Celiac Artery Dissection Research Articles

Coeliac artery dissection in neuroendocrine neoplasms: coincidence or cause?

Coeliac artery dissection in neuroendocrine neoplasms: coincidence or cause?

Duodenal Obstruction Caused by an Isolated Spontaneous Celiac Artery Dissection.

Duodenal Obstruction Caused by an Isolated Spontaneous Celiac Artery Dissection.

Spontaneous Isolated Celiac Artery Dissection in a Young Woman

Spontaneous Isolated Celiac Artery Dissection in a Young Woman

Isolated celiac artery injury: Brief report, review of literature, and suggested grading guidelines

Blunt traumatic dissection of the celiac artery without aortic dissection is a rare event. There is paucity of data on the appropriate management of such injuries. In this brief report, we present a patient with isolated celiac artery dissection after blunt abdominal trauma. The patient was managed non-operatively with anticoagulation and developed splenic infarct. Due to its rarity, no grading criteria and management guidelines exist for the spectrum of isolated blunt CA injuries. Furthermore, it remains unlikely that injury volume will increase to create robust management guidelines. We therefore suggest that isolated celiac artery injury be graded based on the Biffl grading criteria for blunt cerebrovascular injury and managed accordingly.

The characteristics and comparison between young and old patients with spontaneous isolated celiac artery dissection: Analysis based on 60 reports.

Though increasing studies reported the management of spontaneous isolated celiac artery dissection (ICAD), the characteristics and etiology of ICAD in different age-stage patients have not been well-studied. Our study was designed to describe and further to compare the clinical features of spontaneous ICAD between young and old patients. We searched PubMed, Embase, and Web of Science up to March 1, 2023 for spontaneous ICAD case reports. Two reviewers screened the titles and abstracts of searched records for qualified reports according to the including and excluding criteria and extracted the data independently. Statistical analysis was performed using SPSS software (version 19.0; IBM Corp, Armonk, NY) and Stata 12.0 (Stata Corp., College Station, TX). Descriptive results were presented as the mean ± standard deviation or percent. The comparison results between young and old patients were displayed as risk ratio (RR) or standardized mean difference (SMD) with its 95% confidence intervals (CI). We totally identified 60 reports in the present analysis. The mean age of patients was 52.4 years, with the majority of patients being male (84.4%). The majority of patients were symptomatic and commonest presentation was abdominal pain (76.7%). Most patients (63.2%) had comorbidities or history and hypertension and smoking were the top 2 conditions with proportion of 63.3% and 40.5% respectively. When comparing young to old patients with ICAD, no significant difference was found in demographic and clinical features including sex, comorbidities/history, and symptoms. However, we found that young patients with ICAD experienced significantly longer dissection length (SMD 1.01, 95% CI 0.16-1.86; P = .015) and distance from ostium (SMD 0.96, 95% CI 0.07-1.85; P = .013), but no significant difference was observed in true lumen compression (SMD -0.39, 95% CI -1.22-0.44; P = .364). In addition, our results showed that ICAD in young patients extending more to distal arteries, including common hepatic artery/hepatic artery (RR 2.04, 95% CI 1.13-3.68; P = .01), splenic artery (RR 2.36, 95% CI 1.24-4.49; P = .017) and left gastric artery (RR 25.42; 95% CI 1.55-417.74; P = .04). Though spontaneous ICAD had multitudinous clinic-pathologic features, it was apt to middle-aged males and symptomatic and abdominal pain was always the commonest presentation. Hypertension and smoking were the top 2 conditions of ICAD patients. There was significant difference between young and old patients in radiographic characteristics of ICAD which may lead to different treatment and outcomes.

Mid-term evolution of patients after spontaneous celiac artery dissection

Mid-term evolution of patients after spontaneous celiac artery dissection

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

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. 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. 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.

Single Center Experience of Operative Management in Isolated Mesenteric Artery Dissections

Isolated mesenteric dissection of vessels is a rare occurrence with management strategies dependent on patient presentation. The study aimed to evaluate a single institution's experience on patient characteristics, treatment modalities, and outcomes on operative vs nonoperative management of mesenteric dissection. Patients from a single institution between January 2017 and November 2022 with diagnosis of superior mesenteric artery (SMA) or celiac artery dissection and its branches were included. Patients with concomitant descending aortic dissection were excluded. Patient demographics, imaging, treatments, and follow-up data was collected and underwent descriptive statistical analysis. All SMA dissections were categorized using the modified Sakamoto classification (types I-VI), with type VI indicating total occlusion of vessel due to dissection. There were 30 patients with diagnosis of isolated mesenteric dissection. Mean age was 61 years, and the majority were male (86%), Asian (60%), and symptomatic (70%). Majority had isolated SMA dissection (n = 19; 63.3%) with the remainder having isolated celiac (n = 9; 30%) or concomitant SMA and celiac dissection (n = 2; 6.7%). Twenty-one patients had involvement of SMA and categorized using the modified Sakamoto Classification (n = 5 type I, n = 0 type II, n = 2 type III, n = 4 type IV, n = 1 type V, n =7 type VI). Nonoperative treatment occurred in 63.3% (n = 19). Operative intervention rate was 33% (n = 10). All patients who underwent an operation were symptomatic with abdominal pain on presentation (P < .01) (Table I). Two patients presented with rupture and five presented with signs of acute mesenteric ischemia necessitating emergent exploration. Two patients required bowel resection for necrosis. Sakamoto classification was also significantly associated with operative intervention (P < .01). Patients presenting with abdominal pain were three times as likely to undergo operative treatment (odds ratio, 3.13; P < .01) (Table II), while patients with a modified Sakamoto classification type V and above were 10 times more likely to undergo an operative intervention (odds ratio, 10.5; P < .02) (Table II). A large majority of operative cases (n = 9; 90%) were diagnosed with involvement of SMA dissection. Unplanned secondary intervention rate was 30% (n = 3). There was 9.5% mortality rate amongst those with SMA vessel involvement (10% overall mortality). Among those patients that followed-up, all were asymptomatic at the time of follow-up (n = 16). Patients with nonoperative interventions had 57% favorable remodeling (n = 4). Symptomatic patient presentation and higher modified Sakamoto classification type (types V and VI) tend to require operative intervention. Although a majority of spontaneous isolated mesenteric dissections may be treated nonoperatively with either medical therapy or observation alone, identifying patient characteristics amongst those that require operative intervention are important considerations for management of this rare disease process.Table IClinical characteristics by operative interventionOverall, n = 30Operative repair, n = 10Nonoperative, n = 20P valueaAge61.00 ± 12.0854.30 ± 13.4164.35 ± 10.11.031Gender.6 Female4 (13)2 (20)2 (10) Male26 (87)8 (80)18 (90)Ethnicity/Race.032 Asian18 (60)5 (50)13 (65) Hispanic5 (17)2 (20)3 (15) Other3 (10)3 (30)0 (0) White4 (13)0 (0)4 (20)Smoking history.7 Yes10 (33)4 (40)6 (30) No20 (67)6 (60)14 (70)Atrial fibrillation.7 Yes7 (23)3 (30)4 (20) No23 (77)7 (70)16 (80)Hypertension.4 Yes10 (33)2 (20)8 (40) No20 (67)8 (80)12 (60)White blood cells.4 >1211 (37)5 (50)6 (30) 4-1219 (63)5 (50)14 (70)Systolic blood pressure groups>.9 High (>140)17 (57)6 (60)11 (55) Normal (100-140)11 (37)3 (30)8 (40) Low (<100)2 (6.7)1 (10)1 (5.0)Modified Sakamoto class (types I-VI).008 Type I5 (24)1 (11)4 (33) Type II0 (0)0 (0)0 (0) Type III2 (9.5)1 (11)1 (8.3) Type IV4 (19)0 (0)4 (33) Type V2 (9.5)0 (0)2 (17) Type VI8 (38)7 (78)1 (8.3)Symptomatic at presentation.011 Yes20 (67)10 (100)10 (50) No10 (33)0 (0)10 (50)Length of stay7.67 ± 8.5614.00 ± 10.424.50 ± 5.35.004Intensive care unit length of stay2.57 ± 4.766.50 ± 6.430.60 ± 1.67<.001Deceased.3 Yes3 (10)2 (20)1 (5) No27 (90)8 (80)19 (95)Values are mean ± SD or number (%).aWilcoxon rank-sum test; Fisher's exact test. Open table in a new tab Table IIOdds ratio analysis of symptomatic presentation and Sakamoto classification with operative interventionOR95% CIP valueSymptomatic at presentation3.131.08-406.55.011Sakamoto class type V-VI10.51.57-105.00.024CI, Confidence interval; OR, odds ratio. Open table in a new tab

孤立性特発性腹腔動脈解離に続発した解離性脾動脈瘤破裂の2例(Ruptured dissected splenic artery aneurysms secondary to isolated spontaneous celiac artery dissection: a report of two cases)

【症例1】52歳の男性。腹痛を主訴に近医を受診したところ，腹部造影CTで急性膵炎および脾動脈瘤破裂と診断され当院紹介となった。当院CTでは腹腔動脈起始部の解離と仮性動脈瘤を認めた。血管内治療を試みたが，脾動脈遠位の屈曲・蛇行が強く，金属コイルとNBCA併用による近位塞栓で終了とした。不完全塞栓であったため最終的には手術治療を要した。【症例2】53歳の男性。受傷2日前に突然の腹痛を自覚。受傷当日，乗用車運転中に意識消失し対向車と正面衝突し搬送となった。来院時ショック状態であり，腹部超音波検査では腹腔内液体貯留を認め，造影CTでは腹腔動脈起始部より脾動脈遠位に至る偽腔開存型解離および解離性脾動脈瘤破裂と周囲血腫を認めた。腹腔動脈起始部は正中弓状靱帯圧迫症候群により狭小化していた。血管内治療を施行したところ，脾動脈解離の真腔は偽腔に圧排され完全閉塞し，偽腔より横隔脾間膜内への造影剤漏出を認めた。偽腔の近位・遠位を金属コイルで塞栓し止血を得た。経過観察後のCTでは脾門部に仮性動脈瘤の出現を認め，金属コイル・NBCA塞栓術を追加し根治し得た。孤立性特発性腹腔動脈解離に伴う解離性脾動脈瘤破裂は非常に稀ではあるが，内因性腹部出血の鑑別の一つとして考慮すべきであり，発症様式や全身状態により各施設で最適な止血方法を選択する必要がある。 Here we report the features of two cases of ruptured dissected splenic artery aneurysm associated with isolated spontaneous celiac artery dissection encountered in our institute. Case 1: A 52–year–old male was referred to us following diagnosis with acute pancreatitis with pancreatic pseudocyst, dissection of the origin of the celiac artery, and a dissecting pseudoaneurysm of the splenic artery on computed tomography(CT). Endovascular treatment was attempted, but the distal splenic artery was difficult to reach due to high flexion and tortuosity; therefore, proximal embolization alone was performed. Follow–up CT showed incomplete embolization, and radical surgical treatment was subsequently performed. Case 2: A 53–year–old male lost consciousness while driving a passenger car and was injured in a head–on collision with an oncoming car. CT showed dissection from the origin of the celiac artery to the proximal splenic artery and rupture of the splenic artery aneurysm. The celiac artery was narrowed due to median arcuate ligament syndrome. Endovascular treatment was performed, the proximal and distal portions of the false lumen were embolized with coil and cyanoacrylate, and hemostasis was achieved. Follow–up CT revealed a pseudoaneurysm at the splenic hilum, and embolization was performed again. Although, very rare cases, we should consider as one of the differentials diagnoses. 孤立性特発性腹部内臓動脈解離は稀な病態であるが，腹腔動脈解離は上腸間膜動脈解離に次いで多いとされている 1。孤立性特発性腹腔動脈解離（isolated spontaneous celiac artery dissection: ISCAD）はmulti detector–row CT（MDCT）の普及により報告数が近年増加しているものの，無症候から症候性に至るまで臨床経過は様々である。一般的には初回治療として保存的治療を選択することが多いが，合併症を有する例では侵襲的治療が選択される 2。今回我々は，解離性脾動脈瘤破裂を伴ったISCADの2例を経験したため，文献的考察とともに報告する。 本稿は倫理委員会の承認を要しない症例報告である。また，個人情報保護法に基づき匿名化されており，患者家族から論文の出版に関する同意を得ている。 患 者：52歳の男性 主 訴：左側腹部痛 既往歴：特記事項なし 飲酒歴：焼酎500〜1,000mL/日 喫煙歴：20〜30本/日×30年間 現病歴：来院10日前より左側腹部痛を自覚していたが，徐々に増悪したために前医へ救急搬送された。造影CT検査で急性膵炎および脾動脈瘤破裂と診断され，当院へ転送となった。 来院時現症：意識レベルJapan coma scale（JCS）I–0，Glasgow coma scale（GCS）E4V5M6，呼吸数18/分，心拍数110/分，血圧140/80mmHg，体温37.2℃（腋窩），SpO2 100%（室内気）腹部は平坦・軟であり左側腹部の自発痛はほぼ消失していた。血液検査では白血球17,000/μL，CRP 6.92mg/dLと軽度の炎症所見を認めた。Amyは70U/Lと基準値内であった。 腹部造影CT動脈相では，腹腔動脈起始部は解離しておりISCADの所見を認めた（補足図1a）。動脈解離は腹腔動脈から脾動脈中程まで連続しており，脾動脈起始部は偽腔に圧排され高度に狭小化しており，偽腔は瘤状に拡張していた。さらに，破裂した偽腔周囲には最大径約25mmの不整に拡張した仮性動脈瘤を認めた（補足図1b）。また，膵体尾部の腫大と膵周囲の脂肪織濃度上昇を認め，急性膵炎の所見を認めた（補足図1c）。 初療経過：循環動態は安定していたため，仮性動脈瘤に対し動脈塞栓術（transcatheter aterial embolization: TAE）の方針とした。腹腔動脈造影では，腹腔動脈起始部から脾動脈へ及ぶ解離を認め，解離性脾動脈瘤を形成していた。解離性脾動脈瘤の周囲には最大径47mmの血腫を認め，仮性動脈瘤を形成していた（補足図2a）。脾動脈の真腔は拡張した偽腔に圧排されて狭小化しておりアプローチ不能であったため，偽腔よりアプローチした。偽腔から解離性脾動脈瘤遠位の選択を試みたが，屈曲と蛇行が強く困難であった。そのため，アイソレーションを断念し，仮性動脈瘤に連続する解離性脾動脈瘤内をコイル6本でパッキングし，解離性脾動脈瘤近位に2本のコイルを留置して50%NBCA 2mLを注入した。NBCAは解離性脾動脈瘤の尾側に停滞した。その後の造影では，解離性脾動脈瘤の一部に造影効果を認めたが，これ以上の塞栓は技術的に困難と判断し手技を終了した（補足図2b）。 入院後経過：TAE後は腹痛の再燃や貧血の進行なく経過したが，第4病日の造影CTではコイル塞栓部腹側に結節状の造影効果が残存し，塞栓部の遠位にも血流を認めた（補足図2c）。不完全塞栓であったがTAEによる再アプローチは困難と考え，待機的に第8病日に手術となった。開腹時，活動性出血はほぼ認めなかった。膵体尾部に膵炎の影響と思われる高度癒着を認め，瘤との剥離は困難であった。脾動静脈を根部で結紮し，膵体尾部・脾臓合併切除を行った（補足図3a, b）。術中出血量2,320mL，濃厚赤血球輸血計4単位使用した。術後経過は良好で第25病日に退院となった。切除膵の病理組織診断では，膵炎の炎症が脾動脈へ波及し，脾動脈外膜が破壊されている所見を認めた。 患 者：53歳の男性 主 訴：意識消失，腹痛 既往歴：糖尿病，高血圧 現病歴：受傷2日前の早朝に突然の激しい腹痛とめまいを自覚したが，自宅で様子を見ていた。受傷当日，乗用車を運転中に意識消失感が出現し，車を停車させたところで対向車と正面衝突し救急要請となった。救急隊接触時ショック状態であり，ドクターヘリで当院搬送となった。 来院時現症：意識レベルJCS I–1，GCS E4V5M6，呼吸数18/分，心拍数121/分，血圧81/54mmHg，体温35.2℃（腋窩温），SpO2 99%（酸素10Lリザーバーマスク），瞳孔径は両側3.0mmで対光反射は迅速であった。腹部超音波検査でモリソン窩，脾周囲，膀胱直腸窩に液体貯留を認めた。体表上は明確な外傷痕は認めず，腹部も平坦軟であったが，上腹部に軽度の圧痛を認めた。血液・生化学検査では，白血球の上昇（25,100/μL）と貧血（Hb 10.2mg/dL）を認めたほか，Cr 1.08mg/dL，CRP 2.29mg/dL，乳酸32mg/dLと上昇を認めた。Amyは110U/Lと基準値内であった。 初療経過：ドクターヘリ医師接触時は血圧測定不能であったが，現場より初期輸液，O型赤血球輸血開始後，来院時収縮期血圧は80mmHg以上に上昇したため，直ちに腹部造影CTを施行した。腹部造影CTでは血性腹水貯留を認め，腹腔動脈起始部は正中弓状靱帯圧迫症候群（median arcuate ligament syndrome: MALS）により狭小化（補足図4a）しており，かつ解離（ISCAD）を認めた（補足図4b）。ISCADは脾動脈遠位に及び，解離性脾動脈瘤の破裂に伴う仮性動脈瘤が形成されていた。さらに，横隔脾間膜内には大量の血腫を伴っていた（補足図4c）。来院時は、“外傷性”腹腔内出血として初療を進めていたが，受傷機転が軽微なこと，腹部に外傷痕を認めないこと，来院2日前からの腹痛と意識消失のエピソードがあることを考慮し，解離性脾動脈瘤破裂による出血性ショックと最終的に判断した。開腹止血術も考慮したが，輸液・輸血により循環動態の安定化が得られたこと，CT上腸管損傷などの絶対的に手術介入を要する病態がないことからTAEの方針とした。腹腔動脈造影では仮性動脈瘤はやや遅れて描出された（補足図5a）。膵尾枝や大膵動脈は描出されず，遠位で僅かに脾実質が造影された。腹腔動脈造影を施行したところ，腹腔動脈解離に続く解離性脾動脈瘤の真腔は偽腔に圧排されて狭小化し，完全閉塞していた。そのため，偽腔内へガイドワイヤーを進め，偽腔内から仮性動脈瘤の遠位をコイル計5本，近位をコイル計7本にてアイソレーションした（補足図5b）。最終的に腹腔動脈造影，上腸間膜動脈造影で仮性動脈瘤が描出されないことと，短胃動脈から脾実質の造影効果が保たれていることを確認して手技を終了した。 入院後経過：循環動態は安定して経過し，貧血進行もなく，止血は得られたと判断した。第8病日の造影CTでは，脾門部に短胃動脈を血液流入路とする仮性動脈瘤の出現を認めた。瘤径は小さく血栓化を期待し経過観察を行ったが，第18病日のCTで瘤径14×16mmと増大を認めたため再度TAEを施行した。腹腔動脈から胃十二指腸動脈，胃大網動脈を介してアプローチし，仮性動脈瘤近位と遠位で金属コイル2本と40%NBCAにて塞栓を行った（補足図6a, b）。脾臓血流は，短胃動脈・後胃動脈を介して温存された。その後は経過良好で，第21病日に退院となった。 今回我々は，ISCADを伴う解離性脾動脈瘤破裂の症例で，それぞれ異なる治療アプローチを要した2症例を経験した。ISCADはMDCTの普及により近年報告数が増加しており，初回治療として降圧，鎮痛，抗血小板療法，抗凝固療法などによる保存的治療を選択されることが多い。腹腔内出血などの合併症を有する例では侵襲的治療が選択されるが，確立した治療法はなく，症例により手術あるいは血管内治療が選択されている 2, 3, 4。 侵襲的治療の適応として，症状持続，腹腔動脈径拡大（≧15～20mm）や瘤化，真腔の狭小化や閉塞による臓器虚血，動脈瘤破裂が挙げられる 5。ISCAD 169例のシステマティックレビューでは血管内治療が11.8%に，開腹手術が8.9%に行われており，近年では血管内治療が主流となっている 6。また，別のシステマティックレビュー（68症例）では，解離の進展範囲に関し腹腔動脈限局が22.6%，脾動脈への進展が50.9%，総肝動脈への進展が45.3%と報告されている 5。破裂症例は腹腔動脈1.2%，脾動脈2.9%に認め全例死亡している 5, 6。このように，ISCADから破裂に至る症例は非常に稀であり，文献検索した範囲では腹腔動脈起始部の解離が遠位へ進展し破裂した例は4例のみであった 2, 3, 7, 8。 今回提示した2症例では，ISCADが脾動脈遠位まで解離を来し，かつ解離性動脈瘤破裂に至った点と，その背景にそれぞれ膵炎やMALSを有していた点で非常に稀な症例であった。これまでにISCADの成因として，動脈硬化，血管炎，線維筋性異形成，結合織疾患（Marfan，Ehlers–Danlos症候群），結節性多発動脈炎，segmental arterial mediolysis，梅毒や真菌感染症などが報告されている 2。 症例1では，循環動態が安定していたことからTAEを第一選択としたが，脾動脈の屈曲・蛇行と狭小化が著しく，不完全塞栓となり最終的に手術を要した。ISCADの解離が脾動脈へ進展した結果解離性脾動脈瘤を形成し，さらに脆弱性の高い偽腔に急性膵炎の炎症が波及し破裂を来し，仮性動脈瘤を形成したものと考えられた。ISCADそのものの成因として膵炎が背景となっていたかに関しては報告が存在しない。症例2は，MALSに続発したISCADが脾動脈に進展し，解離性脾動脈瘤の形成から破裂に至った症例であった。MALSがISCADの発生に関与した症例は過去に報告されており，MALSに腹腔動脈解離が合併し膵十二指腸動脈瘤破裂に至った例 9や，MALSに腹腔動脈解離を伴い血管内治療を施行した例 10，および血管内治療に加え腹腔鏡による弓状靭帯切離を施行した例 11の3症例のみが存在している。MALSからISCADを生ずる機序は，腹腔動脈起始部の物理的狭小化によって血管内腔の圧上昇を来し，内膜と中膜の解離を生じるためと考えられる。無症候性のMALSが多く存在することは知られており，剖検例の検討では約1/3にMALSによる腹腔動脈圧迫を認めたとの報告もある 12, 13。また，CTなどの画像検査で約7%に腹腔動脈の無症候性狭窄が発見されたとの報告もある 14。ゆえに，症例2のように無症候性のMALSにISCADを潜在的に有している例も少なからず存在する可能性がある。なお，CTでISCADが偶発的に見つかった場合でも，循環動態が安定しており破裂や仮性動脈瘤を伴っていない場合にはルーチンでの血管造影は不要であり，MDCTでの形態的評価と経時的な経過観察で十分と考える。症例2ではTAEを第一選択としたが，もし仮に初期輸液にて循環動態の安定化が得られなかった場合，CT撮像ができないまま外傷性腹腔内出血として開腹止血術を先行させていた可能性があり，その場合ISCADによる内因性の解離性脾動脈瘤破裂との診断がつかなかった可能性がある。このように内臓動脈瘤破裂は，発症様式や全身状態においても選択される治療法が異なる病態であり，施設のリソースや各科のバックアップ体制なども考慮し，個々の施設で最適な止血方法を選択する必要があると考える。血管内治療，外科的治療のいずれを選択するにしても，初療を担う救急医がリーダーとして治療方針を決定し，専門的治療につなげることが要求されるため，内因性腹部出血の鑑別の一つとして常にこのような病態を念頭に置く必要がある。 また，MALSにおいては，根本原因である弓状靭帯圧迫を解除しないと，腹腔動脈，脾動脈塞栓に伴い，理論的に側副路への負担が増し将来的に瘤化から破裂を来す危険が残存する。現在ではより低侵襲な腹腔鏡下切離術が可能であり，ステントグラフト治療と組み合わせた根治的治療が将来的に期待されよう。 ISCADによる解離性脾動脈瘤破裂の2例を経験した。内因性腹部出血の鑑別としてISCADの破裂を念頭に入れる必要がある。 本稿における利益相反はない。 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Stent-Graft Placement and Coil Embolization for Splenic Artery Aneurysm Derived from Isolated Spontaneous Celiac Artery Dissection

We encountered a case of complex isolated spontaneous celiac artery dissection with a patent false lumen with both entry and re-entry and extensive aneurysmal degeneration of the splenic artery. The dissection entry was wide and was located at the origin of the celiac artery. The false lumen extended to the distal part of the splenic artery, obstructed the true lumen, and was connected to the true lumen at the splenic hilum via the re-entry. Treatment was successful by stent-graft placement for the occlusion of the entry and embolization of the re-entry with microcoils via the false lumen of the splenic artery.

Comparative analysis of prevalence, evaluation, management, and rehabilitation outcome of spontaneous isolated visceral artery dissection: a systematic review and meta-analysis of 80 reports.

Because of relatively little data for management and evaluation surrounding spontaneous isolated visceral artery dissection (IVAD), existing studies have failed to provide comprehensive analysis for the management, evaluation, prevalence, as well as natural course of the disease. Therefore, we collected and analyzed current evidence on spontaneous IVAD with the aim of providing quantitative pooled data for the natural course and treatment standardization of the disease. A systematic search of PubMed, Embase, the Cochrane Library, and Web of Science up to 1 June 2022, was conducted for relevant studies that investigating the natural course, treatment, classification, and outcomes of IVAD. The primary outcomes were to determine the difference in prevalence, risk factors, and characteristics between different spontaneous IVAD. Two reviewers assessed the trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2 and Stata 12.0. A total of 80 reports with 1040 patients were identified. The pooled results indicated that in IVAD, isolated superior mesenteric artery dissection (ISMAD) was more prevalent, with a pooled prevalence of 60% (95% CI: 50-71%), followed by isolated celiac artery dissection (ICAD) (prevalence: 37%; 95% CI: 27-46%). IVAD was male predominated with a pooled proportion of 80% (95% CI: 72-89%). Similar results were found in ICAD (prevalence: 73%; 95% CI: 52-93%). More IVAD patients were diagnosed with symptoms than ICAD (64 vs. 59%). Regarding to the risk factors, this pooled analysis found smoking and hypertension were the top two conditions in both spontaneous IVAD and ICAD patients, with proportion of 43, 41, 44, and 32%, respectively. It was observed that ICAD appeared shorter dissection length (mean difference: -3.4cm; 95% CI: -4.9 to -2.0; P <0.0001), higher prevalence of Sakamoto's classification Π (odds ratio: 5.31; 95% CI: 1.77-15.95; P= 0.003) and late progression (odds ratio: 2.84; 95% CI: 1.02-7.87; P= 0.05) than ISAMD. Spontaneous IVAD was male predominant and ISMAD was most prevalent followed by ICAD. Smoking and hypertension were the top two conditions in both spontaneous IVAD and ICAD patients. The majority of patients diagnosed with IVAD received observation and conservative treatment and experienced a low proportion of reintervention or progression, especially for ICAD patients. In addition, ICAD and ISMAD had several differences in clinical features and dissection characteristics. Future studies with enough sample size and long follow-up are required to clear the management, long-term outcome, and risk factors of the IVAD prognosis.

Spontaneous celiac artery dissection treated by balloon angioplasty

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition, defined as dissection of the celiac artery without aortic involvement. Because of its low prevalence, most studies have been limited to case reports and case series. We have described the case of a 44-year-old woman who had presented with symptomatic SICAD that had resulted in compromised flow to the hepatic arteries and was successfully treated with balloon angioplasty. Angioplasty alone might be effective for cases of extensive false lumen thrombosis in SICAD for immediate flow restoration to the true lumen, expediting positive remodeling.

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

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. 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. 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. 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.

S2823 Endoscopic Bypass of Gastric Outlet Obstruction After Spontaneous Celiac Artery Dissection

Introduction: Spontaneous isolated celiac artery dissection (SICAD) is a unique pathology with unclear management guidelines. Complications include hematoma formation and rarely intestinal ischemia. Gastric outlet obstruction (GOO) may occur because of luminal narrowing from ischemic duodenitis or extrinsic compression from hematoma. EUS-guided gastroenterostomy (EUS-GE) is an accepted approach in the management of malignant obstruction however currently there is no guidance for benign obstruction. We describe a case of SICAD complicated by GOO requiring bypass with EUS-GE. Case Description/Methods: A 56 year-old man presented with a weeklong history of epigastric abdominal pain. A computed tomography angiography (CTA) of the abdomen demonstrated a 1.3cm dissection of the celiac artery with associated hemorrhage. He was managed with intravenous anti-hypertensive medications and discharged 2 days later. He returned in 1 week with intractable nausea and vomiting. Repeat CT abdomen demonstrated duodenitis, dilation of the stomach and proximal duodenum and resolving hemorrhage surrounding the celiac artery. Nasogastric decompression returned 1100ml bilious output. Esophagogastroduodenoscopy (EGD) demonstrated edematous mucosa within the proximal duodenum with luminal narrowing preventing passage of the scope. The decision was made to proceed with EGD-EUS. EUS demonstrated a dilated. Celiac artery with a areas of hemorrhage within the celiac axis and adjacent to the duodenum. After successful creation of an EUS-GE the patient was discharged on oral intake a day later. Surveillance imaging 2 months later demonstrated improvement of hemorrhage. (Figure) Discussion: Our case Illustrates a rare case of GOO as a result of a hematoma causing duodenal compression. Until the recently, the only option for management for benign GOO was radical surgical intervention. Endoscopic management with either ballon dilation or intraduodenal stents are poor choices due to risk of perforation and durable patency is not guaranteed. Current guidelines do not provide recommendations on EUS-GE for benign etiologies of GOO. Small retrospective studies have illustrated success however prospective and randomized trials are needed to demonstrate efficacy and safety in benign causes of GOO.Figure 1.: Panel A. EGD with duodenal narrowing. B. EUS demonstrating celiac artery dissection. C. Lumen-apposing metal stent (LAMS).

A RARE CASE OF ISOLATED CELIAC ARTERY DISSECTION DIAGNOSED IN THE EMERGENCY DEPARTMENT

Introduction: Spontaneous isolated visceral artery dissection is an uncommon event with an unpredictable natural history and may lead to aneurysmal formation, rupture or arterial occlusion. Pre-disposing factors are not specific. With the development of new imaging modalities, Spontaneous isolated visceral artery dissection can be diagnosed at an early stage and can be treated medically or surgically. Case Report: We report a case of a previously healthy male patient who presented to the emergency department with the complain of tearing kind of back pain radiating to right side of the abdomen for the last 2 hours. The patient was examined and diagnosed with celiac artery dissection. Conservative management was done and patient improved with symptomatic relief. Discussion: Celiac artery dissection in adults are asymptomatic until an insidious injury occurs and will typically present with rare complains. If dissection involves a branch of the hepatic artery, it may cause liver ischemia leading to higher mortality. Conclusion: This case demonstrates the importance of considering advanced imaging as a useful diagnostic tool and importance of immediate management to improve outcome of the patient.

Current status of spontaneous isolated celiac artery dissection.

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

An Unusual Cause of Acute Abdominal Pain: Spontaneous Celiac Artery Dissection

Isolated celiac artery dissection was first reported in 1959 and remains a rare phenomenon. Celiac artery dissection may occur in conjunction with aortic dissection or as an isolated event. Its incidence is less than superior mesenteric artery (SMA) dissection. Patients with isolated celiac artery dissection tend to be less symptomatic due to celiac artery communication with SMA. Here, we describe a middle-aged male with hypertension who presented with acute abdominal pain, and was found to have isolated, spontaneous celiac artery dissection.

Isolated Celiac Artery Dissection Successfully Diagnosed by Ultrasonography with Physical Assessment: A Case Report

Isolated Celiac Artery Dissection Successfully Diagnosed by Ultrasonography with Physical Assessment: A Case Report

Diagnosis and treatment of isolated celiac artery dissection following blunt trauma: A case report.

IntroductionCeliac artery (CA) dissection due to blunt abdominal trauma is extremely rare and, as such, the clinical features of this potentially life-threatening injury have not been clearly defined, nor have treatment strategies been established.Presentation of caseWe describe the case of a 61-year-old man who presented to our emergency department after a motor vehicle accident. Although the patient did not report abdominal pain, enhanced computed tomography (CT) revealed CA dissection. The patient was treated conservatively using antiplatelet therapy and was discharged from the hospital on day 8, without complications.DiscussionAs abdominal pain is not a common presenting factor of CA dissection after blunt trauma, it should be suspected as a potential injury in all affected patients and comprehensively assessed, with CT being the most useful diagnostic modality.ConclusionIn the absence of any signs of organ ischemia, changes in the CA aneurysm, and persistent, severe abdominal pain following blunt abdominal trauma, conservative treatment is indicated, with or without anticoagulation or antiplatelet therapy.

Celiac artery dissection in polycystic kidney disease.

Autosomal‐dominant polycystic kidney disease (ADPKD) is rarely complicated by celiac artery dissection. Dissection of the aorta and its major branches should be carefully differentiated in ADPKD patients with acute‐onset abdominal pain.