Spontaneous Isolated Dissection of the Celiac Trunk with Rupture of the Proximal Splenic Artery: A Case Report

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

OBJECTIVES

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

METHODS AND RESULTS

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

CONCLUSIONS

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

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

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

Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review

BACKGROUND

Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs.

MATERIALS AND METHODS

A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications.

RESULTS

We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups.

CONCLUSIONS

Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.

Spontaneous Celiac Artery Dissection with Splenic Infarction: A Report of Two Cases

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that is characterized by sudden onset abdominal pain, typically occurring in middle-aged men. Although its clinical course is mostly benign, it may progress to true lumen occlusion. No established therapeutic guidelines are available for SICAD associated with splenic infarction. This report describes two patients who presented with sudden onset abdominal pain and were diagnosed with SICAD with splenic infarction based on computed tomography (CT) findings. Patients were treated with bowel rest and anticoagulants. After a week of medical therapy, the abdominal pain resolved. Follow-up CT revealed no progression of the dissection flap. The patients received oral anticoagulants for 3 months and did not experience any symptom recurrence. Medical therapy with anticoagulants may be considered for patients with SICAD and splenic infarction. Associated splenic infarction itself is not an indication for endovascular or surgical intervention for SICAD.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Spontaneous isolated celiac and splenic artery dissection with splenic infarction

Spontaneous isolated celiac artery dissection is considered an uncommon clinical condition. Rarer still is spontaneous isolated celiac and splenic artery dissection, with a total of 42 reported cases. There is no known definitive cause of visceral artery dissections, but risk factors include male sex, age in 5th or 6th decade, hypertension, and connective tissue disorders. The presentation varies, diagnosis is principally radiographic, and the mainstay of treatment is anticoagulation or antiplatelet therapy. Splenic infarction is a common finding with splenic artery dissection, although the strength of this association has not previously been reported. Herein we present a case of spontaneous isolated celiac and splenic artery dissection with splenic infarction that was successfully managed with blood pressure control and antiplatelet therapy. We review previous literature, principles of diagnosis and management, and incidence and outcomes of splenic infarction as it related to splenic artery dissection.

Current status of spontaneous isolated celiac artery dissection

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Mid- to Long-Term Outcomes in Management of Spontaneous Isolated Coeliac Artery Dissection (SICAD)

OBJECTIVE

Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment.

METHODS

Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed.

RESULTS

The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period.

CONCLUSION

Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.

Coeliac trunk dissection causing splenic infarction: a comprehensive review

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

Coil embolization of an acutely expanding spontaneous splenic artery dissection

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

Spontaneous Ruptured Splenic Artery Aneurysm: A Case Report

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

Spontaneous dissection of the celiac artery in the young: a case report and systematic review of the literature

INTRODUCTION

The spontaneous isolated celiac artery dissection (siCAD) represents a challenging cause of abdominal pain and complete information regarding incidence, etiology and risk factors in the young is still lacking. In this study, we report a case of siCAD occurred in a young woman and we systematically searched for information on siCADs in literature databases.

METHODS

PubMed/Embase and Cochrane were searched for, using the following terms: Isolated celiac trunk dissection, isolated celiac artery dissection, celiac artery dissection, celiac trunk dissection, spontaneous isolated visceral artery dissection, spontaneous isolated dissection of visceral arteries, isolated celiac artery dissection in the young, isolated celiac trunk dissection in the young. Patients were included if they were younger than 50 years, if they had a spontaneous etiology and a selective involvement of the celiac artery (with or without involvement of its branches).

RESULTS

180 studies were found, and 18 remained after screening. Twenty-one patients (male = 19, female = 2) with siCADs were included. Mean age was 44.71 ± 3.61 years. Hypertension was the most prevalent comorbidity. All patients presented with abdominal pain, more often located in the epigastrium (n = 11). Almost all patients underwent CT to confirm the diagnosis. A conservative treatment was adopted in 13 patients while an invasive approach was adopted in 8 patients (endovascular approach in 7).

DISCUSSION

siCADs represent a rare but important cause of vascular dissection in the young. Uncomplicated cases can be safely treated with conservative strategies. The surgical or endovascular repair is indicated when dissections complicate or symptoms persist despite an adequate conservative treatment.

Ten-year review of isolated spontaneous mesenteric arterial dissections

OBJECTIVE

Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition; however, it has been increasingly noted incidentally on diagnostic imaging. The purpose of this study was to examine the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissection (SMAD). We hypothesized that most SMADs can be treated nonoperatively.

METHODS

This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes.

RESULTS

A total of 77 patients were found to have CA dissection, SMA dissection, or both in the absence of aortic dissection diagnosed on computed tomography or magnetic resonance imaging. The average age was 56 years (range, 26-86 years), 80% were male, and 10 patients (13%) had underlying connective tissue disorders. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients; 33 (43%) presented with isolated CA dissection, and 30 (39%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up. One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 73 patients were managed nonoperatively; 40 (52%) were treated with a short course of anticoagulation, 23 (30%) were treated with antiplatelet therapy, and 10 (13%) were treated with observation alone. No other late interventions or recurrences were noted during a mean follow-up of 21 months.

CONCLUSIONS

Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Only a small number of patients require surgical revascularization for bowel ischemia.

A Case of Spontaneous Isolated Celiac Artery Dissection with Pseudoaneurysm Formation

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

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

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

Atypical presentation of a spontaneous coeliac artery dissection resulting in jejunal ischaemia

We describe a case of a 59-year-old man with no significant medical history apart from a hiatus hernia and depression who presented with periumbilical pain which woke him at night. Before this he had 6 weeks of generalised abdominal pain. Blood tests were relatively normal and CT revealed some ill-defined stranding around the coeliac artery. He was diagnosed with a spontaneous coeliac artery dissection. Given the complexity of the case, a multidisciplinary team approach was adopted. He was managed conservatively and improved significantly over the next few days. Further investigations confirmed ischaemic changes to the distal duodenum and proximal jejunum. He has since been followed-up with CT scans and has had no further episodes 12 months from his initial admission.

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

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

Targeted Nanotherapies for the Treatment of Surgical Diseases

OBJECTIVE

To describe the components of targeted nanotherapeutics and to review their applications in the treatment of surgical diseases.

BACKGROUND

Targeted nanotherapeutic is a novel strategy for treating a variety of diseases and is an emerging technology that offers advantages over current treatment strategies. The nanoscale size, combined with the ability to surface functionalize the delivery vehicle to enable targeting and incorporate a therapeutic payload, provides a new and innovative therapeutic platform to treat surgical diseases that has yet to be fully realized in the surgical arena.

METHODS

A comprehensive literature review of nanotherapeutics, targeting strategies, and their utility in treating surgical diseases is performed.

RESULTS

Targeted nanotherapeutics have demonstrated safety and biocompatibility in treating surgical diseases. The ability to surface functionalize the nanoparticles affords a unique tailorability that enables targeting specificity and therapeutic payload delivery to treat a variety of surgical diseases. Moreover, the small size and targeting capabilities allow access to biological compartments, such as the blood-brain barrier, that have previously been difficult to treat.

CONCLUSIONS

Targeted nanotherapeutics represent a novel therapeutic platform and have great potential to impact the treatment of surgical diseases.

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

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

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

BACKGROUND

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

CASE REPORT

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

CONCLUSIONS

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

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

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

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

Clinical usefulness with the combination of color Doppler and contrast-enhanced harmonic EUS for the assessment of visceral vascular diseases

GOALS

To evaluate the clinical usefulness of the color Doppler and contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) in diagnosing visceral vascular diseases and in assessing morphologic and hemodynamic characteristics required for optimized patient management.

BACKGROUND

Mesenteric arteries are easily accessible with EUS because of its proximities to the gastrointestinal tract.

STUDY

EUS was performed in 12 patients with clinically suspected visceral vascular disease, as determined by computed tomography (CT) scan between February 2012 and March 2013. Conventional B-mode, color Doppler, and CEH-EUS was performed to evaluate vascular status of the celiac artery and superior mesenteric artery (SMA).

RESULTS

CT scan imaging suggested arterial dissection in 9 patients; arterial stenosis or occlusion in 2 patients, and periarterial soft tissue cuffing in 1 patient. EUS accurately identified all the visceral vascular lesions of 11 patients and 1 patient with suspected SMA dissection on CT imaging was proven to be normal by EUS. EUS also identified one undefined dissection not detected on abdominal CT. EUS examination revealed vascular intimal flap in 5 patients and blood flow within the true lumen and thrombi within the false lumen in 8 patients. In addition, the stenotic area could be calculated using color Doppler EUS. Two patients underwent surgical thrombectomy and angioplasty because of total occlusion of SMA on color Doppler and CEH-EUS.

CONCLUSIONS

The combination of color Doppler and CEH-EUS may be a promising diagnostic modality to assess the splanchnic artery without exposure to radiation. Moreover, EUS is a useful tool to determine the appropriate treatment options for patients with isolated mesenteric artery dissection.

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

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

A rare cause of epigastric pain in a middle-aged man

A 50-year-old man presents to the emergency department with epigastric pain and is found to have severe hypertension on clinical examination. After admission to hospital, further investigation with CT imaging reveals the patient has an uncomplicated splenic artery dissection. Conservative management is chosen as advised by a vascular surgery team and the patient was subsequently discharged from hospital with warfarin anticoagulation and antihypertensive medicines. This case report aims to build a profile of a patient who may present with splenic artery dissection and details our recommended management plan.

Endovascular treatment of isolated spontaneous celiac artery dissection

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

Symptomatic spontaneous celiac artery dissection treated by conservative management: serial imaging findings

BACKGROUND

The aim of this study was to evaluate the correlation of clinical characteristics with serial imaging findings of symptomatic spontaneous celiac artery dissection treated by conservative management.

METHODS

Eight consecutive, hemodynamically stable patients with symptomatic spontaneous celiac artery dissection without associated aortic dissection that received non-operative treatments were included in this study. Their clinical characteristics, treatment methods, serial imaging findings and outcomes were analyzed retrospectively.

RESULTS

Acute left flank pain related to splenic infarction was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography scan showed celiac artery dissection with partial thrombosis in all eight patients and involvement of branch vessels in 7. Full anticoagulation was carried out immediately after the diagnosis in seven patients. All patients, except one with endovascular stent placement, were asymptomatic after successful conservative management and follow-up computed tomography scan showed preservation of distal perfusion with ongoing regression of false lumen in five patients. After a mean follow-up of 16 months, there was no mortality or morbidity related to the dissection.

CONCLUSIONS

Serial imaging findings showed that conservative management of celiac artery dissection can be performed successfully in selective patients with stable hemodynamics.

Isolated spontaneous dissection of the celiac trunk in a patient with bicuspid aortic valve

Isolated spontaneous dissection of celiac trunk is a rare entity. The spontaneous dissection of the visceral artery occurs without aortic dissection. The most consistent presenting symptom is acute onset abdominal pain. Complications consist of ischemia, aneurysm formation, and rupture. We report an exceptional case of an isolated spontaneous dissection of the celiac trunk which occurred in a 49 year old male with a previously undiagnosed bicuspid aortic valve (BAV). We also describe the classical appearance in different imaging modalities with a particular emphasis on multidetector computed tomography, and discuss the clinical manifestation and its relationship to BAV.

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

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