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Pulivarthi VSKK, Katamreddy Y, Vulasala SS, Onteddu J, Mandyam S, Onteddu N. Spontaneous Subdiaphragmatic Hemorrhage From an Aneurysm of Inferior Phrenic Artery. ACG Case Rep J 2024; 11:e01395. [PMID: 38912373 PMCID: PMC11191900 DOI: 10.14309/crj.0000000000001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/17/2024] [Indexed: 06/25/2024] Open
Abstract
Inferior phrenic artery (IPA) aneurysms are the rarest type of visceral aneurysms. It usually occurs secondary to trauma, surgery, or as a complication of pancreatitis. In addition, it can be a manifestation of underlying systemic pathology such as vasculitis, collagen vascular disorders, sepsis, or segmental arterial mediolysis. It can be associated with hypertension in 43% of cases. The presentation of IPA aneurysm is nonspecific with abdominal pain, melena, hematochezia, and anemia. The ruptured and actively bleeding aneurysm can lead to hemorrhagic shock, and immediate management is required with angiography and endovascular embolization with coil or gel foam or stent etc. Inaccessible locations are reached with surgical intervention, but it is associated with high morbidity and mortality. We here report a rare case of spontaneously ruptured IPA pseudoaneurysm extending from the posterior mediastinum to the subdiaphragmatic area and managed with coil and gel foam embolization.
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Affiliation(s)
| | - Yamini Katamreddy
- Department of Internal Medicine, West Anaheim Medical Center, Anaheim, CA
| | - Sai Swarupa Vulasala
- Department of Internal Medicine/Radiology, East Carolina Health Medical Center, Greenville, NC
| | - Jayabharath Onteddu
- Department of Internal Medicine, Viswabharathi Medical College, Andhra Pradesh, India
| | | | - Nirmal Onteddu
- Department of Internal Medicine, Flowers Hospital, Dothan, AL
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2
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Larson AS, Bathla G, Brinjikji W, Lanzino G, Cheek-Norgan EH, Aubry MC, Huston J, Benson JC. A review of histopathologic and radiologic features of non-atherosclerotic pathologies of the extracranial carotid arteries. Neuroradiol J 2024:19714009241242592. [PMID: 38557110 DOI: 10.1177/19714009241242592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Diseases of the carotid arteries can be classified into different categories based on their origin. Atherosclerotic carotid disease remains the most encountered arterial wall pathology. However, other less-common non-atherosclerotic diseases can have detrimental clinical consequences if not appropriately recognized. The underlying histological features of each disease process may result in imaging findings that possess features that are obvious of the disease. However, some carotid disease processes may have histological characteristics that manifest as non-specific radiologic findings. The purpose of this manuscript is to review various non-atherosclerotic causes of carotid artery disease as well as their histologic-radiologic characteristics to aid in the appropriate recognition of these less-commonly encountered pathologies.
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Affiliation(s)
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, USA
- Department of Neurosurgery, Mayo Clinic, USA
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, USA
- Department of Neurosurgery, Mayo Clinic, USA
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3
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Bowie RA, Clapp AD, Reese RL, Nguyen CQ, Chipi PY. A Case Report of Renal Infarcts Secondary to Segmental Arterial Mediolysis. Cureus 2024; 16:e58933. [PMID: 38659713 PMCID: PMC11042666 DOI: 10.7759/cureus.58933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 04/26/2024] Open
Abstract
Flank pain is an exceptionally common presenting symptom in the emergency and primary care setting; however, most clinicians may not include a differential diagnosis of renal infarct (RI) due to the reported low incidence of this condition. Delayed diagnosis or treatment intervention for RI can have dire consequences for the patient including hypertension and longstanding renal impairment. In this report, we review a case of a previously healthy 39-year-old male presenting with flank pain, which after extensive workup, was revealed to be caused by renal infarction from a renal artery dissection secondary to segmental arterial mediolysis (SAM).
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Affiliation(s)
| | | | - Robyn L Reese
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School Multicampus Geriatric Fellowship Program, Boston, USA
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4
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Hayama T, Ochiai H, Nozawa K, Kikuchi Y, Sasajima Y, Fukagawa T. A case of rectal cancer complicated with segmental arterial mediolysis (SAM) safely treated with curative resection - A case report. Int J Surg Case Rep 2024; 116:109418. [PMID: 38417239 PMCID: PMC10943991 DOI: 10.1016/j.ijscr.2024.109418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Recent advances in diagnostic imaging techniques have led to an increasing number of case reports of segmental arterial mediolysis (SAM). However, reports of abnormalities associated with SAM of abdominal organs, including the bowel, are limited. SAM, a rare vascular disease that causes spontaneous intra-abdominal bleeding, including shock and intestinal ischemia, has been reported to be associated with high mortality, but it has not been reported to coexist with rectal cancer. CASE PRESENTATION A 74 year-old male was referred to our hospital with a rectal cancer and he was admitted for further examination. Computed tomography angiography (CTA) revealed dissection and aneurysm in the celiac artery, superior mesenteric artery (SMA), and the inferior mesenteric artery were dilated, leading to a diagnosis of SAM. CLINICAL DISCUSSION Surgery for rectal cancer requires cutting the inferior mesenteric artery. The risk of bleeding during surgery increases when SAM is associated with the inferior mesenteric artery. The radical surgery for rectal cancer was executed without complications, including significant bleeding. This was achieved through careful management of SAM, meticulous control of blood pressure throughout the surgical procedure, and the delicate treatment of the SMA. A pathological diagnosis of the resected inferior mesenteric artery at the time of radical surgery was performed, and a definitive diagnosis of SAM was made. CONCLUSION We present a first known case in which high anterior resection was successfully performed for rectal cancer complicated by SAM. The relationship between cancer and SAM is unclear and further case accumulation is needed.
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Affiliation(s)
- Tamuro Hayama
- Department of Surgery, Teikyo University School of Medicine, Japan.
| | - Hiroki Ochiai
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Yoshinao Kikuchi
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Yuko Sasajima
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Takeo Fukagawa
- Department of Surgery, Teikyo University School of Medicine, Japan
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Saha MK. Overview of Vasculitides in Adults. Neuroimaging Clin N Am 2024; 34:1-12. [PMID: 37951696 DOI: 10.1016/j.nic.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Vasculitis is characterized by the inflammation of blood vessels. Vasculitides refers to the different forms of vasculitis, often classified according to the size of the blood vessel that is involved. Vasculitis may occur as a primary process or secondary to many systemic diseases. This topic provides an overview of the clinical features, diagnosis, and classification of the different forms of vasculitides.
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Affiliation(s)
- Manish K Saha
- Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA.
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Hirose Y, Tajima Y, Sakata H, Uekusa T, Kamada K, Ikehara T, Matsuda I, Yoneyama S, Hidemura A, Suzuki H. Gallbladder hemorrhage associated with segmental arterial mediolysis: a case report. Surg Case Rep 2024; 10:8. [PMID: 38185806 PMCID: PMC10772053 DOI: 10.1186/s40792-023-01799-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Gallbladder hemorrhage is a rare but fatal condition. The reported causes of gallbladder hemorrhage include iatrogenesis, atherosclerotic changes in the cystic arteries, acute cholecystitis or cholelithiasis, malignancy, trauma, hemophilia, pseudoaneurysm, and the use of oral anticoagulant medications. Recently, segmental arterial mediolysis (SAM) has been reported as a possible etiology of life-threatening abdominal, retroperitoneal, and intracranial hemorrhages. However, no previous reports have described the association between gallbladder hemorrhage and SAM. CASE PRESENTATION A 59-year-old man was transferred to our hospital complaining of upper abdominal pain and vomiting. Contrast-enhanced computed tomography revealed high-density images of the gallbladder and common bile duct. However, there were no obvious findings of gallstones, cholecystitis, tumors, or aneurysms. He was diagnosed with gallbladder hemorrhage and bile duct obstruction. We performed a laparoscopic cholecystectomy after endoscopic biliary drainage. The gross appearance of the surgically resected specimen showed 12 small (3-12 mm), slightly elevated lesions on the gallbladder mucosa. Histologically, these slightly elevated lesions consisted of dilated muscular arteries of the gallbladder wall with fibrinoid degeneration of the media and focal loss of the internal and external elastic laminae. The histopathological diagnosis was confirmed as SAM. CONCLUSIONS To the best of our knowledge, this is the first reported case of a gallbladder hemorrhage associated with SAM. Our case report shows that SAM can cause gallbladder hemorrhage, suggesting that SAM should be considered in the differential diagnosis of gallbladder hemorrhage.
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Affiliation(s)
- Yuichi Hirose
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan.
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Yusuke Tajima
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Hiroki Sakata
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Toshimasa Uekusa
- Department of Pathology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Kentaro Kamada
- Department of Gastrointestinal Medicine, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Takashi Ikehara
- Department of Gastrointestinal Medicine, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Izuru Matsuda
- Department of Radiology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Satomi Yoneyama
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Akio Hidemura
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Hiroyuki Suzuki
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
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van Twist DJL, Appelboom Y, Magro-Checa C, Haagmans M, Riedl R, Yazar O, Bouwman LH, Mostard GJM. Differentiating between segmental arterial mediolysis and other arterial vasculopathies to establish an early diagnosis - a systematic literature review and proposal of new diagnostic criteria. Postgrad Med 2024; 136:1-13. [PMID: 37998079 DOI: 10.1080/00325481.2023.2288561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/23/2023] [Indexed: 11/25/2023]
Abstract
Segmental arterial mediolysis (SAM) is a rare vascular disease, characterized by acute but transient vulnerability of the wall of medium-sized arteries. The most characteristic feature of SAM is its biphasic course: an injurious phase marked by acute weakness of the arterial wall leading to acute dissection and/or hemorrhage, followed by a reparative phase in which granulation tissue and fibrosis restore the injured arterial wall. Residual stenosis, aneurysms, and/or arterial wall irregularities may remain visible on future imaging studies. Differentiating between SAM and other arterial vasculopathies is difficult due to its similarities with many other vascular diseases, such as vasculitis, fibromuscular dysplasia, inherited connective tissue disorders, and isolated visceral artery dissection. In this systematic review, we provide an overview on SAM, with an emphasis on the differential diagnosis and diagnostic work-up. We propose new diagnostic criteria to help establish a prompt diagnosis of SAM, illustrated by case examples from our multidisciplinary vascular clinic.
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Affiliation(s)
- Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Y Appelboom
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Cesar Magro-Checa
- Department of Rheumatology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Mark Haagmans
- Department of Radiology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Robert Riedl
- Department of Pathology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Ozan Yazar
- Department of Vascular Surgery, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Lee H Bouwman
- Department of Vascular Surgery, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
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A case of transcatheter arterial embolization for intraperitoneal hemorrhage due to giant hepatic segmental arterial mediolysis. Clin J Gastroenterol 2023; 16:397-401. [PMID: 36732461 DOI: 10.1007/s12328-023-01766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023]
Abstract
This study aimed to demonstrate the effect of transcatheter arterial embolization (TAE) on hepatic segmental arterial mediolysis (SAM). The patient, a 68-year-old female, suddenly developed right upper abdominal pain in October 2021, which was initially relieved. However, she was rushed to a local hospital the next day when her abdominal pain recurred. An abdominal computed tomography scan suggested a ruptured hepatic aneurysm; therefore, she was transferred to our hospital and admitted on the same day. On the first day after admission, she underwent emergency catheterization and N-butyl-2-cyanoacrylate (NBCA)/lipiodol embolization for an aneurysm in the hepatic S6. A multi-detector computed tomography on hospital day 8 to probe for extrahepatic lesions revealed multiple beaded irregularities in the superior mesenteric and bilateral renal arteries. A head magnetic resonance angiography performed on the ninth day showed no aneurysms or irregularities. She did well after TAE, did not have rebleeding, and was discharged on hospital day 16. Rupture of an aneurysm associated with SAM occurs frequently in the colonic and gastroepiploic arteries, and rupture of a hepatic aneurysm is relatively rare. TAE hemostasis was able to save the patient by preventing intraperitoneal bleeding caused by hepatic segmental arterial mediolysis.
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9
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Ito C, Koyama T, Fujimori D, Takahashi I, Kasuya M, Oe K, Sakamoto S, Yoshida R, Yoshiike H, Ito M, Yamashita W, Watanabe S, Isogai J. Segmental arterial mediolysis with a ruptured visceral artery on two consecutive days. Acute Med Surg 2023; 10:e899. [PMID: 37814653 PMCID: PMC10560134 DOI: 10.1002/ams2.899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/23/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023] Open
Abstract
Background We describe a case of segmental arterial mediolysis in which a vessel ruptured on two consecutive days. Case Presentation A 69-year-old man presented with sudden-onset abdominal pain. Computed tomography showed a hematoma in the gastric wall. The patient was discharged after the pain was relieved but returned 8 h later with abdominal pain and shock. Repeated computed tomography revealed a massive intra-abdominal hemorrhage without previous aneurysm formation. Emergency angiography and coil embolization were successfully carried out. Segmental arterial mediolysis was diagnosed after irregular vasodilated lesions were observed in multiple arteries. Conclusion This case suggests that accurately predicting the next vessel rupture is difficult. For patients experiencing intra-abdominal bleeding with segmental arterial mediolysis, we suggest treating only ruptured aneurysms and closely following-up unruptured aneurysms.
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Affiliation(s)
- Chikao Ito
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Tomohide Koyama
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Daisuke Fujimori
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Isao Takahashi
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Miyuki Kasuya
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Kyoji Oe
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - So Sakamoto
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | - Ryuhei Yoshida
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | | | - Masaaki Ito
- Department of Emergency MedicineAsahi General HospitalChibaJapan
| | | | - Sho Watanabe
- Department of RadiologyAsahi General HospitalChibaJapan
| | - Jun Isogai
- Department of RadiologyAsahi General HospitalChibaJapan
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10
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Matsuura C, Fuchinoue Y, Terazono S, Kondo K, Harada N, Sugo N. Intraperitoneal hemorrhage due to segmental arterial mediolysis associated with cerebral vasospasm after subarachnoid hemorrhage. Clin Case Rep 2022; 10:e6371. [PMID: 36188053 PMCID: PMC9487451 DOI: 10.1002/ccr3.6371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 11/08/2022] Open
Abstract
A man in his 50s with no significant past medical history developed subarachnoid hemorrhage due to ruptured left middle cerebral artery aneurysm. On the ninth hospital day, he had a ruptured visceral aneurysm with segmental arterial mediolysis, and we successfully treated with transarterial embolization using metallic coils.
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Affiliation(s)
- Chie Matsuura
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
| | - Yutaka Fuchinoue
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
| | - Sayaka Terazono
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
| | - Kosuke Kondo
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
| | - Naoyuki Harada
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
| | - Nobuo Sugo
- Department of Neurosurgery Toho University Omori Medical Center Tokyo Japan
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Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J. Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review. Angiology 2022:33197221100601. [PMID: 35921630 DOI: 10.1177/00033197221100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.
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Affiliation(s)
- Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Jenna Smith
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Sydney L Olson
- 12244Northwestern University Feiberg School of Medicine, Chicago, IL, USA
| | - Opema L Lohese
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Aleem Mirza
- Department of Cardiovascular and Vascular Surgery, 12340University of Texas Health Science, Houston, TX, USA
| | - Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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12
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Matsubara K, Fukuhara N, Hoshina K, Miyahara K, Suhara M, Taniguchi R, Matsukura M, Takayama T. Specific Features of Patients Under 40 Years Old With Small-to-Medium-Sized Arterial Deterioration. Front Surg 2022; 9:808383. [PMID: 35284485 PMCID: PMC8907261 DOI: 10.3389/fsurg.2022.808383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Arterial deterioration is mostly caused by atherosclerosis, which progresses with age. However, we have observed serious backgrounds or etiologies in younger patients with non-atherosclerotic diseases and deterioration of small-to-medium-sized arterial lesions. Therefore, we aimed to identify the specific features of patients aged <40 years with deterioration of small-to-medium-sized arteries. Methods We selected patients who were admitted to our department from 1995 to 2019 with deterioration of small-to-medium-sized arteries (aneurysms, dissection, rupture, or arterial injury/damage) and focused on the cohort aged <40 years. We examined the backgrounds or etiologies of the patients including genetic and inflammatory diseases, which might have caused the arterial deterioration. Results Consequently, more than half (54.1%) of the patients aged <40 years had non-atherosclerotic comorbid diseases. However, the number of deteriorated arterial lesions was higher in patients aged <40 years than in patients aged ≥40 years (3.13 vs. 1.33 lesion/patient; P = 0.011). Furthermore, the data analysis of patients with multiple arterial lesions (≥3) revealed that the younger population tended to have more specific backgrounds or etiologies, notably Ehlers-Danlos syndrome and Behçet's disease. There were no differences in the all-cause mortality and cardiovascular disease-related mortality between patients aged <40 and ≥40 years (P = 0.89 and 0.29, respectively). Conclusions Over 50% of patients aged <40 years with deterioration of small-to-medium-sized arteries had non-atherosclerotic, specific clinical backgrounds or etiologies, including genetic and inflammatory diseases. In addition, they exhibited more arterial lesions than older patients.
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13
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A Single Center 8 Year Experience of Segmental Arterial Mediolysis Management. Ann Vasc Surg 2021; 81:273-282. [PMID: 34775009 DOI: 10.1016/j.avsg.2021.09.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Segmental Arterial Mediolysis (SAM) is a rare, poorly understood vasculopathy that involves vacuolization of the arterial wall, most commonly of the visceral arteries. There are no established therapeutic or monitoring guidelines for SAM, and intervention typically depends on patient presentation. The purpose of this study is to review the management and outcomes of patients with this rare vascular disease METHODS: Single center retrospective review of patients diagnosed with SAM between 2011 and 2019. Included were patients with radiological diagnosis of SAM. Demographic factors, past medical history, presenting symptoms, affected vessels, management, and lesion characteristics over time were collected. Demographic and periprocedural factors, and medical management strategies were compared for those who required operative intervention versus those managed non-operatively. RESULTS Thirty patients were included, 21 (70%) were male, mean age was 53.5 years (range: 35.7-72.2). Twenty-seven patients were managed non-operatively, 3 patients required surgical intervention. Patients who underwent operative intervention were more likely to present with pain >30 days (P < 0.05), and hemorrhage (P < 0.01). Abdominal pain was the most common presenting symptom (n = 24, 80%). Arterial dissection was the most common radiological finding at time of presentation (n = 20, 67%). The celiac artery and its branches were most often involved (n=22, 73%) followed by the superior mesenteric artery and its branches (n = 15, 50%). Non-operative management most often consisted of anti-hypertensive therapy (n = 13, 43%), antiplatelet agents (n = 17, 57%%), and lipid-lowering agents (n = 13, 43%), with 7 patients receiving all three. Six patients demonstrated confirmed resolution of lesions during surveillance imaging, with average time to resolution of 325.5 days. CONCLUSIONS Patients who underwent intervention for SAM presented with either mesenteric ischemia or pseudoaneurysm rupture. In patients that present without those conditions, medical management consisting of anti-hypertensives, antiplatelet agents, and lipid-lowering therapy was effective. Non operative management resulted in symptom resolution in all patients and surveillance imaging showed resolution of radiographic abnormalities in 6 patients out of 27 at less than one year.
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14
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Yiu AC, Hussain A, Byrne MM, Villacorta-Lyew R. Segmental arterial mediolysis: differentiation of rare arteriopathy from vascular mimics. BMJ Case Rep 2021; 14:e245737. [PMID: 34404675 PMCID: PMC8372798 DOI: 10.1136/bcr-2021-245737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Alvin C Yiu
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Ali Hussain
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Matthew M Byrne
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Rachel Villacorta-Lyew
- Department of Critical Care Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA
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15
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A case presenting as fatal subarachnoid hemorrhage due to segmental arterial mediolysis associated with Crohn's disease. Cardiovasc Pathol 2021; 54:107363. [PMID: 34216776 DOI: 10.1016/j.carpath.2021.107363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/08/2021] [Accepted: 06/24/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Segmental arterial mediolysis (SAM) is a rare arterial pathology and can cause rupture or dissection of the intracranial arterial wall. The etiology is unveiled, but vasospastic stimuli such as migraine are considered as a possible cause of SAM. We present the first case of subarachnoid hemorrhage (SAH) due to SAM associated with Crohn's disease and migraine, and discuss the possible contribution of Crohn's disease to the development of SAM besides migraine. CASE DESCRIPTION A 33-year-old man with Crohn's disease, which had been treated with adalimumab, repeatedly underwent 3-tesla magnetic resonance (MR) imaging and angiography for severe headache due to migraine and the subsequent development of fatigue in the left arm and both legs. At 7 months after the last MR imaging studies showing no abnormalities, he had a sudden onset of severe SAH, which was caused by rupture or dissection of the terminal portion in the right internal carotid artery. As his brain-stem reflexes were absent, the patient was conservatively treated and died 6 days after the ictus. By postmortem histopathological examination, SAM was diagnosed as the cause of SAH. Vasa vasorum was also observed around the rupture point. CONCLUSIONS Our case suggests that: 1) the formation of vasa vasorum may be an antecedent pathology for vessel rupture of the fragile arterial wall affected by SAM, and 2) vasospastic nature of both Crohn's disease and migraine may contribute to the development of intracranial SAM.
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O'Shea JP, Gordon S, Horak R, Meadows JM. Segmental Arterial Mediolysis (SAM) Leading to Chronic Renal Insufficiency. Int J Nephrol Renovasc Dis 2021; 14:117-123. [PMID: 33911893 PMCID: PMC8075308 DOI: 10.2147/ijnrd.s287829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/19/2020] [Indexed: 11/23/2022] Open
Abstract
Background Segmental arterial mediolysis (SAM) is a rare self-limiting non-atherosclerotic, non-inflammatory vasculopathy. SAM typically affects the visceral arteries of the abdomen to include the celiac, mesenteric, and renal arteries. SAM has a favorable prognosis in most cases with an asymptomatic course but can have mortality rates as high as 50% due to acute aneurysmal rupture. Very few cases of adverse long-term sequelae involving SAM have been described, and this report of chronic kidney disease represents a sentinel case illustrating that chronic disease can and does occur as a result of SAM and should be investigated for at follow-up. Case Presentation In this case report, we describe a case of a 45-year-old male with erectile dysfunction but without any readily identifiable risk factors for chronic kidney disease (CKD) or vasculopathy, who presented with bilateral renal infarction and parenchymal infarcts due to SAM and who subsequently developed CKD at follow-up. We conduct a mini-literature review that discusses the pathogenesis of SAM in the context of vasospastic diseases, as well as compares the outcomes of observation-only, versus medical-management, versus endovascular-interventions in patients with SAM. Conclusion This is the first case to our knowledge of CKD occurring as an outcome of SAM without any preceding significant comorbidity, highlighting that whereas SAM is of itself rare and typically resolves, chronic disease can linger and should be evaluated for on follow-up. Further, we argue that radiological evidence of precursor vasospastic disease may exist in several locations apart from the index lesion and thus warrants wider whole-body radiographic exploration for lesions as an opportunity to prevent chronic sequelae as illustrated in this case report from occurring. Finally, a review of published case-series suggests that disease progression is less likely to occur after endovascular-intervention compared to observation-only or medical management and the risk of intervention vs conservative management should therefore be discussed with the patient.
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Affiliation(s)
- John-Paul O'Shea
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI, 96859, USA
| | - Sarah Gordon
- Department of Nephrology, Walter Reed National Military Medical Center, Bethesda, MD, 20889, USA
| | - Richard Horak
- Department of Radiology, Tripler Army Medical Center, Honolulu, HI, 96859, USA
| | - J Matthew Meadows
- Department of Radiology, Tripler Army Medical Center, Honolulu, HI, 96859, USA
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Castelli F, Inì C, Scavone G, Zagarella M, Giulietti G, Caltabiano G, Pizzarelli MV, Varsallona B, Scavone A, Basile A. Clinically Suspected Segmental Arterial Mediolysis of the Splanchnic Arteries: A Report of 2 Rare Cases. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929013. [PMID: 33830972 PMCID: PMC8042417 DOI: 10.12659/ajcr.929013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Case series Patients: Female, 89-year-old • Male, 52-year-old Final Diagnosis: Segmental arterial mediolysis Symptoms: Abdominal pain • bleeding Medication: — Clinical Procedure: — Specialty: Radiology
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Affiliation(s)
- Federica Castelli
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Corrado Inì
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies, University Hospital 'Policlinico - Vittorio Emanuele', University of Catania, Catania, Italy
| | - Giovanni Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Marco Zagarella
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Giorgio Giulietti
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Giuseppe Caltabiano
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Marco Vittorio Pizzarelli
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Bruno Varsallona
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Antonio Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Antonio Basile
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies, University Hospital 'Policlinico - Vittorio Emanuele', University of Catania, Catania, Italy
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Natural History of Unruptured Visceral Artery Aneurysms Due to Segmental Arterial Mediolysis and Efficacy of Transcatheter Arterial Embolization: A Retrospective Multiinstitutional Study in Japan. AJR Am J Roentgenol 2021; 216:691-697. [PMID: 33439045 DOI: 10.2214/ajr.19.22547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to clarify the natural history of unruptured visceral artery aneurysms due to segmental arterial mediolysis and the efficacy of transcatheter arterial embolization. MATERIALS AND METHODS. Patients with a pathologic or clinical diagnosis of visceral artery aneurysms due to segmental arterial mediolysis between 2005 and 2015 were enrolled. For patients with clinical diagnoses, images were collected and assessed by central radiologic review. To clarify the natural history of unruptured aneurysms, the morphologic changes were assessed. The efficacy and safety of transcatheter arterial embolization for aneurysms due to segmental arterial mediolysis were evaluated. RESULTS. Forty-five patients with 123 aneurysms due to segmental arterial mediolysis were enrolled. Among the 123 aneurysms, 70 unruptured aneurysms were evaluated for natural history. Forty-five of the 70 (64%) aneurysms had no change in morphology. Among the other 25 aneurysms, nine (13% of the 70) were reduced in size, 13 (19%) disappeared, and three (4%) were newly found at follow-up. Aneurysms of the middle colic artery were ruptured in 10 of 11 (91%) cases. Transcatheter arterial embolization was performed on 45 aneurysms and was successful in all cases but caused slight arterial injury in three cases (6.7%). CONCLUSION. At initial diagnosis, unruptured aneurysms due to segmental arterial mediolysis are likely to be stable or to resolve, but the risk of rupture of aneurysms of the middle colic artery appears high. Transcatheter arterial embolization is a useful treatment, but careful manipulation is necessary.
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Honma K, Yamaoka T, Matsuda D. Ileocolic arterial aneurysm associated with segmental arterial mediolysis: A case report. Vascular 2020; 29:841-845. [PMID: 33375923 DOI: 10.1177/1708538120982696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Segmental arterial mediolysis is a rare disease that most commonly affects the superior mesenteric artery among abdominal arteries. However, aneurysms involving the ileocolic arterial branch of the superior mesenteric artery are extremely rare. Here, we describe the treatment of a patient with an ileocolic arterial aneurysm suspected to have occurred secondary to segmental arterial mediolysis. METHODS We confirmed the diagnosis of ileocolic arterial aneurysm, which showed the characteristic "string-of-beads" appearance of the distal main trunk of the superior mesenteric artery on angiography. We performed endovascular coil embolization for the aneurysm, and for both the inflow and outflow vessels. After confirming that the aneurysm was no longer visible, the treatment was completed. RESULTS There were no clinical findings suspicious of ischemic enteritis or intestinal necrosis after embolization. We confirmed that the ileocolic arterial aneurysm was not observed on computed tomography angiography one month after treatment. CONCLUSIONS While development of an ileocolic arterial aneurysm associated with segmental arterial mediolysis is very rare, it is at a high risk of sudden rupture. Therefore, coil embolization is a useful intervention in such patients and can be implemented based on the size and morphology of the aneurysm.
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Affiliation(s)
- Kenichi Honma
- Department of Vascular Surgery, 37100Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, 37100Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Matsuda
- Department of Vascular Surgery, 37100Matsuyama Red Cross Hospital, Matsuyama, Japan
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Berti A, Moura MC, Sechi E, Squizzato F, Costanzo G, Chen JJ, Warrington KJ. Beyond Giant Cell Arteritis and Takayasu's Arteritis: Secondary Large Vessel Vasculitis and Vasculitis Mimickers. Curr Rheumatol Rep 2020; 22:88. [PMID: 33159612 DOI: 10.1007/s11926-020-00965-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of mimickers of large vessel vasculitis (LVV), by the main presenting manifestation, i.e., systemic, vascular, and cranial manifestations. RECENT FINDINGS The main differential diagnoses in patients with giant cell arteritis (GCA) and Takayasu arteritis (TAK) presenting with systemic manifestations (i.e., fever, anorexia, weight loss, night sweats, arthralgia/myalgia, and/or increased inflammatory indexes) are neoplastic, infectious, or other inflammatory conditions. In patients with vascular manifestations (such as peripheral ischemia, vascular stenoses, or aneurysms), atherosclerosis and non-inflammatory vascular diseases should be excluded. In those presenting with predominant cranial symptoms (i.e., temporal headache, jaw claudication, scalp tenderness, transient or permanent vision loss), other causes of headache, cerebrovascular accidents, optic neuropathy, and neuromuscular syndromes need to be considered. The diagnosis of LVV maybe challenging, especially when patients present with atypical or incomplete clinical forms. In these cases, a multidisciplinary approach is strongly recommended.
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Affiliation(s)
- Alvise Berti
- Rheumatology Department, Santa Chiara Regional Hospital and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Largo Madaglie D'Oro 9, 38121, Trento, Italy. .,Thoracic Disease Research Unit, Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA.
| | - Marta Casal Moura
- Thoracic Disease Research Unit, Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Elia Sechi
- Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | | | - Giulia Costanzo
- Allergy and Clinical Immunology, University of Cagliari, Cagliari, Italy
| | - John J Chen
- Ophthalmology and Neurology, Mayo Clinic, Rochester, MN, USA
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Ota K, Matsubara N. A Case of Segmental Arterial Mediolysis: Hemoperitoneum with Hemorrhagic Shock due to Rupture of a Visceral Artery Aneurysm Following Subarachnoid Hemorrhage. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:189-194. [PMID: 37502735 PMCID: PMC10370665 DOI: 10.5797/jnet.cr.2020-0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/03/2020] [Indexed: 07/29/2023]
Abstract
Objective Segmental arterial mediolysis (SAM) is a non-inflammatory and non-atherosclerotic vascular disease characterized by segmental medial defect/necrosis of muscular arteries as a result of mediolysis. SAM affects the visceral and intracranial arteries, and causes arterial dissection and aneurysm. We report a case of aneurysmal subarachnoid hemorrhage (SAH) followed by hemoperitoneum due to a ruptured visceral artery aneurysm. Case Presentation A 54-year-old man developed SAH from a ruptured anterior communicating artery aneurysm, which was clipped on the same day. Thereafter, he was treated to prevent cerebral vasospasm. Six days after onset, he developed acute anemia and his blood pressure decreased, suggesting hemorrhagic shock. Hemoperitoneum was detected on computed tomography and abdominal angiography was performed. Irregular and stenotic arterial findings, and an unusual aneurysm with contrast stasis were found in a branch vessel from the right gastroepiploic artery. SAM was diagnosed based on the clinical course and angiographic characteristics. Endovascular treatment consisted of embolization of the visceral artery aneurysm with liquid embolic material. after embolization, the vital signs stabilized and he recovered from shock. Acute treatment for SAH was continued. Although the patient did not develop vasospasm-related sequelae, he was transferred to the rehabilitation hospital 7 weeks after onset and his modified Rankin Scale score at 3 months after onset was 2. Conclusion Visceral artery aneurysm associated with SAM should be considered as the cause of hemoperitoneum with hemorrhagic shock during the acute phase of SAH.
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Affiliation(s)
- Keisuke Ota
- Department of Neurosurgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Noriaki Matsubara
- Department of Neurosurgery and Neuroendovascular Therapy, Osaka Medical College, Takatsuki, Osaka, Japan
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Matsuura S, Takayama T, Endo T, Akai T, Isaji T, Hoshina K. A case of endovascular therapy for treating idiopathic arterial deteriorations of unknown etiology. Int J Surg Case Rep 2020; 76:202-206. [PMID: 33039783 PMCID: PMC7560634 DOI: 10.1016/j.ijscr.2020.09.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/25/2020] [Indexed: 11/27/2022] Open
Abstract
A 50-year-old patient presented with multiple idiopathic arterial deteriorations. He had a renal artery tear and a pseudoaneurysm of the left internal iliac artery. Previous direct intervention failed and we suspected vascular fragility. The two lesions were treated by simultaneously placing endografts. Endovascular treatment is a desirable option in the case of vascular fragility.
Introduction Peripheral artery pseudoaneurysm as a consequence of arterial deterioration is relatively rare in young populations, who typically lack an atherosclerotic background. Such pseudoaneurysms are known to pose a risk of rupture, which is correlated with high mortality and morbidity rates. Pseudoaneurysms are more prone to rupture than true aneurysms are, as their vessel walls tear more easily. We present the case of a 50-year-old patient who had multiple arterial deteriorations. Case presentation The patient experienced backache, and computed tomography revealed a tear of the right renal artery, and a pseudoaneurysm of the left internal iliac artery. He had a history of graft replacement for the right superficial artery pseudoaneurysm, which had been occluded. Although various tests were performed for differential diagnosis, the etiology was unidentified. Considering the suspected vascular fragility and failure of previous direct intervention, these 2 lesions were treated by placing endografts simultaneously. Discussion We investigated various diseases causing vascular fragility in the reported case, such as vascular Behçet disease, vascular Ehlers-Danlos syndrome, fibromuscular dysplasia, and segmental arterial mediolysis. However, these were all excluded and the etiology remains unclear. Progress in endovascular techniques enables the use of minimally invasive treatment in patients with vascular fragility. Conclusion When vascular fragility may exist, endovascular treatment is a desirable option, as it can be performed repetitively and is less invasive.
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Affiliation(s)
- Sohei Matsuura
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
| | - Takashi Endo
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
| | - Takafumi Akai
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
| | - Toshihiko Isaji
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan.
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23
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Roy M, Roy AK, McCrate ME. Segmental arterial mediolysis: a commonly overlooked aetiology of acute abdominal pain. BMJ Case Rep 2020; 13:13/6/e234576. [PMID: 32540880 DOI: 10.1136/bcr-2020-234576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Segmental arterial mediolysis (SAM) is an uncommon condition and commonly missed diagnostic aetiology of acute abdominal pain, initially described in 1976. SAM is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries with notable asymmetric involvement of the walls of the mesenteric arteries and their branches. Clinical presentation ranges from postprandial abdominal discomfort suggestive of mesenteric ischaemia to intra-abdominal bleeding. Pathophysiological explanation and prognosis of these cases are not well understood and therefore no clear guidelines for management exist. In this case report, we emphasise the imaging modalities used to reach the diagnosis and the management options available.
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Affiliation(s)
- Moni Roy
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA .,Department of Internal Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Ashish Kumar Roy
- Department of Internal Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Mary E McCrate
- Department of Radiology, University Of Illinois College Of Medicine, Peoria, Illinois, USA.,Central Illinois Radiological Associates, Inc, Peoria, Illinois, USA
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Peng KX, Davila VJ, Stone WM, Shamoun FE, Naidu SG, McBane RD, Money SR. Natural history and management outcomes of segmental arterial mediolysis. J Vasc Surg 2020; 70:1877-1886. [PMID: 31761101 DOI: 10.1016/j.jvs.2019.02.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 02/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Segmental arterial mediolysis (SAM) is a poorly understood, nonatherosclerotic, noninflammatory disease resulting from arterial medial degeneration. Patients may present with aneurysm, dissection, stenosis, or bleeding from visceral or renal arteries. Treatment algorithms are poorly characterized. METHODS A retrospective review of all patients diagnosed with SAM was performed at our institution. Patients were identified by established criteria that include clinical presentation in combination with radiographic and serologic findings. Demographics, presenting symptoms, diagnostic evaluation, management, and outcomes were reviewed. RESULTS There were 117 patients diagnosed with SAM between 2000 and 2016; 67.5% (n = 79) were male. Mean age was 52.7 years (range, 23.4-90 years); 69.2% (n = 81) presented with acute abdominal pain, 22.2% (n = 26) with flank pain, and 19.7% (n = 23) with back pain; 15.4% (n = 18) had abdominal pain longer than 30 days; 13.7% (n = 16) had acute hypertension, and 5.1% (n = 6) were hypotensive; 10.3% (n = 12) were asymptomatic. There were 93 (79.5%) dissections and 61 (52.1%) aneurysms. Hemorrhage was seen in 10 (8.5%). The celiac axis was affected in 54.7% (n = 64), renal arteries in 49.6% (n = 5 8), superior mesenteric artery in 43.6% (n = 51), and inferior mesenteric artery in 2.6% (n = 3). After diagnosis of SAM, aspirin was prescribed in 60.7% (n = 71). Statins were prescribed in 29.9% (n = 35). Antihypertensive medications were prescribed in 65% (n = 76), including beta blockers in 42.7% (n = 50); 40.2% (n = 47) of patients were prescribed anticoagulation. Interventions were performed in 26 (22%) patients; 13 had endovascular intervention only, 9 open surgery only, and 4 open and endovascular interventions. Of the 17 patients undergoing endovascular intervention, 19 procedures were performed, most commonly embolization (78.9% [n = 15]), followed by stenting (10.5% [n = 2]). Of the 13 patients undergoing open surgery, 14 procedures were performed, including arterial bypass (50% [n = 7]) and splenectomy with aneurysm ligation (15.4% [n = 2]). Other surgery involved thrombectomy (21.4% [n = 3]) and angioplasty (14.3% [n = 2]). Only 11.5% (n = 3) experienced a perioperative complication, including one hematoma, one abscess, and one death secondary to ongoing hemorrhage. Follow-up imaging was performed in 96.6% (n = 112). Mean follow-up was 1258 days (range, 2-5017 days). Of these, 27.7% (n = 31) had regression, 43.8% (n = 49) stability, and 28.6% (n = 32) progression. Average time between initial diagnosis and progression was 666 days. CONCLUSIONS SAM is an uncommon disease that may require intervention; it is therefore important that the vascular surgery community be aware of this disease. Follow-up imaging is required to monitor for disease progression.
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Affiliation(s)
- Kate X Peng
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz.
| | - Victor J Davila
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | - William M Stone
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | - Fadi E Shamoun
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Minn
| | - Sailendra G Naidu
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | - Robert D McBane
- Department of Vascular Medicine, Mayo Clinic Rochester, Rochester, Minn
| | - Samuel R Money
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz
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Kumar P, Chua JME, Yeo JJY, Choke ETC, Sachdeva P. Percutaneous Transgastric–Transpancreatic Treatment of a Dissecting Splenic Artery Pseudoaneurysm due to Segmental Arterial Mediolysis. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2020. [DOI: 10.1055/s-0039-3401395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AbstractDissecting splenic artery pseudoaneurysm due to segmental arterial mediolysis (SAM) is a rare condition. We describe a case of direct percutaneous transgastric–transpancreatic thrombin injection into a dissecting splenic artery pseudoaneurysm due to SAM. The direct thrombin injection resulted in successful thrombosis of the pseudoaneurysm. At 1-month follow-up, the patient remained well with persistent thrombosis of the pseudoaneurysm.
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Affiliation(s)
- Pradesh Kumar
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Jasmine Ming Er Chua
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Jared Jue Ying Yeo
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | | | - Pooja Sachdeva
- Department of General Medicine, Sengkang General Hospital, Singapore
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26
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Aortic dissection or spontaneous renal artery dissection, a rare diagnosis? CEN Case Rep 2020; 9:257-259. [PMID: 32246273 DOI: 10.1007/s13730-020-00469-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022] Open
Abstract
Spontaneous renal artery dissection (SRAD) is a rare entity causing muscle spasm due to acute low back pain, back pain, or flank pain symptoms or misleading clinical diagnosis such as renal colic. A 25-year-old Syrian male refugee presented to the emergency department with sudden onset of left-sided flank pain in the evening. Physical examination results were normal except left-sided costovertebral angle sensitivity. Abdominal, pelvic and thoracic contrast computed tomography angiography (CTA) was performed to evaluate aortic dissection, which was our urgent preliminary diagnosis. Left renal artery dissection was detected in CTA. The patient was treated with medical conservative treatment and spontaneous recovery was observed during the follow-up period. Early detection of SRAD in the emergency department can be difficult due to the fact that the clinical presentation is misleading.
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Moriarty HK, Martin K, Koukounaras J, Goh GS, Clements W. Omental apoplexy: Unravelling the mystery. J Med Imaging Radiat Oncol 2020; 64:319-325. [PMID: 32216060 DOI: 10.1111/1754-9485.13024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/01/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION To describe cases omental haemorrhage and to review the literature on this topic. METHODS We describe three cases of spontaneous omental haemorrhage and discuss various management strategies, in an attempt to provide direction for similar cases in the future. RESULTS A number of case reports of spontaneous or idiopathic omental haemorrhage exist in the literature. These cases are often attributed to an underlying vasculopathy, such as segmental arterial mediolysis (SAM). Appropriate resuscitation is paramount for best outcome. Severe bleeding may require surgery or transcatheter arterial embolisation, which is best performed early if required. Endovascular management using selective catheterisation of the bleeding vessel and embolisation is a minimally invasive alternative to emergent operative intervention. In the three cases we present, endovascular embolisation was performed in two patients, and surgical ligation in a third. Segmental arterial mediolysis is considered the likely aetiology in at least 2 of the 3 cases, based on imaging findings. No further episodes of haemorrhage occurred at follow-up (ranging from 6 months to 2 years). CONCLUSIONS Acute omental haemorrhage is a rare condition; however, it may be associated with significant morbidity and mortality. CT angiography is the imaging of choice. Management strategies include both endovascular and surgical intervention.
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Affiliation(s)
- Heather K Moriarty
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Katherine Martin
- Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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McNally M, Bolster F, Lahiff C. Gut Claudication: The Usual Suspect? Gastroenterology 2020; 158:831-833. [PMID: 31838075 DOI: 10.1053/j.gastro.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Mairéad McNally
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland.
| | - Ferdia Bolster
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland
| | - Conor Lahiff
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland
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A Review of Primary Vasculitis Mimickers Based on the Chapel Hill Consensus Classification. Int J Rheumatol 2020; 2020:8392542. [PMID: 32148510 PMCID: PMC7049422 DOI: 10.1155/2020/8392542] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
Primary systemic vasculitides are rare diseases that may manifest similarly to more commonly encountered conditions. Depending on the size of the vessel affected (large vessel, medium vessel, or small vessel), different vasculitis mimics must be considered. Establishing the right diagnosis of a vasculitis mimic will prevent unnecessary immunosuppressive therapy.
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Ko M, Kamimura K, Sakamaki A, Niwa Y, Tominaga K, Mizuno K, Terai S. Rare Mesenteric Arterial Diseases: Fibromuscular Dysplasia and Segmental Arterial Mediolysis and Literature Review. Intern Med 2019; 58:3393-3400. [PMID: 31327836 PMCID: PMC6928505 DOI: 10.2169/internalmedicine.3094-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases that cause aneurysm, occlusion, and thromboses. These diseases are rarely seen in mesenteric arterial lesions; however, as they can be lethal if appropriate management is not provided, the accumulation of clinical information from cases is essential. We herein report the cases of a 57-year-old man diagnosed with FMD and a 63-year-old man diagnosed with SAM. We conclude that an early diagnosis with imaging modalities and clinical information followed by the appropriate treatment improves the prognosis of these arterial diseases.
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Affiliation(s)
- Masayoshi Ko
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Yusuke Niwa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Kenichi Mizuno
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
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A Ruptured Blood Blister-Like Aneurysm Associated with Intraperitoneal Hemorrhage due to Segmental Arterial Mediolysis: A Case Report and Literature Review. World Neurosurg 2019; 134:79-85. [PMID: 31669242 DOI: 10.1016/j.wneu.2019.10.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Segmental arterial mediolysis (SAM) is a rare non-atherosclerotic, noninflammatory vascular disease, characterized by mediolysis. We report an extremely rare case of subarachnoid hemorrhage (SAH) due to a ruptured blood blister-like aneurysm (BBA) of the internal carotid artery associated with SAM-related arteriopathy. CASE DESCRIPTION We experienced a case of SAH followed by intraperitoneal hemorrhage that occurred 12 days after the SAH onset. SAH was caused by a ruptured BBA of the internal carotid artery, which was treated by trapping with high-flow bypass. Intraperitoneal hemorrhage was caused by a rupture of a posterior inferior pancreaticoduodenal artery (PIPDA) aneurysm, which induced hypovolemic shock resulting in death in spite of endovascular internal trapping. Postmortem pathologic examination revealed that the PIPDA pseudoaneurysm was due to SAM. CONCLUSIONS We should pay attention to the association of SAM, which is a potentially life-threatening pathology when treating cerebral BBAs.
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Skeik N, Hyde JR, Olson SL, Thaler CM, Abuatiyeh W, Ahmed AK, Lyon DR, Witt DR, Garberich R, Sullivan T. Nonatherosclerotic Abdominal Vasculopathies. Ann Vasc Surg 2019; 60:128-146. [DOI: 10.1016/j.avsg.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/11/2019] [Accepted: 04/04/2019] [Indexed: 11/28/2022]
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33
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Segmental arterial mediolysis. RADIOLOGIA 2019. [DOI: 10.1016/j.rxeng.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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34
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Hybrid Surgery for Multiple Visceral Artery Aneurysms: A Case Report. Ann Vasc Surg 2019; 60:478.e19-478.e24. [PMID: 31200042 DOI: 10.1016/j.avsg.2019.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND We present a case with multiple visceral artery aneurysms that were treated with a hybrid approach involving both surgical and endovascular treatment. CASE REPORT The patient was a 48-year-old female. She was diagnosed with multiple visceral artery aneurysms including 2 splenic artery aneurysms, celiac artery aneurysm, and bilateral renal artery aneurysms during an examination for loss of appetite. With regard to 2 splenic artery aneurysms, the proximal aneurysm was treated surgically, whereas the peripheral aneurysm that was located deeply in the abdomen was treated with coil embolization. The celiac artery aneurysm located at the bifurcation of the common hepatic artery and splenic artery, an intracranial aneurysm clip was used. The left and right renal aneurysms were resected and renal arteries were reconstructed surgically. The postoperative course was uneventful. The pathological diagnosis of all aneurysms was segmental arterial mediolysis. The reconstructed vessels were patent without stenosis or recurrence at 1 year after the operation. CONCLUSIONS Hybrid treatment involving surgical resection, endovascular coil embolization, and obliteration with clips was useful in the treatment of multiple visceral artery aneurysms.
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Jurado Basildo C, Santos Armentia E, Silva Priege N, Villanueva Campos AM. Segmental arterial mediolysis. RADIOLOGIA 2019; 61:430-434. [PMID: 31155224 DOI: 10.1016/j.rx.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 11/19/2022]
Abstract
This article reports the case of a 51-year-old woman in whom brain MRI to follow up multiple sclerosis incidentally discovered an intramural hematoma in the extracranial internal carotid artery. MR angiography of the supra-aortic trunks and CT angiography of the aorta showed arterial dilations, aneurysms, dissections, and intramural hematomas in the internal carotid arteries, vertebral arteries, and arteries in the splanchnic territory. These findings raised suspicion of segmental arterial mediolysis. After 6 months of treatment with antiplatelet drugs, the arterial involvement resolved. Segmental arterial mediolysis is an uncommon disease; low clinical suspicion and radiologists' lack of knowledge about this entity mean that it can go undetected or be confused with other vasculitides. This report describes the most relevant pathophysiological findings and correlates them with the imaging findings.
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Affiliation(s)
- C Jurado Basildo
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España.
| | - E Santos Armentia
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España
| | - N Silva Priege
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España
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Kaneko S, Watanabe E, Abe M, Watanabe S, Yabe H, Kojima S, Takagi K, Hirai K, Morishita Y, Terai C. Scleroderma renal crisis with coexisting segmental arterial mediolysis presenting as intraperitoneal bleeding: a case report. J Med Case Rep 2019; 13:74. [PMID: 30890184 PMCID: PMC6425683 DOI: 10.1186/s13256-019-1993-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 01/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Segmental arterial mediolysis is a rare nonarteriosclerotic and noninflammatory vascular disease that may cause intraperitoneal bleeding. Scleroderma renal crisis is a rare complication of systemic sclerosis, leading to severe hypertension and renal dysfunction. To the best of our knowledge, this is the first reported case of a patient with concurrent systemic sclerosis with scleroderma renal crisis and pathologically confirmed segmental arterial mediolysis. Case presentation We report a case of a 68-year-old Chinese woman diagnosed with systemic sclerosis who was found to have coexisting segmental arterial mediolysis. She presented with back pain, and massive intraperitoneal bleeding was detected by computed tomography. She underwent laparotomy, and the bleeding was found to originate from the gastroepiploic artery. The pathological examination demonstrated gastroepiploic arterial dissection caused by segmental arterial mediolysis. After surgery, she developed severe hypertension with hyperreninemia and progressive renal dysfunction. Given the risk factors of corticosteroid administration and the presence of anti-ribonucleic acid polymerase III antibody, she was diagnosed with scleroderma renal crisis. The patient was proved to have a very rare case of coexisting scleroderma renal crisis and segmental arterial mediolysis. Conclusions There is no known etiological connection between segmental arterial mediolysis and systemic sclerosis or scleroderma renal crisis, but it is possible that coexisting segmental arterial mediolysis and scleroderma renal crisis may have interacted to trigger the development of the other in our patient.
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Affiliation(s)
- Shohei Kaneko
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.,Department of Nephrology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Eri Watanabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Mai Abe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Shinji Watanabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroki Yabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Shigehiro Kojima
- Department of Surgery, Sainokuni Higashiomiya Medical Center, 1522 Toro-cho, Kita-ku, Saitama, 331-8577, Japan
| | - Kenji Takagi
- Department of Rheumatology, Sainokuni Higashiomiya Medical Center, 1522 Toro-cho, Kita-ku, Saitama, 331-8577, Japan
| | - Keiji Hirai
- Department of Nephrology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Yoshiyuki Morishita
- Department of Nephrology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Chihiro Terai
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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Valluru B, Yang B, Sharma K, Adam AA, Wei D, Zhou Z, Ali MO. Significance of radiology in the diagnosis and management of ruptured left gastric artery aneurysm associated with acute pancreatitis: Case report. Medicine (Baltimore) 2019; 98:e14824. [PMID: 30855508 PMCID: PMC6417524 DOI: 10.1097/md.0000000000014824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Left gastric artery aneurysms are very rare which progresses into hemorrhagic shock and diagnosis is very challenging particularly in patients with acute pancreatitis and cholecystitis whose vitals become unstable suddenly. PATIENT CONCERNS A 72-year-old female has presented with severe progressing abdominal pain was treated with total parenteral nutrition for acute pancreatitis based on preliminary work up, but suddenly became unstable with dropping vitals over the ensuing 48 hours. Physical examination has a positive Murphy sign and appeared lethargic. She has no past history of any chronic systemic illness or malignancy. DIAGNOSES Ruptured left gastric artery aneurysm and left hepatic artery aneurysm with intraperitoneal hemorrhage associated with acute pancreatitis and cholecystitis. INTERVENTIONS Emergency interventional surgery was performed to embolize both the aneurysms and the giant aneurysmal sac of the left gastric artery was secured with a micrometallic occluding coil which eventually controlled the active hemorrhage. OUTCOMES The patient became stable and was discharged after 15 days without any recurrence or complications during the 6-month follow-up. LESSONS This case is a peculiar example of a missed diagnosis of left gastric artery aneurysm associated with acute pancreatitis and cholecystitis with deteriorating clinical condition. Exhaustive radiological investigations are necessary for early diagnosis correlating with presenting clinical situations. Radiologists should be familiar with the challenges in diagnosis and management.
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Affiliation(s)
- Bimbadhar Valluru
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali University Institute of Materia Medica
| | - Bin Yang
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, Yunnan, People's Republic of China
| | - Kalyan Sharma
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, Yunnan, People's Republic of China
| | - Ahmed Abdullahi Adam
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, Yunnan, People's Republic of China
| | - Du Wei
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali University Institute of Materia Medica
| | - Zhou Zhou
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, Yunnan, People's Republic of China
| | - Mahamed Osman Ali
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, Yunnan, People's Republic of China
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Jojima K, Nogami E, Shimauchi K, Kuwano A, Kitsuka T, Mukae Y, Furutachi A, Takamatsu M, Itou M, Yunoki J, Tanaka A, Nishida T. Acute Dissection of the Middle Colic Artery Immediately after Endovascular Abdominal Aortic Aneurysm Repair: A Case Report. Ann Vasc Surg 2019; 58:382.e11-382.e14. [PMID: 30802565 DOI: 10.1016/j.avsg.2018.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/07/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
A 78-year-old man underwent endovascular abdominal aortic aneurysm repair (EVAR) for a true aortic aneurysm. He developed sudden abdominal pain 4 hr after EVAR. Angiography revealed a dissected aneurysm of the middle colic artery (MCA). Despite conservative treatment, follow-up computed tomography revealed an expanded aneurysm of the MCA. We therefore performed coil embolization of the dissected MCA to prevent a rupture of the aneurysm. There has never been a reported case of acute dissection of the MCA immediately after EVAR that was not caused by catheters. In this report, we discuss the possible underlying mechanisms and the optimal therapeutic strategy for this rare complication.
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Affiliation(s)
- Kota Jojima
- Center for Graduate Medical Education Development and Research, Faculty of Medicine, Saga University Hospital, Saga, Japan.
| | - Eijiro Nogami
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kota Shimauchi
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Akito Kuwano
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takahiro Kitsuka
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yousuke Mukae
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Akira Furutachi
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masanori Takamatsu
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Manabu Itou
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Junji Yunoki
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Atsuhisa Tanaka
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takahiro Nishida
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
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Abramovitz B, Leonberg-Yoo A, Bahrainwala JZ, Litt H, Rudnick MR. Bilateral Renal Infarctions During the Use of Sumatriptan. Kidney Int Rep 2018; 3:1233-1236. [PMID: 30197992 PMCID: PMC6127403 DOI: 10.1016/j.ekir.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Blaise Abramovitz
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Correspondence: Blaise Abramovitz, 3096 Henrich Farm Lane, Allison Park, Pennsylvania 15101, USA.
| | - Amanda Leonberg-Yoo
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jehan Z. Bahrainwala
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harold Litt
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael R. Rudnick
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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40
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Ko M, Kamimura K, Ogawa K, Tominaga K, Sakamaki A, Kamimura H, Abe S, Mizuno K, Terai S. Diagnosis and management of fibromuscular dysplasia and segmental arterial mediolysis in gastroenterology field: A mini-review. World J Gastroenterol 2018; 24:3637-3649. [PMID: 30166859 PMCID: PMC6113722 DOI: 10.3748/wjg.v24.i32.3637] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/17/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
The vascular diseases including aneurysm, occlusion, and thromboses in the mesenteric lesions could cause severe symptoms and appropriate diagnosis and treatment are essential for managing patients. With the development and improvement of imaging modalities, diagnostic frequency of these vascular diseases in abdominal lesions is increasing even with the small changes in the vasculatures. Among various vascular diseases, fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases which need to be diagnosed urgently because these diseases could affect various organs and be lethal if the appropriate management is not provided. However, because FMD and SAM are rare, the cause, prevalence, clinical characteristics including the symptoms, findings in the imaging studies, pathological findings, management, and prognoses have not been systematically summarized. Therefore, there have been neither standard diagnostic criteria nor therapeutic methodologies established, to date. To systematically summarize the information and to compare these disease entities, we have summarized the characteristics of FMD and SAM in the gastroenterological regions by reviewing the cases reported thus far. The information summarized will be helpful for physicians treating these patients in an emergency care unit and for the differential diagnosis of other diseases showing severe abdominal pain.
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Affiliation(s)
- Masayoshi Ko
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Kohei Ogawa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Hiroteru Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Satoshi Abe
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Kenichi Mizuno
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 9518510, Japan
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Rothenberg KA, McFarland GE, Stern JR. Endovascular Repair of Ruptured Hepatic Artery Pseudoaneurysm Secondary to Fibromuscular Dysplasia. Vasc Endovascular Surg 2018; 53:66-70. [DOI: 10.1177/1538574418794075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We describe successful endovascular treatment of a patient with fibromuscular dysplasia of the celiac axis leading to development of a common hepatic artery pseudoaneurysm with contained rupture. An 81-year-old woman was transferred to our quaternary care center with concern for a hepatic artery rupture. Further imaging demonstrated a common hepatic artery pseudoaneurysm with surrounding hematoma as well as multifocal areas of narrowing and dilatation in the celiac trunk consistent with fibromuscular dysplasia. A similar pattern was subsequently identified in the bilateral renal and carotid arteries. The patient underwent successful endovascular exclusion of the pseudoaneurysm with a balloon-expandable covered stent and was discharged home without incident. Fibromuscular dysplasia is a nonatherosclerotic arteriopathy that can lead to stenosis, occlusion, dissection, and aneurysm formation. While it primarily affects the carotid and renal arteries, there are rare case reports involving the mesenteric vasculature. Endovascular therapy appears to be a feasible treatment option for the complicated sequelae of this condition in the rare case of mesenteric arterial involvement.
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Affiliation(s)
- Kara A. Rothenberg
- Department of Surgery, University of California San Francisco–East Bay, Oakland, CA, USA
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
| | | | - Jordan R. Stern
- Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA
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42
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Segmental Arterial Mediolysis of Omental Arteries with Haemoperitoneum: Case Report with Embolization of the Left Omental Artery and Brief Review of Literature. Case Rep Radiol 2018; 2018:4749356. [PMID: 30112243 PMCID: PMC6077596 DOI: 10.1155/2018/4749356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/11/2018] [Indexed: 11/18/2022] Open
Abstract
Segmental arterial mediolysis of an omental artery is an exceptionally rare condition. A 69-year-old man presented with haemoperitoneum six days after being hospitalized due to pneumogenic sepsis. Computed tomography of the abdomen showed a short segment dilatation of an omental artery in the left upper abdomen, compatible with segmental arterial mediolysis. Angiographic examination revealed alterations of omental branches of the right gastroepiploic artery and an aneurysm of the left omental artery, both characteristic of segmental arterial mediolysis. Embolization of the left omental artery with use of N-butyl-2-cyanoacrylate was performed. The postinterventional course was uneventful with increase of haemoglobin levels and without symptoms of omental infarction. Transcatheter embolization in the setting of haemoperitoneum due to segmental arterial mediolysis of an omental branch is technically feasible and a valuable alternative to emergency operation.
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43
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Olivares E, Vingan H, Zhou Q. Spontaneous hemoperitoneum resulting from segmental arterial mediolysis. Radiol Case Rep 2018; 13:732-735. [PMID: 29765485 PMCID: PMC5948471 DOI: 10.1016/j.radcr.2017.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/19/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022] Open
Abstract
Segmental arterial mediolysis is a rare but potentially life-threatening arteropathy of medium to large arteries that can be managed with endovascular treatment for patients who are hemodynamically unstable. We present a case of segmental arterial mediolysis in a 73-year-old woman who developed spontaneous hemoperitoneum in the emergency department after initially presenting with unrelated upper respiratory complaints. Her initial computed tomography revealed an aneurysm arising off the right hepatic artery. She was taken to the interventional radiology suite for embolization and multiple aneurysms along the right hepatic artery were identified that had the appearance of segmental arterial mediolysis. She initially stabilized but then developed acute renal failure and had a decrease in hemoglobin on postprocedure day 2. She was taken back to the angiography suite where multiple small left gastric and left hepatic trunk aneurysms were identified, with a small area of extravasation evident. The vessel was coiled from the liver to the origin of the left gastric artery. She was discharged and had a follow-up angiogram 2 months later, which showed interval development of an aneurysm to the distal right hepatic artery.
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Affiliation(s)
- Emily Olivares
- Department of Radiology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Harlan Vingan
- Department of Radiology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Qiao Zhou
- Department of Radiology, Emory University, Atlanta, GA, USA
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44
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Segmental Arterial Mediolysis: Abdominal Imaging of and Disease Course in 111 Patients. AJR Am J Roentgenol 2018; 210:899-905. [PMID: 29446669 DOI: 10.2214/ajr.17.18309] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to identify the imaging characteristics of segmental arterial mediolysis (SAM) at presentation and establish the longitudinal course of disease. MATERIALS AND METHODS We retrospectively identified patients with SAM at a single institution from 2000 through 2015. Diagnosis was based on published guidelines with multidisciplinary consensus. Imaging studies obtained at initial evaluation were reviewed to evaluate imaging findings and vascular territory distribution. All subsequent follow-up imaging studies were reviewed to assess for progression, stability, or regression. RESULTS We identified 111 patients (79 men and 32 women; median age, 51 years) who met the diagnostic criteria for SAM. Abdominal pain was the most common presentation (74%), followed by flank pain (21%). SAM most commonly affected the renal arteries (47%), superior mesenteric artery (46%), celiac trunk (46%), hepatic artery (23%), iliac arteries (18%), and splenic artery (14%). The most common imaging findings were dissection (86%), aneurysm (57%), beading or webs (28%), occlusion (19%), and a rind or wall thickening (15%). The 247 available follow-up imaging studies for 97 patients (median follow-up, 12 months) showed progression in 19 patients (20%), with either stability or regression observed in the remaining patients. CONCLUSION SAM most commonly affects the renal arteries, superior mesenteric artery, and celiac artery. Dissections and aneurysms are the most common imaging findings. Follow-up imaging studies show stability or regression in most patients.
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Landry GJ, Yarmosh A, Liem TK, Jung E, Azarbal AF, Abraham CZ, Mitchell EL, Moneta GL. Nonatherosclerotic vascular causes of acute abdominal pain. Am J Surg 2018; 215:838-841. [PMID: 29361271 DOI: 10.1016/j.amjsurg.2017.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND To examine the epidemiology, treatments, and outcomes of acute symptomatic non-atherosclerotic mesenteric vascular disease. METHODS Subjects were reviewed over a six year period. Categories included embolism (EM), dissection (DI), and aneurysm (AN). Presentation, demographics, treatment and outcomes were compared. RESULTS 46 patients were identified (EM:20, AN:15, DI:11). Age at presentation differed (EM: 66.3, AN 62.4, DI 54.6, p < .05). EM more likely affected the superior mesenteric artery (EM80%, AN20%, DI45%, p = .002), DI hepatic artery (EM20%, AN13%, DI55%, p < .05), and AN mesenteric branches (EM5%, AN47%, DI0%; p = .001). EM more likely had history of arrhythmia (EM40%, AN7%, DI0%, p,0.05) and diarrhea (EM30%, AN7%, DI0%, p < .05). Treatment was most often surgical in EM (EM85%, AN33%, DI9%, p < .001), endovascular in AN (EM5%, AN40%, DI 9%, p < .02), and conservative in DI (EM15%, AN 33%, DI82%, p < .05). In hospital mortality was infrequent (EM10%, AN7%, DI0%, p = ns). Mean hospital length of stay differed by mechanism (EM13.6days, AN9.2, DI2.3, p = .005). Median follow up was 61 months. Survival at 1, 3 and 5 years for emboli was 75%, 70% and 59%, for aneurysms 93%, 86%, and 77%, and for dissections 100% at all time points (p = .043 log rank). CONCLUSIONS Patients with EM, AN, and DI differ in age, anatomic distribution and method of treatment. The etiology significantly affects long term survival.
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Affiliation(s)
- Gregory J Landry
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA.
| | - Alla Yarmosh
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Timothy K Liem
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Enjae Jung
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Amir F Azarbal
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Cherrie Z Abraham
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Erica L Mitchell
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
| | - Gregory L Moneta
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OP11, Portland, OR 97239-3098, USA
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Hellstern V, Aguilar Pérez M, Kohlhof-Meinecke P, Bäzner H, Ganslandt O, Henkes H. Concomitant Retroperitoneal and Subarachnoid Hemorrhage Due to Segmental Arterial Mediolysis : Case Report and Review of the Literature. Clin Neuroradiol 2017; 28:445-450. [PMID: 29101412 PMCID: PMC6105144 DOI: 10.1007/s00062-017-0641-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- V Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | | | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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Japikse RD, Sevenson JE, Pickhardt PJ, Repplinger MD. Segmental Arterial Mediolysis: An Unusual Case Mistaken to be a Strangulated Hernia. WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2017; 116:173-176. [PMID: 29323836 PMCID: PMC8369498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Segmental arterial mediolysis (SAM) is a rare nonatherosclerotic, noninflammatory vasculopathy causing arterial wall necrosis that leads to strictures, dissections, and aneurysms, particularly in medium-sized abdominal arteries. Awareness of SAM is important because, unlike vasculitides, immunosuppressive treatment may worsen the disease process. CASE A 58-year-old man with multiple medical comorbidities presented with acute epigastric pain and a right incarcerated inguinal hernia that was interpreted as showing bowel strangulation on computed tomography. The hernia was unable to be reduced in the emergency department, so the patient was taken for open reduction by the surgical service. Intraoperatively, he was noted to have a ruptured superior mesenteric artery aneurysm. Conventional angiography demonstrated a bead-like appearance of several jejunal branches of the superior mesenteric artery, raising concern for a vasculitis. His hospital course included rheumatologic consultation, and initial recommendations were to start immunosuppressive therapy for treatment of polyarteritis nodosa. Further testing demonstrated normal antinuclear antibody, antineutrophil cytoplasmic antibodies, and complement levels. Due to a lack of systemic symptoms or signs and otherwise unremarkable laboratory evaluation, the patient ultimately was diagnosed with SAM and immunosuppressive therapy was halted. DISCUSSION Unexplained medium arterial stenosis, dissection, aneurysm, and hemorrhage should raise suspicion for possible SAM. The initial management approach should focus on treatment of the acute hemorrhage, usually involving endovascular stenting or coil embolization. Unlike vasculitides, SAM does not benefit from, and may actually be harmed by, immunosuppressive therapy. CONCLUSIONS Clinicians involved in the longitudinal care of emergency department patients should be aware of this rare clinical entity in order to initiate appropriate treatment.
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Affiliation(s)
- Russell D Japikse
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - James E Sevenson
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael D Repplinger
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Welch BT, Brinjikji W, Stockland AH, Lanzino G. Subarachnoid and intraperitoneal hemorrhage secondary to segmental arterial mediolysis: A case report and review of the literature. Interv Neuroradiol 2017; 23:378-381. [PMID: 28443482 DOI: 10.1177/1591019917703074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Segmental arterial mediolysis (SAM) is an uncommon or underdiagnosed arteriopathy that presents with life-threatening hemorrhage. SAM can affect the intracranial, spinal, and visceral arteries, with reported cases of concomitant intracranial and visceral hemorrhage. Case description We present the case of a 61-year-old male with concurrent subarachnoid and intraperitoneal hemorrhage caused by simultaneously bleeding posterior spinal artery and splenic artery pseudoaneurysms. The posterior spinal artery pseudoaneurysms were treated with selective injection of polyvinyl alcohol particles into the posterior spinal artery, while the splenic artery pseudoaneurysm was treated with Gelfoam embolization. The constellation of imaging, clinical, and laboratory features led to a presumptive diagnosis of SAM, which remains the only reported cause of concurrent neurovascular and visceral artery aneurysm rupture. Conclusion SAM is a key diagnostic consideration in cases of concomitant intracranial, spinal, and visceral artery aneurysm rupture.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- 1 Departments of Radiology, Mayo Clinic, USA.,2 Departments of Neurosurgery, Mayo Clinic, USA
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Abstract
Segmental arterial mediolysis (SAM) is an uncommon, non-atherosclerotic, non-inflammatory arteriopathy that tends to affect the medium-sized splanchnic branches of the aorta along with renal, carotid, cerebral, and coronary arteries. The clinical presentation ranges from asymptomatic to severe, life-threatening intra-abdominal hemorrhage and shock. SAM overlaps clinically and radiologically with other inflammatory vasculitides. This article describes the pathologic-radiologic correlation, imaging findings, and the management of the disease. Radiologists should be familiar with this disease entity as imaging plays a crucial role in the diagnosis.
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Felipe-Silva A, de Campos FPF, Martinês JADS. Fatal hemoperitoneum due to segmental arterial mediolysis. AUTOPSY AND CASE REPORTS 2016; 6:7-15. [PMID: 27818953 PMCID: PMC5087978 DOI: 10.4322/acr.2016.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 11/23/2022] Open
Abstract
Spontaneous hemoperitoneum due to vascular injury is a life-threatening condition mostly associated with aortic or splanchnic arterial disease, which stems from atherosclerotic, inflammatory, or infectious origin. However, in 1976, Slavin and Gonzales described a nonatherosclerotic arterial disease that may render aneurysmal formation predominantly in the splanchnic arterial bed. The clinical presentation is diverse, but abdominal pain and shock prevail. We report the case of a middle-aged man who presented a hemoperitoneum due to a middle colic artery aneurysm rupture and died after undergoing a surgical treatment attempt. The preoperative imaging study revealed the presence of a huge hematoma in the epiplon retrocavity, and abdominal free liquid as well as extensive arterial disease with multiple aneurysms. The autopsy findings included hemoperitoneum, hematoma in the upper left abdominal quadrant, the surgical ligature of the middle colic artery, and histologic features consistent with segmental arterial mediolysis. The authors call attention to this rare entity and highlight the autopsy as a fundamental examination to accurately reach this diagnosis.
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Affiliation(s)
- Aloísio Felipe-Silva
- Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil.; Department of Pathology - Medical School - Universidade de São Paulo, São Paulo/SP - Brazil
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