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Spontaneous celiac artery dissection: a rare vascular cause of abdominal pain An otherwise well 61-year-old Caucasian man presented to the emergency department with a 24-h history of sudden and worsening epigastric pain radiating to the back. There was associated nausea. He was not on long-term anticoagulants or steroids, but had used an oral non-steroidal anti-inflammatory analgesic following the onset of pain. He was an ex-smoker with a five pack-year history. On examination, he had a non-peritonitic abdomen, but was tender in the epigastrium. Full blood count, biochemistry and liver enzymes were all unremarkable on blood testing, as were serial troponins and serum amylase. His C-reactive protein was mildly elevated at 16 g/L (normal range 0–5 g/L) and anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies (ANA/ANCA) titres were negative. There were no abnormalities on abdominal ultrasonography or erect chest X-ray and an upper gastrointestinal endoscopy was also unremarkable. Abdominal computed tomography (CT) showed wall thickening involving the celiac trunk, with a dissection flap and pseudoaneurysm projecting superiorly. There was no underlying abnormality of the aorta. The wall thickening extended along the hepatic artery but spared the left gastric and splenic arteries and resulted in approximately 50% reduction in vessel diameter over a length of 17 mm prior to the division of the hepatic and splenic artery (Fig. 1). The patient was commenced on low dose aspirin (100 mg once daily) and his pain was satisfactorily managed with simple, nonopioid analgesia. Repeat CT angiography of the abdomen was repeated at day 7, which showed stable appearances of the celiac
Fig. 1. Computed tomography angiogram showing dissection flap in the celiac artery.
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artery dissection (Figs 2,3). His pain had markedly improved and he was therefore discharged home. A repeat CT angiogram at 6 weeks showed an interval improvement in the appearance of the celiac trunk. He was scheduled for review in vascular clinic. Isolated celiac artery dissection is defined by intramural haematoma separating the layers of the arterial wall, specifically in the
Fig. 2. Stable appearance of celiac artery dissection on computed tomography angiogram at day 7.
Fig. 3. Three-dimensional reconstruction of celiac trunk from computed tomography angiogram on day 7.
ANZ J Surg •• (2015) ••–••
absence concomitant abdominal aortic dissection. It is a rare phenomenon, with only 34 cases reported between 1958 and 2012.1,2 Over half the cases reported in the literature have been published in the last decade, which may reflect the more routine use of CT scanning in the investigation of the acute abdomen.2 The typical patient is middle-aged and male, often with a smoking history but lacking the vascular risk factors disposing to dissection of other major arteries.3,5 The most common presentation is epigastric pain, often in isolation.6 The pathognomic feature on contrast-enhanced CT is the intimal flap within the celiac artery.3 This may be accompanied by non-specific inflammatory change in the surrounding fat, although it is important to recognize that this infiltration does not necessarily indicate an inflammatory or infective aetiology.3 Extension of the dissection to involve hepatic, splenic or renal arteries may also be present, with or without evidence of end-organ ischaemia. This may influence the decision to opt for surgical intervention and additional imaging of the surrounding vasculature with conventional or magnetic resonance angiography may be indicated for preoperative planning.3,7 The natural history of celiac artery dissection is poorly understood, with a broad spectrum of outcomes ranging from spontaneous resolution to aneurysm formation and rupture reported.1 As a consequence, the optimal management and follow-up surveillance remain uncertain. Surgical intervention may be mandated by major complications, such as splenic infarction, haemorrhage secondary to rupture or intestinal ischaemia.1,3,7 Surgical repair has also been recommended in occlusive lesions, aneurysm formation or extension of the dissection into the hepatic arteries.7 Endovascular stenting of the celiac artery has been successful in uncomplicated but symptomatic patients.2 However, there is no definite consensus on the superiority of open versus endovascular treatment and ultimately the decision is based on the clinical presentation and local vascular expertise. Recent case reports of stable, uncomplicated isolated celiac artery dissection support a conservative management approach using antiplatelet agents and strict blood pressure control.3–9 Empirical use of anticoagulants to limit thromboembolic complications is frequently advocated, although this may be unnecessary as intestinal perfusion is often adequately maintained by the superior mesenteric arterial collateral supply, even in the presence of complete celiac occlusion.10 Furthermore, long-term anticoagulation in these patients has no proven benefit.2 The duration of inpatient observation is subject to debate, but average hospital stay in the largest case series of conservative management was 7 days.3
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Similarly, there is little precedent for the optimal follow-up regime on discharge, and although an interval CT scan is typically performed within 6 months, there are no reports that this alters subsequent management.1,2,3,5,6,8 As the natural history of the condition becomes better understood in the future, it may be that the necessity of ongoing follow-up becomes redundant.
References 1. Nordanstig J, Gerdes H, Kocys E. Spontaneous isolated dissection of the coeliac trunk with rupture of the proximal splenic artery: a case report. Eur. J. Vasc. Endovasc. Surg. 2009; 37: 194–7. 2. Obon-Dent M, Shabaneh B, Doughery KG, Strickman NE. Spontaneous celiac artery dissection. Case report and literature review. Tex. Heart Inst. J. 2012; 39: 703–6. 3. D’Ambrosio N, Friedman B, Siegel D, Katz D, Newatia A, Hines J. Spontaneous isolated dissection of the coeliac artery: CT findings in adults. AJR Am. J. Roentgenol. 2007; 188: 506–11. 4. Vaidya S, Dighe M. Spontaneous celiac artery dissection and its management. J. Radiol. Case Rep. 2010; 4: 30–3. 5. Ozturk TC, Yaylaci S, Yesil O, Cevik SE, Guneysel O. Spontaneous isolated celiac artery dissection. J. Res. Med. Sci. 2011; 16: 699–702. 6. Woodard J, Ammar A. Spontaneous dissection of the celiac artery: a case report. J. Vasc. Surg. 2007; 45: 1256–8. 7. Glehen O, Feugier P, Aleksic Y, Delannoy P, Chevalier JM. Spontaneous dissection of the celiac artery. Ann. Vasc. Surg. 2001; 15: 687–92. 8. Oh S, Cho YP, Kim JH, Shin S, Kwon TW, Ko GY. Symptomatic spontaneous celiac artery dissection treated by conservative management: serial imaging findings. Abdom. Imaging 2011; 36: 79–82. 9. Polylin V, Hile C, Campbell D. Medical management of spontaneous celiac artery dissection: case report and literature review. Vasc. Endovascular Surg. 2008; 42: 62–4. 10. Takayama Y, Takao M, Inoue T, Yoshimi F, Koyama K, Nagai H. Isolated spontaneous dissection of the celiac artery: report of two cases. Ann. Vasc. Dis. 2014; 7: 64–7.
Rachel Falconer,* MBChB, BMedSci Greg S. McMahon,* MBChB, MD, FRCS (Eng) Martin Krauss,† Tim Beresford,* MBBS, FRCS (Eng) *Department of Vascular, Endovascular and Transplant Surgery, Christchurch Public Hospital, Christchurch, New Zealand and †Department of Diagnostic and Interventional Radiology, Christchurch Public Hospital, Christchurch, New Zealand doi: 10.1111/ans.13204
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