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• W1997051314 abstract "This report describes a 43-year-old man with a history of acute abdominal pain with shock. Emergency intervention was decided. No evidence of active bleeding was found. A contrast-enhanced computed tomography scan after the intervention revealed a celiac artery dissection with an intimal flap, with associated aneurysmal dilation. The patient was referred to our institution for endovascular management by upstream and downstream occlusion. Coils and detachable vascular plugs were successfully deployed to occlude the aneurysm. Vascular plugs are easy to use, reduce costs, and shorten the duration of the procedure. A contrast-enhanced computed tomography scan at 9 months showed complete occlusion of the aneurysm. This report describes a 43-year-old man with a history of acute abdominal pain with shock. Emergency intervention was decided. No evidence of active bleeding was found. A contrast-enhanced computed tomography scan after the intervention revealed a celiac artery dissection with an intimal flap, with associated aneurysmal dilation. The patient was referred to our institution for endovascular management by upstream and downstream occlusion. Coils and detachable vascular plugs were successfully deployed to occlude the aneurysm. Vascular plugs are easy to use, reduce costs, and shorten the duration of the procedure. A contrast-enhanced computed tomography scan at 9 months showed complete occlusion of the aneurysm. Isolated spontaneous splanchnic dissection is a rare condition most commonly associated with the superior mesenteric artery (SMA). It is only rarely seen with the celiac artery.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar The etiology and natural history of these lesions are ill-defined, and treatment options remain a subject of debate. This case report describes a celiac artery dissection with associated aneurysmal dilation, revealed by intra-abdominal hemorrhage, which was successfully managed by endovascular intervention. A 43-year-old man presented in December 2009 with acute upper abdominal pain and shock. He had no significant medical history. The patient was referred emergently to a general hospital. Owing to his hemodynamic instability, an emergency intervention was performed. A hematoma was evacuated, but no evidence of active bleeding was found. A transfusion of 3 units of packed red blood cells was required. A computed tomography (CT) angiography in the early arterial phase after the intervention revealed a normal aorta. However, maximal intensity projection images demonstrated a 2.3-cm isolated spindle-shaped aneurysm with an intimal flap. A 3-dimensional (3D) virtual reconstruction showed that the extension of the aneurysm was proximal to the common hepatic and splenic arteries. The 2D axial view demonstrated the extensive wall dissection extending to the ostium of the common hepatic artery. The remainder of the hepatic artery presented wall irregularities. Infiltration of the fat surrounding the celiac artery was observed (Fig 1). No other aneurysm and no other cause of the intra-abdominal hemorrhage was visible on the CT scan. Extensive evaluation revealed no serologic evidence of vasculitis or an inflammatory disorder. The patient was referred to our institution for endovascular management of the dissecting celiac artery aneurysm (CAA) in March 2010. In the angiographic suite with intravenous sedation, the celiac artery was catheterized with a 5F Cobra Super Torque catheter (Cordis, Bridgewater, NJ). The lateral view did not reveal any celiac compression. Angiography confirmed a celiac artery dissection with aneurysmal dilation (Fig 2, A). The left gastric and splenic arteries originating from the celiac artery were normal. Selective SMA injection revealed opacification of the hepatic artery via the pancreaticoduodenal arcade. Hemodynamic stenosis of the common hepatic artery related to the dissection was a significant finding (Fig 2, B). An 8F, 45-cm-long sheath (Cook Medical Inc, Australia Pty, Ltd, Brisbane, QLD, Australia) was positioned through the celiac artery, and a 0.21-inch Progreat microcatheter (Terumo, Tokyo, Japan) was introduced superselectively into the left gastric artery. Three 6-mm-diameter conventional platinum-fiber coils (Cook Medical) were next advanced into the gastric artery, successfully occluding the vessel (Fig 3, A). Two 10-mm Amplatzer Vascular Plugs (AVP) II (AGA Medical, Golden Valley, Minn) were placed proximally in the splenic and the hepatic arteries (Fig 3, B) and one 14-mm AVP II was positioned proximally in the ostium of the celiac artery. The diameter of the AVP IIs was approximately 30% to 50% larger than that of the artery. Vessel occlusion was confirmed angiographically. The patient's postoperative course was uneventful, and no increase was noted in the serum transaminase level. The patient was discharged 2 days later. A contrast-enhanced CT-scan at 9 months showed complete exclusion and thrombosis of the CAA. Isolated spontaneous dissections (SDs) of the peripheral arteries, without involvement of the aorta, are rare. These lesions concern, in order of decreasing frequency, the renal arteries, the coronary arteries, the carotid arteries, and the splanchnic arteries.3Guthrie W. Maclean H. Dissecting aneurysms of arteries other than the aorta.J Pathol. 1972; 108: 219-235Crossref PubMed Scopus (87) Google Scholar SDs of the celiac artery are the least common of all splanchnic artery dissections.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar From 1975 to 2008, 74 SDs of the SMA were described1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar vs only 31 SDs of the celiac artery. In a review of the literature, 40 cases of SDs of the celiac artery (including 31 cases of Takach1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar) were described.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 4Bartoli J.M. Moulin G. Di Stefano D. Rudondy P. Gerolami A. Kasbarian M. et al.Isolated dissection of the celiac trunk and its branches X-ray computed tomography and angiography findings. A case report.Ann Radiol (Paris). 1990; 33: 264-266PubMed Google Scholar, 5Takeda H. Matsunaga N. Sakamoto I. Obata S. Nakamura S. Hayashi K. et al.Spontaneous dissection of the celiac and hepatic arteries treated by transcatheter embolization.AJR Am J Roentgenol. 1995; 165: 1288-1289Crossref PubMed Scopus (40) Google Scholar, 6Chaillou P. Moussu P. Noel S.F. Sagan C. Pistorius M.A. Langhard J.M. et al.Spontaneous dissection of the celiac artery.Ann Vasc Chir. 1997; 11: 413-415Abstract Full Text PDF PubMed Scopus (52) Google Scholar, 7Matsuo R. Ohta Y. Ohya Y. Kitazono T. Irie H. Shikata T. et al.Isolated dissection of the celiac artery–a case report.Angiology. 2000; 51: 603-607Crossref PubMed Scopus (48) Google Scholar, 8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar, 9Fenoglio L. Allione A. Scalabrino E. Alberto G. Benedetti V. Pomero F. et al.Spontaneous dissection of the celiac artery: a pitfall in the diagnosis of acute abdominal pain Presentation of two cases.Dig Dis Sci. 2004; 49: 1223-1227Crossref PubMed Scopus (50) Google Scholar, 10Hirakawa E. Inada K. Tsuji K. Asymptomatic dissecting aneurysm of the celiac artery: a variant of segmental arterial mediolysis.Histopathology. 2005; 47: 534-548Crossref PubMed Scopus (11) Google Scholar, 11Batsis J.A. Arora A.S. Celiac artery dissection: an uncommon cause of abdominal pain and weight loss.Clin Gastroenterol Hepatol. 2005; 3: 113-115Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 12Mc Guinness B. Kennedy S. Holden A. Spontaneous celiac artery dissection.Austral Radiol. 2006; 50: 400-401Crossref PubMed Scopus (21) Google Scholar, 13Woolard J.D. Ammar A.D. Spontaneous dissection of the celiac artery: A case report.J Vasc Surg. 2007; 45: 1256-1258Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 14D'Ambrosio N. Friedman B. Siegel D. Katz D. Newatia A. Hines J. et al.Spontaneous isolated dissection of the celiac artery: CT findings in adults.AJR Am J Roentgenol. 2007; 188: W506-W511Crossref PubMed Scopus (79) Google Scholar, 15Poylin V. Hile C. Campbell D. Medical management of spontaneous celiac artery dissection: case report and literature review.Vasc Endovasc Surg. 2008; 42: 62-64Crossref PubMed Scopus (29) Google Scholar However, the incidence of these last lesions is probably underestimated. Most of the patients described were symptomatic, yet asymptomatic forms are probably more frequent and remain undetected.2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar Risk factors for SD include atherosclerotic disease, hypertension, fibromuscular dysplasia, cystic medial necrosis, trauma, pregnancy, and connective tissue disorders.14D'Ambrosio N. Friedman B. Siegel D. Katz D. Newatia A. Hines J. et al.Spontaneous isolated dissection of the celiac artery: CT findings in adults.AJR Am J Roentgenol. 2007; 188: W506-W511Crossref PubMed Scopus (79) Google Scholar The etiology in our patient was unclear, and none of these risk factors was found. Expansion of a false lumen may cause malperfusion secondary to mechanical compression of true lumen flow, aneurysmal dilation, or rupture. Similarly, celiac artery SD may be revealed by abdominal pain or a typical picture of intestinal angina.6Chaillou P. Moussu P. Noel S.F. Sagan C. Pistorius M.A. Langhard J.M. et al.Spontaneous dissection of the celiac artery.Ann Vasc Chir. 1997; 11: 413-415Abstract Full Text PDF PubMed Scopus (52) Google Scholar Roh and LeSher16Roh L.S. LeSher A. Dissecting aneurysm of the hepatic artery.Am J Forensic Med Pathol. 1989; 10: 67-70Crossref PubMed Scopus (14) Google Scholar reported a rupture that resulted in the death of the patient before any intervention. Our patient was fortunate. He not only survived the CAA rupture, but there was no recurrence of rupture during the 3 months that preceded CAA embolization. Abdominal ultrasound imaging is very useful for evaluation and the follow-up,8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar, 17Tulsyan N. Kashyap V.S. Greenberg R.K. Sarac T.P. Clair D.G. Pierce G. et al.The endovascular management of visceral artery aneurysms and pseudoaneurysms.J Vasc Surg. 2007; 45: 276-283Abstract Full Text Full Text PDF PubMed Scopus (447) Google Scholar, 18Stone W.M. Abbas M.A. Gloviczki P. Fowl R.J. Cherry K.J. Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar but contrast-enhanced CT imaging is the best diagnostic and follow-up modality because of its convenience, rapidity, low invasiveness, and reliability.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar Identification of an intimal flap is diagnostic (Fig 1). D'Ambrosio et al14D'Ambrosio N. Friedman B. Siegel D. Katz D. Newatia A. Hines J. et al.Spontaneous isolated dissection of the celiac artery: CT findings in adults.AJR Am J Roentgenol. 2007; 188: W506-W511Crossref PubMed Scopus (79) Google Scholar described another CT finding, some of which was noted in our patient: CAA and nonspecific inflammatory infiltration of the fat surrounding the celiac artery. Selective arteriography of the celiac artery and SMA is usually performed for pretreatment evaluation (Fig 2, A). Extension of the dissection into the proximal hepatic artery caused hepatic malperfusion and opacification of the distal hepatic artery from the SMA via the pancreaticoduodenal arcade (Fig 2, B). This finding is consistent with a dissection in the celiac artery causing stenosis of the proximal common hepatic artery. Although no optimum treatment for SD of the celiac artery has yet been established,1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar surveillance or surgical or endovascular repair may be indicated, depending on the clinical features.8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar For some authors, patients with asymptomatic lesions are candidates for imaging surveillance.2Takayama T. Miyata T. Shirakawa M. Nagawa H. Isolated spontaneous dissection of the splanchnic arteries.J Vasc Surg. 2008; 48: 329-333Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 8Glehen O. Feugier P. Aleksic Y. Delannoy P. Chevalier J.M. Dissection spontanée du tronc coeliaque.Ann Chir Vasc. 2001; 15: 682-692Abstract Full Text PDF Scopus (79) Google Scholar, 13Woolard J.D. Ammar A.D. Spontaneous dissection of the celiac artery: A case report.J Vasc Surg. 2007; 45: 1256-1258Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 14D'Ambrosio N. Friedman B. Siegel D. Katz D. Newatia A. Hines J. et al.Spontaneous isolated dissection of the celiac artery: CT findings in adults.AJR Am J Roentgenol. 2007; 188: W506-W511Crossref PubMed Scopus (79) Google Scholar In contrast, complicated dissection with persistent pain, expansion of a false lumen, or aneurysmal dilation and rupture, as in our report, warrant immediate operative1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 6Chaillou P. Moussu P. Noel S.F. Sagan C. Pistorius M.A. Langhard J.M. et al.Spontaneous dissection of the celiac artery.Ann Vasc Chir. 1997; 11: 413-415Abstract Full Text PDF PubMed Scopus (52) Google Scholar or endovascular intervention.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 5Takeda H. Matsunaga N. Sakamoto I. Obata S. Nakamura S. Hayashi K. et al.Spontaneous dissection of the celiac and hepatic arteries treated by transcatheter embolization.AJR Am J Roentgenol. 1995; 165: 1288-1289Crossref PubMed Scopus (40) Google Scholar Endovascular techniques are currently considered the method of choice for first-line treatment of CAAs of ≥2 cm in diameter to prevent rupture.1Takach T.J. Madjarov J.M. Holleman J.H. Robicsek F. Roush T.S. Spontaneous splanchnic dissection: application and timing of therapeutic options.J Vasc Surg. 2009; 50: 557-563Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 17Tulsyan N. Kashyap V.S. Greenberg R.K. Sarac T.P. Clair D.G. Pierce G. et al.The endovascular management of visceral artery aneurysms and pseudoaneurysms.J Vasc Surg. 2007; 45: 276-283Abstract Full Text Full Text PDF PubMed Scopus (447) Google Scholar, 18Stone W.M. Abbas M.A. Gloviczki P. Fowl R.J. Cherry K.J. Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar, 19Atkins B.Z. Ryan M.J. Gray J.L. Treatment of a celiac artery aneurysm with endovascular stent grafting.Vascul Surg. 2003; 37: 367-373Crossref Scopus (37) Google Scholar, 20Sessa C. Tinelli G. Porcu P. Aubert A. Thony F. Magne J.L. et al.Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients.Ann Vasc Surg. 2004; 18: 695-703Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar In the literature, the 2-cm threshold appears quite arbitrary. However, in the Mayo Clinic series of 18 CAAs, ruptures occurred in 2 patients, both of whom had CAAs >2 cm.18Stone W.M. Abbas M.A. Gloviczki P. Fowl R.J. Cherry K.J. Celiac arterial aneurysms: a critical reappraisal of a rare entity.Arch Surg. 2002; 137: 670-674Crossref PubMed Google Scholar Endovascular management has numerous potential advantages: the intervention is possible with local anesthesia, collateral circulation is easily assessed with selective splanchnic arteriography during the procedure, fewer postoperative complications occur, and hospital stays are shorter. Good patient selection is crucial for the technical success and safety of this procedure. A contraindication would be the presence of a stenotic or occluded SMA or gastroduodenal artery. Patency of theses arteries is necessary to provide collateral flow to the pancreas, liver, and spleen. The configuration of the CAA is also important: a wide neck would not be amenable to this technique because the coils could not be anchored.20Sessa C. Tinelli G. Porcu P. Aubert A. Thony F. Magne J.L. et al.Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients.Ann Vasc Surg. 2004; 18: 695-703Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar However, a recent report documented use of stent graft to treat a true CAA with a wide neck.19Atkins B.Z. Ryan M.J. Gray J.L. Treatment of a celiac artery aneurysm with endovascular stent grafting.Vascul Surg. 2003; 37: 367-373Crossref Scopus (37) Google Scholar Takeda et al5Takeda H. Matsunaga N. Sakamoto I. Obata S. Nakamura S. Hayashi K. et al.Spontaneous dissection of the celiac and hepatic arteries treated by transcatheter embolization.AJR Am J Roentgenol. 1995; 165: 1288-1289Crossref PubMed Scopus (40) Google Scholar was the first to treat SD of the celiac and hepatic arteries by transcatheter embolization, as in our patient. The trapping technique consists of upstream and downstream occlusion, equivalent to exclusion by ligature. In our patient, coils and detachable vascular plugs were associated in the large splenic artery to avoid coil migration and splenic infarction. Vascular plugs are easy to use, reduce costs, and shorten the duration of the procedure. One of the major problems after coil embolization is the occurrence of recanalization, which occurs with an incidence of 8% to 50%.20Sessa C. Tinelli G. Porcu P. Aubert A. Thony F. Magne J.L. et al.Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients.Ann Vasc Surg. 2004; 18: 695-703Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar Like Gabelman et al,21Gabelman A. Gorich J. Merkle E.M. Endovascular treatment of visceral artery aneurysms.J Endovasc Ther. 2002; 9: 38-47Crossref PubMed Scopus (202) Google Scholar we believe that an extensive embolization is preferable to prevent recanalization. Celiac artery dissection with aneurysmal dilation can be successfully managed by percutaneous embolization techniques that appear to provide durable results. Follow-up imaging is necessary to ensure continued aneurysm exclusion." @default.
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• W1997051314 title "Successful percutaneous embolization of a symptomatic celiac artery dissection with aneurysmal dilation with detachable vascular plugs" @default.
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