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Pierce TT, Prabhu V, Baliyan V, Hedgire S. Imaging of Visceral Vessels. Radiol Clin North Am 2024; 62:543-557. [PMID: 38553185 DOI: 10.1016/j.rcl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The visceral vasculature is inextricably intertwined with abdominopelvic disease staging, spread, and management in routine and emergent cases. Comprehensive evaluation requires specialized imaging techniques for abnormality detection and characterization. Vascular pathology is often encountered on nondedicated routine imaging examinations, which may obscure, mimic, or confound many vascular diagnoses. This review highlights normal arterial, portal venous, and systemic venous anatomy and clinically relevant variants; diagnostic pitfalls related to image-acquisition technique and disease mimics; and characteristics of common and rare vascular diseases to empower radiologists to confidently interpret the vascular findings and avoid misdiagnosis.
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Affiliation(s)
- Theodore T Pierce
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, White Building, Room 270, 55 Fruit Street, Boston, MA 02114, USA.
| | - Vinay Prabhu
- Department of Radiology, NYU Langone Health, 660 First Avenue, Third Floor, New York, NY 10016, USA
| | - Vinit Baliyan
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital-Harvard Medical School, 175 Cambridge Street, Boston, MA 02114, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital-Harvard Medical School, 175 Cambridge Street, Boston, MA 02114, USA
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2
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Hayama T, Ochiai H, Nozawa K, Kikuchi Y, Sasajima Y, Fukagawa T. A case of rectal cancer complicated with segmental arterial mediolysis (SAM) safely treated with curative resection - A case report. Int J Surg Case Rep 2024; 116:109418. [PMID: 38417239 PMCID: PMC10943991 DOI: 10.1016/j.ijscr.2024.109418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Recent advances in diagnostic imaging techniques have led to an increasing number of case reports of segmental arterial mediolysis (SAM). However, reports of abnormalities associated with SAM of abdominal organs, including the bowel, are limited. SAM, a rare vascular disease that causes spontaneous intra-abdominal bleeding, including shock and intestinal ischemia, has been reported to be associated with high mortality, but it has not been reported to coexist with rectal cancer. CASE PRESENTATION A 74 year-old male was referred to our hospital with a rectal cancer and he was admitted for further examination. Computed tomography angiography (CTA) revealed dissection and aneurysm in the celiac artery, superior mesenteric artery (SMA), and the inferior mesenteric artery were dilated, leading to a diagnosis of SAM. CLINICAL DISCUSSION Surgery for rectal cancer requires cutting the inferior mesenteric artery. The risk of bleeding during surgery increases when SAM is associated with the inferior mesenteric artery. The radical surgery for rectal cancer was executed without complications, including significant bleeding. This was achieved through careful management of SAM, meticulous control of blood pressure throughout the surgical procedure, and the delicate treatment of the SMA. A pathological diagnosis of the resected inferior mesenteric artery at the time of radical surgery was performed, and a definitive diagnosis of SAM was made. CONCLUSION We present a first known case in which high anterior resection was successfully performed for rectal cancer complicated by SAM. The relationship between cancer and SAM is unclear and further case accumulation is needed.
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Affiliation(s)
- Tamuro Hayama
- Department of Surgery, Teikyo University School of Medicine, Japan.
| | - Hiroki Ochiai
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Yoshinao Kikuchi
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Yuko Sasajima
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Takeo Fukagawa
- Department of Surgery, Teikyo University School of Medicine, Japan
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3
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Hirose Y, Tajima Y, Sakata H, Uekusa T, Kamada K, Ikehara T, Matsuda I, Yoneyama S, Hidemura A, Suzuki H. Gallbladder hemorrhage associated with segmental arterial mediolysis: a case report. Surg Case Rep 2024; 10:8. [PMID: 38185806 PMCID: PMC10772053 DOI: 10.1186/s40792-023-01799-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Gallbladder hemorrhage is a rare but fatal condition. The reported causes of gallbladder hemorrhage include iatrogenesis, atherosclerotic changes in the cystic arteries, acute cholecystitis or cholelithiasis, malignancy, trauma, hemophilia, pseudoaneurysm, and the use of oral anticoagulant medications. Recently, segmental arterial mediolysis (SAM) has been reported as a possible etiology of life-threatening abdominal, retroperitoneal, and intracranial hemorrhages. However, no previous reports have described the association between gallbladder hemorrhage and SAM. CASE PRESENTATION A 59-year-old man was transferred to our hospital complaining of upper abdominal pain and vomiting. Contrast-enhanced computed tomography revealed high-density images of the gallbladder and common bile duct. However, there were no obvious findings of gallstones, cholecystitis, tumors, or aneurysms. He was diagnosed with gallbladder hemorrhage and bile duct obstruction. We performed a laparoscopic cholecystectomy after endoscopic biliary drainage. The gross appearance of the surgically resected specimen showed 12 small (3-12 mm), slightly elevated lesions on the gallbladder mucosa. Histologically, these slightly elevated lesions consisted of dilated muscular arteries of the gallbladder wall with fibrinoid degeneration of the media and focal loss of the internal and external elastic laminae. The histopathological diagnosis was confirmed as SAM. CONCLUSIONS To the best of our knowledge, this is the first reported case of a gallbladder hemorrhage associated with SAM. Our case report shows that SAM can cause gallbladder hemorrhage, suggesting that SAM should be considered in the differential diagnosis of gallbladder hemorrhage.
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Affiliation(s)
- Yuichi Hirose
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan.
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Yusuke Tajima
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Hiroki Sakata
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Toshimasa Uekusa
- Department of Pathology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Kentaro Kamada
- Department of Gastrointestinal Medicine, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Takashi Ikehara
- Department of Gastrointestinal Medicine, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Izuru Matsuda
- Department of Radiology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Satomi Yoneyama
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Akio Hidemura
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
| | - Hiroyuki Suzuki
- Department of Surgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-Ku, Kanagawa, 211-8510, Japan
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4
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van Twist DJL, Appelboom Y, Magro-Checa C, Haagmans M, Riedl R, Yazar O, Bouwman LH, Mostard GJM. Differentiating between segmental arterial mediolysis and other arterial vasculopathies to establish an early diagnosis - a systematic literature review and proposal of new diagnostic criteria. Postgrad Med 2024; 136:1-13. [PMID: 37998079 DOI: 10.1080/00325481.2023.2288561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/23/2023] [Indexed: 11/25/2023]
Abstract
Segmental arterial mediolysis (SAM) is a rare vascular disease, characterized by acute but transient vulnerability of the wall of medium-sized arteries. The most characteristic feature of SAM is its biphasic course: an injurious phase marked by acute weakness of the arterial wall leading to acute dissection and/or hemorrhage, followed by a reparative phase in which granulation tissue and fibrosis restore the injured arterial wall. Residual stenosis, aneurysms, and/or arterial wall irregularities may remain visible on future imaging studies. Differentiating between SAM and other arterial vasculopathies is difficult due to its similarities with many other vascular diseases, such as vasculitis, fibromuscular dysplasia, inherited connective tissue disorders, and isolated visceral artery dissection. In this systematic review, we provide an overview on SAM, with an emphasis on the differential diagnosis and diagnostic work-up. We propose new diagnostic criteria to help establish a prompt diagnosis of SAM, illustrated by case examples from our multidisciplinary vascular clinic.
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Affiliation(s)
- Daan J L van Twist
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Y Appelboom
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Cesar Magro-Checa
- Department of Rheumatology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Mark Haagmans
- Department of Radiology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Robert Riedl
- Department of Pathology, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Ozan Yazar
- Department of Vascular Surgery, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Lee H Bouwman
- Department of Vascular Surgery, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
| | - Guy J M Mostard
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands
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Koster MJ, Guarda M, Ghaffar U, Warrington KJ. Rheumatic masqueraders: mimics of primary vasculitis - a case-based review. Expert Rev Clin Immunol 2024; 20:83-95. [PMID: 37837326 DOI: 10.1080/1744666x.2023.2270774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Vasculitis conditions are often serious and sometimes fatal diseases, therefore it is paramount to diagnose correctly and treat appropriately. Mimics of primary vasculitis can include either non-inflammatory syndromes or secondary vasculitis where the underlying etiology of the vasculitis is being driven by infection, malignancy, drug-effect or other. AREAS COVERED This review comprises six individual cases of vasculitis mimics. Each case is presented and the clinical, radiographic, and histological features that distinguish the case from primary vasculitis are highlighted. Key mimics in large, medium and small vessel vasculitis are outlined. EXPERT OPINION The diagnosis of vasculitis requires a comprehensive assessment of clinical, radiographic, and histologic features. Clinicians should be familiar with mimics of primary vasculitis conditions. In the case of non-inflammatory mimics, it is important to differentiate from primary vasculitides in order to avoid unnecessary and potentially harmful immunosuppression. For cases of secondary vasculitis, identification of the correct etiologic cause is critical because treatment of the underlying stimulus is necessary for successful management and outcomes.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Max Guarda
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Umar Ghaffar
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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6
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Ishihara T, Matsui T, Katoh T, Kobayashi K, Sekigawa K, Suzuki T, Mitsui H. Pancreaticoduodenal Artery Aneurysm Rupture Presenting as Duodenal Obstruction Successfully Treated with Early Transcatheter Arterial Embolization: A Case Report of Suspected Segmental Arterial Mediolysis. Intern Med 2023; 62:3479-3482. [PMID: 37062731 PMCID: PMC10749823 DOI: 10.2169/internalmedicine.1278-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/05/2023] [Indexed: 04/18/2023] Open
Abstract
Visceral aneurysms are a rare but important form of abdominal vascular disease. Rupture of the aneurysms leads to serious symptoms, such as acute abdomen or abdominal bleeding. However, duodenal obstruction due to arterial rupture of an aneurysm is very rare. We herein report a 50-year-old woman with suspected segmental arterial mediolysis (SAM) who was first diagnosed with acute abdomen and duodenal obstruction. Rupture of a pancreaticoduodenal artery aneurysm was confirmed, and she was treated with transcatheter arterial embolization. In cases of acute abdomen, SAM is a rare but important possibility to consider as a differential diagnosis.
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Affiliation(s)
| | - Toru Matsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | - Tomoji Katoh
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
| | | | | | - Takeo Suzuki
- Department of Intervention Radiology, Tokyo Teishin Hospital, Japan
| | - Hiroshi Mitsui
- Department of Gastrohepatology, Tokyo Teishin Hospital, Japan
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7
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Sugaya T, Suzuki T, Wada J, Shimizu H, Uchihara D, Yokogawa Y, Ichii O, Tai M, Ejiri Y, Ohira H. Transarterial embolization for ruptured pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis combined with median arcuate ligament syndrome: a case report. Clin J Gastroenterol 2023; 16:859-863. [PMID: 37608145 DOI: 10.1007/s12328-023-01847-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
A 75-year-old female with a history of Parkinson's disease treatment and hypertension presented at the emergency section with sudden onset of right abdominal pain. Contrast-enhanced computed tomography revealed beaded irregular stenosis and dilation of the superior mesenteric artery (SMA) and an aneurysm in the branch of the pancreaticoduodenal artery (PDA) that communicates with the common hepatic artery and SMA. Additionally, a hematoma had formed in the retroperitoneal space, and extravasation of contrast medium from the pancreaticoduodenal artery aneurysm (PDAA) into the hematoma was observed. The celiac artery (CA) was compressed by the median arcuate ligament; stenosis of the CA at its origin and dilation on the distal side were observed. Based on the imaging findings, it was diagnosed that PDAA was ruptured, SMA developed segmental arterial mediolysis (SAM), and CA developed median arcuate ligament syndrome (MALS). The ruptured PDAA was thought to be caused by SAM combined with MALS. Transcatheter arterial embolization (TAE) was performed for the ruptured PDAA. To the best of our knowledge, there have been no reports of TAE for a ruptured PDAA caused by SAM and MALS. After TAE, the PDAA did not re-rupture.
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Affiliation(s)
- Tatsuro Sugaya
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan.
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Tomohiro Suzuki
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Jun Wada
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroshi Shimizu
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Daiki Uchihara
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yuko Yokogawa
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Osamu Ichii
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Mayumi Tai
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yutaka Ejiri
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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8
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Huart J, Stoenoiu MS, Zedde M, Pascarella R, Adlam D, Persu A. From Fibromuscular Dysplasia to Arterial Dissection and Back. Am J Hypertens 2023; 36:573-585. [PMID: 37379454 DOI: 10.1093/ajh/hpad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 06/30/2023] Open
Abstract
Fibromuscular dysplasia (FMD) is an idiopathic and systemic non-inflammatory and non-atherosclerotic arterial disease. Fifteen to 25% of patients with FMD present with arterial dissection in at least one arterial bed. Conversely, a substantial number of patients with renal, carotid, and visceral dissection have underlying FMD. Also, while few patients with FMD develop coronary artery dissection, lesions suggestive of multifocal FMD have been reported in 30-80% of patients with spontaneous coronary artery dissection (SCAD), and the relation between these two entities remains controversial. The frequent association of FMD with arterial dissection, both in coronary and extra-coronary arteries raises a number of practical and theoretical questions: (i) Are FMD and arterial dissections two different facets of the same disease or distinct though related entities? (ii) Is SCAD just a manifestation of coronary FMD or a different disease? (iii) What is the risk and which are predictive factors of developing arterial dissection in a patient with FMD? (iv) What proportion of patients who experienced an arterial dissection have underlying FMD, and does this finding influence the risk of subsequent arterial complications? In this review we will address these different questions using fragmentary, mostly cross-sectional evidence derived from large registries and studies from Europe and the United States, as well as arguments derived from demographics, clinical presentation, imaging, and when available histology and genetics. From there we will derive practical consequences for nosology, screening and follow-up.
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Affiliation(s)
- Justine Huart
- Division of Nephrology, University of Liège Hospital (ULiège CHU), University of Liège, Liège, Belgium
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Division of Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - Maria S Stoenoiu
- Department of Internal Medicine, Rheumatology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
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Andersen JC, Mannoia K, Patel ST. Endovascular treatment of an isolated iliac artery aneurysm associated with segmental arterial mediolysis. J Vasc Surg Cases Innov Tech 2023; 9:101224. [PMID: 37799842 PMCID: PMC10547849 DOI: 10.1016/j.jvscit.2023.101224] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/08/2023] [Indexed: 10/07/2023] Open
Abstract
Segmental arterial mediolysis is a noninflammatory nonatherosclerotic vasculopathy of uncertain etiology characterized by dissection and/or aneurysm formation. It affects medium-to-large arteries, primarily the celiac, superior mesenteric, and renal arteries. Iliac involvement is rare, and its specific treatment has not been described. We detail a patient who presented with intrabdominal hemorrhage from a ruptured right colic artery aneurysm. He underwent transcatheter arterial embolization followed by right hemicolectomy. Histopathology confirmed the diagnosis of segmental arterial mediolysis. Endovascular treatment of a 3-cm iliac artery aneurysm was performed 18 months later. There was successful exclusion of the aneurysm demonstrated on computed tomography angiography at 10 years.
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Affiliation(s)
- James C. Andersen
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Kristyn Mannoia
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
| | - Sheela T. Patel
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA
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10
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Pokharel A, Karageorgiou I, Shah S, Bhattarai M, Acharya I, Bateman J. Hepatic segmental arterial mediolysis: A case report and brief literature review. Clin Case Rep 2023; 11:e7668. [PMID: 37434956 PMCID: PMC10332256 DOI: 10.1002/ccr3.7668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/13/2023] Open
Abstract
Key Clinical message When evaluating patients with abdominal pain, it is important to consider SAM in the differential diagnosis, along with vasculitis, fibromuscular dysplasia (FMD), atherosclerosis, mycotic aneurysms, and cystic medial degeneration. Abstract Segmental arterial mediolysis (SAM) is a rare arteriopathy which is an under-recognized and commonly missed diagnosis of abdominal pain. We report a case of a 58-year-old female who presented with abdominal pain and was misdiagnosed with a urinary tract infection. The diagnosis was made with CTA and managed with embolization. Despite appropriate intervention and close hospital monitoring, further complications were inevitable. We conclude that though literature has shown better prognosis and even complete resolution after medical and/or surgical intervention, close follow up and monitoring is needed to avoid unexpected complications.
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Affiliation(s)
- Ashbina Pokharel
- Department of Internal MedicineWilliam Beaumont University HospitalRoyal OakMichiganUSA
| | - Ioannis Karageorgiou
- Department of Internal MedicineWilliam Beaumont University HospitalRoyal OakMichiganUSA
| | - Sangam Shah
- Tribhuwan University, Institute of MedicineKathmanduNepal
| | | | - Indira Acharya
- Department of Internal Medicine, Medstar Union Memorial HospitalBaltimoreMarylandUSA
| | - Judith Bateman
- Department of RheumatologyWilliam Beaumont University HospitalRoyal OakMichiganUSA
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11
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Bhesania N, Patil DT, McCleary B, Selvakumar PKC, Radhakrishnan K. Segmental Arterial Mediolysis Presenting as a Pancreatic Mass in a Pediatric Patient: A Case Report. JPGN REPORTS 2023; 4:e298. [PMID: 37200713 PMCID: PMC10187858 DOI: 10.1097/pg9.0000000000000298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 01/14/2023] [Indexed: 05/20/2023]
Abstract
We describe a case of segmental arterial mediolysis (SAM) in a 2-year-old male who presented with symptoms of acute pancreatitis. SAM is a vascular entity of unknown etiology that involves medium-sized arteries in which the integrity of the vessel wall is compromised, resulting in increased susceptibility to ischemia, hemorrhage, and dissection. The clinical presentation is variable and can range from abdominal pain to more ominous findings of abdominal hemorrhage or organ infarction. This entity should be considered in the correct clinical setting and after other vasculopathies have been excluded. We aim to bring awareness to pediatric providers given this is a rare entity with variable presentation, which could be potentially life threatening.
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Affiliation(s)
- Natalie Bhesania
- From the Division of Pediatric Gastroenterology, UMMC, Jackson, MS
| | - Deepa T. Patil
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
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12
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Kaviani R, Farrell J, Dehghan N, Moosavi S. Single organ hepatic artery vasculitis as an unusual cause of epigastric pain: A case report. World J Clin Cases 2022; 10:9384-9389. [PMID: 36159425 PMCID: PMC9477682 DOI: 10.12998/wjcc.v10.i26.9384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/07/2022] [Accepted: 07/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Single-organ vasculitis (SOV) is characterized by inflammation of a blood vessel, affecting one organ, such as the skin, genitourinary system, or the aorta without systemic features. Gastrointestinal SOV is rare, with hepatic artery involvement reported only in two prior published cases. Herein, we presented a case of isolated hepatic artery vasculitis presenting after Pfizer-BioNTech mRNA corona virus disease 2019 (COVID-19) vaccination.
CASE SUMMARY A 50-year-old woman with hypertension presented to our Emergency Department with recurrent diffuse abdominal pain that localized to the epigastrium and emesis without diarrhea that began eight days after the second dose of the Pfizer-BioNTech COVID-19 vaccine. Blood work revealed an elevated C-reactive protein (CRP) of 19 mg/L (normal < 4.8 mg/L), alkaline phosphatase 150 U/L (normal 25-105 U/L), gamma-glutamyl transferase (GGT) 45 U/L (normal < 43 U/L) and elevated immunoglobulins (Ig) G 18.4 g/L (normal 7-16 g/L) and IgA 4.4 g/L (normal 0.7-4 g/L). An abdominal computed tomography revealed findings in keeping with hepatic artery vasculitis. A detailed review of her history and examination did not reveal infectious or systemic autoimmune causes of her presentation. An extensive autoimmune panel was unremarkable. COVID-19 polymerase chain reaction nasopharyngeal swab, human immunodeficiency virus, viral hepatitis and Heliobacter pylori serology were negative. At six months, the patient’s symptoms, and blood work spontaneously normalized.
CONCLUSION High clinical suspicion of SOV is required for diagnosis in patients with acute abdominal pain and dyspepsia.
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Affiliation(s)
- Rojin Kaviani
- Internal Medicine, University of British Columbia, Vancouver V5Z 1M9, British Columbia, Canada
| | - Jessica Farrell
- Division of Radiology, Providence Health Care, Vancouver V5T 3N4, British Columbia, Canada
| | - Natasha Dehghan
- Division of Rheumatology, Providence Health Care, Vancouver V5T 3N4, British Columbia, Canada
| | - Sarvee Moosavi
- Division of Gastroenterology, University of British Columbia, Vancouver V6Z 2K5, British Columbia, Canada
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13
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Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J. Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review. Angiology 2022:33197221100601. [PMID: 35921630 DOI: 10.1177/00033197221100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Jenna Smith
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Sydney L Olson
- 12244Northwestern University Feiberg School of Medicine, Chicago, IL, USA
| | - Opema L Lohese
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Aleem Mirza
- Department of Cardiovascular and Vascular Surgery, 12340University of Texas Health Science, Houston, TX, USA
| | - Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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14
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Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning. Diagnostics (Basel) 2022; 12:diagnostics12041012. [PMID: 35454060 PMCID: PMC9024490 DOI: 10.3390/diagnostics12041012] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023] Open
Abstract
Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.
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15
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Alavandar E, Umapathy S, Poyyamoli S, Arunachalam VK, Mehta P, Cherian M. Clinical Presentation, Imaging, and Management of Segmental Arterial Mediolysis: A Rare Vascular Disorder. Indian J Radiol Imaging 2021; 31:983-989. [PMID: 35136513 PMCID: PMC8817817 DOI: 10.1055/s-0041-1736583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives
Our objective was to analyze the clinical presentation, imaging findings, and the management of segmental arterial mediolysis (SAM) in different case scenarios within our medical institution.
Materials and Methods
We retrospectively analyzed 13 cases of SAM in our institution from July 2017 to March 2020. The images from the cases were collected from picture archiving and communication system (PACS) along with other pertinent clinical information from the hospital's information system. All the patients we studied underwent contrast-enhanced computed tomography (CT) using a third-generation Siemens SOMATOM Force dual-source CT scanner. Once the dual-phase scanning was completed, the images were analyzed using the workstation's syngo.via software.
Results
Three out of the 13 cases required stent-grafting of the renal/celiac artery, and the involved branch of the superior mesenteric artery was embolized in one case. The rest of the cases were managed conservatively with antiplatelets/anticoagulants. Subsequent follow-ups of the patients were conducted and showed stabilization/regression of the initial findings without finding any evidence of worsening.
Conclusion
SAM should be considered when making a differential diagnosis of acute abdominal pain when associated with dissection or aneurysms in splanchnic arteries, and in cases of unexplained intra-abdominal hemorrhaging. The radiologist needs to be aware of this possibility to raise suspicion, alert the clinician, and guide appropriate management.
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Affiliation(s)
- Ezhilmathi Alavandar
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Shobana Umapathy
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Santhosh Poyyamoli
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | | | - Pankaj Mehta
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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16
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Kennedy CA, Toomey DP. Segmental arterial mediolysis: a rare cause of an acute abdomen. J Surg Case Rep 2021; 2021:rjab370. [PMID: 34667588 PMCID: PMC8520468 DOI: 10.1093/jscr/rjab370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 11/14/2022] Open
Abstract
Segmental arterial mediolysis (SAM) is a nonatherosclerotic, noninflammatory and nonimmune arteriopathy of unknown aetiology. We present the case of a 43-year-old male who presented to the emergency department with abdominal pain. A computed tomography of abdomen and pelvis showed a narrow, hypodense superior mesenteric artery after the origin, raising the possibility of thrombus or vasculitis. He was commenced on rivaroxaban and steroids. He subsequently presented with an acute abdomen in a collapsed state. Repeat imaging of his abdomen and pelvis revealed an ischaemic ileal segment and caecum. He required an emergency laparotomy with resection of the ischaemic segment and formation of a double-barrelled stoma. SAM is an important diagnosis for clinicians and radiologists to be aware of, given the risks of life-threatening haemorrhage and acute organ ischaemia. This is a commonly overlooked cause of abdominal pain, where an early diagnosis with lifestyle modifications may prevent disease progression and subsequent development of life-threatening complications.
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Affiliation(s)
- Czara A Kennedy
- Department of General and Colorectal Surgery, Midland Regional Hospital Mullingar, Mullingar, Co. Westmeath, Ireland
| | - Desmond P Toomey
- Department of General and Colorectal Surgery, Midland Regional Hospital Mullingar, Mullingar, Co. Westmeath, Ireland
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17
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Connolly CM, Yu A, Seo P, Paik JJ. Segmental arterial mediolysis: a rare cause of abdominal pain masquerading as vasculitis. Rheumatology (Oxford) 2021; 60:e354-e355. [PMID: 33788907 DOI: 10.1093/rheumatology/keab326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/28/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Alice Yu
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, USA
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18
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127034.186.dbf92.19420.2@bxss.me] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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19
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: ./10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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20
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Cheng EM, Chen KL, Sharma V, Yee J, Power M, Lemech LD, Chu F. Rapid Formation and Rupture of Multiple Abdominal Pseudoaneurysms: A Life Threatening Case of Segmental Arterial Mediolysis. Ann Vasc Dis 2021; 14:256-259. [PMID: 34630769 PMCID: PMC8474093 DOI: 10.3400/avd.cr.20-00172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
We present a 62-year-old gentleman with rapidly forming abdominal pseudoaneurysms due to segmental arterial mediolysis (SAM). With rupture of his pseudoaneurysms, he underwent angiography and successful coil embolisation. In this case, we demonstrate the potential for rapid progression of pseudoaneurysms in SAM, with the need for prompt diagnosis and urgent endovascular intervention.
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Affiliation(s)
- Ernest M Cheng
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
| | - Kerry L Chen
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
| | - Varsha Sharma
- Department of Surgery, St George Hospital, Sydney, Australia
| | - Juliana Yee
- Department of Radiology, St George Hospital, Sydney, Australia
| | - Mark Power
- Department of Radiology, St George Hospital, Sydney, Australia
| | - Lubomyr D Lemech
- Department of Vascular Surgery, St George Hospital, Sydney, Australia
| | - Francis Chu
- Department of Surgery, St George Hospital, Sydney, Australia.,St George Clinical School, University of New South Wales, Sydney, Australia
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21
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021; 78:898-911. [PMID: 34455817 PMCID: PMC8415524 DOI: 10.1161/hypertensionaha.121.17004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James’s Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.)
- Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
- CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.)
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
- II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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22
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Persu A, Canning C, Prejbisz A, Dobrowolski P, Amar L, Chrysochou C, Kądziela J, Litwin M, van Twist D, Van der Niepen P, Wuerzner G, de Leeuw P, Azizi M, Januszewicz M, Januszewicz A. Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension. Hypertension 2021. [PMID: 34455817 DOI: 10.1161/hypertensionaha.121.17004
bcc:009247.186-127706.186.264be.19420.2@bxss.me] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
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Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (A.P.)
| | - Caitriona Canning
- Department of Vascular Medicine and Surgery, St. James's Hospital, Dublin, Ireland (C.C.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
| | - Laurence Amar
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | | | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland (J.K.)
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland (M.L.)
| | - Daan van Twist
- Zuyderland Medical Centre, Sittard/Heerlen, the Netherlands (D.v.T.)
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Belgium (P.V.d.N.)
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Switzerland (G.W.)
| | - Peter de Leeuw
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Heerlen, the Netherlands (P.d.L.).,Department of Internal Medicine, Division of General Internal Medicine (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands.,CARIM School for Cardiovascular Diseases (P.d.L.), Maastricht University Medical Center, Maastricht University, the Netherlands
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, France (L.A., M.A.).,AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, Reference Centre for Rare Vascular Disease, Paris, France (L.A., M.A.)
| | - Magda Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.).,II Department of Clinical Radiology, Medical University of Warsaw, Poland (M.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.)
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Segmental Arterial Mediolysis. J Belg Soc Radiol 2021; 105:27. [PMID: 34046547 PMCID: PMC8139293 DOI: 10.5334/jbsr.2470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Teaching Point: Segmental arterial mediolysis is a rare cause of acute abdominal pain due to dissection and/or aneurysm formation in visceral arteries with subsequent stenosis, occlusion, or haemorrhage.
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Maningding E, Kermani TA. Mimics of vasculitis. Rheumatology (Oxford) 2021; 60:34-47. [PMID: 33167039 DOI: 10.1093/rheumatology/keaa495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/07/2020] [Accepted: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.
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Affiliation(s)
- Ernest Maningding
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
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Castelli F, Inì C, Scavone G, Zagarella M, Giulietti G, Caltabiano G, Pizzarelli MV, Varsallona B, Scavone A, Basile A. Clinically Suspected Segmental Arterial Mediolysis of the Splanchnic Arteries: A Report of 2 Rare Cases. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929013. [PMID: 33830972 PMCID: PMC8042417 DOI: 10.12659/ajcr.929013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Case series Patients: Female, 89-year-old • Male, 52-year-old Final Diagnosis: Segmental arterial mediolysis Symptoms: Abdominal pain • bleeding Medication: — Clinical Procedure: — Specialty: Radiology
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Affiliation(s)
- Federica Castelli
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Corrado Inì
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies, University Hospital 'Policlinico - Vittorio Emanuele', University of Catania, Catania, Italy
| | - Giovanni Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Marco Zagarella
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Giorgio Giulietti
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Giuseppe Caltabiano
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Marco Vittorio Pizzarelli
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Bruno Varsallona
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Antonio Scavone
- Department of Diagnostic Radiology, Neuroradiology and Interventional Radiology, ARNAS 'Garibaldi Centro' Hospital, Catania, Italy
| | - Antonio Basile
- Radiology Unit I, Department of Medical Surgical Sciences and Advanced Technologies, University Hospital 'Policlinico - Vittorio Emanuele', University of Catania, Catania, Italy
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Natural History of Unruptured Visceral Artery Aneurysms Due to Segmental Arterial Mediolysis and Efficacy of Transcatheter Arterial Embolization: A Retrospective Multiinstitutional Study in Japan. AJR Am J Roentgenol 2021; 216:691-697. [PMID: 33439045 DOI: 10.2214/ajr.19.22547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to clarify the natural history of unruptured visceral artery aneurysms due to segmental arterial mediolysis and the efficacy of transcatheter arterial embolization. MATERIALS AND METHODS. Patients with a pathologic or clinical diagnosis of visceral artery aneurysms due to segmental arterial mediolysis between 2005 and 2015 were enrolled. For patients with clinical diagnoses, images were collected and assessed by central radiologic review. To clarify the natural history of unruptured aneurysms, the morphologic changes were assessed. The efficacy and safety of transcatheter arterial embolization for aneurysms due to segmental arterial mediolysis were evaluated. RESULTS. Forty-five patients with 123 aneurysms due to segmental arterial mediolysis were enrolled. Among the 123 aneurysms, 70 unruptured aneurysms were evaluated for natural history. Forty-five of the 70 (64%) aneurysms had no change in morphology. Among the other 25 aneurysms, nine (13% of the 70) were reduced in size, 13 (19%) disappeared, and three (4%) were newly found at follow-up. Aneurysms of the middle colic artery were ruptured in 10 of 11 (91%) cases. Transcatheter arterial embolization was performed on 45 aneurysms and was successful in all cases but caused slight arterial injury in three cases (6.7%). CONCLUSION. At initial diagnosis, unruptured aneurysms due to segmental arterial mediolysis are likely to be stable or to resolve, but the risk of rupture of aneurysms of the middle colic artery appears high. Transcatheter arterial embolization is a useful treatment, but careful manipulation is necessary.
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Chatterjee T, Stephens J, Roy M. Segmental Arterial Mediolysis: An Under-Recognized Cause of Chronic Abdominal Pain. Eur J Case Rep Intern Med 2020; 7:001830. [PMID: 33083366 DOI: 10.12890/2020_001830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 11/05/2022] Open
Abstract
Segmental arterial mediolysis (SAM) is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries. SAM was recently recognized as a more prevalent aetiology of abdominal pain than initially thought by healthcare providers. It is still a commonly missed diagnosis in patients with recurrent emergency room (ER) visits for abdominal pain. Most published case reports in the past have highlighted catastrophic sequelae such as intra-abdominal haemorrhage requiring surgical intervention. We report a case of SAM where the diagnosis was initially missed. After diagnosis, conservative medical management was offered which led to clinical improvement. LEARNING POINTS To recognize segmental arterial mediolysis (SAM) as a cause of chronic abdominal pain in the middle-aged and elderly population.To differentiate SAM from inflammatory vasculitis and atherosclerotic conditions.For cases with mild symptoms and haemodynamic stability, conservative management such as early lifestyle modifications, hypertension and hyperlipidaemia control and regular imaging follow-up should be offered.
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Affiliation(s)
- Tulika Chatterjee
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Johnathon Stephens
- Department of Radiology, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Moni Roy
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA.,OSF Saint Francis Medical Center, Peoria, Illinois, USA
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Xu JJ, Rasuli P, Burns KD. Case Report: Segmental Arterial Mediolysis, a Rare Cause of Hypertension. Can J Kidney Health Dis 2020; 7:2054358120950885. [PMID: 32913655 PMCID: PMC7444149 DOI: 10.1177/2054358120950885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/08/2020] [Indexed: 11/17/2022] Open
Abstract
Rationale: The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension. Presenting concerns of the patient: A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts. Diagnoses: After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made. Interventions: Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation. Outcomes: The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events. Teaching points: Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.
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Affiliation(s)
- Jieqing Jessica Xu
- Department of Medicine, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Pasteur Rasuli
- Department of Radiology, Division of Angiography and Interventional Radiology, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - Kevin D Burns
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, ON, Canada
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29
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Henkin S, Wysokinski WE, Tweet M, Shamoun F, Naidu S, Sutkowska K, Bator K, Shields R, Greene E, Keller S, Hodge D, McBane R. Spontaneous visceral artery dissections in otherwise normal arteries: Clinical features, management, and outcomes compared with fibromuscular dysplasia. J Vasc Surg 2020; 73:516-523.e2. [PMID: 32623103 DOI: 10.1016/j.jvs.2020.05.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/22/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Visceral artery dissection with otherwise normal-appearing arteries (VADNA), diagnosed on imaging and suggestive of segmental arterial mediolysis, is a poorly understood disease entity. Study objectives were to define the clinical features, management, and outcomes of patients with VADNA compared with patients with fibromuscular dysplasia (FMD). METHODS In this single-center retrospective cohort study, consecutive patients with a diagnosis of VADNA or FMD evaluated in the Mayo Clinic Gonda Vascular Center (January 1, 2000-April 1, 2017) were identified. Patient demographics, symptom presentation, management, composite adverse arterial events (recurrent arterial dissection, stroke or transient ischemic attack, myocardial infarction, mesenteric or renal infarction, or need for revascularization), and overall survival were compared between VADNA and FMD patients. RESULTS There were 103 VADNA patients (age [mean ± standard deviation], 51.7 ± 11.0 years; 27.9% female) and 248 FMD controls (49.8 ± 8.9 years; 81.8% female) identified. The most common symptom for VADNA patients was abdominal or flank pain (80.6%). For FMD, chest pain, headache, and dizziness were more frequent presenting complaints. The median follow-up was longer for VADNA patients (42 months; interquartile range, 9-76 months) compared with FMD patients (19 months; interquartile range, 0.6-52 months; P < .001). During this time interval, there were twofold more composite arterial events in the VADNA group compared with the FMD group (17% vs 8.1%; P = .01). This difference was primarily driven by recurrent dissections. All-cause mortality was low and similar for both groups (3.8% vs 0.4%; P = .10). CONCLUSIONS VADNA patients carry a higher risk of recurrent arterial events compared with those with FMD. This difference was primarily driven by recurrent dissections.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Marysia Tweet
- Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Fadi Shamoun
- Cardiovascular Department, Mayo Clinic, Scottsdale, Ariz
| | | | | | - Kaja Bator
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Raymond Shields
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - Eddie Greene
- Nephrology and Hypertension Division, Mayo Clinic, Rochester, Minn
| | - Shelly Keller
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Robert McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, Minn; Cardiovascular Department, Mayo Clinic, Rochester, Minn.
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Roy M, Roy AK, McCrate ME. Segmental arterial mediolysis: a commonly overlooked aetiology of acute abdominal pain. BMJ Case Rep 2020; 13:13/6/e234576. [PMID: 32540880 DOI: 10.1136/bcr-2020-234576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Segmental arterial mediolysis (SAM) is an uncommon condition and commonly missed diagnostic aetiology of acute abdominal pain, initially described in 1976. SAM is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries with notable asymmetric involvement of the walls of the mesenteric arteries and their branches. Clinical presentation ranges from postprandial abdominal discomfort suggestive of mesenteric ischaemia to intra-abdominal bleeding. Pathophysiological explanation and prognosis of these cases are not well understood and therefore no clear guidelines for management exist. In this case report, we emphasise the imaging modalities used to reach the diagnosis and the management options available.
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Affiliation(s)
- Moni Roy
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA .,Department of Internal Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Ashish Kumar Roy
- Department of Internal Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Mary E McCrate
- Department of Radiology, University Of Illinois College Of Medicine, Peoria, Illinois, USA.,Central Illinois Radiological Associates, Inc, Peoria, Illinois, USA
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Abstract
OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.
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Ghodasara N, Liddell R, Fishman EK, Johnson PT. High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know. Radiographics 2020; 39:559-577. [PMID: 30844348 DOI: 10.1148/rg.2019180131] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ©RSNA, 2019.
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Affiliation(s)
- Nevil Ghodasara
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Robert Liddell
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Elliot K Fishman
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Pamela T Johnson
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
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McNally M, Bolster F, Lahiff C. Gut Claudication: The Usual Suspect? Gastroenterology 2020; 158:831-833. [PMID: 31838075 DOI: 10.1053/j.gastro.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Mairéad McNally
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland.
| | - Ferdia Bolster
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland
| | - Conor Lahiff
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland; University College Dublin School of Medicine and Medical Science, Dublin, Ireland
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Skeik N, Olson SL, Hari G, Pavia ML. Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases. Vasc Med 2019; 24:549-563. [DOI: 10.1177/1358863x19873410] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Segmental arterial mediolysis (SAM) is a rare but serious nonatherosclerotic, noninflammatory vasculopathy of unknown etiology that often results in dissection, aneurysm, occlusion, or stenosis of, primarily, the abdominal arteries. Current literature lacks consensus on diagnostic criteria and management options for SAM. This review summarizes 143 cases and aims to advance appropriate recognition and management of SAM. Literature review of all relevant SAM case studies from 2005 to 2018 yielded 126 individual SAM cases from 66 reports. We identified 17 additional SAM cases from our center, bringing our analysis to 143 patients. Patients with SAM were most commonly men (68%) in their 60s. Hypertension (43%), tobacco use (12%), and hyperlipidemia (12%) were common comorbidities. Abdominal pain (80%) and intraabdominal bleeding (50%) were the most common presenting symptoms. Computed tomography was the most frequently used imaging method (78%), and histology was available in 44% of cases. The most commonly affected vessels were the superior mesenteric (53%), hepatic (45%), celiac (36%), renal (26%), and splenic (25%) arteries with aneurysm (76%), dissection (61%), and arterial rupture (46%). Treatments included coil embolization (28%), abdominal organ surgery (24%), open arterial repair (21%), and medical management (20%). Case-specific treatment modalities yielded symptom relief in the vast majority (91%) of patients, with a mortality rate of 7%.
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Affiliation(s)
- Nedaa Skeik
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Sydney L Olson
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Gopika Hari
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Mary L Pavia
- Vascular Medicine Section, Minneapolis Heart Institute, Minneapolis, MN, USA
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A Ruptured Blood Blister-Like Aneurysm Associated with Intraperitoneal Hemorrhage due to Segmental Arterial Mediolysis: A Case Report and Literature Review. World Neurosurg 2019; 134:79-85. [PMID: 31669242 DOI: 10.1016/j.wneu.2019.10.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Segmental arterial mediolysis (SAM) is a rare non-atherosclerotic, noninflammatory vascular disease, characterized by mediolysis. We report an extremely rare case of subarachnoid hemorrhage (SAH) due to a ruptured blood blister-like aneurysm (BBA) of the internal carotid artery associated with SAM-related arteriopathy. CASE DESCRIPTION We experienced a case of SAH followed by intraperitoneal hemorrhage that occurred 12 days after the SAH onset. SAH was caused by a ruptured BBA of the internal carotid artery, which was treated by trapping with high-flow bypass. Intraperitoneal hemorrhage was caused by a rupture of a posterior inferior pancreaticoduodenal artery (PIPDA) aneurysm, which induced hypovolemic shock resulting in death in spite of endovascular internal trapping. Postmortem pathologic examination revealed that the PIPDA pseudoaneurysm was due to SAM. CONCLUSIONS We should pay attention to the association of SAM, which is a potentially life-threatening pathology when treating cerebral BBAs.
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Skeik N, Hyde JR, Olson SL, Thaler CM, Abuatiyeh W, Ahmed AK, Lyon DR, Witt DR, Garberich R, Sullivan T. Nonatherosclerotic Abdominal Vasculopathies. Ann Vasc Surg 2019; 60:128-146. [DOI: 10.1016/j.avsg.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/11/2019] [Accepted: 04/04/2019] [Indexed: 11/28/2022]
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Tan R. Segmental Arterial Mediolysis: A Case Study and Review of the Literature in Accurate Diagnosis and Management. Vasc Specialist Int 2019; 35:174-179. [PMID: 31620405 PMCID: PMC6774432 DOI: 10.5758/vsi.2019.35.3.174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 11/20/2022] Open
Abstract
Segmental arterial mediolysis (SAM) is a rare noninflammatory, nonarteriosclerotic arteriopathy of an unknown etiology. It most commonly affects the medium-sized vessels of the abdomen and is characterized by the disruption of the arterial medial layer. Although histological confirmation remains the gold standard in diagnosis, the use of computed tomography angiography (CTA) has greatly aided the diagnosis and surveillance of SAM. Given its rarity and angiographic similarities to other vasculopathies, the diagnosis of SAM can be challenging and is often missed. We describe the case of a 46-year-old male patient who presented to our institution with abdominal pain and multiple foci of intra-abdominal arterial dissections on CTA. We report the acute management via endovascular intervention and review the literature with respect to the diagnosis and management of this rare condition. SAM remains an uncommon yet significant disease process requiring prompt and accurate diagnosis. Initiation of immediate treatment is crucial, given the knowledge gap about its natural progression.
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Affiliation(s)
- Rebekah Tan
- Department of Vascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
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38
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Segmental arterial mediolysis. RADIOLOGIA 2019. [DOI: 10.1016/j.rxeng.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Winkler MA, Kapoor H, Elashery AR, Issa M, Raissi D, Gupta V, Sheppard M. Coronary Artery Involvement in Segmental Arterial Mediolysis: A Case Report. Radiol Cardiothorac Imaging 2019; 1:e190035. [PMID: 33778511 DOI: 10.1148/ryct.2019190035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/07/2019] [Indexed: 11/11/2022]
Abstract
Segmental arterial mediolysis (SAM) is an increasingly recognized disorder affecting small- to medium-sized muscular arteries. A patient with SAM involving the visceral arteries who was also found to have multivessel coronary artery involvement is described. The patient underwent a battery of biochemical, imaging, and genetic tests to exclude other vasculitides and connective tissue disorders. The aim is to shed light on the potential for SAM to affect the coronary arteries and recommend screening of the coronary arteries of patients with SAM. © RSNA, 2019.
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Affiliation(s)
- Michael A Winkler
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Harit Kapoor
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Ahmad Ramy Elashery
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Mohamed Issa
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Driss Raissi
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Vedant Gupta
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
| | - Mary Sheppard
- Divisions of Cardiovascular and Thoracic Radiology (M.A.W., H.K., M.I., D.R., V.G.), Cardiovascular Medicine (M.A.W., A.R.E., V.G.), and Vascular Surgery (M.S.), and Departments of Obstetrics and Gynecology (D.R.) and Family and Community Medicine (M.S.), University of Kentucky Chandler Medical Center, UK HealthCare Enterprise, 800 Rose St, Room HX-313A, Lexington, KY 40536-0293
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Jurado Basildo C, Santos Armentia E, Silva Priege N, Villanueva Campos AM. Segmental arterial mediolysis. RADIOLOGIA 2019; 61:430-434. [PMID: 31155224 DOI: 10.1016/j.rx.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 11/19/2022]
Abstract
This article reports the case of a 51-year-old woman in whom brain MRI to follow up multiple sclerosis incidentally discovered an intramural hematoma in the extracranial internal carotid artery. MR angiography of the supra-aortic trunks and CT angiography of the aorta showed arterial dilations, aneurysms, dissections, and intramural hematomas in the internal carotid arteries, vertebral arteries, and arteries in the splanchnic territory. These findings raised suspicion of segmental arterial mediolysis. After 6 months of treatment with antiplatelet drugs, the arterial involvement resolved. Segmental arterial mediolysis is an uncommon disease; low clinical suspicion and radiologists' lack of knowledge about this entity mean that it can go undetected or be confused with other vasculitides. This report describes the most relevant pathophysiological findings and correlates them with the imaging findings.
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Affiliation(s)
- C Jurado Basildo
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España.
| | - E Santos Armentia
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España
| | - N Silva Priege
- Departamento de Radiología, Hospital Povisa, Vigo, Pontevedra, España
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Tani R, Hori T, Yamamoto H, Harada H, Yamamoto M, Yamada M, Yazawa T, Tani M, Kamada Y, Aoyama R, Sasaki Y, Zaima M. Severely Calcified True Aneurysm: A Thought-Provoking Case of Solitary Origin and Postoperative Management. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:620-627. [PMID: 31031402 PMCID: PMC6501733 DOI: 10.12659/ajcr.915010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patient: Male, 70 Final Diagnosis: Splenic artery aneurysm Symptoms: Asymptomatic Medication: — Clinical Procedure: Surgery and Endoscopy Specialty: Surgery
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Affiliation(s)
- Ryotaro Tani
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Tomohide Hori
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | | | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Takefumi Yazawa
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Masaki Tani
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yasuyuki Kamada
- Department of Surgery, Shiga General Hospital, Moriyama, Japan
| | - Ryuhei Aoyama
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yudai Sasaki
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
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Rooke T. From the Masters: Lumper? Or splitter? Vasc Med 2018; 24:3-5. [PMID: 30428783 DOI: 10.1177/1358863x18808903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Thom Rooke
- Krehbiel Professor of Vascular Medicine, Mayo Clinic, Rochester, MN, USA
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Segmental Arterial Mediolysis of Omental Arteries with Haemoperitoneum: Case Report with Embolization of the Left Omental Artery and Brief Review of Literature. Case Rep Radiol 2018; 2018:4749356. [PMID: 30112243 PMCID: PMC6077596 DOI: 10.1155/2018/4749356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/11/2018] [Indexed: 11/18/2022] Open
Abstract
Segmental arterial mediolysis of an omental artery is an exceptionally rare condition. A 69-year-old man presented with haemoperitoneum six days after being hospitalized due to pneumogenic sepsis. Computed tomography of the abdomen showed a short segment dilatation of an omental artery in the left upper abdomen, compatible with segmental arterial mediolysis. Angiographic examination revealed alterations of omental branches of the right gastroepiploic artery and an aneurysm of the left omental artery, both characteristic of segmental arterial mediolysis. Embolization of the left omental artery with use of N-butyl-2-cyanoacrylate was performed. The postinterventional course was uneventful with increase of haemoglobin levels and without symptoms of omental infarction. Transcatheter embolization in the setting of haemoperitoneum due to segmental arterial mediolysis of an omental branch is technically feasible and a valuable alternative to emergency operation.
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