Spontaneous dissection of the celiac and hepatic arteries treated by transcatheter embolization

Mid-term Results of the Treatment of Isolated Dissection of the Celiac Artery: A Comparative Analysis of Endovascular Versus Conservative Therapy

OBJECTIVES

Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA.

METHODS

Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed.

RESULTS

A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10-85 months) and 44.0 (range, 9-80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001).

CONCLUSIONS

EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required.

CLINICAL IMPACT

Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery.

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.

Conservative Treatment in Two Patients With Spontaneous Hepatic Artery Dissection

BACKGROUND

Spontaneous dissection of the hepatic artery is a rare finding for which there is no specific treatment algorithm. Even though endovascular treatment and surgery have been used to treat other visceral artery dissections, these approaches can be challenging in the case of hepatic artery dissection because it is difficult to access the hepatic artery.

CASE SUMMARY

2 patients with spontaneous dissection of the hepatic artery were admitted due to epigastric pain. Although the liver function test results were normal, and there were no complications such as bleeding, shock, or ischemia in other organs, a subsequent computed tomography scan directly revealed the spontaneous dissection of the hepatic artery in both patients. The patients were treated with anticoagulants without surgery. Because it is difficult to perform surgery or endovascular treatment on the hepatic artery, we focused on preventing the progression of hepatic artery dissection and the formation of a new thrombus in the dissection.

CONCLUSION

Considering the risk of surgical treatment for the hepatic artery and the condition of the patients, medical treatment with anticoagulants may be considered as an initial treatment and provide more benefits than surgical treatment.

Dissecting aneurysm of the proper hepatic artery after laparoscopic hepatectomy possibly related to the Pringle maneuver: A case report

In hepatectomy, the Pringle maneuver is commonly used, but its association with iatrogenic injury is not yet well understood. This report presents a case of dissecting aneurysm of the proper hepatic artery (PHA) possibly associated with the Pringle maneuver during laparoscopic hepatectomy, that was successfully treated by transcatheter arterial embolization (TAE). The patient was a woman in her 70s, and repeat hepatectomy for liver metastasis of rectal neuroendocrine neoplasm was planned. She underwent hand-assisted laparoscopic hepatectomy with the Pringle maneuver. On postoperative day (POD) 7, enhanced computed tomography showed a dissecting aneurysm of the PHA. TAE of the PHA to prevent hemorrhage was performed on POD 9 with no complications. Even after TAE, intrahepatic arterial flow was provided by the peribiliary arteries. This case suggests the possibility that the Pringle maneuver can cause a dissecting aneurysm of the hepatic artery.

Current status of spontaneous isolated celiac artery dissection

BACKGROUND

This study aimed to evaluate the current status of spontaneous isolated celiac artery dissection (SICAD).

METHODS

The English-language literature published in various databases before December 2020 was reviewed. All case reports and series were included. If multiple reports came from the same hospital and covered the same period, only the most recent report was considered. The clinical characteristics, imaging features, and treatment outcome were analyzed.

RESULTS

The study enrolled 88 English language publications between January 1959 and December 2020, including 70 case reports, two case series, and 16 clinical studies. Overall, 316 cases of SICAD were reported in the studies, including 268 men and 44 women (unavailable for 4, men: women ratio: 6:1, p < 0.05). The median age was 50.5 years (range: 6-72) in men and 53.9 years (range: 41-67) in women. Most patients (83.54%, 264/316) complained about stomach pain, primarily in the epigastric region (38.61%, 122/316). The misdiagnosis rate in this study was 3.16% (10/316). The most commonly used imaging modality was computed tomography angiography (CTA), with 97.47% (308/316) cases reporting its use in diagnosis and/or management. The rate of symptom improvement with Conservative Management, with or without antithrombotic agents, was 92.45% (98/106) and 96.58% (141/146), respectively. The rate of symptom improvement after surgical recanalization was 100% (13/13). Moreover, endovascular management resulted in a 100% (50/50) symptom improvement rate.

CONCLUSION

Conservative management is the first-line treatment for SICAD. The surgical or endovascular intervention had a high technical success rate, suggesting that it should be reserved for patients who have failed conservative treatment.

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.

Coil embolization of an acutely expanding spontaneous splenic artery dissection

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

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

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

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

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

Percutaneous embolization of symptomatic dissecting aneurysms of the celiac artery

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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.

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.

Isolated, spontaneous superior mesenteric and celiac artery dissection: case report and review of literature

Spontaneous, isolated dissection of the superior mesenteric artery (SMA) and celiac artery (CA) is rare. Although there are known risk factors, there is no particular mechanism that is common to vascular dissections. The objectives of this study were to review the current literature on diagnosis and treatment of isolated SMA and CA dissection, and to review aortic complications in giant cell arteritis, Takayasu arteritis, and polyarteritis nodosa. Giant cell arteritis, Takayasu arteritis, and polyarterteritis nodosa are vasculitides that are associated with SMA and CA dissection. An interesting aspect of this case is that the patient was a healthy person before presentation, and ultimately, did not have an underlying etiology to explain the dissection. In addition, the patient was successfully managed without operative intervention. Although there are known risk factors in patients who present with isolated, spontaneous SMA and CA dissection, the pathogenesis is still unclear. The prognosis has improved significantly with the early use of computed tomography angiography to diagnosis this entity. Although most cases require surgical intervention, there are some, as in this case, that are managed non-operatively.

Isolated spontaneous dissection of the splanchnic arteries

OBJECTIVES

Isolated dissection of a splanchnic artery, including the celiac artery, superior mesenteric artery (SMA), and inferior mesenteric artery, and their branches, is a relatively rare condition. This study was conducted to define the characteristics of patients with splanchnic artery dissection and the clinical course of isolated splanchnic artery dissection.

METHODS

The records of 19 patients were reviewed to survey demographic data, the location of dissection, symptoms, diagnostic modalities, treatment, and long-term outcome.

RESULTS

The locations of dissection were the superior mesenteric artery (SMA) in 11 patients, celiac artery in 3, both celiac artery and SMA in 2, and common hepatic artery, celiac artery to splenic artery, and celiac artery to proper hepatic artery in 1 each. In all but one with systemic sclerosis and Sjögren syndrome, the underlying cause of dissection was unclear. There were 12 asymptomatic and seven symptomatic patients. All cases were diagnosed by computed tomography. Surgical treatment was performed in one patient with a large aneurysm of the common hepatic artery, and the remaining 18 patients were followed-up conservatively. The mean follow-up duration was 20.9 +/- 25.4 months (range, 2-116 months). No expansion or progression of the false lumen was observed in these patients.

CONCLUSION

Patients with spontaneous dissection of the splanchnic arteries are often asymptomatic, and in this series, none developed significant end organ ischemia. Most patients with this rare condition can be managed expectantly with clinical follow-up including computed tomography imaging to assess aneurysm formation.

Medical Management of Spontaneous Celiac Artery Dissection: Case Report and Literature Review

Spontaneous visceral artery dissections are a rare occurrence. Here we report a case of spontaneous celiac artery dissection that was treated without surgery.

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.

Spontaneous coeliac artery dissection

A patient with spontaneous coeliac artery dissection that presented as upper abdominal pain is reported. This was diagnosed on contrast-enhanced multislice helical CT. The patient was treated conservatively and follow-up CT showed mild aneurysmal change of the splenic artery and a small splenic infarct. Isolated dissection of the visceral arteries (and, in particular, the coeliac artery) is extremely rare. With such limited evidence, decisions over best management are difficult, but depend on initial severity and progression at follow up.

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.

Spontaneous dissection of the celiac artery

Spontaneous dissection of the celiac artery (CA) is uncommon, considering the number of isolated lesions without associated aortic dissection and exclusive of abdominal trauma. We have treated five cases of isolated spontaneous dissection of the CA or its branches. There were three men and two women with a mean age of 54 years. The presenting manifestation was acute epigastralgia in three cases and chronic abdominal pain in one. In the remaining case, dissecting CA was a coincidental finding. All patients underwent abdominal Doppler ultrasound and CT scan imaging, which demonstrated aneurysm in three cases and dissection in two. Work-up also included arteriography in three cases and magnetic resonance (MR) angiography in one. Management consisted of emergency surgical repair in three cases and close surveillance in two. The repair procedure was resection-anastomosis in one case and prosthetic bypass to the hepatic artery in two cases. Postoperative recovery was uneventful in all three cases and patients were symptom-free at 6, 8, and 18 months. Both patients under surveillance were symptom-free at 1 and 2 years. Because of the risk of ischemic and hemorrhagic complications, surgery should be considered for any patient with CA dissection. However, some patients with uncomplicated asymptomatic lesions may be eligible for medical treatment with regular surveillance.

Isolated dissection of the celiac artery--a case report

Isolated arterial dissection, which occurs with the absence of aortic dissection, has been reported in carotid and renal arteries but rarely in visceral arteries. A case of isolated celiac artery dissection is reported here. A healthy 58-year-old man experienced sudden upper abdominal pain, which continued for several days. A body computed tomogram (CT) showed a multiple low-density wedge-shaped area in the spleen, which was diagnosed as splenic infarction, and an aneurysm with thrombus in the celiac artery. A selective angiogram showed dilatation of the celiac artery with wall irregularity, and proximal occlusion of the hepatic artery. The distal hepatic artery was fed by collateral arteries from the superior mesenteric artery. Splenic infarction was probably due to the embolism from the thrombus in the dissected celiac artery. The absence of other vascular lesions and causes or risks for the arterial dissection would suggest the occurrence of spontaneous dissection. The dissection of visceral arteries should be considered in diagnosing acute abdominal pain.

Nonoperative treatment for a ruptured pseudoaneurysm of the celiac trunk: report of a case

We report the case of a 67-year-old man in whom hemorrhage from a ruptured celiac trunk pseudoaneurysm, which occurred as a consequence of leakage at the site of gastroduodenostomy, was successfully controlled by transcatheter arterial embolization (TAE) with stainless steel coils and N-butyl cyanoacrylate (NBCA). The occurrence of a pseudoaneurysm of the celiac trunk associated with anastomotic leakage is etiologically rare. We compiled reports from the literature on TAE for ruptured aneurysms of the celiac trunk, and compared its therapeutic value with that of surgical treatment. Operative death occurred in 4 of a series of 43 patients with aneurysms of the celiac trunk that were surgically treated (9.3%). In 5 patients with ruptured aneurysms, the operative mortality rate was 40% (2/5). Conversely, while the unsuccessful rate of TAE therapy was 17% (1/6), the mortality rate was nil. The patient whose case is presented here was affected by methicillin-resistant staphylococcus aureus (MRSA) at the site of leakage and in the lung. Under septic conditions such as hemorrhage secondary to pancreatitis, the mortality rate of surgical therapy was 23%-29%, whereas the success rate of TAE therapy was 79% and the mortality rate was 4%. Based on these findings, it is suggested that TAE therapy is a viable alternative to surgery for patients even with ruptured pseudoaneurysms of the celiac trunk.