Spontaneous splanchnic dissection: application and timing of therapeutic options

Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival

OBJECTIVE

Visceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement.

METHODS

VBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

A total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P < .001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P < .001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P < .001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P < .001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P < .001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P = .001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P = .001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P = .004) were associated with inferior intervention-free survival.

CONCLUSIONS

Isolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance.

Spontaneous celiac artery dissection treated by balloon angioplasty

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition, defined as dissection of the celiac artery without aortic involvement. Because of its low prevalence, most studies have been limited to case reports and case series. We have described the case of a 44-year-old woman who had presented with symptomatic SICAD that had resulted in compromised flow to the hepatic arteries and was successfully treated with balloon angioplasty. Angioplasty alone might be effective for cases of extensive false lumen thrombosis in SICAD for immediate flow restoration to the true lumen, expediting positive remodeling.

Spontaneous Isolated Superior Mesenteric Artery Dissection With Thrombosis: A Case Report of a Rare Presentation of Acute Abdominal Pain

Spontaneous isolated superior mesenteric artery dissection is a very rare vascular disease that involves the superior mesenteric artery or its branches, with an incidence as low as 0.08%. The majority of cases occur in patients of Asian descent. Due to advances in imaging modalities, particularly abdominal computed tomography angiography, the diagnosis of this disease has been increasing. Herein, we present a rare case of spontaneous isolated superior mesenteric artery dissection with thrombosis in a young male patient with no past medical history. The importance of this disease as a differential diagnosis for acute abdominal pain is emphasized.

Symptomatic spontaneous superior mesenteric artery dissection treated with endovascular stent repair

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare condition in which patients develop an isolated dissection of the superior mesenteric artery without traumatic or iatrogenic causes. We present the case of a 52-year-old woman who presented with SISMAD and underwent endovascular stenting as her symptoms failed to respond to medical management. We also spend the bulk of the report discussing the current literature on management of SISMAD.

Multiple Spontaneous Visceral Arterial Dissections in a Patient With Tolosa-Hunt Syndrome on Corticosteroid Therapy

Multiple spontaneous visceral arterial dissections are an infrequent occurrence. The etiology, risk factors and natural history of these dissections have not been elucidated, and the optimal therapeutic strategy has not been established. We report a rare case of multiple spontaneous visceral arterial dissections involving the celiac artery, splenic artery, superior mesenteric artery, and right renal artery in a patient with Tolosa-Hunt syndrome on short-term corticosteroid therapy. The patient was subjected to conservative treatment and endovascular repair, achieving good clinical and radiological outcomes during the long-term follow-up period.

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

Background and Aims:

There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited.

Material and Methods:

The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis.

Results and Conclusions:

Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

Mid- to Long-Term Outcomes in Management of Spontaneous Isolated Coeliac Artery Dissection (SICAD)

OBJECTIVE

Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment.

METHODS

Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed.

RESULTS

The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period.

CONCLUSION

Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.

Strategy for the treatment of spontaneous isolated visceral artery dissection

Objectives

To determine the incidence of rare spontaneous isolated visceral artery dissection (SIVAD), characterize its pathogenesis, and suggest treatment strategies.

Materials and Methods

We reviewed abdominal contrast-enhanced computed-tomography (CE-CT) scans from January 2005 to December 2016 retrospectively in our institution, identified 47 SIVAD patients and classified them into a symptomatic (n = 22) or asymptomatic group (n = 25). Further, we classified the five types based on the CE-CT images. Patient characteristics, incidence, vascular risk factors, complications, symptoms, treatments outcomes, and morphology features on CE-CT images were analyzed.

Results

SIVAD was seen on 0.09% of all abdominal CE-CT scans, and 0.68% of all abdominal CT-CT scans obtained for the evaluation of acute abdominal symptoms. The asymptomatic group had significantly fewer patients with periarterial fat stranding or branch vessel involvement on CE-CT images (p < 0.01). The mean length of the dissection was longer in the symptomatic group (p < 0.05). In the asymptomatic group, dissection-related abdominal symptoms and complications did not develop; followed-up CE-CT scans showed improvement in the dissection lesions in 1 (4.0%) patient, no changes in 22 (88.0%), and complete remodeling in 2 (8.0%). In the symptomatic group, one patient presented with organ ischemia at diagnosis and five patients developed organ ischemia underwent endovascular intervention. In the remaining 16 patients received nonoperative intervention only, followed-up CE-CT scans showed improvement in 13 (86.7%), and complete remodeling in 2 (13.3%).

Conclusions

Symptomatic SIVAD patients should be hospitalized because some of those may experience organ ischemia or aneurysm formation. Endovascular intervention is a feasible treatment for complications of SIVAD.

Natural history of spontaneous isolated celiac artery dissection after conservative treatment

OBJECTIVE

Optimal treatment of spontaneous isolated celiac artery dissection (SICAD) is not well established because the natural history of this rare disease is poorly understood. We analyzed the natural history of patients who underwent conservative treatment.

METHODS

The study included 28 patients with SICAD from December 2008 to January 2017. Our institutional policy of first-line treatment for SICAD patients was conservative, and invasive procedures were reserved for unstable complications such as severe persistent pain, significant organ malperfusion, rapid aneurysmal change, and rupture or concealed rupture. Demographics, clinical features, morphologic characteristics on computed tomography, treatment modalities, and follow-up results of these patients were retrospectively reviewed.

RESULTS

Mean age was 52 years, and 89% of patients were male; 86% presented with pain, mostly abdominal, and 14% of cases were detected incidentally on abdominal imaging. None of these patients had unstable complications on admission, and all underwent initial conservative treatment. During the follow-up period (22 ± 20 months), aneurysmal change and propagation of thrombosis were noted in one patient and two patients, respectively, all of whom were managed conservatively without adverse clinical events. No difference in clinical and morphologic outcomes was noted between patients who were treated with antihypertensive therapy and those who were not. Patients with intramural hematoma on initial images showed dynamic vascular remodeling (partial to complete resorption) during the follow-up period compared with patients who had dominant intimal flap on initial images.

CONCLUSIONS

The clinical course of patients with SICAD was benign. Even progressive vascular changes during follow-up did not require invasive treatment. Antihypertensive therapy might not modify the clinical course. The short-term results of conservative management are encouraging, but further evaluation with long-term follow-up in a large population is needed.

Natural course and outcomes of spontaneous isolated celiac artery dissection according to morphological findings on computed tomography angiography: STROBE compliant article

We aimed to identify natural course and optimal management of spontaneous isolated celiac artery dissection (SICAD) according to morphologic classification determined on computed tomography angiography (CTA), and to investigate the association between symptoms and morphological classification of SICAD.This retrospective observational study included 21 consecutive patients with SICAD from January 2012 to April 2017. Demographic data, clinical features, treatment modalities, follow-up results, and CTA findings including morphologic classification, dissection length, and relative diameter of the true lumen (TLRD) were reviewed. Changes in follow-up CTA were recorded and compared to prior studies to reveal natural course of the disease.The serial changes of SICAD on follow-up CTA according to morphologic classifications were as follows; type I (5/5, no interval change), type IIa (1/1, no interval change), type IIb (1/1, partial remodeling), type IIIa (1/4, complete remodeling; 1/4, partial remodeling; 1/4, no interval change; 1/4, deterioration), type IIIb (4/6, no interval change; 2/6, partial remodeling), and type IV (2/2, no interval change). Thirteen (61.9%) symptomatic and 8 (38.1%) asymptomatic patients were all treated with conservative management with or without antiplatelet and/or anticoagulation therapies. Symptomatic group (SG) more commonly had type IIb, IIIa, IIIb, and IV than asymptomatic group (AG) (SG; 11 patients, AG; 1 patient, P = .002). TLRD in AG was larger than that in SG (SG: 40.5 ± 24.1%, AG: 61.7 ± 7.0%, P = .045).SICAD might be treated by conservative management in stable patients irrespective of the morphologic classification except for with type IV (dissecting aneurysm) and extension of celiac branch who may need an early intervention. Types IIb, IIIa, IIIb, and IV are TLRD are associated with patients' symptoms. Further studies on extended natural course of SICAD with a larger number of subjects are needed to draw a strong conclusion.

Ten-year review of isolated spontaneous mesenteric arterial dissections

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spontaneous dissections of multiple visceral arteries: an extremely rare case

Spontaneous dissections of visceral arteries without aortic involvement are very rare. The etiologies of these entities are unclear and their clinical managements remain controversial. We report a case of spontaneous multiple dissections affecting 4 visceral arteries including the superior mesenteric artery, the celiac artery and the bilateral renal arteries. The patient was managed conservatively and endovascularly. The clinical manifestation markedly improved and laboratory tests returned to normal limits within 1 week. The regular follow-up suggested a good clinical and radiological outcome until 84 months.

Atypical presentation of a spontaneous coeliac artery dissection resulting in jejunal ischaemia

We describe a case of a 59-year-old man with no significant medical history apart from a hiatus hernia and depression who presented with periumbilical pain which woke him at night. Before this he had 6 weeks of generalised abdominal pain. Blood tests were relatively normal and CT revealed some ill-defined stranding around the coeliac artery. He was diagnosed with a spontaneous coeliac artery dissection. Given the complexity of the case, a multidisciplinary team approach was adopted. He was managed conservatively and improved significantly over the next few days. Further investigations confirmed ischaemic changes to the distal duodenum and proximal jejunum. He has since been followed-up with CT scans and has had no further episodes 12 months from his initial admission.

Robotic system-assisted endovascular treatment of a dissection-related pseudoaneurysm of the celiac axis secondary to fibromuscular dysplasia

Spontaneous celiac artery dissection caused by fibromuscular dysplasia is rare. Subsequent thrombosis and occlusion of the celiac trunk can result in intestinal ischemia and hepatic failure. We describe a case of spontaneous celiac artery dissection with an associated pseudoaneurysm caused by fibromuscular dysplasia, extending into the common hepatic artery. An endovascular intervention featuring robotic-assisted celiac artery cannulation with stent-assisted coil embolization resulted in successful treatment.

An isolated spontaneous dissecting celiac artery aneurysm with successful endovascular treatment using stenting and coil embolization

Isolated spontaneous dissecting celiac artery aneurysm (DCAA) is a rare event. We report the case of a 50-year-old Japanese man with sudden post-prandial epigastric pain. He was diagnosed as having an isolated DCAA based on the results of contrast-enhanced multi-slice computed tomography (CT). Initially, we gave him conservative therapy, but the aneurysm grew and then we performed endovascular treatment. The DCAA did not cause a rupture, and there were rich collateral channels between the superior mesenteric artery and the common hepatic artery. However, the neck of the aneurysm was too broad to indwell coils, and it was thought that coils might drop out from the aneurysm. We chose endovascular therapy with a self-expanding stent and coil embolization, and the aneurysm was extinguished. He was successfully treated and has recovered favorably. To our knowledge, few cases of a DCAA treated with both a self-expanding stent and coil embolization have been reported and this strategy may be one of the endovascular treatment options for a DCAA. More data accumulation of this method and investigation of long-term treatment effect are required in the future. <Learning objective: A dissecting celiac artery aneurysm is a rare event. Conservative, endovascular, and surgical therapies have been described, but no optimum treatment exists. For the present patient, we chose endovascular therapy with a stent and coil embolization, and he was successfully treated. To our knowledge, few cases of this condition treated with both stenting and coiling have been reported. We suggest that this strategy be one of the endovascular treatment options for this condition.>.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Isolated celiac artery dissection

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A major pain in the … Back and epigastrium: an unusual case of spontaneous celiac artery dissection

A 60-year-old woman with mitral valve prolapse, chronic low back pain, and a 30-pack year smoking history presented for a second admission of poorly controlled mid-back pain 10 days after her first admission. She had concomitant epigastric pain, sharp/burning in quality, radiating to the right side and to the mid-back, not associated with food nor improving with pain medications. She denied nausea, vomiting, diarrhea, constipation, dark stools, or blood per rectum. Our purpose was to determine the cause of the patient's epigastric pain. Physical examination revealed epigastric and mid-back tenderness on palpation. Labs were normal except for a hemoglobin drop from 14 to 12.1 g/dL over 2 days. Abdominal ultrasound and subsequent esophagogastroduodenoscopy were normal. Contrast-enhanced abdominal computed tomographic (CT) scan revealed the development of a spontaneous celiac artery dissection as the cause of the epigastric pain. The patient was observed without stenting and subsequent CT angiography 4 days later did not reveal worsening of the dissection. She was discharged on aspirin and clopidogrel with outpatient follow-up. Thus far, less than 100 cases of isolated spontaneous celiac artery dissections have been reported. The advent of CT scans and magnetic resonance imaging has increasingly enabled its detection. Risk factors may include hypertension, arteriosclerosis, smoking, and cystic medial necrosis. There is a 5:1 male to female ratio with an average presenting age of 55. Management of dissections may include surgical repair, endovascular stenting, and selective embolization. Limited dissections can be managed conservatively with anti-platelet and/or anticoagulation agents and strict blood pressure control, as done in our patient.

Percutaneous embolization of symptomatic dissecting aneurysms of the celiac artery

BACKGROUND

Isolated spontaneous dissection of visceral arteries, not associated with aortic dissection, is a rare condition. To date, there is no consensus on the optimal treatment strategy.

PURPOSE

To investigate the feasibility, efficacy, and safety of percutaneous embolization for the treatment of isolated and symptomatic dissecting aneurysm of the celiac artery.

MATERIAL AND METHODS

From March 2010 to October 2011, four patients were diagnosed at our institution with symptomatic dissecting aneurysm of the celiac trunk. All patients had acute abdominal pain, two had intra-abdominal hemorrhage and bleeding shock. Three patients underwent elective "trapping" embolization of the celiac trunk with Amplatzer vascular plugs in the hepatic and splenic artery and celiac trunk, and coils in left gastric artery. One patient had a splenic artery rupture and underwent selective embolization of this vessel with platinum-fiber coils.

RESULTS

Angiography and postoperative CT scan confirmed artery occlusion after embolization in all cases. Revascularization of celiac trunk branches was obtained via collaterals. No procedure-related adverse events occurred during follow-up (median, 4.5 months; range, 3-24 months) and vessel occlusion was maintained.

CONCLUSION

Isolated and symptomatic dissecting aneurysm of the celiac trunk can be successfully managed by embolization techniques with good short- to mid-term results.

CT imaging findings and endovascular management of isolated spontaneous dissecting aneurysm of celiac artery

Isolated spontaneous dissecting aneurysm of celiac artery without concomitant involvement of aorta is a rare entity and only a few cases are reported in the literature. More cases are being detected recently with greater advancements in CT technology. Clinicians and emergency physicians should be aware of this condition and should include it in the differential diagnosis of patients who present with refractory postprandial epigastric pain, particularly in middle-aged men. We present a case of a 45-year-old male with isolated spontaneous dissecting celiac artery aneurysm, with special emphasis on CT findings and the role of endovascular management.

Clinical and radiologic course of symptomatic spontaneous isolated dissection of the superior mesenteric artery treated with conservative management

OBJECTIVE

To determine the clinical and radiological outcomes of patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated with conservative management.

METHODS

This retrospective study included 27 consecutive patients who were diagnosed with symptomatic SIDSMA and managed conservatively from April 2007 to April 2013. Twenty-six patients were treated using anticoagulation therapy, and one patient with chronic liver disease underwent observation only. For evaluation, patients were divided into two groups, those with a patent false lumen with both entry and re-entry (group I), and those with partial or complete thrombosis of the false lumen (group II). In general, the patients underwent follow-up computed tomography angiography (CTA) 1 week, 1 month, and 6 months after admission. Thereafter, they underwent annual CTAs.

RESULTS

There were five group I and 22 group II patients. During hospitalization, none of the patients needed additional endovascular or surgical intervention, and after conservative management, every patient was asymptomatic upon discharge. The mean duration of clinical follow-up was 27.3 months. There was no recurrent abdominal pain associated with SIDSMA, and no invasive procedures due to SIDSMA were needed. During a mean of 17.1 months of CTA follow-up in group I patients, serial CTAs found sustained patent false lumen and no angiographic changes in all patients. Among 22 group II patients, despite anticoagulation and symptomatic relief, CTA 1 week after admission revealed increased stenosis of the true lumen in 84.2% (16/19) of patients including six cases of progressive SMA occlusion. Five patients, including the three patients initially presenting with SMA occlusion, had no interval changes, and only one patient had improved compression of the true lumen. During a mean of 18.0 months of CTA follow-up in group II patients, serial CTAs revealed improvement in the occlusion or stenosis of the true lumen in 89% (16/18) of patients and progressive resolution of false lumen thrombosis in all patients. Aneurysmal dilatation greater than 2 cm was not detected in either group of patients during follow-up.

CONCLUSIONS

During the acute stage of SIDSMA, we found a discrepancy between the clinical and angiographic findings. The therapeutic regimen should be based on clinical symptoms, and conservative management is feasible in most cases. SMA stenosis could not be an indication for invasive treatment, because stenosis of the true lumen has been seen to improve after the acute stage of dissection.

Endovascular stent graft for treatment of complicated spontaneous dissection of celiac artery: report of two cases

We report 2 cases of complicated spontaneous dissection of the celiac artery, which were successfully treated by a stent graft. The first patient was a 47-year-old man who presented with acute abdominal pain. CT scan showed ruptured saccular aneurysm with surrounding retroperitoneal hematoma. The second patient was a 57-year-old man with progressive dissecting aneurysm. Endovascular stent graft was placed in the celiac trunk to control bleeding, and to prevent rupture in each patient. Follow-up CT scans showed complete obliteration of a dissecting aneurysm.

Dissecção espontânea do tronco celíaco: qual a melhor abordagem terapêutica?

A dissecção espontânea das artérias viscerais é um evento relativamente raro. Dor abdominal súbita no epigástrio é o sintoma mais frequentemente manifestado pelos pacientes. O avanço das técnicas de exames de imagem possibilitou o diagnóstico deste evento com maior facilidade, aumentando a incidência das dissecções das artérias viscerais. O tratamento clínico conservador, a revascularização cirúrgica, e a terapia endovascular são as três possíveis opções terapêuticas. Neste artigo, relatamos os casos de dois pacientes com dissecção espontânea do tronco celíaco conduzidos de formas diversas, de acordo com a apresentação clínica e exames de imagem, além de realizar uma revisão bibliográfica sobre esta doença.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inference from clinical and fluid dynamic studies about underlying cause of spontaneous isolated superior mesenteric artery dissection

PURPOSE

Due to increased use and improvements in diagnostic imaging studies, spontaneous isolated superior mesenteric artery dissection (SISMAD), which is a rare vascular event, has been reported to occur on a more frequent basis. Although there have been some anecdotal case reports describing the underlying pathology of SISMAD, the etiology of the majority of SISMAD is still poorly understood. The purpose of this study was to determine the underlying cause of SISMAD.

METHOD

From July 2001 to March 2010, 51 consecutive patients with SISMAD (symptomatic 39, asymptomatic 12) and 38 patients with combined aortic and superior mesenteric artery dissection (CASMAD) were identified in a single institution by retrospective investigations. Diagnosis was dependent on multi-detector helical computed tomography (CT) scan. To find clinical characteristics of SISMAD, we compared demographic, clinical, and lesion (site of entry tear, type, length) characteristics between the two groups. To find any flow dynamic abnormalities at the proximal segment of the superior mesenteric artery (SMA), we conducted flow dynamic studies using computational fluid dynamic models (V.12; ANSYS, Inc., Canonsburg, Pa). Streamline patterns and wall shear stress distributions were tested with computer simulation models using three different branching angles of SMA from the abdominal aorta.

RESULTS

Compared to CASMAD, SISMAD was more common in men (90.2% vs 71.1%; P = .02), less frequently associated with hypertension (31.4% vs 65.8%; P = .001), and more frequently associated with intra-abdominal cancers (11.8% vs 0%; P = .036). In a fluid dynamic study using computational fluid dynamic models, we found abnormal mechanical stresses at the anterior wall around the convex portion of the SMA.

CONCLUSION

Development of SISMAD seems to be less likely the result of hypertension or connective tissue disease but more likely due to hemodynamic force caused by convex curvature.