Management of Symptomatic Spontaneous Isolated Visceral Artery Dissection: Is Emergent Intervention Mandatory?

The management of spontaneous isolated celiac artery dissection: A case report and literature review

OBJECTIVES

Spontaneous isolated celiac artery dissection (SICAD) without associated aortic dissection is a rare disease. Complications are ischemia, aneurysm formation, and rupture. Different treatment options have been reported for managing SICAD, including conservative management, endovascular intervention, and open surgery. Despite the increased recognition of this disease, there are no consensus guidelines on management of this condition. To improve the knowledge and treatment of this disease, a case of SICAD was reported.

METHODS AND RESULTS

We describe the case of a 57-year-old woman with SICAD whose symptoms improved after endovascular treatment when conservative treatment failed and systematically analyze the management strategy for patients with SICAD.

CONCLUSIONS

SICAD is a rare disease and has no universally agreed upon guidelines for treatment. Most patients can be first treated conservatively for dissection with strict blood pressure control, antithrombotic therapy, and intensive surveillance. For SICAD patients with aneurysms located in the celiac trunk, stent grafts can be used in such patients without affecting the branch blood supply.

A rare and unusual cause of acute abdominal pain: A case of spontaneous isolated dissection of the celiac trunk

Spontaneous dissection of the celiac trunk is a rare and uncommon cause of acute abdominal pain. Risk factors, natural history and optimal treatment are still unclear due to the rarity of the disorder. Therapeutic strategies and follow-up procedures are based on limited observations, and the absence of guidelines warrants a patient-tailored approach. We report the case of a 50-year-old woman who presented to our emergency department for epigastric pain, nausea, and vomiting resulting from a spontaneous dissection of the celiac trunk, successfully treated endovascular technique.

Current status of spontaneous isolated celiac artery dissection

BACKGROUND

This study aimed to evaluate the current status of spontaneous isolated celiac artery dissection (SICAD).

METHODS

The English-language literature published in various databases before December 2020 was reviewed. All case reports and series were included. If multiple reports came from the same hospital and covered the same period, only the most recent report was considered. The clinical characteristics, imaging features, and treatment outcome were analyzed.

RESULTS

The study enrolled 88 English language publications between January 1959 and December 2020, including 70 case reports, two case series, and 16 clinical studies. Overall, 316 cases of SICAD were reported in the studies, including 268 men and 44 women (unavailable for 4, men: women ratio: 6:1, p < 0.05). The median age was 50.5 years (range: 6-72) in men and 53.9 years (range: 41-67) in women. Most patients (83.54%, 264/316) complained about stomach pain, primarily in the epigastric region (38.61%, 122/316). The misdiagnosis rate in this study was 3.16% (10/316). The most commonly used imaging modality was computed tomography angiography (CTA), with 97.47% (308/316) cases reporting its use in diagnosis and/or management. The rate of symptom improvement with Conservative Management, with or without antithrombotic agents, was 92.45% (98/106) and 96.58% (141/146), respectively. The rate of symptom improvement after surgical recanalization was 100% (13/13). Moreover, endovascular management resulted in a 100% (50/50) symptom improvement rate.

CONCLUSION

Conservative management is the first-line treatment for SICAD. The surgical or endovascular intervention had a high technical success rate, suggesting that it should be reserved for patients who have failed conservative treatment.

Acalculous Ischemic Cholecystitis Caused by Spontaneous Celiac Artery Dissection

We herein report a case of spontaneous isolated dissection of the celiac artery. A Japanese man in his 50s visited an emergency unit, complaining of sudden epigastralgia. Contrast-enhanced computed tomography indicated dissection of the celiac artery with patent false and true lumina, extending to the splenic and common hepatic arteries. On day 3 of hospitalization, the dissection progressed to the proper and right hepatic arteries. Progression of the dissection to the right hepatic artery provoked acalculous ischemic cholecystitis, and cholecystectomy followed. The resected gallbladder revealed extensive aseptic necrosis with little inflammatory reaction, and the gallbladder neck was spared from ischemia.

Primary conservative treatment for peritonitis-absent symptomatic isolated dissection of the superior mesenteric artery with severely compressed true lumen

Objectives

The purpose of this study was to evaluate the safety and efficacy of primary conservative treatment (PCT) for peritonitis-absent symptomatic spontaneous isolated dissection of the superior mesenteric artery (S-SIDSMA) with severely compressed true lumen.

Methods

From January 2013 to December 2018, PCT was used in 26 cases of peritonitis-absent S-SIDSMA with severely compressed true lumen in our center based on our previous proposed treatment algorithm for S-SIDSMA. The demographics, duration from the onset to the admission, duration from the start of the conservative treatment to the alleviation of the symptoms, and in-hospital and follow-up clinical and angiographic outcomes were prospectively recorded and then analyzed.

Results

Among the 26 included patients, 84.6% were male. The mean age of the patients was 54.7 years. The mean duration from the onset to the admission was 3.1 days (range, 1–14 days). Symptoms in 22 patients were markedly or completely relieved during the first five-day medical treatment. Endovascular stent placement was attempted in the remaining four patients, which was successfully performed in three (75%) of them. The technical failure occurred in a patient whose compressed true lumen failed to be cannulated. Medical treatment was then continued in this patient, and his symptoms were relieved after a two-day medical treatment. During the mean follow-up period of 14.3 months, endovascular stent placement was performed in three patients due to the recurrence of the abdominal pain and the chronic intestinal ischemia. No patient showed dissection progression during the follow-up. The complete remodeling rate of the stent group was significantly higher than that of the medical group (83.3% vs. 25%, P = 0.021).

Conclusions

Based on our previous proposed treatment algorithm for S-SIDSMA, PCT could achieve satisfactory results both clinically and morphologically in peritonitis-absent S-SIDSMA with severely compressed true lumen.

Spontaneous dissection of the celiac artery in the young: a case report and systematic review of the literature

INTRODUCTION

The spontaneous isolated celiac artery dissection (siCAD) represents a challenging cause of abdominal pain and complete information regarding incidence, etiology and risk factors in the young is still lacking. In this study, we report a case of siCAD occurred in a young woman and we systematically searched for information on siCADs in literature databases.

METHODS

PubMed/Embase and Cochrane were searched for, using the following terms: Isolated celiac trunk dissection, isolated celiac artery dissection, celiac artery dissection, celiac trunk dissection, spontaneous isolated visceral artery dissection, spontaneous isolated dissection of visceral arteries, isolated celiac artery dissection in the young, isolated celiac trunk dissection in the young. Patients were included if they were younger than 50 years, if they had a spontaneous etiology and a selective involvement of the celiac artery (with or without involvement of its branches).

RESULTS

180 studies were found, and 18 remained after screening. Twenty-one patients (male = 19, female = 2) with siCADs were included. Mean age was 44.71 ± 3.61 years. Hypertension was the most prevalent comorbidity. All patients presented with abdominal pain, more often located in the epigastrium (n = 11). Almost all patients underwent CT to confirm the diagnosis. A conservative treatment was adopted in 13 patients while an invasive approach was adopted in 8 patients (endovascular approach in 7).

DISCUSSION

siCADs represent a rare but important cause of vascular dissection in the young. Uncomplicated cases can be safely treated with conservative strategies. The surgical or endovascular repair is indicated when dissections complicate or symptoms persist despite an adequate conservative treatment.

Ten-year review of isolated spontaneous mesenteric arterial dissections

OBJECTIVE

Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition; however, it has been increasingly noted incidentally on diagnostic imaging. The purpose of this study was to examine the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissection (SMAD). We hypothesized that most SMADs can be treated nonoperatively.

METHODS

This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes.

RESULTS

A total of 77 patients were found to have CA dissection, SMA dissection, or both in the absence of aortic dissection diagnosed on computed tomography or magnetic resonance imaging. The average age was 56 years (range, 26-86 years), 80% were male, and 10 patients (13%) had underlying connective tissue disorders. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients; 33 (43%) presented with isolated CA dissection, and 30 (39%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up. One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 73 patients were managed nonoperatively; 40 (52%) were treated with a short course of anticoagulation, 23 (30%) were treated with antiplatelet therapy, and 10 (13%) were treated with observation alone. No other late interventions or recurrences were noted during a mean follow-up of 21 months.

CONCLUSIONS

Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Only a small number of patients require surgical revascularization for bowel ischemia.

Spontaneous Isolated Visceral Artery Dissection in a Middle Aged Male

Epigastric pain is a common complaint made by patients being evaluated in the emergency department. Spontaneous isolated visceral artery dissection is a rare cause with no reported prevalence. We present a case of a 37-year-old male evaluated in the emergency department for epigastric pain and subsequently diagnosed with a spontaneous isolated celiac artery dissection with involvement of the hepatic and splenic arteries. Recent case series suggest this disease may be managed medically in most cases. Surgical intervention may be considered for significant bleeding or signs of intestinal ischemia.

Spontaneous isolated left gastric artery dissection: unusual visceral artery dissection

Case

A 51-year-old woman visited our emergency department complaining of acute onset of upper abdominal pain and nausea. Abdominal contrast-enhanced computed tomography showed an isolated left gastric artery dissection and pseudoaneurysm. After conservative management for 6 days, endovascular embolization was carried out for treatment of the pseudoaneurysm. Spontaneous dissection of a visceral artery rarely occurs in the case of a left gastric artery.

Outcome

Contrast-enhanced computed tomography is essential to make an accurate diagnosis and establish a therapeutic strategy.

Conclusion

We should consider the occurrence of minor visceral artery dissection if a patient has acute abdominal pain without other obvious causes.

Hypertensive emergency presenting with an isolated celiac artery dissection: A rare case study

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To the best of our knowledge, we present the 25th case of isolated celiac artery dissection.

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This is the first case of hypertensive emergency induced spontaneous isolated celiac trunk dissection in literature.

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Visceral artery dissection is a rare commodity, and celiac artery dissection is less common than dissection in the SMA.

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It is a difficult diagnosis to make on history and physical alone, necessitating contrast enhanced CT imaging.

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Our patient was managed nonoperatively with a labetalol drip and did well.

Introduction

To our knowledge the most recent article on celiac dissection was published in 2015 and reported 24 known cases of spontaneous isolated celiac trunk dissection [2]. While some of those cases reported hypertension as a risk factor, no other case presents as hypertensive emergency with an isolated celiac artery dissection.

Presentation of case

A 43 year-old man with a past medical history of uncontrolled hypertension, for which he had reportedly been non-compliant with follow-up, presented with complaints of severe, sudden-onset epigastric pain which was non-radiating and constant for 1 hour prior to arrival. On CT an intimal flap was noted within the celiac trunk, starting at the origin and extending into the left gastric, splenic, and the common hepatic arteries.

Discussion

The most common symptom in patients with celiac artery dissection is acute or chronic epigastric or abdominal pain [2,4,9,11]. The crux of the diagnosis of this condition relies on contrast enhanced CT. The superiority of the CT scan is because of the contrast tracking capability [11]. The two most common risk factors for celiac artery dissection are hypertension followed by vasculitis. Patients can be managed nonoperatively or with one of a few operative procedures. Conservative treatment consists of anticoagulants, antihypertensives, and antiplatelet therapy [2].

Conclusion

To the best of our knowledge, we present the 25th case of isolated celiac artery dissection. This is the first case of hypertensive emergency induced spontaneous isolated celiac trunk dissection in literature. Our patient was managed primarily with a labetalol drip.

Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery

OBJECTIVE

We report the morphologic findings and treatment of spontaneous isolated dissection of the celiac artery (SIDCA).

METHODS

Twenty-three patients with SIDCA presenting between January 2009 and December 2014 were enrolled in this retrospective study. The demographic data, clinical features, morphologic findings, treatment modalities, and follow-up results of these patients were reviewed. We proposed a morphologic classification for SIDCA similar to that of spontaneous isolated dissection of the superior mesenteric artery.

RESULTS

Initially, 11 patients were treated endovascularly, and 12 were treated medically. Four patients treated medically had an aggravation of the dissection and needed endovascular salvage. All patients recovered successfully. None of the patients developed abdominal pain, required reintervention, or died. In the medically treated group, the false lumen was completely thrombosed and absorbed in 4 patients, partially thrombosed in 2, and patent in 2. All stents were patent with the false lumen completely thrombosed and absorbed in the endovascular group.

CONCLUSIONS

SIDCA can be treated medically in stable patients but requires intensive follow-up. Endovascular therapy can be applied in high-risk patients with recurrent symptoms, visceral malperfusion, or aneurysm. Open surgery should be considered if endovascular repair is not suitable or has failed. The short-term results of endovascular management are encouraging but further evaluation with long-term follow-up is necessary.

Isolated celiac artery dissection

OBJECTIVE

Spontaneous celiac artery dissection is rare, and its natural history is not well studied. The objective of this study was to review our experience with the evaluation and management of this condition.

METHODS

During the last 8 years, 19 patients (14 men, five women) presented with the diagnosis of spontaneous celiac artery dissection. Each patient's clinical course was retrospectively reviewed, and patients were contacted for assessment of current symptoms.

RESULTS

All patients had computed tomography scans documenting a celiac artery dissection without concomitant aortic dissection. Ages ranged from 39 to 76 years. Seven patients presented with abdominal pain, and 12 were diagnosed incidentally. All patients were initially treated with observation because none had threatened end organs. Patients presenting with aspirin or clopidogrel therapy were continued on these medications, but no patients were prescribed any medications due to their dissection. Three patients continued to have abdominal pain and eventually underwent celiac artery stenting. Pain improved after the intervention in all three. One patient with aneurysmal degeneration of the celiac artery underwent surgical repair. No other patients required intervention. Eighteen patients had follow-up within a year of data collection in the clinic or over the phone. The average time from the initial diagnosis to follow-up for the entire cohort was 46 months. None had abdominal or back pain related to the celiac dissection, had lost weight, or had to change their eating habits.

CONCLUSIONS

Celiac artery dissection can be safely managed initially with observation. If abdominal pain is persistent, endovascular stenting may stabilize or improve the pain, and surgical reconstruction can be done for aneurysmal degeneration or occlusion, both unusual events. Long-term anticoagulation does not appear necessary in these patients.

Isolated dissection of the superior mesenteric artery treated using open emergency surgery

Background

Isolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts.

Methods

Two cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided.

Results

Both patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities.

Conclusion

Open surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.

Approaches to the management of spontaneous isolated visceral artery dissection

BACKGROUND

Spontaneous isolated celiac and superior mesenteric artery dissection without aortic dissection is a rare disease. Recently, an increasing number of cases have been diagnosed and the prognosis has improved significantly because of technical progress in computed tomography (CT). However, management approaches vary from conservative treatment or endovascular repair to open surgery. This study analyzed the clinical findings of patients with spontaneous visceral artery dissection, and attempted to illuminate how to manage these cases.

MATERIALS AND METHODS

From June 2005 to February 2012, a total of 17 patients were diagnosed with spontaneous isolated visceral artery dissection in the authors' hospital (4 celiac arteries, 12 superior mesenteric arteries, and 1 inferior mesenteric artery) based on CT findings. The clinical characteristics, Sakamoto's classification, imaging appearance, and early outcomes of these patients were retrospectively compared.

RESULTS

The mean age of the patients was 51.47 ± 8.65 years (range, 39-73 years) and the mean follow-up period was 35.18 ± 25.55 months (range, 1-79 months). Fifteen (88.2%) patients had abdominal pain and no ischemic changes of the bowel. The dissections initiated at a mean distance of 13.04 ± 10.41 mm (range, 4.00-43.39 mm) from the origin of the artery, with a mean length of 53.39 ± 28.06 mm (range, 10.00-108.46 mm). There were 4 type I (23.8%), 1 type II (5.9%), 9 type III (52.9%), and 3 type IV (17.6%) dissections according to Sakamoto's classification. Treatments included observation without anticoagulation treatment in 3 patients (17.6%), anticoagulation treatment in 12 (70.6%), and endovascular stenting in 2 (11.8%). The disease stabilized in all patients during follow-up.

CONCLUSIONS

If bowel perfusion is not compromised and patency is well compensated by collateral circulation, most patients can be managed conservatively with or without anticoagulation treatment. However, patients must be monitored closely and followed up regularly for early detection of progression.

Symptomatic spontaneous celiac artery dissection treated by conservative management: serial imaging findings

BACKGROUND

The aim of this study was to evaluate the correlation of clinical characteristics with serial imaging findings of symptomatic spontaneous celiac artery dissection treated by conservative management.

METHODS

Eight consecutive, hemodynamically stable patients with symptomatic spontaneous celiac artery dissection without associated aortic dissection that received non-operative treatments were included in this study. Their clinical characteristics, treatment methods, serial imaging findings and outcomes were analyzed retrospectively.

RESULTS

Acute left flank pain related to splenic infarction was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography scan showed celiac artery dissection with partial thrombosis in all eight patients and involvement of branch vessels in 7. Full anticoagulation was carried out immediately after the diagnosis in seven patients. All patients, except one with endovascular stent placement, were asymptomatic after successful conservative management and follow-up computed tomography scan showed preservation of distal perfusion with ongoing regression of false lumen in five patients. After a mean follow-up of 16 months, there was no mortality or morbidity related to the dissection.

CONCLUSIONS

Serial imaging findings showed that conservative management of celiac artery dissection can be performed successfully in selective patients with stable hemodynamics.

Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery

BACKGROUND

Spontaneous isolated dissection of the superior mesenteric artery (SMA) is uncommon. Because of its rarity, the risk factors, aetiology and natural history are unclear, and there is no consensus on the optimal treatment strategy.

METHODS

Seven consecutive patients with symptomatic spontaneous isolated SMA dissection who received conservative treatment between March 2003 and February 2008 were included in this study. Their clinical characteristics, treatment methods and outcomes were analysed retrospectively.

RESULTS

Acute abdominal pain was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography (CT) showed isolated SMA dissection with partial thrombosis in all seven patients. Full anticoagulation was carried out immediately after the diagnosis. Clinical symptoms disappeared within 14 days and follow-up CT showed complete resolution of the dissection in four patients. After a mean follow-up of 23 months, there was no mortality or morbidity related to the dissection.

CONCLUSION

In patients with symptomatic spontaneous isolated dissection of the SMA, conservative management is feasible if there is no evidence of bowel infarction or bleeding.

Clinical and angiographic follow-up of spontaneous isolated superior mesenteric artery dissection

OBJECTIVES

To observe the clinical features and angiographic findings in patients with a spontaneous isolated superior mesenteric artery dissection (SISMAD) and to identify any correlation between them.

METHODS

From a single institution, 32 patients (22 symptomatic patients at presentation; mean age 54years; men 97%) with SISMAD were retrospectively reviewed. All patients were available for clinical follow-up after treatment (conservative, n=28, 88%, open or endovascular superior mesenteric artery (SMA) reconstruction, n=4, 12%), and follow-up CT scans were available in 28 patients (mean 22months, range 1-80months).

RESULTS

We found a positive correlation between pain severity and dissection length (p=0.03, rho=0.50, Spearman's partial correlation analysis). After conservative treatment, only one patient (3%) required bowel resection, and there was no difference in outcome between patients who were treated with anticoagulation or anti-platelet therapy and those who were not (p=1.00, Fisher's exact test). No patients had progression of their lesion on the follow-up CT angiography.

CONCLUSIONS

In SISMAD patients, dissection length is positively associated with more severe clinical symptoms. After conservative treatment, we observed a benign clinical course and no CT progression of the dissection, even without anticoagulation or anti-platelet therapy. Based on our observation, patients with SISMAD can be treated conservatively without anticoagulation therapy.