Successful percutaneous embolization of a symptomatic celiac artery dissection with aneurysmal dilation with detachable vascular plugs

Coil embolization of an acutely expanding spontaneous splenic artery dissection

Symptomatic dilation of a spontaneous splenic artery dissection is a very rare and potentially catastrophic nonatherosclerotic vascular disease. Splenic artery rupture has not been reported after acute diffuse dilation, but it has been reported with celiac artery dissections. We believe treatment is mandatory if pain persists despite blood pressure control. The presentation and endovascular treatment of a spontaneous celiac trunk dissection with continued expansion of the splenic artery branch are discussed.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Ten-year review of isolated spontaneous mesenteric arterial dissections

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Endovascular Treatment of a Dissected Celiac Trunk Aneurysm Complicated with Consequent Pseudoaneurysm: Primary Treatment and Treatment Relapse after 5 Years

We report on an asymptomatic 56-year-old male with incidental diagnosis of celiac trunk aneurysm, diagnosed during an ultrasound scan performed to control polycystic kidney disease. The CT scan revealed a 3.8 cm saccular aneurysm of the celiac artery dissected in the superior wall with a consequent 4.3 cm pseudoaneurysm; we adopted an endovascular approach to exclude the lesion by catheterizing the celiac trunk and positioning a vascular plug in the common hepatic artery and a covered stent in the splenic artery; finally we fulfilled the aneurysm sac with Onyx. 30-day control CT scan revealed procedural success. Five years later he came back to our department for an aneurysm relapse in the common hepatic artery. We performed a second endovascular approach with a superselective catheterization of the pancreaticoduodenal arcade in order to exclude the lesion with Onyx and microcoils. Nowadays the patient is in good clinical conditions. Endovascular approach is a valuable method to treat visceral aneurysms; however, long-term imaging follow-up is essential to monitor the risk of relapse.

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.

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.