Shenouda M, Riga C, Naji Y, Renton S

KSS Core Surgery Prize DayFriday 4th January 2013

Mrs X, 85 y/oPC – acute onset epigastric pain

Sharp, associated with nausea, vomiting, sweating.No haematemesis/melaena; no neck/chest painNo previous episodes

PMHx – 2 previous visceral aneurysm repairs (15y previously), HTN, recent NSTEMI

FHx – IHDSHx – lives alone, independent, active, ex-smoker (50-

pack years – stopped 6/12 previously)

O/EAlert, orientated, GCS 15/15Stable vital signs: Temp 35.8, HR 52, BP 132/53, RR 18, SaO2 96% O/APale, clammy, otherwise normal CVS/resp ex

Abdo: midline scar; severe epigastric/central tenderness with guarding. No pulsatile masses, absent bowel sounds

Peripheral vasc:No signs of acute ischaemiaAll pulses presentNo radio-radial or radio-femoral delayCRT <2 sec in all four limbs

Neurology intact

Basic IxUrine NAD, ECG - SR

Bloods – Hb 9.2, WCC 16.2, Plt 183, Clot NAD, CRP <5 Cr 81, Ur 7.4, Na 141, K 4.7, Trop 0.13

Clotting, LFTs NAD

Urgent CT Angio….

CTA11 mm aneurysm arising from a branch of the gastroduodenal

artery is seen with surrounding haematoma, suspicious for rupture.

Difficult anatomy is seen with common trunk for the celiac and SMA, and a 10mm aneurysm in SMA trunk.

Multiple other aneurysms – 25mm splenic artery aneurysm, 14mm aneurysm at the origin of the IMA.

ManagementCross-matched 6 units, fluid resuscitationUrgent angiogram…

Angiogram & EmbolisationLA, R CFA puncture Selective catheterisation of the celiac axis and then GDA

cannulated. The aneurysm was identified. Embolisation with several microcoils proximal and distal to the aneurysm in the GDA; complete cessation of flow within the aneurysm.

Findings in keeping with CTA – multiple visceral aneurysms.

Also noted multiple narrowings and irregularities in the visceral arteries.

SEGMENTAL ARTERIAL MEDIOLYSIS

SEGMENTAL ARTERIAL MEDIOLYSIS

1976 – Slavin RE, Gonzalez-Vitale JC. Segmental mediolytic

arteritis. A clinical pathologic study. Lab Interv 1976;35:23–91.

Described 3 autopsy cases partial or total mediolysis arterial gaps dissecting

aneurysms rupture massive haemorrhage

85 cases in literatureAbdominal visceral arteries, intracranial arteriesAetiology unknown

SEGMENTAL ARTERIAL MEDIOLYSIS

Presentation – intra-abdominal/intracranial haemorrhageasymptomatic on routine investigationspost-mortem

Diagnosis – radiological – arterial dilatation, single/multiple aneurysms,

stenoses/occlusion, dissectionhistological – surgical resection, post-mortem

Literature review, 1976-201262 studies, 85 cases69% confirmed histologically (24% on autopsy)M:F – 1.5:1Age range 0-91 (median 57)21% had history of hypertension13% mortality before further investigation/managementOverall mortality 25%Management – open vs endovascular

SEGMENTAL ARTERIAL MEDIOLYSIS

SummarySAM is a rare diagnosis of unknown aetiology

May be asymptomatic or present with massive haemorrhage

Treatment usually restricted to symptomatic cases

Endovascular embolisation can prevent the need for major surgeryCan also be a temporary measure before definite surgery at a

later stage

ReferencesSlavin, RE. Gonzalez-Vitale, JC. Segmental mediolytic

arteritis: a clinical pathologic study. Lab Invest 1976; 35:23–29.

Michael, M. Widmer, U. Wildermuth, et al. Segmental arterial mediolysis: CTA findings at presentation and follow-up. AJR Am J Roentgenol 2006; 187:1463-9

Tameo, MN. Dougherty, MJ. Calligaro, KD. Spontaneous dissection with rupture of the superior mesenteric artery from segmental arterial mediolysis. J Vasc Surg 2011;53:1107-12.