally. Fifteen patients received general anesthesia and local anesthesia in this context, while 39 patients received analgesia and local anesthesia.

Arterial access route: Decision-making for each specific issue, such as femoral percutaneous, femoral surgical approach, brachial artery percutaneous, and brachial artery surgical approach, may involve multiple responses across different categories. In our study, the main arterial access route was predominantly via percutaneous groin puncture (n= 549, 84.9%). Percutaneous brachial puncture represented a secondary access route, utilized in 97 (15.0%) patients. A surgical approach, either primary or secondary, was employed less frequently, with 20 (3.1%) patients undergoing femoral access and 19 (2.9%) patients via brachial access. We have indicated the percentages for the access routes; however, due to the changes implemented, the overall total exceeds 100%. This occurs because a secondary access route was ultimately employed for certain patients. For further analyses, the arterial access route was dichotomized into femoral and brachial access.

Technical success: In the study, the aim of achieving the correct placement of embolization material was successful in 590 patients, representing 91.2% of the study cohort. In the 99 cases treated as emergencies, correct material placement was achieved in 97 cases (98.0%). Additionally, primary incomplete embolization was reported in 306 patients, accounting for 47.3% of the patients analyzed. The embolization material used included coiling, implantation of covered and bare metal stents, and stent grafts.

Complications: The overall complication rate in our study was 4.8%, involving a total of 31 cases. These complications were further categorized into specific subtypes: Aneurysm-related complications occurred in 9.7% (n=3) of cases, unintended arterial occlusion of the carrier vessel was observed in 25.8% (n=8) of cases, arterial bleeding was reported in 22.6% (n=7) of cases, material displacement accounted for 12.9% (n=4) of complications, and other complications were identified in 29% (n=9) of cases. With reference to the Society of Interventional Radiology (SIR) classification, we observed 11 (35.5%) complications of Type A, 6 (19.4%) complications of Type B, 7 (22.6%) complications of Type C, and 7 (22.6%) complications of Type D. There were no complications of type E [15]. Within the initial 30 days post-treatment, the overall mortality rate was 0.2% (n=1). In this specific case, the patient succumbed to organ failure caused by a severe infection. In the 99 cases treated as emergencies, there was only one complication (1.0%), namely a parenchymal infarction.

Intervention time, radiation exposure and fluoroscopic time: The mean duration of the intervention was 67 min (± 102 min). The median DAP (dose area product) was 9560 cgycm² (IQR = 2972–29271). Additionally, the mean fluoroscopic time was 36 min (± 48 min).

Group comparisons regarding different aneurysm locations and types

Aneurysm locations: GA (Chi-Square = 0.0, df=7, p=1.0) did not show a statistically significant difference in group comparisons, while access route via femoral artery (Chi-Square = 35.010, df=7, p < 0.001) did. Correct placement of embolization material (Chi-Square = 10.795, df=7, p = 0.148), primary incomplete embolization (Chi-Square = 10.907, df=7, p = 0.143), and complication rate (Chi-Square = 8.145, df=7, p = 0.320) did not exhibit any group differences in the Kruskal-Wallis test ([Table 2]).

Table 2 Kruskal-Wallis test with aneurysm location.

Aneurysm location	Kruskal-Wallis test
GA = general anesthesia. The Kruskal-Wallis test showed substantial group differences regarding aneurysm location and femoral access, but did not show substantial group differences regarding GA, the correct placement of embolization material, occurrence of a primary incomplete embolization, or the complication rate. * = statistically significant results
GA	Chi-Square = 0.0, df=7, p = 1.0
Femoral access	Chi-Square = 35.010, df=7, p < 0.001*
Correct placement of embolization material	Chi-Square = 10.795, df=7, p = 0.148
Primary incomplete embolization	Chi-Square = 10.907, df=7, p = 0.143
Complication rate	Chi-Square = 8.145, df=7, p = 0.320

In post-hoc Dunn-Bonferroni tests, statistically significant differences were seen in an access route via femoral artery in all subgroups concerning the celiac trunk. In detail, between celiac trunk and superior mesenteric artery (z=2.95, p=0.003), celiac trunk and splenic artery (z=4.393, p < 0.001), celiac trunk and hepatic artery (z=–4.854, p < 0.001), celiac trunk and renal artery (z=–5.139, p < 0.001), celiac trunk and inferior mesenteric artery (z=–4.147, p < 0.001), celiac trunk and gastroduodenal artery (z=–3.907, p < 0.001), and celiac trunk and others (z=–4.647, p < 0.001). In the probing of the celiac trunk, a brachial approach was more frequently employed (n=19, 20.9%) compared to other locations, although the femoral access route remained the chosen method in most cases (n=33, 79.1%).

Duration (p=0.129) and DAP (p=0.071) did not show significant differences in group comparisons via ANOVA ([Table 3]).

Table 3 ANOVA with aneurysm location, DAP, and duration of endovascular treatment.

Aneurysm location	ANOVA
DAP = dose-area-product. The one-way ANOVA did not show substantial group differences regarding aneurysm location and duration or DAP.
Duration	F (7,634) = 1.613, p = 0.071
DAP	F (7,619) = 0.3, p = 0.129

Aneurysm types: GA (Chi-Square = 0.0, df=6, p = 1.0), access route via femoral artery (Chi-Square = 2.389, df=6, p = 0.881), and correct placement of embolization material (Chi-Square = 7.027, df=6, p = 0.318) did not show statistically differences in group comparisons, while primary incomplete embolization (Chi-Square = 15.307, df=6, p = 0.018) did. Complication rate (Chi-Square = 2.897, df=6, p = 0.822) did not show statistically significant group differences ([Table 4]).

Table 4 Kruskal-Wallis test for aneurysm type.

Aneurysm type	Kruskal-Wallis test
GA = general anaesthesia. On analysis, the types of aneurysms included true aneurysms, pseudoaneurysms, dissections, free and localized perforations, and non-infectious as well as infectious (mycotic) aneurysms. The Kruskal-Wallis test showed substantial group differences regarding aneurysm type and occurrence of a primary incomplete embolization, whereas there were no significant differences for GA, femoral access, complication rate, or the correct placement of embolization material. * = statistically significant results
GA	Chi-Square = 0.0, df=6, p = 1.0
Femoral access	Chi-Square = 2.389, df=6, p = 0.881
Correct placement of embolization material	Chi-Square = 7.027, df=6, p = 0.318
Primary incomplete embolization	Chi-Square = 15.307, df=6, p = 0.018*
Complication rate	Chi-Square = 2.897, df=6, p = 0.822

In post-hoc Dunn-Bonferroni tests, statistically significant differences were seen in the occurrence of a primary incomplete embolization in the pseudoaneurysm and dissection group (z=–3.754, p=0.004) and in the true aneurysm and dissection group (z=–3.151, p=0.034).

DAP (F(6, 620) = 2.47, p = 0.023) and duration (F(6, 635) = 4.73, p < 0.001) showed significant differences in group comparisons with ANOVA ([Table 5]). DAP did not show significance in the post-hoc Tukey test. Duration did show significant differences in the subgroup of pseudoaneurysms (mean=79.61 min) and true aneurysms (mean=108.81 min, p< 0.001) and in the subgroup of pseudoaneurysms (mean=79.61 min) and dissections (mean=123.61 min, p< 0.001).

Table 5 ANOVA with aneurysm type, DAP, and duration of endovascular treatment.

Aneurysm type	ANOVA
DAP = dose area product. The one-way ANOVA showed substantial group differences regarding aneurysm type and duration or DAP. * = statistically significant results
Duration	F (6,635) = 4.728, p < 0.001*
DAP	F (6,620) = 2.465, p = 0.023*

Discussion

Quality management has become increasingly significant over the last decade. The knowledge of frequencies and procedural specifics of rare interventions, like the treatment of visceral aneurysms, provides an overview and holds the potential to enhance success rates and reduce complication rates. Furthermore, it allows for an exchange of experiences among interventionalists, gaining knowledge regarding indications and treatment strategies. The DeGIR registry has therefore proven invaluable by providing crucial data to elevate the quality of endovascular interventions on a nationwide scale [10].

Endovascular treatment of visceral aneurysms rapidly increased since 2021 ([Fig. 1]). Treatment numbers nearly tripled from 2020 (n=68) to 2021 (n=208). These fluctuations are mainly due to the recording of interventional procedures by the performing clinics.

Depending on the specific characteristics of the patient or the aneurysm, visceral aneurysms may be observed or undergo either surgical or endovascular treatment. The latter option offers essential advantages, including a shorter recovery time and lower complication and mortality rates [16] [17]. Nevertheless, it is vital to note that in surgical therapy, maintaining the integrity of the carrier vessel is usually not attainable, whereas in endovascular therapy vessel preservation becomes feasible [1] [18]. The safety and effectiveness of endovascular treatment for visceral aneurysms have already been demonstrated, including in a major study by Pitton et al., which also emphasized the importance of endovascular emergency treatment and confirmed by the results of our study [19].

These advantages were underscored by the registry results, revealing only one (0.2%) patient death within the first 30 days after treatment, attributed to organ failure from a severe infection. Conversely, we observed a notably low complication rate of 4.8%, which is in line with prior investigations [6] [20]. In this context, it is important to distinguish between a therapeutically intended embolization of the feeding vessel, which is deliberate, and an unintended embolization of the feeding vessel, which can lead to critical ischemia, for example. In comparison to a surgical approach, where overall mortality rates typically range between 1–3% and consecutively higher complications rates up to 12.9% in non-ruptured visceral aneurysms, the rates observed in endovascular treatment are remarkably low [1] [5] [21]. This emphasizes the safety profile of endovascular treatment, making it a favorable option in the context of visceral aneurysm management.

Technical success is determined by the accurate placement of embolization material, which may include coils, stent grafts, or covered stents, for example. These rates are notably high, with an overall success rate of 91.2%, suggesting successful treatment. However, a drawback in this context is the absence of follow-up, which would provide crucial information on aneurysm occlusion rates. The lack of follow-up stems from the nature of the registry, which assesses interventions in the short term and does not incorporate longer-term follow-up. Nevertheless, this issue has already been recognized and the possibility of follow-up assessment may be included as an optional feature in future software updates.

Generally, occlusion rates of visceral aneurysms treated endovascularly demonstrate favorable outcomes, comparable to those achieved through a surgical approach, with both methods yielding occlusion rates exceeding 90% [1] [6] [22]. Treatment recommendations for aneurysms vary depending on size and growth rate. In this current study, the majority of aneurysms had a diameter of less than 20 mm. Some studies recommend treatment only at this size, while others have shown that the risk of rupture does not necessarily depend on the size of the aneurysm [19] [23] [24].

Overall, we have observed that percutaneous access to either the brachial or femoral artery is employed more frequently than surgical access to these arteries. This aligns with expectations, as percutaneous access is a significant advantage of endovascular procedures, which are associated with lower complication rates and shorter recovery times [3] [16] [25]. Surgical access is typically reserved as a rescue approach, if percutaneous access proves unsuccessful. In general, access via the common femoral artery is much more common than access via the brachial artery. This preference may be attributed to the ability to use larger materials through the femoral artery and the easier, shorter access route to a visceral aneurysm [3] [26]. Another advantage here is that a vascular closure device can be safely used for femoral access, whereas it is currently off-label for brachial access [27]. In the case of an aneurysm involving the celiac trunk, the brachial access route was chosen more frequently compared to other locations. This preference can primarily be attributed to the favorable angle of origin of the celiac trunk when approached cranially [5].

Regarding anesthesia types, local anesthesia is the most frequently used type – either in combination with analgesia or intubation narcosis or administered alone. The use of local anesthesia alone offers several advantages, including the avoidance of risks associated with intubation anesthesia, the ability to communicate with the patient, and a reduction in the overall time of the intervention and personnel required [7] [28]. We did not observe any differences in the use of intubation narcosis concerning the location or type of visceral aneurysms. This can primarily be attributed to the fact that the choice of anesthesia is more likely influenced by patient-specific factors such as overall condition or hemodynamic instability [29].

In our investigation, we explored the influence of aneurysm location and type on various aspects of the intervention. We observed that there was no distinct difference in the endovascular treatment of visceral aneurysms concerning their location in relation to the occurrence of a primary incomplete embolization, the complication rate, or the correct placement of embolization material. Additionally, there was no disparity in the duration of the intervention or the DAP. While certain arteries may pose varying levels of difficulty, interventionalists across Germany performing abdominal embolization were achieving successful embolization regardless of the location.

Our findings indicate that the occurrence of a primary incomplete embolization was the highest in dissective aneurysms (69.5%) compared to true aneurysms (47.4%) or pseudoaneurysms (40.7%). Additionally, the duration of endovascular treatment and the DAP were notably longer and higher, respectively, in dissective aneurysms than in true aneurysms or pseudoaneurysms. This is attributed to the inherent complexity of treating dissective aneurysms, which are significantly more challenging to treat [29] [30] [31]. Furthermore, technically challenging interventions may prolong the intervention time [32]. The intricacy of the procedure extends the overall duration of the intervention and, consequently, increases radiation exposure.

Limitations

On the one hand, there is a large amount of data available that provides insight into the entity and treatment modalities for this rare condition. However, there are limitations such as the absence of follow-up data extending beyond the 30-day course. Furthermore, this also affects other data points due to the voluntary entry into the registry, resulting in incomplete datasets. Additionally, a lack of monitoring of data entry presents a challenge, as does reporting bias. Further difficulties stem from the progressive encoding by different centers [33]. Beyond that, the retrospective nature of the study underscores the need for further prospective investigations to enhance the robustness of the findings. The registry only includes entries for cases that have been treated. Therefore, statements regarding frequency and active surveillance cannot be made. However, the study serves as a promising basis for a prospective study to clarify the prevailing questions more comprehensively.

Conclusions

The current analysis of data within the DeGIR quality management system consistently demonstrates a high technical success rate and a low complication rate in the endovascular treatment of visceral aneurysms regardless of whether it is a planned or emergency procedure. The underlying representative frequencies of aneurysms align with those found in previous studies. Overall, we found that the localization of the aneurysm had no significant influence on the outcome of the intervention. However, we also found that dissecting aneurysms had significantly higher rates of a primary incomplete embolization and were associated with a longer intervention time and higher radiation dose for the patient and thus probably also for the interventionalist. Moreover, with regard to enhancing the DeGIR registry, the possibility of follow-up assessment may be included as an optional feature in future software updates.

Abbreviations

ANOVA: analysis of variance

DAP: dose area product

DeGIR: German Society for Interventional Radiology and Minimally Invasive Therapy

DGNR: German Society for Neuroradiology

GA: general anesthesia

IMA: inferior mesenteric artery

IQR: interquartile range

SMA: superior mesenteric artery

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publikationsverlauf

Eingereicht: 10. Juni 2024

Angenommen nach Revision: 04. Januar 2025

Artikel online veröffentlicht:
20. Februar 2025