A rare case of sequential visceral artery aneurysm rupture associated with multifocal vascular abnormalities

Visceral artery aneurysms (VAAs) are rare but potentially fatal, with rupture representing their most serious complication. We report the case of a previously healthy 35-year-old woman who presented to the emergency department with acute abdominal pain caused by rupture of a splenic artery aneurysm, resulting in massive hemoperitoneum. She underwent emergency laparotomy with splenectomy, but approximately one hour postoperatively developed recurrent hemorrhagic shock, necessitating a second surgical intervention with proximal splenic artery ligation. Postoperative CT revealed multiple visceral aneurysms, including rupture of a hepatic artery aneurysm, along with renal and hepatic ischemia. The patient died before angiographic evaluation could be performed. Autopsy revealed sequential rupture of the splenic and hepatic artery aneurysms, accompanied by approximately 400 mL of blood-stained fluid within the peritoneal cavity. The right kidney showed two aneurysmal dilatations involving the hilar and proximal arterial segments. Examination of the left anterior descending coronary artery demonstrated a parietal dissection with intramural hemorrhage. Death was attributed to cardiac arrest secondary to hemorrhagic shock caused by the sequential rupture of the splenic and hepatic aneurysms, compounded by hemodynamic instability related to right renal artery dissection. Additionally, the pre-existing coronary artery dissection may have aggravated the outcome by limiting myocardial oxygen reserve during the critical period of aneurysm rupture. This case underscores the diagnostic difficulty of visceral artery aneurysms, particularly in young individuals without traditional risk factors, and highlights how multifocal vascular wall abnormalities can exacerbate clinical outcomes, even in the absence of overt rupture in all affected vessels.