Tailored Interventional Approaches to the Management of True and False Aneurysms Affecting Aberrant Visceral Arteries Are Associated with Enhanced Clinical Outcomes

<b>Background:</b> Anatomical variations in visceral arteries are not so uncommon (up to 20% of cases in general population), with splenic and hepatic artery anomalies being the most frequently reported. Aberrant arteries may be affected with aneurysmal lesions that are rare but potentially fatal conditions. In their treatment, a comprehensive understanding and knowledge of the underlining anatomical variation are pivotal to prevent potential ischemic complications for the end organ. <b>Methods:</b> A comprehensive literature search on the PubMed, Cochrane and Scopus databases was done using the terms: "anomalous visceral artery aneurysm", "Aberrant visceral arteries", and "anomalous origin visceral vessels". Eligible studies published from inception to 30 June 2024 were identified. Only those that had included the adopted treatment strategies (open, endovascular or hybrid repair) and the related outcomes (mortality, bleeding, end-organ ischemia, lesions of the surrounding organ, need for reintervention) were analyzed to evaluate the safety and efficacy of each approach. A narrative analysis of the indications informing the selection of each interventional treatment, based on individual procedural risks, was also presented. <b>Results:</b> A total of 30 publications describing 36 patients (mean age 48.9 ± 12.8 years, range 22-73 years) with aneurysms involving aberrant visceral arteries were included. Most patients were female (25/36, 69.4%). True aneurysms predominated (with a mean size of 30.5 ± 11.5 mm, range 6-60 mm), being reported in 33/36 (91.7%) patients. Most lesions involved a splenic artery arising from the superior mesenteric artery (27/36, 75.0%). Overall, 26/36 (72.2%) patients were symptomatic upon presentation, most commonly with abdominal or epigastric pain, often associated with nausea or vomiting, back pain or shortness of breath. All patients underwent preoperative Computed angiotomography or subtraction angiography to define the operative strategy. Most cases were managed electively (31/36, 86.1%), but 11.1% (4/36) of cases required urgent intervention (in one case the urgency status was not specified). Overall, 19/36 (52.8%) patients underwent purely endovascular repair, 15/36 (41.7%) were treated with open surgery, and 2/36 (5.6%) had hybrid procedures combining endovascular coiling with laparoscopic splenic artery ligation. Indication for treatment was based on vessel tortuosity, landing zones, and the presence of side branches supplying end organs. Early outcomes were favorable regardless of treatment strategies. A single organ-related complication was reported (1/36, 2.8%) following open/endovascular repair, consisting of mild pancreatitis, which resolved with conservative management. No perioperative or aneurysm-related deaths were reported in any of the included cases. No recurrent aneurysms or late aneurysm-related complications were described during the reported follow-up intervals (mean ≈ 10.5 months, range 1.5-42 months). <b>Conclusions:</b> Aneurysms arising from aberrant visceral arteries present unique challenges because their origin, course, and collateral networks deviate from standard anatomy. Patient selection and detailed anatomic mapping preoperatively are decisive as inadequate imaging or failure to recognize an aberrant origin can lead to the incomplete exclusion or inadvertent sacrifice of critical branches. Understanding the anatomy of visceral arteries and their variations is paramount in clinical practice, particularly when planning interventions for minimizing procedural risks, optimizing outcomes, and preventing potential complications. Contemporary practice favors endovascular repair due to lower perioperative morbidity, but success depends on vessel tortuosity, landing zones, and the presence of important side branches that supply end organs.