Abdominal Imaging

ª Springer Science+Business Media, LLC 2010 Published online: 28 October 2010

Abdom Imaging (2011) 36:79–82 DOI: 10.1007/s00261-010-9657-x

Symptomatic spontaneous celiac artery dissection treated by conservative management: serial imaging findings
Seonok Oh,1 Yong-Pil Cho,1 Ji-Hoon Kim,1 Sung Shin,1 Tae-Won Kwon,1 Gi-Young Ko2
Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan Medical College, Asanbyeongwon-gil 86, Songpa-gu, Seoul 138-736, Korea 2 Department of Radiology, Asan Medical Center, University of Ulsan Medical College, Seoul, Korea
1

Abstract
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. Key words: Celiac artery—Dissection—Spontaneous— Management—Imaging

Although spontaneous dissection of a visceral artery without associated aortic dissection has recently been reported more frequently due to advancements in diagnostic imaging technology, it still occurs infrequently. Most of the reported cases have been associated with the superior mesenteric artery (SMA), and symptomatic spontaneous dissection of the celiac artery (CA) is extremely rare [1–23]. Because of its rarity, the risk factors, etiology, and natural history of this problem are ill defined and, additionally, there is no consensus on the optimal treatment strategy. Selective cases have been known to undergo spontaneous resolution with thrombosis of the false lumen and preservation of distal flow. However, other cases have been associated with both substantial mortality and morbidity [1–23]. The aim of this study was to evaluate the correlation of clinical characteristics with serial imaging findings of symptomatic spontaneous CA dissection treated by conservative management and whether this management modality can be performed successfully in selective patients with stable hemodynamics.

Materials and methods
This is a retrospective study of medical records, with approval of Institutional Review Board. The diagnosis of the CA dissection was confirmed by contrast-enhanced dynamic computed tomography (CT) scan. Asymptomatic CA dissections, complicated dissections with suspicion of rupture, and those associated with aortic dissection, trauma, or vasculitis were excluded in this study. We examined eight consecutive, hemodynamically stable patients who had symptomatic spontaneous dissection of the CA treated non-operatively from January 2008 to April 2010 to investigate the clinical characteristics, treatment methods, follow-up contrast-enhanced CT imaging findings and outcomes.

Correspondence to: Yong-Pil Cho; email: ypcho@amc.seoul.kr

This could also account for the very few reported cases in comparison with SMA dissection [7]. follow-up CT scan was done within 1 month. and creatinine and lactate levels. The mean interval from the onset of symptoms to the initial diagnosis was 7 days (range 1–30). The percentage of true lumen compression by the false lumen was calculated from the CT scan. and reports of the CA are even rarer [1–23]. In cases with hemodynamic and clinical stability. Failure of conservative management occurred in one patient with worsening symptoms 3 days after initial management with anticoagulation who received endovascular stent placement. and later to aneurysm formation with an increased risk for thromboembolic events. which in part may be explained by the good collateral flow via the SMA [6. noted in 4 of 8 patients. except the one with endovascular stent placement. Acute left flank pain was the most common clinical manifestation. distal perfusion insufficiency in 4. orally administered warfarin. Non-operative managements include anticoagulants with a regimen of heparin and later. contrast-enhanced CT scan. hyperlipidemia (2). All patients. None of these patients had collagen disease. The dissections were characterized by initial CT scan: vessel of origin. comparing the smallest true lumen diameter with a reference diameter of contiguous. Upon complete follow-up (mean 16 months. hepatic and pancreatic tests. Three patients also had a concomitant SMA dissection. at which CA dissection with partial thrombosis was seen in all 8 patients. 24]. The most common presenting symptom in patients with CA dissection is abdominal Results The eight consecutive patients with symptomatic spontaneous CA dissection that received initial treatments conservatively were all males. spontaneous dissections of the artery usually occur free of coexisting vascular disease. was carried out in 7 patients and antiplatelet therapy in 1. In the early literature. increasing reports of visceral artery dissections have been published in recent years because of advancement in diagnostic imaging technology. full anticoagulation. Approximately one half of the patients with CA dissection are asymptomatic. Spontaneous dissections of the visceral artery without associated aortic dissection are extremely rare. these were diagnosed by autopsy [5]. and branch vessel involvement. range. parallel. with heparin followed by warfarin. and previous abdominal surgery. Risk factors included smoking (4 patients). Aneurysm formation was defined as >50% dilatation of the CA lumen compared with the normal caliber of the CA for each patient as measured by CT scan [1]. and splenic infarction in 4. Most of the reported cases have been associated with the SMA.80 S.0 INR. then every 6 months until complete regression of the false lumen. and cerebrovascular disease (1). Anticoagulant and/or antiplatelet therapies were continued empirically until follow-up CT scan demonstrated either regression or unchanged diameter of false lumen. Follow-up CT scan showed preservation of distal perfusion with ongoing regression of the false lumen in 5 patients (Fig. There was no mortality or morbidity related to the CA dissection. and clinical symptoms in 7 patients disappeared within 14 days. presence or absence of thrombosis. and the pathogenesis is poorly understood [4. cystic medial necrosis. sudden abdominal pain located in the epigastric region in 3 and acute chest pain in 1. aneurysm formation. The resulting intramural hematoma usually extends distally and can lead to acute stenosis or occlusion. 1) and no interval change in 3. were asymptomatic after successful conservative management. which can weaken the vessel wall [3]. fibromuscular dysplasia. If clinical symptoms persisted or aggravated despite conservative management.: Imaging findings of CA dissection Each patient underwent a thorough clinical examination. trauma. atheroma. respectively. Although it is known that risk factors for arterial dissection include hypertension. distal perfusion insufficiency with visceral ischemia/infarction. was noted in 7 patients: splenic artery in 2 and both splenic and common hepatic arteries in 5.0–3. A raised white blood cell count and the deterioration of liver function were noted in 2 and 3 patients. Immediately after the diagnosis. pregnancy. The patients receiving conservative management were discharged following initial diagnosis upon resolution of symptoms. non-dissected vessel [2]. All had contrast-enhanced dynamic CT scan on admission. and a biological check-up including complete blood count. adjusted to maintain a prothrombin time of 2. and distal perfusion insufficiency was defined as >80% compromise of the true lumen. Arterial dissection occurs when disruption of the intima allows blood to extravasate between layers of the vessel wall. Oh et al. and/or antiplatelet therapy in combination with blood pressure control and close observation. all patients including the one with endovascular stent placement remained asymptomatic. and follow-up laboratory data were normal within 14 days. Discussion Serial contrast-enhanced dynamic CT scan demonstrated that conservative management of the symptomatic spontaneous CA dissection led to preservation of distal perfusion with ongoing regression of false lumen in 5 of 8 patients. 5–32 months). However. There was no dissection-related mortality or morbidity. hypertension (2). Branch vessel involvement . in combination with blood pressure control and close observation. follow-up CT scan was performed immediately or emergent intervention (endovascular treatment or surgery) was proposed. combined with aneurysm formation in 6. 7]. with a mean age of 46 (range 39–57).

B At 6 days’ follow-up. The CA is the first branch of the abdominal aorta. pain of sudden onset [8. Conventional angiography has long been considered the gold standard for diagnosing arterial dissection. the contrast-enhanced dynamic CT scan has been shown to be an accurate and less invasive alternative to angiography for the diagnosis and follow-up serial images of arterial dissection [8. After passing almost horizontally forward 1/2 inch. Oh et al. As the resolution of CT scanners has improved. are initially painful for hours to days. However. Serial axial reconstructed contrast-enhanced computed tomography images of a 39-year-old man with symptomatic spontaneous celiac artery (CA) dissection. but it is invasive and associated with possible complications [8. 13]. as a consequence of the artery separation itself [4]. A Initial images show dissection (arrows) of the CA and the common hepatic artery with preservation of the hepatic arterial flow (curved arrows). 10. Spontaneous CA dissections. 1. it trifurcates into the left gastric. contrast-enhanced dynamic CT scan has become one of the most useful diagnostic modalities for assessing the visceral artery dissections.S. and the natural history of this process is difficult to predict. In this study. and provides details concerning the course of the dissection and its extension into smaller branches of the arterial tree [8–12]. it is short. about 1/2 inch long. this patient presents with deterioration of liver function and images show progression of the dissection (arrows) to the distal common hepatic artery and the splenic artery with nearly complete occlusion of the common hepatic artery (curved arrow). D At 1 year’s follow-up. 10].: Imaging findings of CA dissection 81 Fig. various clinical presentations may occur according to extent of dissection and involvement of branch vessels. C At 1 month’s follow-up. In the reported literature. CT scan also allows for follow-up comparisons and measurements of the extent of the disease [10]. images show normalization of the common hepatic artery (curved arrows) with residual dissection in the splenic artery (arrow). Dissection is a dynamic process. Acute signs . The most common clinical manifestation was acute left flank pain in four patients. the splenic and the hepatic arteries [25]. images show disappearance of the dissection with improved arterial flow in the common hepatic artery (curved arrows). involvement of branch vessels was noted in 7 of 8 patients: splenic artery in 2 and both splenic and common hepatic arteries in 5. presenting with splenic infarction related to the splenic artery dissection on contrastenhanced dynamic CT scan. like trauma-related dissections. Note the improved but residual dissection in the CA (arrow). 9]. because of its unique anatomic characteristics. and thick.

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