Endovascular treatment of isolated spontaneous celiac artery dissection

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

OBJECTIVES

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

METHODS AND RESULTS

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

CONCLUSIONS

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

General features, management strategies, and outcomes of symptomatic spontaneous isolated celiac artery dissection

Objectives

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that has not been fully investigated and reported, and very little is known regarding its prognosis and management. Here, we aimed to provide more evidence on the management strategy and outcome for symptomatic SICAD based on the experience of a single center.

Methods

From January 2018 to December 2021, a total of consecutive 51 patients with symptomatic SICAD were retrospectively included in this study. These patients had been selectively treated with conservative treatment (n = 31) or endovascular treatment (n = 20). Baseline data, imaging findings, treatment strategy, outcomes, and follow-up data have been described and analyzed.

Results

The mean age of the patients was 53.2 ± 9.6 years, 44 (86.3%) were male, and 36 (70.6%) had hypertension. The median length of stay was 10.0 days. The complete remission rate was 92.2% on discharge. The median follow-up time was 21.0 months. A secondary intervention was required for two patients during follow-up in the conservative group, wherein one underwent a stent placement three months after discharge because of progression of symptoms and extension of dissection, and the other required intervention one month after discharge because of symptomatic progression. No secondary intervention was required in the endovascular group. Occasional and mild relapse of symptoms occurred in two patients in both the conservative and endovascular groups, with no secondary intervention. The length of dissection (25.5 ± 11.8 mm vs. 19.1 ± 7.4 mm, P = 0.022) and complete remodeling rate (85.7% vs. 15.4%, P < 0.001) in the endovascular group were greater than that in the conservative group.

Conclusion

Patients with symptomatic SICAD who were selectively treated with conservative treatment or endovascular treatment had satisfactory early and medium-term outcomes. Endovascular treatment showed significant advantages in the complete remodeling of the celiac artery and presented with a lower rate of secondary intervention. Moreover, it was found to be a safe and effective remedy for failed conservative treatment.

Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review

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.

Natural course of incidentally detected isolated Celiac Artery Dissection with hepatic artery occlusion

Isolated celiac artery dissection (ICAD) is a rare entity with over 160 cases described in literature. We report a case of incidentally detected isolated celiac artery dissection during computed tomography evaluation for occult gastrointestinal bleeding. Though most cases of isolated celiac artery dissection are initially managed conservatively with antiplatelet and anticoagulants, some patients may require endovascular or occasionally surgical treatment. In our case, the celiac artery dissection had already progressed to cause hepatic artery occlusion and secondary collateral formation in the porta hepatis region. We retrospectively analyze the natural course of celiac artery dissection with hepatic artery occlusion in an asymptomatic patient for over 3 years.

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

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

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

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

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

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

Introduction

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

Presentation of case

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

Discussion

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Isolated spontaneous dissection of the celiac artery: report of two cases

Isolated spontaneous dissection of the celiac artery (DCA) is extremely rare and its therapeutic strategy is still not established. We report two cases of DCA, in which 58-year-old and 43-year-old male patients with right hypogastralgia and back pain, respectively, were diagnosed by enhanced computed tomography and treated conservatively with antihypertensive agents. They were doing well under circumspect medical management without recurrence of symptoms or progression of dissection after 3.5 years and 3 months, respectively, after detection of DCA. Conservative treatment with blood pressure control and careful surveillance is considered to be applicable in most cases of DCA.

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.