Isolated dissection of the celiac artery--a case report

Arterial dissections: Common features and new perspectives

Arterial dissections, which involve an abrupt tear in the wall of a major artery resulting in the intramural accumulation of blood, are a family of catastrophic disorders causing major, potentially fatal sequelae. Involving diverse vascular beds, including the aorta or coronary, cervical, pulmonary, and visceral arteries, each type of dissection is devastating in its own way. Traditionally they have been studied in isolation, rather than collectively, owing largely to the distinct clinical consequences of dissections in different anatomical locations - such as stroke, myocardial infarction, and renal failure. Here, we review the shared and unique features of these arteriopathies to provide a better understanding of this family of disorders. Arterial dissections occur commonly in the young to middle-aged, and often in conjunction with hypertension and/or migraine; the latter suggesting they are part of a generalized vasculopathy. Genetic studies as well as cellular and molecular investigations of arterial dissections reveal striking similarities between dissection types, particularly their pathophysiology, which includes the presence or absence of an intimal tear and vasa vasorum dysfunction as a cause of intramural hemorrhage. Pathway perturbations common to all types of dissections include disruption of TGF-β signaling, the extracellular matrix, the cytoskeleton or metabolism, as evidenced by the finding of mutations in critical genes regulating these processes, including LRP1, collagen genes, fibrillin and TGF-β receptors, or their coupled pathways. Perturbances in these connected signaling pathways contribute to phenotype switching in endothelial and vascular smooth muscle cells of the affected artery, in which their physiological quiescent state is lost and replaced by a proliferative activated phenotype. Of interest, dissections in various anatomical locations are associated with distinct sex and age predilections, suggesting involvement of gene and environment interactions in disease pathogenesis. Importantly, these cellular mechanisms are potentially therapeutically targetable. Consideration of arterial dissections as a collective pathology allows insight from the better characterized dissection types, such as that involving the thoracic aorta, to be leveraged to inform the less common forms of dissections, including the potential to apply known therapeutic interventions already clinically available for the former.

Coeliac trunk dissection causing splenic infarction: a comprehensive review

We describe the case of a 49-year-old man who presented with a 6-day history of epigastric abdominal pain radiating to his right shoulder which started suddenly after swinging a golf club. A CT angiography of the abdomen was performed which showed dissection of the coeliac trunk extending into the splenic artery and splenic infarct. Anticoagulation was initially started but discontinued due to a small retroperitoneal haemorrhage. The patient remained stable and was discharged on aspirin 325 mg for 1 month followed by aspirin 81 mg. We present this case as well as a review of previously reported cases of splenic infarct due to spontaneous coeliac trunk dissection with the treatments employed as well as the outcomes.

Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33-85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4-18 months), 12 months (IQR, 6-19 months) and 14 months (IQR, 6-20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

Spontaneous Ruptured Splenic Artery Aneurysm: A Case Report

Splenic artery aneurysms are rare and occur predominantly in women. Most of them are asymptomatic until the aneurysms rupture. We report a previously healthy 46-year-old female who attended emergency department with abdominal pain for four hours. She had left upper quadrant tenderness and pulsatile mass. Laboratory tests showed her haematocrit 29.8%. Subsequent examinations with ultrasound and computed tomography (CT) showed a large aneurysm of the splenic artery and a heterogeneous hypodense shadows around the aneurysmal sac and perihepatic area. Just after CT scan she collapsed and was taken into emergency surgery. Splenectomy was performed following the ligation of splenic artery proximal to lesion. On the fifth day, she was discharged from the hospital with complete recovery. This case report highlights that rapid resuscitation, diagnostic imaging, surgical consultation, and subsequent laparotomy remain the priorities in patient management.

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.

Optimal management strategy for spontaneous isolated dissection of a visceral artery

Objectives

To describe our clinical experiences and recommend a management strategy for spontaneous isolated dissection of a visceral artery.

Methods

A retrospective study of patients from December 2005 to December 2015 was performed. Thirty-two patients had spontaneous isolated dissection of a visceral artery. Clinical features, computed tomography findings, the treatment method, and follow-up results were evaluated.

Results

There were 28 men and 4 women (mean age, 54 years). Dissection locations were the celiac artery in 10, superior mesenteric artery in 17, and celiac artery and superior mesenteric artery in 5 patients. Celiac artery stenosis existed with spontaneous isolated dissection of a visceral artery at a high rate. After diagnosis, the blood pressure of all patients was immediately controlled to a lower level. Three patients with arterial rupture and one patient with bowel infarction underwent operations for complications. Overall, the treatment of dissection involved drug therapy alone. The last follow-up computed tomography results of the true lumen residual ratio and the length of the dissected artery improved compared to the values on admission; the maximum diameter of the dissected artery did not enlarge. Eleven patients almost completely improved. No patients had any adverse event.

Conclusions

Most patients with spontaneous isolated dissection of a visceral artery can be first treated conservatively for dissection with strict blood pressure control and surveillance.

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.

Case report of hepatic artery dissection secondary to hepatic artery pseudoaneurysm after living donor liver transplantation

Background

Hepatic artery pseudoaneurysm (HAP) and Hepatic artery dissection are rare vascular complications after living donor liver transplantation (LDLT), which may lead to graft loss and death of the recipients. Conventional gray-scale and Doppler ultrasound, as well as contrast-enhanced ultrasound (CEUS), play important roles in identifying vascular complications in the early postoperative period and during follow-up. We report a case of hepatic artery dissection secondary to HAP after LDLT, which was diagnosed and followed for one year by ultrasound. To the best of our knowledge, few studies have reported similar cases after liver transplantation in the English literature.

Case presentation

A 43-year-old man underwent right-lobe LDLT for treatment of a severe acute hepatitis B infection and was followed up with ultrasound examinations for one year. Conventional gray-scale and Doppler ultrasound combined with contrast-enhanced ultrasound (CEUS) accurately revealed the occurrence of HA dissection secondary to HAP and accompanied by thrombosis and collateral circulation, as well as secondary biliary complications, which provided a prompt diagnosis and guidance for the treatment.

Conclusion

Our case suggests that ultrasound can help detect hepatic artery pseudoaneurysm and dissection, as well as secondary biliary lesions after LDLT in an accurate and timely manner and provide useful information for the treatment chosen. CEUS shows potential as an important complementary technique to gray-scale and Doppler ultrasound.

Isolated Celiac and Splenic Artery Dissection: A Case Report and Review of the Literature

An isolated dissection of the celiac artery is an extremely rare condition that requires a high level of suspicion to evoke the diagnosis. Once established, the natural course is unpredictable in view of the discrepancies in its management requiring a case-by-case analysis. In this paper, we report an unusual case of spontaneous abdominal pain that was diagnosed with celiac and splenic artery rupture secondary to physical stress. This paper underlines the necessity to maintain a high level of suspicion for arterial dissections and we also review the management plan in such cases.

Spontaneous dissection of celiac trunk with concurrent splenic artery dissection

Isolated spontaneous dissection of the celiac trunk is rarely diagnosed in acute abdominal pain. We present two cases of celiac trunk and splenic artery dissection with splenic infarction. Patients were successfully managed and stabilized by medical treatment. Isolated celiac trunk dissection can be fatal, therefore providers should be careful not to overlook this entity.

Spontaneous dissection of the celiac trunk: report of three cases and review of the literature

Spontaneous dissection of the celiac trunk is quite an uncommon medical condition, with few case reports in the medical literature. Sudden epigastric abdominal pain is the most common complaint reported by patients, but due to the rarity of this disease in clinical practice and the nonspecific nature of its symptoms, a high degree of clinical suspicion is needed to establish diagnosis. However, improvements in imaging techniques are facilitating diagnosis of this clinical entity, increasing its detection rate. The ideal treatment has not yet been fully established in the literature and the available therapeutic strategies are conservative medical treatment, surgical revascularization or endovascular intervention. In this article we report on three cases of spontaneous dissection of the celiac trunk and conduct a review of the literature on this disease

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.

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.

Endovascular treatment of isolated spontaneous celiac artery dissection

This report presents the case of a patient with isolated spontaneous celiac artery dissection. The patient developed acute abdominal pain that was induced by eating. Computed tomography and selective angiography revealed an intimal flap that separated the true and false lumens located 3 cm from the origin of the celiac artery. We treated the patient with a stent that was deployed endovascularly into the celiac artery to seal the entry site. Postoperative angiography revealed that the graft was patent and the follow-up period was uneventful. The etiology, clinical features, diagnostic modalities and treatment options of isolated spontaneous celiac artery dissection are reported.

Splenic infarction as a complication of celiac artery thromboembolism: an unusual cause of abdominal pain

Splenic infarction is a relatively uncommon diagnosis and this clinical presentation can mimic other causes of acute abdominal pain. Cardiologic and hematologic disorders are common reasons for this entity. There have been a few series and single case reports of splenic infarction published in peer-reviewed medical journals. We report a 53-year-old patient who had splenic infarction caused by celiac artery thromboembolism. The importance of this case, without any etiological predisposing factors, is that this kind of clinical situation should be considered in the differential diagnosis of abdominal pain.

Fibromuscular dysplasia associated with simultaneous spontaneous dissection of four peripheral arteries in a 30-year-old man

A 30-year-old man had a sudden bout of severe abdominal pain. An enhanced computed tomographic scan revealed dissections of the celiac artery, superior mesenteric artery, left renal artery, and right external iliac artery; stenosis of the right renal artery; and left kidney infarction. After careful evaluation, the patient was diagnosed with fibromuscular dysplasia (medial dysplasia), based on the findings obtained from the enhanced computed tomographic scan. This case is extremely rare because fibromuscular dysplasia occurred concurrently with simultaneous spontaneous dissections of four peripheral arteries in a young man.

Dissecção isolada do tronco celíaco: relato de caso

A dissecção espontânea isolada do tronco celíaco sem a dissecção concomitante da aorta é uma condição rara, pouco descrita na literatura. O objetivo do presente trabalho é descrever um caso dessa entidade clínica em um paciente masculino, 74 anos, assintomático, cujo diagnóstico foi feito por ultrassonografia e confirmado com angiotomografia computadorizada. O paciente tem sido acompanhado com sucesso mediante observação clínica por um período de 25 meses.

Spontaneous celiac artery dissection and its management

Spontaneous visceral artery dissection is an uncommon event with an unpredictable natural history with superior mesenteric artery being the most common affected artery. It is most often asymptomatic and usually diagnosed at autopsy. Pre-disposing factors are not specific but have been suggested to be pre-existing vascular disease, hypertension and pregnancy. Spontaneous resolution, definitive occlusion of the artery, and formation of an aneurysm with associated complications are some other possible outcomes. Isolated dissection of the celiac artery (CA) is rare and there are only a few cases reported in the literature. We present a case of a 65 year old male with spontaneous celiac artery dissection and provide a review of the current literature about imaging findings and management of this entity.

Acute occlusion of the celiac axis and its branches with perforation of gastric fundus and splenic infarction, findings on spiral computed tomography: a case report

We present the contrast-enhanced spiral CT findings in a case of acute celiac artery occlusion with gastric perforation and total splenic infarction. Spiral CT depicted thrombus in the celiac axis and its branches, stenosis of the superior mesenteric artery, splenic infarction and lack of enhancement of the gastric wall with a large necrotic gap. Spiral CT enabled prompt diagnosis and therapy in this rare condition in a patient with suspicion of acute mesenteric ischemia.

Nonoperative Management of Isolated Celiac and Superior Mesenteric Artery Dissection: Case Report and Review of the Literature

Isolated dissection of the origin of both celiac and superior mesenteric arteries is a rare vascular pathology with limited management guidelines. The presentation is generally nonspecific, most often manifesting with epigastric pain radiating to the back. A high diagnostic index of suspicion and stepwise management are essential for a successful outcome. This case report details the clinical course of a 57-year-male who presented with a 2-week history of epigastric discomfort with back pain and was found to have focal celiac artery dissection with aneurysmal dilation of 1.2 cm. His vital signs were stable, and the physical examination was unremarkable. At this time, he was placed on antiplatelet medication and was scheduled for endovascular repair of his celiac aneurysm with a covered stent graft. Two weeks later, recurrent abdominal pain prompted a repeat computed tomographic scan that revealed sequential superior mesenteric artery (SMA) dissection. The patient was admitted and anticoagulated. A complete workup ruled out underlying collagen vascular and autoimmune pathology. He remained stable, with significant symptomatic improvement. After 6 months, anticoagulation was discontinued and antiplatelet therapy was instituted for long-term management. Subsequent operative or endovascular intervention was not required. The patient was continuing to do well on his 18-month clinical follow-up. There are 71 cases of SMA and 12 cases of celiac artery dissection in the literature. This report outlines this rare presentation of isolated, proximal sequential celiac artery and SMA dissection. This case illustrates that conservative management may be warranted in uncomplicated, isolated visceral arterial dissection.

Spontaneous splanchnic dissection: application and timing of therapeutic options

BACKGROUND

Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes.

METHODS

Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3).

RESULTS

All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management.

CONCLUSION

Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Spontaneous isolated superior mesenteric artery dissection: a case report and literature review with management algorithm

BACKGROUND

An isolated spontaneous superior mesenteric artery (SMA) dissection is the most frequent type of digestive artery dissection. Hepatic, splenic, left gastric, and celiac artery dissections are much less frequently observed. Dissection of the SMA is usually an extension of an aortic dissection. A true isolated SMA dissection is a relatively rare clinical cause of abdominal pathology. Only 106 cases (including the present case) of isolated spontaneous SMA dissection without associated aortic dissection were identified from the literature.

METHODS

Our vascular team managed a 56-year-old woman with spontaneous SMA dissection conservatively. Prior to the initiation of systemic anticoagulation, she underwent diagnostic laparoscopy. A repeat angiogram done at 2 months showed complete resolution of the dissection. She has been repeatedly examined for 5 years, which is the longest follow-up mentioned in the literature.

CONCLUSION

To our knowledge, this is the first case wherein laparoscopy was used to confirm the absence of mesenteric ischemia in acute presentation of SMA dissection. Using information from a review of the literature, we have designed a management protocol for this rare condition.

Single vessel abdominal arterial disease

The long-standing discussion concerning the mere existence of single vessel abdominal artery disease can be closed: chronic gastrointestinal ischaemia (CGI) due to single vessel abdominal artery stenosis exists, can be treated successfully and in a safe manner. The most common causes of single vessel CGI are the coeliac artery compression syndrome (CACS) in younger patients, and atherosclerotic disease in elderly patients. The clinical symptoms of single vessel CGI patients are postprandial and exercise-related pain, weight loss, and an abdominal bruit. The current diagnostic approach in patients suspected of single vessel CGI is gastrointestinal tonometry combined with radiological visualisation of the abdominal arteries to define possible arterial stenosis. Especially in single vessel abdominal artery stenosis, gastrointestinal tonometry plays a pivotal role in establishing the diagnosis CGI. First-choice treatment of single vessel CGI remains surgical revascularisation, especially in CACS. In elderly or selected patients endovascular stent placement therapy is an acceptable option.

The Risks of Celiac Artery Coverage During Endoluminal Repair of Thoracic and Thoracoabdominal Aortic Aneurysms

The risks of purposeful celiac artery coverage during endovascular thoracic aortic aneurysm repair (TEVAR) to obtain an adequate distal landing zone have received scant scientific attention. Patients undergoing TEVAR at 6 tertiary centers from January 2000 to June 2007 were identified (n = 434); cases requiring celiac artery exclusion (n = 19; 4.4% of the total) were analyzed. The mean follow-up was 8.7 months (range, 0.2-21.2). The mean patients' age was 73.6 years (range, 56-86); 57.9% were men. The mean aneurysm diameter was 6.7 cm (range, 5-8.6). In 2 patients, the celiac artery balloon occlusion test was performed prior to TEVAR. In both, intact collateral foregut circulation was seen. Both underwent TEVAR without celiac artery revascularization; 1 did well, whereas the other developed foregut ischemia. In 16 cases (84.2%), the celiac artery was not revascularized prior to TEVAR. In those patients, 19 complications were reported (3 deaths; 2 paraplegia). No similar events occurred in those who underwent celiac artery revascularization (n = 3). Celiac artery coverage during TEVAR is required in 4.4% of cases. TEVAR correlated with a nonnegligible number of major complications. Complications were more frequent and severe in patients who did not have celiac artery revascularization prior to TEVAR. Specific celiac artery coverage complications are rare and not readily predictable based on preprocedure arteriography.

Spontaneous Isolated Dissection of the Celiac Artery: CT Findings in Adults

OBJECTIVE

Our objective was to describe the CT features of spontaneous isolated celiac artery dissection in a series of six otherwise healthy patients with acute abdominal pain.

CONCLUSION

Although once believed rare, isolated spontaneous celiac artery dissection should be considered in the diagnosis of acute abdominal pain, especially in middle-aged adults.

Spontaneous dissection of the celiac artery: A case report

Spontaneous dissection of visceral arteries is rare in the absence of concurrent dissection of the aorta, iatrogenic injury from instrumentation, or trauma. We describe a spontaneous dissection of the celiac artery that was identified by computed tomographic scan in an otherwise healthy man with acute onset abdominal pain and no identifiable causes of dissection. The patient was successfully managed medically. Although endovascular treatment or surgical intervention is the procedure of choice for complicated cases, medical management with close observation is an acceptable management strategy for stable, uncomplicated cases of spontaneous celiac artery dissection.

Chronic mesenteric ischemia: imaging and percutaneous treatment

Chronic mesenteric ischemia (CMI) is rare and is often diagnosed late. Fatal malabsorption-related complications or acute ischemic events occur in the absence of treatment. Diagnosis depends on careful acquisition of a medical history and elimination of other conditions. No sensitive and specific tests are available for functional diagnosis of CMI. If other causes of abdominal pain and weight loss have been confidently ruled out, evidence of visceral artery occlusion at noninvasive imaging (Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) suggests CMI. Until the 1990s, open surgery was considered the treatment of choice; percutaneous transluminal angioplasty (PTA) was reserved for patients for whom surgery carried a high risk. However, open surgery carries a nonnegligible risk of morbidity and mortality. In recent years, PTA with stent placement has been recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate and consequently has been suggested for primary treatment of CMI. New treatments including administration of fibrinolytic agents before PTA of chronic occlusions, routine revascularization of one or more arteries, and stent placement will probably be validated in the near future. Similarly, new data on selection of the best approach will become available soon.