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Farkašová Iannaccone S, Kholová I, Ginelliová A, Fröhlichová L, Farkaš D. Segmental arterial mediolysis leading to spontaneous rupture of splenic artery and fatal hemorrhage in pregnancy. Cardiovasc Pathol 2024; 71:107650. [PMID: 38677635 DOI: 10.1016/j.carpath.2024.107650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024] Open
Abstract
We report an unexpected death of a 22-year-old primigravida who was admitted to the hospital with sudden abdominal pain two days before a scheduled delivery. During an emergency caesarean section due to intrauterine asphyxia, intraabdominal bleeding was observed with no apparent source of bleeding. Newly formed blood clots in the subdiaphragmatic space and arterial bleeding near the splenic hilum required a surgery on the next day. Hemorrhagic shock led to multiple organ failure on the fourth day of admission. The autopsy revealed ruptured splenic artery at the pancreatic tail and near the splenic hilum. Microscopically, different stages of segmental arterial mediolysis were observed in partially thinned and aneurysmatic artery.
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Affiliation(s)
- Silvia Farkašová Iannaccone
- Department of Forensic Medicine, Faculty of Medicine, Pavol Jozef Šafárik University, Trieda SNP 1, 040 11 Košice, Slovakia
| | - Ivana Kholová
- Pathology, Fimlab Laboratories, Arvo Ylpön katu 4, 33520 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland.
| | - Alžbeta Ginelliová
- Department of Forensic Pathology, Health Care Surveillance Authority, Ipeľská 1, 04374 Košice, Slovakia
| | - Lucia Fröhlichová
- Department of Pathology, Louis Pasteur University Hospital, Rastislavova 43, 04001 Košice, Slovakia
| | - Daniel Farkaš
- Department of Forensic Pathology, Health Care Surveillance Authority, Ipeľská 1, 04374 Košice, Slovakia
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Lim ET, Gilkison A, Elstub H, Colgan F, Buckenham T, Khanafer A. Segmental arterial mediolysis after fenestrated endovascular abdominal aortic aneurysm repair-A rare complication. J Vasc Surg Cases Innov Tech 2024; 10:101470. [PMID: 38591016 PMCID: PMC10999811 DOI: 10.1016/j.jvscit.2024.101470] [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: 10/09/2023] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Segmental arterial mediolysis (SAM) is a rare, noninflammatory, nonatherosclerotic condition that occurs commonly in mesenteric vessels. There are no known predisposing risk factors to the development of SAM. We present a case of a 67-year-old woman who presented with abdominal pain 2 days following discharge after an elective endovascular abdominal aortic intervention. Repeat imaging 2 days after readmission showed the presence of multiple new aneurysms involving the mesenteric vasculature. She underwent attempted endovascular embolization of the largest aneurysm. The postmortem and histopathologic examinations confirmed the diagnosis of SAM.
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Affiliation(s)
- Eric T.A. Lim
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew Gilkison
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
- Forensic Pathology South Island, Christchurch Hospital, Christchurch, New Zealand
| | - Hannah Elstub
- Forensic Pathology South Island, Christchurch Hospital, Christchurch, New Zealand
| | - Frances Colgan
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - Timothy Buckenham
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - Adib Khanafer
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
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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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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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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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Koster MJ, Guarda M, Ghaffar U, Warrington KJ. Rheumatic masqueraders: mimics of primary vasculitis - a case-based review. Expert Rev Clin Immunol 2024; 20:83-95. [PMID: 37837326 DOI: 10.1080/1744666x.2023.2270774] [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: 03/31/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other. AREAS COVERED This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined. EXPERT OPINION The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Max Guarda
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Umar Ghaffar
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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Ishihara T, Matsui T, Katoh T, Kobayashi K, Sekigawa K, Suzuki T, Mitsui H. Pancreaticoduodenal Artery Aneurysm Rupture Presenting as Duodenal Obstruction Successfully Treated with Early Transcatheter Arterial Embolization: A Case Report of Suspected Segmental Arterial Mediolysis. Intern Med 2023; 62:3479-3482. [PMID: 37062731 PMCID: PMC10749823 DOI: 10.2169/internalmedicine.1278-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/05/2023] [Indexed: 04/18/2023] Open
Abstract
Visceral aneurysms are a rare but important form of abdominal vascular disease. Rupture of the aneurysms leads to serious symptoms, such as acute abdomen or abdominal bleeding. However, duodenal obstruction due to arterial rupture of an aneurysm is very rare. We herein report a 50-year-old woman with suspected segmental arterial mediolysis (SAM) who was first diagnosed with acute abdomen and duodenal obstruction. Rupture of a pancreaticoduodenal artery aneurysm was confirmed, and she was treated with transcatheter arterial embolization. In cases of acute abdomen, SAM is a rare but important possibility to consider as a differential diagnosis.
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Affiliation(s)
| | - Toru Matsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | - Tomoji Katoh
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | | | | | - Takeo Suzuki
- Department of Intervention Radiology, Tokyo Teishin Hospital, Japan
| | - Hiroshi Mitsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
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8
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Sugaya T, Suzuki T, Wada J, Shimizu H, Uchihara D, Yokogawa Y, Ichii O, Tai M, Ejiri Y, Ohira H. Transarterial embolization for ruptured pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis combined with median arcuate ligament syndrome: a case report. Clin J Gastroenterol 2023; 16:859-863. [PMID: 37608145 DOI: 10.1007/s12328-023-01847-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
A 75-year-old female with a history of Parkinson's disease treatment and hypertension presented at the emergency section with sudden onset of right abdominal pain. Contrast-enhanced computed tomography revealed beaded irregular stenosis and dilation of the superior mesenteric artery (SMA) and an aneurysm in the branch of the pancreaticoduodenal artery (PDA) that communicates with the common hepatic artery and SMA. Additionally, a hematoma had formed in the retroperitoneal space, and extravasation of contrast medium from the pancreaticoduodenal artery aneurysm (PDAA) into the hematoma was observed. The celiac artery (CA) was compressed by the median arcuate ligament; stenosis of the CA at its origin and dilation on the distal side were observed. Based on the imaging findings, it was diagnosed that PDAA was ruptured, SMA developed segmental arterial mediolysis (SAM), and CA developed median arcuate ligament syndrome (MALS). The ruptured PDAA was thought to be caused by SAM combined with MALS. Transcatheter arterial embolization (TAE) was performed for the ruptured PDAA. To the best of our knowledge, there have been no reports of TAE for a ruptured PDAA caused by SAM and MALS. After TAE, the PDAA did not re-rupture.
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Affiliation(s)
- Tatsuro Sugaya
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan.
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Tomohiro Suzuki
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Jun Wada
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroshi Shimizu
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Daiki Uchihara
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yuko Yokogawa
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Osamu Ichii
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Mayumi Tai
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yutaka Ejiri
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Andersen JC, Mannoia K, Patel ST. Endovascular treatment of an isolated iliac artery aneurysm associated with segmental arterial mediolysis. J Vasc Surg Cases Innov Tech 2023; 9:101224. [PMID: 37799842 PMCID: PMC10547849 DOI: 10.1016/j.jvscit.2023.101224] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/08/2023] [Indexed: 10/07/2023] Open
Abstract
Segmental arterial mediolysis is a noninflammatory nonatherosclerotic vasculopathy of uncertain etiology characterized by dissection and/or aneurysm formation. It affects medium-to-large arteries, primarily the celiac, superior mesenteric, and renal arteries. Iliac involvement is rare, and its specific treatment has not been described. We detail a patient who presented with intrabdominal hemorrhage from a ruptured right colic artery aneurysm. He underwent transcatheter arterial embolization followed by right hemicolectomy. Histopathology confirmed the diagnosis of segmental arterial mediolysis. Endovascular treatment of a 3-cm iliac artery aneurysm was performed 18 months later. There was successful exclusion of the aneurysm demonstrated on computed tomography angiography at 10 years.
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Affiliation(s)
- James C. Andersen
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Kristyn Mannoia
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sheela T. Patel
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
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10
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Pokharel A, Karageorgiou I, Shah S, Bhattarai M, Acharya I, Bateman J. Hepatic segmental arterial mediolysis: A case report and brief literature review. Clin Case Rep 2023; 11:e7668. [PMID: 37434956 PMCID: PMC10332256 DOI: 10.1002/ccr3.7668] [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] [Received: 05/03/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/13/2023] Open
Abstract
Key Clinical message When evaluating patients with abdominal pain, it is important to consider SAM in the differential diagnosis, along with vasculitis, fibromuscular dysplasia (FMD), atherosclerosis, mycotic aneurysms, and cystic medial degeneration. Abstract Segmental arterial mediolysis (SAM) is a rare arteriopathy which is an under-recognized and commonly missed diagnosis of abdominal pain. We report a case of a 58-year-old female who presented with abdominal pain and was misdiagnosed with a urinary tract infection. The diagnosis was made with CTA and managed with embolization. Despite appropriate intervention and close hospital monitoring, further complications were inevitable. We conclude that though literature has shown better prognosis and even complete resolution after medical and/or surgical intervention, close follow up and monitoring is needed to avoid unexpected complications.
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Affiliation(s)
- Ashbina Pokharel
- Department of Internal MedicineWilliam Beaumont University HospitalRoyal OakMichiganUSA
| | - Ioannis Karageorgiou
- Department of Internal MedicineWilliam Beaumont University HospitalRoyal OakMichiganUSA
| | - Sangam Shah
- Tribhuwan University, Institute of MedicineKathmanduNepal
| | | | - Indira Acharya
- Department of Internal Medicine, Medstar Union Memorial HospitalBaltimoreMarylandUSA
| | - Judith Bateman
- Department of RheumatologyWilliam Beaumont University HospitalRoyal OakMichiganUSA
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11
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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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12
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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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13
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Intra-abdominal Bleeding due to Segmental Arterial Mediolysis and Coexisting Pulmonary Thromboembolism: a Case Report. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03465-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract Segmental arterial mediolysis (SAM) is a rare but important cause of abdominal haemorrhage and is usually treated with endovascular management. Surgical or conservative management can be performed depending on the patient’s situation. Since the course of conservative treatment is not well described in the existing literature, it must be used with caution. We describe the case of a 52-year-old man who was transferred to the emergency department because of abdominal pain, diarrhoea, and haematemesis. On arrival, he was haemodynamically unstable, with a blood pressure of 70/40 mmHg. After he was transfused and stabilised in the emergency department, contrast-enhanced computed tomography (CECT) revealed a haematoma around the transverse colon and ascites, without any evident extravasation. The peripheral branch of the middle colic artery (MCA) showed irregular calibre, suggesting SAM. Since the patient remained stable, we initially chose conservative management. However, a CECT scan performed on the third day of hospitalisation showed coexisting pulmonary thromboembolism (PTE). Because of the need for anticoagulation therapy, we performed open surgery. The pathological examination was consistent with SAM. Anticoagulation therapy was initiated the next day. A CECT scan performed on a postoperative day (POD) 13 showed no PTE. Although the patient defecated haemorrhagic stool and experienced hematemesis on PODs 19 and 23, respectively, colonoscopy, esophagogastroduodenoscopy, and repeated CECT scans revealed no evidence of rebleeding, and no recurrence was observed. Open surgery produced a relatively good postoperative course for the patient. Endovascular management, however, remains a reasonable first approach, considering its reportedly excellent outcomes.
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14
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Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning. Diagnostics (Basel) 2022; 12:diagnostics12041012. [PMID: 35454060 PMCID: PMC9024490 DOI: 10.3390/diagnostics12041012] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023] Open
Abstract
Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.
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15
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Hashimoto K, Sakai R, Shibata A, Okada Y, Yoshinaga S, Kurasawa T, Kondo T, Amano K. Concurrent Takayasu Arteritis and Vascular Ehlers–Danlos Syndrome: A Case Report. Front Cardiovasc Med 2022; 9:805505. [PMID: 35155630 PMCID: PMC8825418 DOI: 10.3389/fcvm.2022.805505] [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: 11/05/2021] [Accepted: 01/03/2022] [Indexed: 11/17/2022] Open
Abstract
Takayasu arteritis (TAK) is a rare primary systemic inflammatory vasculopathy. It is classified as a large-vessel vasculitis and is known to cause inflammatory aneurysms and vascular stenosis. Vascular Ehlers–Danlos syndrome (vEDS) is an autosomal dominant condition known to cause multiple aneurysms and arterial dissection at a young age owing to a mutation in the gene for type III collagen, COL3A1. Here, we present a case of TAK associated with vEDS with the development of multi-organ infarction of the brain, kidney, and spleen owing to multiple arterial aneurysms and stenosis of the internal carotid artery. The patient was successfully treated using anti-inflammatory agents, glucocorticoids, and tocilizumab with the addition of interventional radiology. In our case, a high inflammatory response led to vasculitis being the main cause of the disease with concurrent vEDS. When patients develop multiple aneurysms, stenosis, and dissections leading to multiple organ infarctions, a systemic differential diagnosis to consider concurrent vasculitis syndrome and non-inflammatory vasculopathy, including hereditary disorders, is important even with time constraints.
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Affiliation(s)
- Kyota Hashimoto
- Clinical Training Center, Saitama Medical University Hospital, Saitama, Japan
| | - Ryota Sakai
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
- *Correspondence: Ryota Sakai
| | - Akiko Shibata
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yusuke Okada
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Syoichi Yoshinaga
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takahiko Kurasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tsuneo Kondo
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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16
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Stone JR. Diseases of small and medium-sized blood vessels. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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17
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Alabousi M, Junek M, Garner S, Khalidi N, Rebello R. Value of second opinion subspecialty radiology consultation in suspected abdominal medium vessel vasculitis. Abdom Radiol (NY) 2021; 46:5763-5771. [PMID: 34550415 DOI: 10.1007/s00261-021-03277-4] [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: 07/09/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To perform a descriptive analysis of individuals with suspected Polyarteritis nodosa (PAN) referred for second opinion imaging consultation. METHODS A retrospective observational cohort study was performed at a single institution. A consecutive sample was performed of individuals who underwent a second opinion CT or MR angiography subspecialty radiologist consultation between January 2008 and September 2019 for suspected abdominal medium vessel vasculitis. Demographic, clinical, and imaging data were collected. Clinical and imaging findings were reported for PAN, small vessel vasculitis, and "non-vasculitis" groups. Agreement and diagnostic accuracy between final clinical and second opinion imaging diagnoses for PAN were determined. Two-tailed t-tests with a significant p-value < 0.05 were utilized. RESULTS Of the 58 participants, 9 were clinically diagnosed with PAN, 11 with small vessel vasculitis (including lupus, IgA, and ANCA-associated vasculitis), and 38 with non-vasculitis diagnoses. The non-vasculitis group included 15 SAM, 3 FMD, and 1 SAM-FMD spectrum diagnoses. Higher C-reactive protein level (51 vs 17, p = 0.04) and superior mesenteric artery involvement (56% vs 21%, p = 0.04) were more common in PAN than non-vasculitis diagnoses, while arterial dissection (40% vs 0%, p = 0.02) and celiac vasculature involvement (53% vs 0%, p = 0.003) were more common in the non-vasculitis group. There was 88% agreement (51/58; Cohen's kappa 0.56); sensitivity was 67% [95%-confidence interval (CI) 30-93%] and specificity was 92% (95%-CI 80-98%). CONCLUSION Isolated celiac artery involvement and arterial dissection were more common in non-inflammatory vasculopathies than PAN. Our findings highlight the need for multidisciplinary collaboration and awareness of the diverse findings of abdominal vasculopathies.
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18
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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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19
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Connolly CM, Yu A, Seo P, Paik JJ. Segmental arterial mediolysis: a rare cause of abdominal pain masquerading as vasculitis. Rheumatology (Oxford) 2021; 60:e354-e355. [PMID: 33788907 DOI: 10.1093/rheumatology/keab326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/28/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Alice Yu
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, USA
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20
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127034.186.dbf92.19420.2@bxss.me] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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21
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: ./10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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22
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Cheng EM, Chen KL, Sharma V, Yee J, Power M, Lemech LD, Chu F. Rapid Formation and Rupture of Multiple Abdominal Pseudoaneurysms: A Life Threatening Case of Segmental Arterial Mediolysis. Ann Vasc Dis 2021; 14:256-259. [PMID: 34630769 PMCID: PMC8474093 DOI: 10.3400/avd.cr.20-00172] [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: 12/20/2020] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
We present a 62-year-old gentleman with rapidly forming abdominal pseudoaneurysms due to segmental arterial mediolysis (SAM). With rupture of his pseudoaneurysms, he underwent angiography and successful coil embolisation. In this case, we demonstrate the potential for rapid progression of pseudoaneurysms in SAM, with the need for prompt diagnosis and urgent endovascular intervention.
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Affiliation(s)
- Ernest M Cheng
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
| | - Kerry L Chen
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
| | - Varsha Sharma
- Department of Surgery, St George Hospital, Sydney, Australia
| | - Juliana Yee
- Department of Radiology, St George Hospital, Sydney, Australia
| | - Mark Power
- Department of Radiology, St George Hospital, Sydney, Australia
| | - Lubomyr D Lemech
- Department of Vascular Surgery, St George Hospital, Sydney, Australia
| | - Francis Chu
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
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23
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021; 78:898-911. [PMID: 34455817 PMCID: PMC8415524 DOI: 10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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24
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127706.186.264be.19420.2@bxss.me] [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: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James's Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.).,Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands.,CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.).,II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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De Marchi S, Pianca S, Ceriani L, Cippà PE. Multiple abdominal artery dissections: how to distinguish two rare diseases. BMJ Case Rep 2021; 14:e243196. [PMID: 34373241 PMCID: PMC8354269 DOI: 10.1136/bcr-2021-243196] [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] [Accepted: 07/31/2021] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old woman was referred to the emergency room with acute abdominal pain. A CT scan revealed multiple dissections and microaneurysms of the superior mesenteric, the hepatic and the renal arteries. Stenting of the superior mesenteric artery was required. A non-invasive diagnostic procedure was instrumental to establish the diagnosis and guide appropriate treatment, which resulted in a rapid and sustained recovery.
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Affiliation(s)
- Sara De Marchi
- Division of Nephrology, Department of Medicine, Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
| | - Silvio Pianca
- Division of Nephrology, Department of Medicine, Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
| | - Luca Ceriani
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Ticino, Switzerland
| | - Pietro E Cippà
- Division of Nephrology, Department of Medicine, Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
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Feld K, Mellin W, Melzer B, Rothschild MA, Fries J. Fatal hemorrhage after tonsillectomy. Rechtsmedizin (Berl) 2021. [DOI: 10.1007/s00194-021-00502-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractThis is the first report of a segmental mediolysis occurring in arterioles, affecting the neck/tonsillar region and leading to a fatal hemorrhage after a tonsillectomy in a 20-year-old woman. Arteriolar mediolysis could be observed in tissue layers about 2 cm distant from the tonsillectomy region. Reparative changes were observed in the carotid and small neck arteries as well as in only one intramyocardial arteriole; however, no other vascular regions typically reported in segmental mediolysis arteriopathy were affected and aneurysm formation was not observed. No family history of vascular disease or hypertension was known. Pathophysiologically, previously reported reasons for post-tonsillectomy bleeding could be excluded. Segmental mediolysis may represent a wider spectrum of affected arteriolar vessels besides the reported small and medium sized arteries leading to aneurysms, which impedes radiographic diagnosis.
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Maningding E, Kermani TA. Mimics of vasculitis. Rheumatology (Oxford) 2021; 60:34-47. [PMID: 33167039 DOI: 10.1093/rheumatology/keaa495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/07/2020] [Accepted: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.
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Affiliation(s)
- Ernest Maningding
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, 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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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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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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Francois CJ, Skulborstad EP, Kalva SP, Majdalany BS, Collins JD, Eldrup-Jorgensen J, Ferencik M, Ganguli S, Kendi AT, Khaja MS, Obara P, Ptak T, Reis SP, Sutphin PD, Dill KE. ACR Appropriateness Criteria ® Nonatherosclerotic Peripheral Arterial Disease. J Am Coll Radiol 2020; 16:S174-S183. [PMID: 31054743 DOI: 10.1016/j.jacr.2019.02.026] [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: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/17/2022]
Abstract
A broad range of nonatherosclerotic diseases affect the peripheral arteries. The appropriate initial diagnostic imaging studies vary, depending upon the clinical presentation and suspicion of disease. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome or guiding surgical management. The scenarios discussed in this document include the initial evaluation of suspected popliteal entrapment syndrome, external iliac artery endofibrosis, lower-extremity inflammatory vasculitides, dissection or connective tissue disease, noninflammatory vascular disease, and vascular trauma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | - Bill S Majdalany
- Panel Vice Chair, University of Michigan Health System, Ann Arbor, Michigan
| | | | | | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | | | | | | | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | - Thomas Ptak
- University of Maryland Medical Center, Baltimore, Maryland
| | | | | | - Karin E Dill
- Specialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts
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Xu JJ, Rasuli P, Burns KD. Case Report: Segmental Arterial Mediolysis, a Rare Cause of Hypertension. Can J Kidney Health Dis 2020; 7:2054358120950885. [PMID: 32913655 PMCID: PMC7444149 DOI: 10.1177/2054358120950885] [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: 05/20/2020] [Accepted: 07/08/2020] [Indexed: 11/17/2022] Open
Abstract
Rationale: The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension. Presenting concerns of the patient: A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts. Diagnoses: After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made. Interventions: Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation. Outcomes: The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events. Teaching points: Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.
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Affiliation(s)
- Jieqing Jessica Xu
- Department of Medicine, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Pasteur Rasuli
- Department of Radiology, Division of Angiography and Interventional Radiology, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Kevin D Burns
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, ON, Canada
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Kohara Y, Fujimoto K, Katsura H, Komatsubara T, Ichikawa K, Higashiyama H. Biphasic clinical course of a ruptured right gastric artery aneurysm caused by segmental arterial mediolysis: a case report. BMC Surg 2020; 20:191. [PMID: 32854675 PMCID: PMC7450588 DOI: 10.1186/s12893-020-00849-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 08/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gastric artery aneurysms are rarely caused by segmental arterial mediolysis (SAM), a condition that often involves multiple vessels. The clinical course of SAM after vessel rupture may vary depending on the involved vessels. For example, the "double-rupture phenomenon" observed following the rupture of the splenic artery aneurysm manifests as a biphasic and relatively slow clinical course. Even in cases of rupture of gastric artery aneurysm, the double-rupture phenomenon has only been reported in two cases so far. However, the rupture was not caused by SAM in either case. Herein, we present the apparent first case of a right gastric artery (RGA) aneurysm rupture caused by SAM that presented with a biphasic clinical course, possibly due to the double-rupture phenomenon. CASE PRESENTATION A 54-year-old woman was transferred to the emergency department with severe abdominal pain and a cold sweat for a duration of 3 h. She had developed mild abdominal pain and nausea 3 days earlier. Her vital signs were stable. Physical examination revealed tenderness in the epigastric area. Abdominal contrast-enhanced computed tomography revealed an RGA aneurysm with contrast media extravasation. A diagnosis of hemoperitoneum following a ruptured RGA aneurysm was made, and the patient underwent angiography. However, this modality did not reveal any extravasation from the RGA due to an interruption in the peripheral branch of the artery. Nevertheless, to prevent major bleeding, we performed coil embolization at the point of interruption in the RGA, which we suspected to be a ruptured aneurysm. A distal gastrectomy with Roux-en-Y reconstruction for aneurysm resection was performed the following day. There were no postoperative complications, and the patient was discharged 17 days after surgery. Histologically, the RGA demonstrated multiple vacuoles in the medial muscle layer, which were characteristic of SAM. CONCLUSIONS An RGA aneurysm rupture should be considered a differential diagnosis in patients presenting with hemoperitoneum with a slow or biphasic clinical course.
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Affiliation(s)
- Yuichiro Kohara
- Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan.
| | - Koji Fujimoto
- Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan
| | - Hikotaro Katsura
- Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan
| | - Takashi Komatsubara
- Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan
| | - Kazuhito Ichikawa
- Department of pathology, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan
| | - Hiroshi Higashiyama
- Department of gastrointestinal surgery, Shinko Hospital, 1-4-47 Wakinohama-cho, Chuo-ku, Kobe, 651-0072, Japan
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Henkin S, Wysokinski WE, Tweet M, Shamoun F, Naidu S, Sutkowska K, Bator K, Shields R, Greene E, Keller S, Hodge D, McBane R. Spontaneous visceral artery dissections in otherwise normal arteries: Clinical features, management, and outcomes compared with fibromuscular dysplasia. J Vasc Surg 2020; 73:516-523.e2. [PMID: 32623103 DOI: 10.1016/j.jvs.2020.05.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/22/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Visceral artery dissection with otherwise normal-appearing arteries (VADNA), diagnosed on imaging and suggestive of segmental arterial mediolysis, is a poorly understood disease entity. Study objectives were to define the clinical features, management, and outcomes of patients with VADNA compared with patients with fibromuscular dysplasia (FMD). METHODS In this single-center retrospective cohort study, consecutive patients with a diagnosis of VADNA or FMD evaluated in the Mayo Clinic Gonda Vascular Center (January 1, 2000-April 1, 2017) were identified. Patient demographics, symptom presentation, management, composite adverse arterial events (recurrent arterial dissection, stroke or transient ischemic attack, myocardial infarction, mesenteric or renal infarction, or need for revascularization), and overall survival were compared between VADNA and FMD patients. RESULTS There were 103 VADNA patients (age [mean ± standard deviation], 51.7 ± 11.0 years; 27.9% female) and 248 FMD controls (49.8 ± 8.9 years; 81.8% female) identified. The most common symptom for VADNA patients was abdominal or flank pain (80.6%). For FMD, chest pain, headache, and dizziness were more frequent presenting complaints. The median follow-up was longer for VADNA patients (42 months; interquartile range, 9-76 months) compared with FMD patients (19 months; interquartile range, 0.6-52 months; P < .001). During this time interval, there were twofold more composite arterial events in the VADNA group compared with the FMD group (17% vs 8.1%; P = .01). This difference was primarily driven by recurrent dissections. All-cause mortality was low and similar for both groups (3.8% vs 0.4%; P = .10). CONCLUSIONS VADNA patients carry a higher risk of recurrent arterial events compared with those with FMD. This difference was primarily driven by recurrent dissections.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Marysia Tweet
- Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Fadi Shamoun
- Cardiovascular Department, Mayo Clinic, Scottsdale, Ariz
| | | | | | - Kaja Bator
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Raymond Shields
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Eddie Greene
- Nephrology and Hypertension Division, Mayo Clinic, Rochester, Minn
| | - Shelly Keller
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Robert McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn.
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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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Cerebral segmental arterial mediolysis in a pediatric patient: A novel case. HUMAN PATHOLOGY: CASE REPORTS 2020. [DOI: 10.1016/j.ehpc.2020.200377] [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] Open
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38
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Abstract
A variety of nonatherosclerotic diseases affect the arteries of the pelvis and lower extremities. Chronic repetitive traumatic conditions, such as popliteal entrapment and external iliac artery fibroelastosis, vasculitis and connective tissue diseases, and noninflammatory vascular diseases, are a few of the more commonly encountered nonatherosclerotic peripheral vascular diseases. Ultrasound, computed tomography angiography, and magnetic resonance angiography are essential in the initial assessment and management of patients with peripheral vascular disease.
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Affiliation(s)
- Christopher J François
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
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Berti A, Bond M, Volpe A, Felicetti M, Bortolotti R, Paolazzi G. Practical approach to vasculitides in adults: an overview of clinical conditions that can mimic vasculitides closely. ACTA ACUST UNITED AC 2020. [DOI: 10.4081/br.2020.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Primary systemic vasculitides are rare diseases affecting blood vessel walls. The type and patterns of distribution of the organs affected usually reflect the size of the vessels predominantly involved, and the patterns of clinical manifestations are generally useful to reach a specific diagnosis. However, presenting symptoms may lack adequate specificity for a prompt diagnosis, leading to a diagnostic (and therapeutic) delay, often causing irreversible damage to the affected organs. Due to their rarity and variable clinical presentation, the diagnosis of primary vasculitides could be challenging for physicians. Vasculitis mimickers, i.e. the clinical conditions that could be likely mistaken for vasculitides, need to be carefully ruled out, especially before starting the immunosuppressive therapy. We present here a practical approach to the diagnosis of primary systemic vasculitides involving large, medium and small size vessels, and reviewed most of the conditions that could mimic primary systemic vasculitides.
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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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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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Skeik N, Olson SL, Hari G, Pavia ML. Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases. Vasc Med 2019; 24:549-563. [DOI: 10.1177/1358863x19873410] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Segmental arterial mediolysis (SAM) is a rare but serious nonatherosclerotic, noninflammatory vasculopathy of unknown etiology that often results in dissection, aneurysm, occlusion, or stenosis of, primarily, the abdominal arteries. Current literature lacks consensus on diagnostic criteria and management options for SAM. This review summarizes 143 cases and aims to advance appropriate recognition and management of SAM. Literature review of all relevant SAM case studies from 2005 to 2018 yielded 126 individual SAM cases from 66 reports. We identified 17 additional SAM cases from our center, bringing our analysis to 143 patients. Patients with SAM were most commonly men (68%) in their 60s. Hypertension (43%), tobacco use (12%), and hyperlipidemia (12%) were common comorbidities. Abdominal pain (80%) and intraabdominal bleeding (50%) were the most common presenting symptoms. Computed tomography was the most frequently used imaging method (78%), and histology was available in 44% of cases. The most commonly affected vessels were the superior mesenteric (53%), hepatic (45%), celiac (36%), renal (26%), and splenic (25%) arteries with aneurysm (76%), dissection (61%), and arterial rupture (46%). Treatments included coil embolization (28%), abdominal organ surgery (24%), open arterial repair (21%), and medical management (20%). Case-specific treatment modalities yielded symptom relief in the vast majority (91%) of patients, with a mortality rate of 7%.
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Affiliation(s)
- Nedaa Skeik
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Sydney L Olson
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Gopika Hari
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Mary L Pavia
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
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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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Jackson BM. How frequently is visceral arteriopathy attributable to segmental arterial mediolysis? J Vasc Surg 2019; 70:1887-1888. [PMID: 31761103 DOI: 10.1016/j.jvs.2019.03.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 03/30/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pa
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45
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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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46
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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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47
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Delafosse E, Armengol G, Triquenot-Bagan A, Hebant B. A case of segmental arterial mediolysis with widespread involvement of cranial and abdominal arteries. J Neurol Sci 2019; 397:81-83. [DOI: 10.1016/j.jns.2018.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/02/2018] [Accepted: 12/16/2018] [Indexed: 11/17/2022]
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48
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Abstract
Vasculitis mimics need to be differentiated from primary and secondary vasculitides as described in the Chapel Hill nomenclature. The clinical symptomatology resembles that of vasculitis of small and medium, rarely also large vessels and hence imitates the classical vasculitic disorders. Pathogenetically, the causes are partly genetic mutations, embolization syndromes, infections and substance abuse. Also, B‑cell lymphomas can mimic vasculitis. The present manuscript summarizes the vasculitis mimics.
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Affiliation(s)
- I Kötter
- Rheumatologie, Klinische Immunologie, Nephrologie, Asklepios Klinik Altona, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland.
| | - E Reinhold-Keller
- Internistisch-rheumatologische Praxis, Jürgensallee 44, 22609, Hamburg, Deutschland
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Nagamura N, Higuchi H. Segmental Arterial Mediolysis with Preceding Symptoms Resembling Viral Infection Hampers the Differentiation from Polyarteritis Nodosa. Intern Med 2019; 58:2721-2726. [PMID: 31527370 PMCID: PMC6794176 DOI: 10.2169/internalmedicine.2487-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
A middle-aged man presented with a fever, arthralgia, gastrointestinal symptoms, headache, and rash. After two weeks, the patient suddenly complained of severe abdominal pain, and computed tomography revealed aneurysms in the hepatic and splenic arteries, which increased in size progressively. Given the elevated levels of inflammatory markers and orchitis, polyarteritis nodosa (PN) was initially suspected. Catheter embolization for the ruptured hepatic aneurysm and splenectomy for the large splenic ones were performed, and the pathological finding was consistent with segmental arterial mediolysis (SAM). Changes in inflammatory marker levels and aneurysmal size are also informative to differentiate SAM from PN.
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Affiliation(s)
- Norihiro Nagamura
- Department of Rheumatology and Allergology, Shimane Prefectural Central Hospital, Japan
| | - Hiroshi Higuchi
- Department of General Medicine, Shimane Prefectural Central Hospital, 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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