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

A case report of Spontaneous celiac artery dissection treated by endovascular intervention

Spontaneous celiac artery dissection is uncommon. Abdominal pain is a common clinical presentation. Conservative medical treatments, endovascular interventions, and open surgery are used to treat spontaneous celiac artery dissection. A 49-year-old male patient visited our hospital, with back and subxiphoid pain that had persisted for 11 hours. He has been smoking 40 cigarettes a day for 20 years. The blood pressure was 180/100mmHg. Aortic computed tomography angiography (CTA) images revealed dissection of the celiac artery, common hepatic artery, left hepatic artery, right hepatic artery, and splenic artery. Urapidil hydrochloride and isosorbide dinitrate were administered to lower the blood pressure to approximately 110/70 mmHg. However, the back and subxiphoid pain persisted without relief. Angiography was performed and a vascular stent (BARD, LIFE STENT, VASCULAR, 8 × 60) was implanted into the celiac artery without involving the branches. Pain was immediately relieved after interventional therapy. The patient was discharged after 4 days. A subsequent aortic CTA after 10 months confirmed that the celiac artery dissection had still not reoccurred.

Dissection of the Celiac Trunk Is a Mild Disease

BACKGROUND

The purpose of this study was to assess whether the presence of an aneurysmal or dissecting arterial disease was a risk factor of poor prognosis in patients presenting a dissection of the celiac trunk (CT).

METHODS

All patients presenting a CT dissection between January 1, 2014, and June 30, 2022, were included. Patients with a CT dissection due to the extension of an aortic dissection were excluded. Les antécédents familiaux de dissection, de maladie anévrysmale, de maladie athéromateuse ou du tissu conjonctif, la pratique d'une activité physique ou sportive, un effort inhabituel les jours précédant la dissection ainsi qu'un traumatisme étaient recherchés. Family history of dissection, aneurysmal disease, atheromatous or connective tissue disease, physical activity or sport, an unusual effort in the days prior to the dissection and trauma were sought after. Ischemic or aneurysmal complications in the acute phase and the evolution of the dissection were evaluated and compared between patients with an isolated dissection and those presenting an aneurysmal or dissecting arterial disease.

RESULTS

45 patients were included in the study. Twenty-three (51.1%) patients presented with symptomatic CT dissection, and 22 (48.9%) with asymptomatic CT dissection. All the patients initially had medical management alone. The mean follow-up was 32 ± 25 months and all patients were asymptomatic at the time last news. 24 (53.3%) presented an isolated CT dissection, and 21 (46.7%) a CT dissection associated with aneurysmal or dissecting arterial disease. There was no significant difference between patients with an isolated CT dissection and those with an associated dissecting or aneurysmal pathology.

CONCLUSIONS

CT dissection is a stable disease in the midterm, which makes it a mild arterial pathology, with or without aneurysmal or dissecting anomalies in another territory. The mechanical stress exerted on the CT by the arcuate ligament could be responsible for parietal trauma and favor the occurrence of a CT dissection.

Spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma: a rare case

BACKGROUND

Gastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma.

CASE PRESENTATION

A 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma.

CONCLUSION

A gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

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.

Isolated Superior Mesenteric Artery Dissection: An Unusual Etiology of Epigastric Pain

Abdominal pain is a very common presentation in the emergency department (ED). The pain is often well-characterized and leads to the diagnosis, but often, the presentation is vague and nonspecific. Superior mesenteric artery (SMA) dissection is a rare cause of abdominal pain that presents with nonspecific epigastric pain and is common in males, middle age, and patients of Asian descent. A high index of suspicion is usually helpful with imaging modalities such as computer tomography (CT) scan and ultrasonography in experienced hands. A prompt diagnosis is vital to managing this disease which may range from non-surgical intervention with supportive therapy to invasive endovascular procedures and surgery. Here, we report a case of an isolated SMA dissection presenting with vague abdominal symptoms and highlight the need to explore the vascular etiology of abdominal pain as their diagnosis is often difficult and may result in irreversible bowel injury when missed.

Disección espontánea del tronco celíaco. Una emergencia vascular inusual

Introducción. La disección espontánea del tronco o arteria celíaca es una emergencia vascular abdominal inusual, con una incidencia desconocida. Actualmente no existen guías o consensos para su tratamiento, el cual va desde intervenciones vasculares mayores hasta la conducta expectante. Caso clínico. Paciente masculino de 42 años sin antecedentes patológicos, con dolor abdominal intenso de un mes de evolución. Ante la sospecha clínica de patología inflamatoria se realizó una tomografía computarizada abdominal con medio de contraste, en la que se observó una disección del tronco celíaco asociada a un infarto esplénico. Se realizó manejo endovascular de forma exitosa. Discusión. La disección espontánea del tronco celíaco es una patología infrecuente, que puede presentarse en pacientes con hipertensión arterial, tabaquismo, enfermedad ateroesclerótica y vasculitis. Los síntomas más comunes son el dolor abdominal asociado a náuseas y vómito. La sospecha clínica debe ser confirmada mediante estudios imagenológicos que orienten al tratamiento conservador, endovascular o quirúrgico, ante la sospecha de infarto intestinal o ruptura arterial. Conclusiones. La disección espontánea del tronco celíaco es una patología vascular inusual que puede relacionarse con una alta mortalidad. Es importante tener siempre presente la interrelación entre la anatomía vascular abdominal, la anamnesis y el examen físico como elementos claves para realizar este diagnóstico.

A Rare Cause of Acute Abdomen in a 59-Year-Old Male

Celiac artery dissection is often an inconspicuous cause of acute abdomen. Spontaneous celiac artery dissection is most often associated with aortic dissection, and thus isolated spontaneous celiac artery dissection is rare. Herein, we present a case of celiac artery dissection with no aortic involvement. This case emphasizes the importance of including such a condition in the differential diagnosis of patients presenting with acute abdomen.

Results Obtained with the Protege EverFlex Self-expanding Bare Stent in Interventional Treatment of Spontaneous Isolated Visceral Artery Dissection

OBJECTIVE

We evaluated the early and midterm results of the endovascular approach with a certain type of bare stent to treat spontaneous isolated visceral artery dissection (SIVAD).

METHODS

28 patients with symptomatic SIVAD were selected from two hospitals from July 2014 to September 2020. All patients had symptoms of acute persistent abdominal pain accompanied by varying degrees of nausea and vomiting. The diagnosis of SIVAD was made according to the multidetector CT angiography (CTA) findings. We retrospectively analyzed the patients' medical records. According to our previous clinical experience, the Protege EverFlex self-expanding bare stent was used in these patients, and we subsequently followed up the patients to record and analyze their outcomes after surgery. The imaging results before and after the operations were compared.

RESULTS

All 28 patients were successfully implanted with Protege EverFlex stents. The true lumen blood flow of the SIVAD recovered during the operation. The residual stenosis rate was less than 30%, and the technical success rate was 100%. There were no complications, such as bleeding, intestinal necrosis, digestive tract perforation, liver failure or spleen infarction. The abdominal pain was relieved or eliminated in all patients.

CONCLUSION

The Protege EverFlex self-expanding bare stent and the endovascular approach could be a minimally invasive, safe and effective treatment method for SIVAD with a high success rate and a relatively low price.

New technique for false lumen coiling of spontaneous isolated superior mesenteric artery dissection

Background

Spontaneous isolated visceral artery dissection is rarely encountered. Endovascular intervention with good outcomes has become popular for patients with persistent symptoms or developing ischemia. We could perform life-saving treatment for a spontaneous isolated superior mesenteric artery dissection with a unique endovascular intervention.

Case presentation

We describe the case of an 80-year-old man who presented with acute abdominal pain and a spontaneous isolated superior mesenteric artery dissection measuring 35 mm in major diameter and 6.6 mm in minor diameter on abdominal contrast-enhanced computed tomography. After admission, abdominal pain was progressive, and a repeated scan revealed progression of the dissection. As an endovascular intervention, via the bilateral femoral approach, detachable coils were placed in the false lumen of the superior mesenteric artery dissection through the false lumen under the micro-balloon occlusion at the point of re-entry and entry through the true lumen to prevent coil migration. Technical and clinical success was achieved without serious adverse events.

Conclusion

Coil embolization using micro-balloon assistance combined with the double-catheter technique for a large entry and re-entry false lumen of a spontaneous isolated superior mesenteric artery dissection was useful and feasible.

Evaluation of isolated abdominal visceral artery dissection with multi-scale spiral computed tomography: a retrospective case series

Background

To evaluate the role of multi-slice spiral computed tomography (MSCT) angiography in the diagnosis of spontaneous isolated visceral artery dissection (SIVAD).

Methods

Twenty-seven patients with abdominal SIVAD were included in the study. The MSCT scans of the patients were subjected to various post-processing techniques to visualize the visceral artery wall. Clinical features including arterial dissection, thrombosis, dissection length, true/false lumen, and complications were recorded.

Results

Type I, IIa, and IIb SIVADs were observed in 11, 6, and 10 patients, respectively. Superior mesenteric artery (SMA) dissection was the most common (n = 16), followed by abdominal aortic dissection (n = 6), splenic artery dissection (n = 2), renal artery dissection (n = 2), and splenic artery dissection (n = 1). One patient with SMA dissection suffered small intestine ischemia, 1 with splenic artery dissection had splenic infarction, and 1 patient with left renal artery dissection experienced renal infarction. The false lumen was bigger than the true lumen in 20 patients, with 9 patients having thrombus. The true lumen was bigger than the false lumen in 7 patients.

Conclusions

MSCT angiography is a valuable technique in the diagnosis and treatment of patients with SIVAD. Patients with abdominal pain suspected due to SIVAD should be examined with MSCT angiography for early detection of SIVAD.

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.

Clinical implications of perivascular fat stranding surrounding spontaneous isolated superior mesenteric artery dissection on computed tomography

Patients with spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) usually present with acute or chronic abdominal pain and are admitted to the emergency or digestive diseases department to undergo auxiliary examinations, typically abdominal plain CT or contrast-enhanced CT (CECT). Plain CT is the most crucial examination in emergency radiology. An enlarged SMA diameter and perivascular fat stranding (PFS) on plain CT, though non-specific, may be the only indications for SISMAD. These results may be easily overlooked and the diagnosis of SISMAD may be missed. However, PFS around the SMA on CT may be the only indicator of the possible presence of SISMAD, particularly during the early stage when there are no massive changes in the vascular wall. The present study aimed to determine whether PFS surrounding the SMA on CT may help with the diagnosis of SISMAD by indicating the requirement for further examination. The data of 161 consecutive patients with SMA dissection who underwent abdominal CECT or underwent SMA CT angiography (CTA) after abdominal plain CT between February 2015 and February 2018 were retrospectively reviewed. SMA diameter, classification, PFS, complications, comorbidities and treatments were analyzed. The results demonstrated that SISMAD with PFS was significantly associated with admission type (emergency), clinical manifestations (abdominal pain), diagnostic modality and dissection subtype. On plain CT, PFS surrounding the SMA may be a marker for SISMAD, particularly in the emergency setting, and indicates the requirement for CTA examination.

Spontaneous celiac artery dissection

BACKGROUND

Spontaneous celiac artery dissection is a rare visceral artery dissection that typically presents with acute abdominal or flank pain.

CASE REPORT

We describe a case of a 54-year old previously healthy male who presented to the Emergency Department with subacute back pain and was found to have a spontaneous celiac artery dissection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency medicine physicians frequently consider acute aortic dissection in patients presenting to the Emergency Department with acute chest, back, and/or upper abdominal pain. Less commonly thought of are variations of arterial dissection, including those involving the celiac artery. Given readily available diagnostic imaging modalities and therapeutic interventions, it remains important to consider visceral arterial dissection, and to recognize the varied clinical manifestations of this rare clinical entity.

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.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).

A Complicated Entity: Acute Celiac Artery Dissection with Resultant Pancreatitis, Duodenitis, and Cholecystitis

Arterial dissection is a well-recognized pathology often seen in Vascular Surgery offices and Emergency Departments alike; however, visceral arterial dissection is an extremely rare, small subset of this entity. With that, an isolated celiac artery dissection as presented within this report is an exceptionally unique pathology that has scarcely been reported, and due to this, management guidelines are undefined. Given the viscera supplied by the celiac artery, many intra-abdominal structures are at risk for ischemia when damage to the celiac artery occurs, potentially witnessed by this report. Due to the exclusivity of this pathology, we are compelled to report the case of a 71-year-old male who presented with complaints of abdominal pain and was found to have an acute celiac artery dissection, which likely resulted in severe ischemic duodenitis, as well as possibly acute pancreatitis, and questionable influence on cholecystitis.

Small intestinal autotransplantation for spontaneous isolated superior mesenteric artery dissection: A case report

INTRODUCTION

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare differential diagnosis for patients presenting with abdominal pain. Due to limited cases reported, surgical management strategies are poorly defined.

PATIENT CONCERNS

A 54-year-old man presented to our emergency department with a 4-day history of epigastric pain combined with nausea and vomiting. The pain was dull, constant, and unbearable. It was accompanied by abdominal distention, but there was no radiating pain, chills, fever, or hematochezia. The patient did not have a history of abdominal surgeries, or tobacco or illicit drug use.

DIAGNOSIS

A contrast-enhanced computerized tomography (CT) scan demonstrated an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The middle-lower jejunum and the whole ileum were extensively dilated, and the middle jejunum was ischemic with edema.

INTERVENTIONS

Exploratory laparotomy and autologous small bowel transplantation.

OUTCOMES

The patient was successfully treated using exploratory laparotomy and intestinal autotransplantation (IATx) without bowel resection and had a stable recovery without complications.

CONCLUSION

For patients with severe mesenteric ischemia or those who fail to respond to initial conservative treatment, IATx may be a reasonable treatment strategy.

Clinical and CT Angiographic Follow-Up Outcome of Spontaneous Isolated Intramural Hematoma of the Superior Mesenteric Artery

OBJECTIVES

The aim of this study was to evaluate the clinical course and vascular remodeling of spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA) after treatment.

METHODS

In this retrospective study, 24 consecutive patients with SIHSMA admitted from January 2009 through December 2016 were included in this study. The clinical characteristics, type and location of the dissection, clinical outcome and vascular remodeling were analyzed retrospectively.

RESULTS

The subjects included 21 men and three women, with a mean age of 50.58 years. The chief complaint was abdominal pain in all patients. The mean follow-up was 10.08 months. Among the 24 patients examined, two patients (8.33%) showed no obvious changes in the CT. Twenty patients were treated by conservative strategy. One case underwent exploratory laparotomy along with embolectomy and arteriotomy. Another three cases received angioplasty and stent implanting. Complete and partial remodeling was observed in 15 (62.5%) and four patients (16.67%). Three (12.5%) of the lesions had dissection remodeling and aneurysm change.

CONCLUSIONS

SIHSMA represented variable vascular remodeling, while most of the patient got a complete resolution during follow-up, and its clinical course was benign in this study. Vast majority of patients can be managed conservatively when there are no signs indicating organ ischemia.

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.

Spontaneous Celiac Artery Dissection Presenting With Splenic Infarction: A Case Report

Spontaneous isolated celiac artery dissection (SICAD) is extremely rare. We herein report a case of a 43-year-old male with no known history of cardiovascular disease who presented to the emergency department (ED) with sudden onset severe epigastric abdominal pain without a known trigger. Abdominal computed tomography (CT) scan showed a focal dissection and irregular enhancement of the celiac trunk with associated splenic artery embolus and large splenic infarct. The patient was successfully treated conservatively with blood pressure control, antiplatelet and anticoagulation therapy.

Optimal Treatment for Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Obstruction Due to Celiac Artery Dissection

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.

Interventional treatment of isolated dissection of the celiac artery: A case report and literature review

RATIONALE

Isolated dissection of the celiac artery (IDCA) is one of isolated visceral artery dissection, which can occur alone, and can also be complicated with superior mesenteric artery dissection and splenic artery pseudoaneurysm. This disease is very rare in clinic. The exact pathogenesis of IDCA remains unknown. At present, no consensus has yet been reached on the best treatment strategy for this rare disease. In the present study, the clinical data of one IDCA patient diagnosed and treated in our hospital was retrospectively analyzed, and related literatures were reviewed, in order to improve the understanding of the disease.

PATIENT CONCERNS

The patient was a 49-year-old male, who was admitted in our hospital because of "pain of subxyphoid area for one month". One month before, the patient presented with persistent pain in the subxyphoid area after he had a cold, on paroxysmal exacerbation occurred. After taking "stomach drug", the subjective symptoms eased slightly, but the disease attacked again two hours later.

DIAGNOSES

The patient was diagnosed with "isolated dissection of the celiac artery" by enhanced CT.

INTERVENTIONS

The patient was interventionally treated with bare stent implantation.

OUTCOMES

The symptom of the patient disappeared after interventional therapy.

LESSONS

In the present study, the clinical symptoms and treatment process of one patient with IDCA were described. The clinical symptoms of IDCA are often atypical, and its incidence is extremely low, therefore it is extremely easily misdiagnosed. The definite diagnosis depends on imaging examination. Interventional therapy is the first choice for treating this disease due to its advantages of small trauma and good curative effect.

Follow-up with computed tomography after spontaneous isolated dissection of the splanchnic artery

The aim of this study was to evaluate radiological changes after spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and spontaneous isolated dissection of the celiac artery (SIDCA) using computed tomography (CT). This single-center retrospective study was approved by the hospital institutional review board. We reviewed the medical records and morphological CT findings of 33 consecutive patients with SIDSMA or SIDCA who were diagnosed between January 2001 and February 2016. We analyzed changes on follow-up CT images including length of the dissection, presence of a thrombus in the false lumen, maximal outer diameter, degree of luminal stenosis, patency of distal flow, and end-organ injury. We classified short-term (within the first week) and long-term (between the first week and sixth month) follow-up groups and analyzed differences in radiological changes over time using Wilcoxon signed-rank tests (continuous variables) and Fisher exact probability tests (categorical variables). Additionally, we examined patients who completed follow-up CT within 3 days after symptomatic changes. Comparing initial and final CT findings, a majority of patients with SIDSMA and SIDCA showed no significant changes in most CT parameters, including dissection length, thrombus presence, dissection diameter, stenosis degree, and extended distal branch. Between the short-term and long-term CT follow-up groups, there were no significant differences in radiological changes except for in the degree of luminal stenosis at the dissected segment in SIDSMA (P = 0.043). Only 10 patients completed follow-up CT within 3 days after symptomatic changes (progression or regression); of these, 1 patient had radiological findings that matched symptom progression, showing an increase in the degree of luminal stenosis and end-organ injury. There was no splanchnic artery dissection-related mortality, symptom progression, or event recurrence. In conclusion, CT follow-up of SIDSMA and SIDCA was mainly useful in the acute phase of dissection, with no significant radiological changes occurring in the long term. Accordingly, we question the utility of long-term follow-up CT after spontaneous isolated arterial dissection, especially in the absence of symptom progression.

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.

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.

A Case of Spontaneous Isolated Celiac Artery Dissection with Pseudoaneurysm Formation

Spontaneous isolated celiac artery dissection is a rare disease and patients without evidence of significant complications often resolve with medical therapy alone; however, the extension of the dissection can lead to more serious complications including aneurysmal dilatation, complete occlusion, and rupture of a visceral artery. In these patients, optimal management has not yet been clearly defined and treatment primarily depends on clinical presentation and lesions identified on imaging studies. This case report demonstrates the conservative management of spontaneous celiac artery dissection.

A 49-year-old male presented to our emergency department with acute and persistent abdominal pain. A contrast-enhanced computed tomogram (CT) of abdomen showed a pseudoaneurysm involving the ostium of the celiac artery with focal dissection, with no evidence of thrombosis or infarction to the visceral organs. Ultrasound studies demonstrated a prominent but patent celiac artery with adequate distal perfusion. Therefore, conservative medical management with antiplatelet therapy was initiated in our patient. Follow-up repeat ultrasound three weeks following discharge showed no evidence of dissection flap, stenosis, thrombosis or increase in the size of the aneurysm.

This case report demonstrates that conservative medical management with antiplatelet therapy can be sufficient in treating spontaneous isolated celiac artery dissection with pseudoaneurysm formation. We suggest endovascular or surgical intervention should be reserved for patients who present with hemodynamic instability, or other serious complications, such as aneurysm rupture or visceral infarction.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.

Spontaneous Renal Artery Dissection as a Cause of Acute Renal Infarction: Clinical and MDCT Findings

The purpose of this study was to assess the incidence of spontaneous renal artery dissection (SRAD) as a cause of acute renal infarction, and to evaluate the clinical and multidetector computed tomography (MDCT) findings of SRAD. From November 2011 to January 2014, 35 patients who were diagnosed with acute renal infarction by MDCT were included. We analyzed the 35 MDCT data sets and medical records retrospectively, and compared clinical and imaging features of SRAD with an embolism, using Fisher's exact test and the Mann-Whitney test. The most common cause of acute renal infarction was an embolism, and SRAD was the second most common cause. SRAD patients had new-onset hypertension more frequently than embolic patients. Embolic patients were found to have increased C-reactive protein (CRP) more often than SRAD patients. Laboratory results, including tests for lactate dehydrogenase (LDH) and blood urea nitrogen (BUN), and the BUN/creatinine ratio (BCR) were significantly higher in embolic patients than SRAD patients. Bilateral renal involvement was detected in embolic patients more often than in SRAD patients. MDCT images of SRAD patients showed the stenosis of the true lumen, due to compression by a thrombosed false lumen. None of SRAD patients progressed to an estimated glomerular filtration rate < 60 mL/min/1.73 m² or to end-stage renal disease during the follow-up period. SRAD is not a rare cause of acute renal infarction, and it has a benign clinical course. It should be considered in a differential diagnosis of acute renal infarction, particularly in patients with new-onset hypertension, unilateral renal involvement, and normal ranges of CRP, LDH, BUN, and BCR.

Conservative Management of Isolated Superior Mesenteric Artery and Celiac Trunk Dissection: A Case Report and Literature Review

Isolated arterial dissection without aortic pathology has been rarely reported in mesenteric vessels. The natural history and appropriate treatment for this disease is uncertain because of the scarcity of literature which limits the data available to the clinician, resulting in management challenges. Herein, we report a rare case of a 42-year-old Tunisian man with spontaneous dissection and aneurysmal dilatation of the Celiac Artery (CA) and the Superior Mesenteric Artery (SMA) with partial thrombosis. This case was successfully managed conservatively with heparin infusion and blood pressure control and the patient remained symptom free at 15 months follow up. This case demonstrates that conservative management may be warranted in non-complicated isolated visceral arterial dissection.

Spontaneous isolated left gastric artery dissection: unusual visceral artery dissection

Case

A 51-year-old woman visited our emergency department complaining of acute onset of upper abdominal pain and nausea. Abdominal contrast-enhanced computed tomography showed an isolated left gastric artery dissection and pseudoaneurysm. After conservative management for 6 days, endovascular embolization was carried out for treatment of the pseudoaneurysm. Spontaneous dissection of a visceral artery rarely occurs in the case of a left gastric artery.

Outcome

Contrast-enhanced computed tomography is essential to make an accurate diagnosis and establish a therapeutic strategy.

Conclusion

We should consider the occurrence of minor visceral artery dissection if a patient has acute abdominal pain without other obvious causes.

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.

Perceptual type error in everyday practice

Discrepancy or quality improvement meetings are good practice and are now commonplace in most Radiology Departments, with the aim of improving diagnostic accuracy, preventing recurrent and common mistakes, improving the radiological report and thereby improving patient care. A total of 122 cases were assessed from a two-year period. This review highlights some of the more common, recurrent and important issues encountered within a general hospital with an emphasis on learning points and review areas.

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.>.

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 Isolated Celiac Artery and Superior Mesenteric Artery Dissections: A Rare Case

BACKGROUND

Arterial dissection is defined as the cleavage of the arterial wall by an intramural hematoma. Reports of dissection of the celiac and/or superior mesenteric artery are rare; as far as we know, only 24 cases of spontaneous isolated celiac trunk dissection, and 71 cases of spontaneous isolated superior mesenteric artery dissection have been reported.

CASE REPORT

The case presents a 48-year-old male with a sudden-onset epigastric pain. A Computed Tomography Angiography of the thoracoabdominal aorta was applied and dissections of both the celiac artery and SMA were determined. A conservative therapeutic approach was preferred and the patient was discharged with anticoagulant and antihypertensive therapy.

CONCLUSIONS

Although rare, spontaneous isolated celiac artery and superior mesenteric artery dissections must be kept in mind in the differential diagnosis of the epigastric pain in the emergency room. Contrast-enhanced Computed Tomography Angiography examination is the method of choice in the diagnosis.

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.