Visceral Artery Dissection Research Articles

Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival

ObjectiveVisceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement. MethodsVBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models. ResultsA total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P < .001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P < .001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P < .001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P < .001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P < .001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P = .001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P = .001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P = .004) were associated with inferior intervention-free survival. ConclusionsIsolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance.

Visceral Artery Dissections: Overview, Natural History, and Management

Visceral Artery Dissections: Overview, Natural History, and Management

Sequential Multiple Visceral Artery Dissection within a Short Time, without Aortic Dissection.

A 65-year-old Japanese man without medical history presented with sudden onset lower abdominal pain to our emergency department. Contrast-enhanced computed tomography (CT) revealed dissections of the inferior mesenteric artery and left renal artery with false lumen thrombosis without aortic dissection. He was immediately hospitalized, and conservative treatment was administered. However, on the third-day post-onset, the patient reported severe upper abdominal pain and contrast-enhanced CT showed a new superior mesenteric artery dissection. He continued to receive conservative treatment, and his symptoms improved. He was discharged after ten days of hospitalization.

Natural History and Risk Factors Associated with Intervention-free Survival Among Patients with Visceral (Mesenteric and/or Renal) Artery Dissections

Natural History and Risk Factors Associated with Intervention-free Survival Among Patients with Visceral (Mesenteric and/or Renal) Artery Dissections

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.

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.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC). All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI). Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun etal., IMADs were reported as follows: type I (n= 7, 20%), type IIa (n= 6, 18%), type IIb (n= 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n= 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n= 3; type III, n= 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n= 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n= 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n= 4; stenting, n= 1) and or bowel resection (early, n= 3; late, n= 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention. Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

保存的加療で軽快した孤立性内臓動脈解離の4症例(Four cases of isolated dissection of visceral artery relieved by conservative therapy)

要旨 孤立性内臓動脈解離は比較的稀な疾患であるが，近年はmulti detector–row computed tomography（MDCT）などの診断デバイスの性能向上もあり報告例が増加している。今回，突然発症の強い腹痛を初発症状とし，造影CTで診断に至った孤立性内臓動脈解離を4例経験したので報告する。症例はいずれも40歳台の男性で，背景因子として高血圧が3例，喫煙歴ありが2例であった。初診時，腹痛の訴えは強いが腹膜刺激徴候は明らかでなく，嘔気下痢などの消化器症状を認めなかった。採血では，大動脈解離では感度が高いとされるD–dimerの陰性例が3例であった。腹部造影CTの撮影を行い，2例を上腸間膜動脈解離，2例を腹腔動脈解離と診断した。いずれの症例も腸管虚血は認めなかったため，厳密な血圧管理および抗血栓薬による保存的治療を選択した。治療開始後，疼痛症状は第3病日までに全症例で消失し，第7病日以降に行った経過観察の造影CTでは，すべての症例で解離血管の血流の改善を認めるという良好な経過をたどった。以上のように孤立性内臓動脈解離は稀な疾患であるが，腸管虚血を伴わない症例では保存的治療のみで良好な経過を得ることができる可能性が示された。中年男性に突然発症の激しい腹痛を生じた場合には本疾患を鑑別の一つとし，遅滞なく造影CTにて評価診断を行うことが必要と考える。

Spontaneous Celiac Artery Dissection: A Case Report

Spontaneous visceral artery dissection is an exceptional condition. In the literature, about a hundred of cases are reported. It most often involves the superior mesenteric artery, and secondarily the celiac trunk. The presentation is non-specific and the diagnosis is usually made on imaging or at autopsy. Pre-existing vascular diseases, hypertension and pregnancy are the most involved risk factors. We report the case of a 58-year-old patient who presented for a spontaneous dissection of the celiac artery treated medically

Results Obtained with the Protege EverFlex Self-expanding Bare Stent in Interventional Treatment of Spontaneous Isolated Visceral Artery Dissection

We evaluated the early and midterm results of the endovascular approach with a certain type of bare stent to treat spontaneous isolated visceral artery dissection (SIVAD). 28 patients with symptomatic SIVAD were selected from two hospitals from July 2014 to September 2020. All patients had symptoms of acute persistent abdominal pain accompanied by varying degrees of nausea and vomiting. The diagnosis of SIVAD was made according to the multidetector CT angiography (CTA) findings. We retrospectively analyzed the patients' medical records. According to our previous clinical experience, the Protege EverFlex self-expanding bare stent was used in these patients, and we subsequently followed up the patients to record and analyze their outcomes after surgery. The imaging results before and after the operations were compared. All 28 patients were successfully implanted with Protege EverFlex stents. The true lumen blood flow of the SIVAD recovered during the operation. The residual stenosis rate was less than 30%, and the technical success rate was 100%. There were no complications, such as bleeding, intestinal necrosis, digestive tract perforation, liver failure or spleen infarction. The abdominal pain was relieved or eliminated in all patients. The Protege EverFlex self-expanding bare stent and the endovascular approach could be a minimally invasive, safe and effective treatment method for SIVAD with a high success rate and a relatively low price.

148 Acute Renal Infarcts from Spontaneous Intra-Renal Dissection

Abstract Spontaneous renal artery dissection and acute renal infarcts are rare occurrences and often misdiagnosed in clinical practice. We present four male patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension, or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were all treated with endovascular stenting. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram, a rare pathology which is reported in literature to mostly affect women. All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti-platelet therapy for two years and did not experience any post-procedural complications at their 24-month follow up. Classically visceral artery dissection can be managed by anti-platelet therapy alone, however fibromuscular dysplasia can cause spontaneous dissection with renal infarcts and this requires urgent treatment with endovascular stents. Further research is needed on the post-procedural medical management guidelines.

New technique for false lumen coiling of spontaneous isolated superior mesenteric artery dissection

BackgroundSpontaneous isolated visceral artery dissection is rarely encountered. Endovascular intervention with good outcomes has become popular for patients with persistent symptoms or developing ischemia. We could perform life-saving treatment for a spontaneous isolated superior mesenteric artery dissection with a unique endovascular intervention.Case presentationWe describe the case of an 80-year-old man who presented with acute abdominal pain and a spontaneous isolated superior mesenteric artery dissection measuring 35 mm in major diameter and 6.6 mm in minor diameter on abdominal contrast-enhanced computed tomography. After admission, abdominal pain was progressive, and a repeated scan revealed progression of the dissection. As an endovascular intervention, via the bilateral femoral approach, detachable coils were placed in the false lumen of the superior mesenteric artery dissection through the false lumen under the micro-balloon occlusion at the point of re-entry and entry through the true lumen to prevent coil migration. Technical and clinical success was achieved without serious adverse events.ConclusionCoil embolization using micro-balloon assistance combined with the double-catheter technique for a large entry and re-entry false lumen of a spontaneous isolated superior mesenteric artery dissection was useful and feasible.

Evaluation of isolated abdominal visceral artery dissection with multi-scale spiral computed tomography: a retrospective case series

BackgroundTo evaluate the role of multi-slice spiral computed tomography (MSCT) angiography in the diagnosis of spontaneous isolated visceral artery dissection (SIVAD).MethodsTwenty-seven patients with abdominal SIVAD were included in the study. The MSCT scans of the patients were subjected to various post-processing techniques to visualize the visceral artery wall. Clinical features including arterial dissection, thrombosis, dissection length, true/false lumen, and complications were recorded.ResultsType I, IIa, and IIb SIVADs were observed in 11, 6, and 10 patients, respectively. Superior mesenteric artery (SMA) dissection was the most common (n = 16), followed by abdominal aortic dissection (n = 6), splenic artery dissection (n = 2), renal artery dissection (n = 2), and splenic artery dissection (n = 1). One patient with SMA dissection suffered small intestine ischemia, 1 with splenic artery dissection had splenic infarction, and 1 patient with left renal artery dissection experienced renal infarction. The false lumen was bigger than the true lumen in 20 patients, with 9 patients having thrombus. The true lumen was bigger than the false lumen in 7 patients.ConclusionsMSCT angiography is a valuable technique in the diagnosis and treatment of patients with SIVAD. Patients with abdominal pain suspected due to SIVAD should be examined with MSCT angiography for early detection of SIVAD.

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.

Spontaneous visceral artery dissections in otherwise normal arteries: Clinical features, management, and outcomes compared with fibromuscular dysplasia

ObjectiveVisceral artery dissection with otherwise normal-appearing arteries (VADNA), diagnosed on imaging and suggestive of segmental arterial mediolysis, is a poorly understood disease entity. Study objectives were to define the clinical features, management, and outcomes of patients with VADNA compared with patients with fibromuscular dysplasia (FMD). MethodsIn this single-center retrospective cohort study, consecutive patients with a diagnosis of VADNA or FMD evaluated in the Mayo Clinic Gonda Vascular Center (January 1, 2000-April 1, 2017) were identified. Patient demographics, symptom presentation, management, composite adverse arterial events (recurrent arterial dissection, stroke or transient ischemic attack, myocardial infarction, mesenteric or renal infarction, or need for revascularization), and overall survival were compared between VADNA and FMD patients. ResultsThere were 103 VADNA patients (age [mean ± standard deviation], 51.7 ± 11.0 years; 27.9% female) and 248 FMD controls (49.8 ± 8.9 years; 81.8% female) identified. The most common symptom for VADNA patients was abdominal or flank pain (80.6%). For FMD, chest pain, headache, and dizziness were more frequent presenting complaints. The median follow-up was longer for VADNA patients (42 months; interquartile range, 9-76 months) compared with FMD patients (19 months; interquartile range, 0.6-52 months; P < .001). During this time interval, there were twofold more composite arterial events in the VADNA group compared with the FMD group (17% vs 8.1%; P = .01). This difference was primarily driven by recurrent dissections. All-cause mortality was low and similar for both groups (3.8% vs 0.4%; P = .10). ConclusionsVADNA patients carry a higher risk of recurrent arterial events compared with those with FMD. This difference was primarily driven by recurrent dissections.

Clinical Features of Spontaneous Isolated Dissection of Abdominal Visceral Arteries.

BackgroundSpontaneous isolated dissection of abdominal visceral arteries without aortic dissection is rare and its pathology and prognosis are not yet clear; therefore, therapeutic strategies for this disease have not been established. The present multi-institution investigational study analyzed the clinical features of patients with spontaneous isolated dissection of abdominal visceral arteries.MethodsA total of 36 patients diagnosed as spontaneous isolated dissection of abdominal visceral arteries from January 2010 to October 2016 were enrolled. The medical data of the patients were retrospectively reviewed. Imaging characteristics were evaluated. Spontaneous isolated dissection of abdominal visceral arteries was detected on upper abdominal computed tomography examination in almost patients, and was detected on magnetic resonance imaging in one patient.ResultsOf the 36 cases, 26 cases involved the superior mesenteric artery dissection, nine involved the celiac artery, two involved the splenic artery, one involved the common hepatic artery, one involved the gastroduodenal artery and one involved the left gastric artery. Among the 36 patients, 20 had hypertension and 14 were current smokers. Additionally, only one patient had diabetes and four patients had dyslipidemia. Moreover, 32 cases complained of pain including abdominal pain and back pain, one had cough and three had no symptoms. Of the 36 patients, 34 cases (94.4%) were treated conservatively, and two (5.6%) required intravascular treatment. All patients were discharged without complications.ConclusionsOur findings indicate that hypertension and smoking might be closely involved in the pathogenesis of spontaneous isolated dissection of abdominal visceral arteries, whereas dyslipidemia and diabetes might be less involved. Additionally, few asymptomatic patients were accidentally diagnosed, indicating that the absence of symptoms cannot be used to rule out the presence of this disease. Randomized clinical trials cannot be performed because a considerable number of cases are required. Therefore, detailed descriptions of clinical features, as provided in our report, are important.

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。

Spontaneous dissection of visceral arteries. A series of cases

Spontaneous dissections of visceral arteries are rare and usually secondary to other disease. There is paucity of information about their natural course. To describe the imaging, clinical characteristics and follow-up of spontaneous visceral artery dissections diagnosed at our institution. We report a series of 14 patients in whom a spontaneous dissection of a visceral artery was diagnosed on abdominal angio-CT between 2010 and 2018. Clinical features and evolution were recorded. Isolated lesions of the celiac axis were the most common finding. Multiple territories were involved in 14% of cases. A dissection flap was observed in four cases, a hematoma-dissection complex in seven and an aneurysmal dilatation associated with the dissection in three. Of the 10 patients who were followed at our institution, 90% had stabilization or partial regression of the imaging findings. In the remaining case, new dissection events were observed. All cases were managed conservatively, and no death was reported. In this series of patients, spontaneous dissection of visceral arteries had a benign, favorable course, requiring only conservative management.

Strategy for the Treatment of Spontaneous Isolated Visceral Artery Dissection

Abstract Objectives To determine the incidence of rare spontaneous isolated visceral artery dissection (SIVAD), characterize its pathogenesis, and suggest treatment strategies. Materials and Methods We reviewed abdominal contrast-enhanced computed-tomography (CE-CT) scans from January 2005 to December 2016 retrospectively in our institution, identified 47 SIVAD patients and classified them into a symptomatic (n = 22) or asymptomatic group (n = 25). Further, we classified the five types based on the CE-CT images. Patient characteristics, incidence, vascular risk factors, complications, symptoms, treatments outcomes, and morphology features on CE-CT images were analyzed. Results SIVAD was seen on 0.09% of all abdominal CE-CT scans, and 0.68% of all abdominal CT-CT scans obtained for the evaluation of acute abdominal symptoms. The asymptomatic group had significantly fewer patients with periarterial fat stranding or branch vessel involvement on CE-CT images (p Conclusions Symptomatic SIVAD patients should be hospitalized because some of those may experience organ ischemia or aneurysm formation. Endovascular intervention is a feasible treatment for complications of SIVAD.