Celiac Artery Dissection Research Articles

正中弓状靱帯症候群に起因する膵十二指腸動脈瘤破裂を来した5例の臨床的検討(Ruptured aneurysm of the pancreaticoduodenal artery caused by median arcuate ligament syndrome: five case reports)

要旨正中弓状靱帯症候群（median arcuate ligament syndrome: MALS）に起因する膵十二指腸動脈瘤破裂には経カテーテル的動脈塞栓術（transcatheter arterial embolization: TAE）による止血が第一選択とする報告が近年散見される。一方で，TAE後の臨床経過に関する報告は少ない。今回，5例のMALSに起因する膵十二指腸動脈瘤破裂症例を経験し，TAE後の臨床経過を後方視的に検討したので報告する。5例の年齢中央値は58歳（49–78歳），男性4例で，全例でTAEによる止血が行われた。4例は単発症例で1例では多発性に動脈瘤を認めた。TAE後に再出血が生じたのは2例あり，いずれもTAE後約1週間以内に新たな部位に動脈瘤が出現した。追跡期間の中央値は26か月（7～92か月）であるが，正中弓状靱帯切離術を施行された1例を含め，急性期以降は，全例無症状で経過している。MALSに起因する膵十二指腸動脈瘤破裂に対しTAEによる止血を施行した場合は，約1週間以内の早期に新たな動脈瘤形成の危険がある。またその時期を過ぎれば，MALSへの直達手術の有無に関わらず再発や新規の動脈瘤出現の可能性は低く，消化管虚血の症状がなければ保存的に観察できる可能性があると思われた。

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review.

Background and Aims:There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited.Material and Methods:The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis.Results and Conclusions:Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

Clinical features and management strategy of symptomatic spontaneous isolated celiac artery dissection

The aim of this study was to evaluate the clinical features and management strategy for patients with symptomatic spontaneous isolated celiac artery dissection (SICAD). In this retrospective study, consecutive patients with symptomatic SICAD from two institutions were included. The demographics, clinical manifestations, comorbidities, imaging findings and treatment strategy selection were obtained from the medical records. The general epidemiological data, treatment regimens and clinical and follow-up outcomes were analysed. Patients were divided into the conservative treatment group (group A, n = 26) and endovascular treatment group (group B, n = 11). Of these 37 patients, extent of dissection in both groups included only celiac trunk (61.54%% vs. 18.18%, p = 0.03), common hepatic artery (CHA) and splenic artery (SA) (3.85%% vs. 54.55%, p = 0.001), CHA (7.69% vs. 18.18%, p = 0.57), SA (23.08% vs. 9.09, p = 0.65) and left gastric artery (LGA) (3.85% vs. 54.55%, p = 0.99). Of note, the extension of the lesion in group A was shorter than that in group B. In addition, there were significantly more type IIb in group A than in group B (42.31% vs. 9.09%, p = 0.06) and the mean length of dissection in group A was 42.3 ± 54.71 mm which was significantly shorter than that in the group B 58.45 ± 3.71 mm (p =0.04). During a median follow-up of 11.5 months, the 1, 3, 6 and 12 month follow-ups were completed in 100% (37/37), 100% (37/37), 94.59% (35/37) and 91.19% (34/37) of patients, respectively. The cumulative rate of persistent disease stability in patients with endovascular treatment group was higher than in that conservative treatment group at the 3, 6, 9 and 12 months (50% vs. 16.67%, p = 0.001; 80% vs. 37.5%, p =0.03; 100% vs. 62.5%, p = 0.012;100% vs. 91.67%, p = 0.02 respectively). Most symptomatic SICAD have a tendency to persistent disease stability after conservative treatment. Risk factors for failed conservative treatment were length of dissection and branch involvement. Furthermore, endovascular treatment was associated with a high technical success and persistent disease stability rate, which might be reserved for patients with failed conservative treatment.

16. Case Series of Spontaneous Visceral Artery Dissections

Spontaneous visceral artery dissections (SVADs) are rare but are being identified more frequently. The most common dissections are celiac artery (CA) and superior mesenteric artery (SMA) dissections. Historically, the majority of diagnosed SVADs were associated with symptoms, including epigastric pain, bloody stool, or nausea; however, with increased cross-sectional imaging, they are being identified more commonly while asymptomatic. Typical patients are Asian males in their fifth or sixth decade of life. Risk factors include smoking and arteriopathies. Most patients have no evidence of peritonitis. CT angiography (CTA) is the diagnostic modality of choice. Previously, patients were often treated with open or endovascular intervention, but now, patients are often managed medically with anticoagulants or antiplatelet medications. It is unclear whether antiplatelets, dual antiplatelet therapy, anticoagulation, or a combination should be the standard for medical management. Blood pressure control is supported as part of medical management, but the target pressure is not clear. The duration of medical management is also unclear. The ideal surveillance method and duration are unknown as most series are relatively short.

S2221 A Spontaneous Case of Isolated Celiac Artery Dissection

S2221 A Spontaneous Case of Isolated Celiac Artery Dissection

Spontaneous Isolated Celiac Artery Dissection: A Case Report.

IntroductionAbdominal pain is a common chief complaint that can represent a wide breadth of diagnoses, ranging from benign to life-threatening. As our diagnostic tools become more sophisticated, we are able to better identify more causes of potentially life-threatening diseases. One such disease that is relatively unfamiliar to clinicians is spontaneous isolated celiac artery dissection (SICAD).Case ReportWe describe a case of a 46-year-old man who presented to our emergency department with a chief complaint of abdominal pain and was found to have a SICAD and was successfully treated with anticoagulation, antihypertensives, and observation.ConclusionIt is important for emergency physicians to keep this potentially life-threatening condition in mind and to know the appropriate first steps once identified.

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

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes. Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com. Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n=9). Mean age was 31.7years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n=1), medium stenosis (n=1), resolution of the dissection (n=2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n=1), or occlusion of the CA with sufficient collateralization (n=3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid. Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications. III (Retrospective therapeutic study and systematic literature review).

"Step-by-step" principles of safe laparoscopic approach with technical details in "median arcuate ligament syndrome".

The median arcuate ligament syndrome (MALS) is a rare cause of postprandial pain and weight loss. The median arcuate ligament (MAL) is a fibrous band of the diaphragmatic crura. Abnormally downward located MAL or high take off of the celiac artery result in external compression the celiac trunk. MAL narrows the truncus coeliacus even more clearly during the expiration. The chronic compression of the celiac artery reduces blood flow and causes symptoms. Symptomatic patients receive surgical treatment, in recent years, an increasing rate, especially laparoscopic. The rate of conversion to open surgery is 10.3% due to vascular injury in hemorrhage, which generally occurs during dissection. A maneuver is needed to continue with the surgical procedure safely here because of the close neighboring of the aorta, truncus coeliacus, and one of its branches. Technical standardization can reduce the complication rate. There is still no standardized and established laparoscopic method in the world. There are no randomized controlled studies in the literature, which show the superiority of these techniques over one another. The maneuver in this case report, through traction with a tape towards caudal, allows a brilliant view on the celiac axis with shortened operation time. It also makes the operation even safer because of its enabling mastery over the celiac artery and easy dissection.

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

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

Symptomatic Isolated Celiac Artery Dissection following Blunt Trauma

Symptomatic Isolated Celiac Artery Dissection following Blunt Trauma

1445 Spontaneous Isolated Celiac Artery Dissection: A Rare Cause for Acute Pancreatitis

INTRODUCTION: Spontaneous celiac artery dissection is a rare event. Due to similar presenting symptoms of abdominal pain, diagnosis of celiac artery dissection as a cause of acute pancreatitis can be easily missed. CASE DESCRIPTION/METHODS: A 51-year-old man with a history of cholecystectomy presented with severe epigastric pain radiating to bilateral upper quadrants. He denied nausea, vomiting, diarrhea and fevers. Physical exam was notable for epigastric, LUQ, and RUQ tenderness. Labs revealed lipase 35 U/L. CT A/P showed peripancreatic inflammatory changes with hyperdense peripancreatic fluid, concerning for hemorrhagic pancreatitis. Typical etiologies for acute pancreatitis were absent, including alcohol and gallstones, and IgG4 was negative, suggesting this was not autoimmune pancreatitis. MRCP was performed and identified a dissection of the celiac axis extending to the splenic artery. CT angiography confirmed celiac artery dissection and re-demonstrated peripancreatic fat stranding. Patient received aggressive IV fluids for the first 24 hours with improvement in pain. Vascular surgery recommended starting aspirin 81 mg daily without any surgical intervention and the patient was discharged home with close follow-up. DISCUSSION: Though our patient had a normal lipase, he had severe epigastric pain and peripancreatic stranding on imaging, satisfying 2 of the 3 criteria for acute pancreatitis. In the absence of other causes, imaging identified celiac artery dissection as the etiology of his pancreatitis. Of the visceral artery dissections, celiac artery dissection represent only 4% of cases, and only 5 reported cases have identified spontaneous celiac artery dissection as a cause of pancreatitis. In the setting of a dissection, the pancreas likely experienced an ischemia-reperfusion injury, where there was transient hypoperfusion from the celiac trunk, followed by reperfusion from collaterals from the superior mesenteric artery, resulting in exposure to oxygen-free radicals and cellular processes leading to inflammation. There is no standardized treatment, but conservative management with antiplatelet and/or anti-coagulation is pursued in mild cases of pancreatitis. Surgery is reserved for severe cases involving bowel ischemia, vessel rupture, or continued abdominal pain. This case highlights a rare presentation of acute pancreatitis secondary to a spontaneous isolated celiac artery dissection.

Multiple isolated celiac visceral artery dissection: a case report

1例男性、47岁多发孤立性腹腔内脏动脉夹层患者，经股动脉入路行血管腔内介入术，于肠系膜上动脉、脾动脉、腹腔干动脉植入金属裸支架。术后经降脂、抗血小板等药物维持治疗，术后半年复查，效果良好。这对于腹腔干动脉夹层同时累及肝总动脉及脾动脉的处理有一定的参考价值。

Iatrogenic celiac and hepatic artery dissections during intra-arterial regional tumor therapies: a 16-year retrospective review.

To identify the incidence and outcomes of iatrogenic celiac and hepatic artery dissections during transarterial therapies, including bland embolization, chemoembolization, radioembolization (TARE), and pre-TARE scintigraphic mapping. The institution's quality assessment database, electronic medical record, and picture archiving and communication system were reviewed to identify all patients who underwent transarterial locoregional therapy from 1/2001 to 7/2017 and to determine the incidence of iatrogenic dissection, to assess patency of the arteries after dissection, and to assess the ability to complete therapy. 2253 patients underwent 3776 transarterial hepatic oncology procedures. Among 3776 procedures, 40 (1.1%) were associated with dissection of the visceral vasculature, affecting 39 patients (1.7%). The incidence of flow-limiting dissections was 0.3% (13/3776) and non-flow-limiting dissections was 0.7% (27/3776). After dissection, 68% (27/40) of treatments were completed the same day. Among the 13 aborted treatments, 8 (62%) were completed on a subsequent encounter. Follow-up imaging was obtained in 26 of 40 cases at median time of 63days. Complete resolution of the dissection was seen in 15/26 cases (58%), near complete resolution (< 30% luminal narrowing) in 3/26 (12%), unchanged appearance of a non-flow-limiting dissection in 4/26 (15%), progressive luminal narrowing in 3/26 (12%), and complete occlusion in 1/26 (4%). Iatrogenic dissections of visceral arteries rarely occur during tumor embolization procedures. 35/39 (90%) of patients underwent successful treatment despite the dissection.

A Case of Isolated Spontaneous Celiac Artery Dissection with Rupture of a Proximal Splenic Arterial Aneurysm

A Case of Isolated Spontaneous Celiac Artery Dissection with Rupture of a Proximal Splenic Arterial Aneurysm

A Case of Isolated Celiac Artery Dissection Treated with Surgical Revascularization and Aneurysmectomy

A Case of Isolated Celiac Artery Dissection Treated with Surgical Revascularization and Aneurysmectomy

Gastrectomy for Gastric Cancer Complicated by Celiac and Splenic Artery Dissection

Gastrectomy for Gastric Cancer Complicated by Celiac and Splenic Artery Dissection

Celiac Artery Dissection in the Setting of Blunt Abdominal Trauma

Celiac Artery Dissection in the Setting of Blunt Abdominal Trauma

Celiac Artery Aneurysm With Dissection

A 52-year-old male with no history of vascular disease presented with a celiac artery aneurysm. Incidentally, a celiac artery dissection was discovered. The dissection was a result of the aneurysm. The proximal abdominal aorta, celiac artery, and superior mesenteric artery were examined with gray scale, color flow, and spectral Doppler. The proximal abdominal aorta, celiac artery, and superior mesenteric artery were without evidence of atherosclerotic plaque. There was evidence of a celiac artery aneurysm measuring 1.3 cm, which was stable compared with a previous CT (computed tomography) from April 2014. A dissection was visualized within the celiac artery with color flow aliasing and higher velocities visualized in the false lumen, with the highest measuring 402/142 cm/s. The true lumen highest velocity measured 209/56 cm/s. The superior mesenteric artery was patent with normal flow patterns and velocities measuring from 134 to 189 cm/s. Celiac artery aneurysms and dissections are extremely rare and can be difficult to find and treat. By scanning the aneurysm, the dissection could be found, perhaps reducing the risk of embolus or occlusion.

Natural history of spontaneous isolated celiac artery dissection after conservative treatment

ObjectiveOptimal treatment of spontaneous isolated celiac artery dissection (SICAD) is not well established because the natural history of this rare disease is poorly understood. We analyzed the natural history of patients who underwent conservative treatment. MethodsThe study included 28 patients with SICAD from December 2008 to January 2017. Our institutional policy of first-line treatment for SICAD patients was conservative, and invasive procedures were reserved for unstable complications such as severe persistent pain, significant organ malperfusion, rapid aneurysmal change, and rupture or concealed rupture. Demographics, clinical features, morphologic characteristics on computed tomography, treatment modalities, and follow-up results of these patients were retrospectively reviewed. ResultsMean age was 52 years, and 89% of patients were male; 86% presented with pain, mostly abdominal, and 14% of cases were detected incidentally on abdominal imaging. None of these patients had unstable complications on admission, and all underwent initial conservative treatment. During the follow-up period (22 ± 20 months), aneurysmal change and propagation of thrombosis were noted in one patient and two patients, respectively, all of whom were managed conservatively without adverse clinical events. No difference in clinical and morphologic outcomes was noted between patients who were treated with antihypertensive therapy and those who were not. Patients with intramural hematoma on initial images showed dynamic vascular remodeling (partial to complete resorption) during the follow-up period compared with patients who had dominant intimal flap on initial images. ConclusionsThe clinical course of patients with SICAD was benign. Even progressive vascular changes during follow-up did not require invasive treatment. Antihypertensive therapy might not modify the clinical course. The short-term results of conservative management are encouraging, but further evaluation with long-term follow-up in a large population is needed.

Natural course and outcomes of spontaneous isolated celiac artery dissection according to morphological findings on computed tomography angiography: STROBE compliant article.

We aimed to identify natural course and optimal management of spontaneous isolated celiac artery dissection (SICAD) according to morphologic classification determined on computed tomography angiography (CTA), and to investigate the association between symptoms and morphological classification of SICAD.This retrospective observational study included 21 consecutive patients with SICAD from January 2012 to April 2017. Demographic data, clinical features, treatment modalities, follow-up results, and CTA findings including morphologic classification, dissection length, and relative diameter of the true lumen (TLRD) were reviewed. Changes in follow-up CTA were recorded and compared to prior studies to reveal natural course of the disease.The serial changes of SICAD on follow-up CTA according to morphologic classifications were as follows; type I (5/5, no interval change), type IIa (1/1, no interval change), type IIb (1/1, partial remodeling), type IIIa (1/4, complete remodeling; 1/4, partial remodeling; 1/4, no interval change; 1/4, deterioration), type IIIb (4/6, no interval change; 2/6, partial remodeling), and type IV (2/2, no interval change). Thirteen (61.9%) symptomatic and 8 (38.1%) asymptomatic patients were all treated with conservative management with or without antiplatelet and/or anticoagulation therapies. Symptomatic group (SG) more commonly had type IIb, IIIa, IIIb, and IV than asymptomatic group (AG) (SG; 11 patients, AG; 1 patient, P = .002). TLRD in AG was larger than that in SG (SG: 40.5 ± 24.1%, AG: 61.7 ± 7.0%, P = .045).SICAD might be treated by conservative management in stable patients irrespective of the morphologic classification except for with type IV (dissecting aneurysm) and extension of celiac branch who may need an early intervention. Types IIb, IIIa, IIIb, and IV are TLRD are associated with patients’ symptoms. Further studies on extended natural course of SICAD with a larger number of subjects are needed to draw a strong conclusion.