Symptomatic spontaneous celiac arterydissection treated by conservativemanagement: serial imaging findings

Seonok Oh,1 Yong-Pil Cho,1 Ji-Hoon Kim,1 Sung Shin,1 Tae-Won Kwon,1 Gi-Young Ko2

1Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan Medical College,

Asanbyeongwon-gil 86, Songpa-gu, Seoul 138-736, Korea2Department of Radiology, Asan Medical Center, University of Ulsan Medical College, Seoul, Korea

Abstract

Background: The aim of this study was to evaluate thecorrelation of clinical characteristics with serial imagingfindings of symptomatic spontaneous celiac artery dis-section treated by conservative management.Methods: Eight consecutive, hemodynamically stablepatients with symptomatic spontaneous celiac artery dis-section without associated aortic dissection that receivednon-operative treatments were included in this study. Theirclinical characteristics, treatment methods, serial imagingfindings and outcomes were analyzed retrospectively.Results: Acute left flank pain related to splenic infarctionwas the most common clinical manifestation. Initialcontrast-enhanced dynamic computed tomography scanshowed celiac artery dissection with partial thrombosis inall eight patients and involvement of branch vessels in 7.Full anticoagulation was carried out immediately after thediagnosis in seven patients. All patients, except one withendovascular stent placement, were asymptomatic aftersuccessful conservative management and follow-up com-puted tomography scan showed preservation of distalperfusion with ongoing regression of false lumen in fivepatients. After a mean follow-up of 16 months, there wasno mortality or morbidity related to the dissection.Conclusions: Serial imaging findings showed that conser-vative management of celiac artery dissection can beperformed successfully in selective patients with stablehemodynamics.

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

Although spontaneous dissection of a visceral arterywithout associated aortic dissection has recently beenreported more frequently due to advancements in diag-nostic imaging technology, it still occurs infrequently.Most of the reported cases have been associated withthe superior mesenteric artery (SMA), and symptomaticspontaneous dissection of the celiac artery (CA) isextremely rare [1–23]. Because of its rarity, the risk fac-tors, etiology, and natural history of this problem are illdefined and, additionally, there is no consensus on theoptimal treatment strategy. Selective cases have beenknown to undergo spontaneous resolution with throm-bosis of the false lumen and preservation of distal flow.However, other cases have been associated with bothsubstantial mortality and morbidity [1–23].

The aim of this study was to evaluate the correlationof clinical characteristics with serial imaging findings ofsymptomatic spontaneous CA dissection treated byconservative management and whether this managementmodality can be performed successfully in selectivepatients with stable hemodynamics.

Materials and methods

This is a retrospective study of medical records, withapproval of Institutional Review Board. The diagnosis ofthe CA dissection was confirmed by contrast-enhanceddynamic computed tomography (CT) scan. Asymptom-atic CA dissections, complicated dissections with suspi-cion of rupture, and those associated with aorticdissection, trauma, or vasculitis were excluded in thisstudy. We examined eight consecutive, hemodynamicallystable patients who had symptomatic spontaneous dis-section of the CA treated non-operatively from January2008 to April 2010 to investigate the clinical character-istics, treatment methods, follow-up contrast-enhancedCT imaging findings and outcomes.Correspondence to: Yong-Pil Cho; email: ypcho@amc.seoul.kr

ª Springer Science+Business Media, LLC 2010

Published online: 28 October 2010AbdominalImaging

Abdom Imaging (2011) 36:79–82

DOI: 10.1007/s00261-010-9657-x

Each patient underwent a thorough clinical exami-nation, contrast-enhanced CT scan, and a biologicalcheck-up including complete blood count, hepatic andpancreatic tests, and creatinine and lactate levels. Thedissections were characterized by initial CT scan: vesselof origin, presence or absence of thrombosis, aneurysmformation, distal perfusion insufficiency with visceralischemia/infarction, and branch vessel involvement.Aneurysm formation was defined as >50% dilatation ofthe CA lumen compared with the normal caliber of theCA for each patient as measured by CT scan [1]. Thepercentage of true lumen compression by the false lumenwas calculated from the CT scan, and distal perfusioninsufficiency was defined as >80% compromise of thetrue lumen, comparing the smallest true lumen diameterwith a reference diameter of contiguous, parallel,non-dissected vessel [2].

Non-operative managements include anticoagulantswith a regimen of heparin and later, orally administeredwarfarin, adjusted to maintain a prothrombin time of2.0–3.0 INR, and/or antiplatelet therapy in combinationwith blood pressure control and close observation. Thepatients receiving conservative management were dis-charged following initial diagnosis upon resolution ofsymptoms. If clinical symptoms persisted or aggravateddespite conservative management, follow-up CT scan wasperformed immediately or emergent intervention (endo-vascular treatment or surgery) was proposed. In caseswith hemodynamic and clinical stability, follow-up CTscan was done within 1 month, then every 6 months untilcomplete regression of the false lumen. Anticoagulantand/or antiplatelet therapies were continued empiricallyuntil follow-up CT scan demonstrated either regression orunchanged diameter of false lumen.

Results

The eight consecutive patients with symptomatic spon-taneous CA dissection that received initial treatmentsconservatively were all males, with a mean age of 46(range 39–57). Risk factors included smoking (4 patients),hypertension (2), hyperlipidemia (2), and cerebrovasculardisease (1). None of these patients had collagen disease.

Acute left flank pain was the most common clinicalmanifestation, noted in 4 of 8 patients, sudden abdomi-nal pain located in the epigastric region in 3 and acutechest pain in 1. The mean interval from the onset ofsymptoms to the initial diagnosis was 7 days (range1–30). A raised white blood cell count and the deterio-ration of liver function were noted in 2 and 3 patients,respectively. All had contrast-enhanced dynamic CTscan on admission, at which CA dissection with partialthrombosis was seen in all 8 patients, combined withaneurysm formation in 6, distal perfusion insufficiency in4, and splenic infarction in 4. Three patients also had aconcomitant SMA dissection. Branch vessel involvement

was noted in 7 patients: splenic artery in 2 and bothsplenic and common hepatic arteries in 5.

Immediately after the diagnosis, full anticoagulation,with heparin followed by warfarin, in combination withblood pressure control and close observation, was carriedout in 7 patients and antiplatelet therapy in 1. Failure ofconservative management occurred in one patient withworsening symptoms 3 days after initial managementwith anticoagulation who received endovascular stentplacement. All patients, except the one with endovascularstent placement, were asymptomatic after successfulconservative management, and follow-up laboratory datawere normal within 14 days. Follow-up CT scan showedpreservation of distal perfusion with ongoing regressionof the false lumen in 5 patients (Fig. 1) and no intervalchange in 3. Upon complete follow-up (mean 16 months;range, 5–32 months), all patients including the one withendovascular stent placement remained asymptomatic.There was no mortality or morbidity related to the CAdissection.

Discussion

Serial contrast-enhanced dynamic CT scan demonstratedthat conservative management of the symptomaticspontaneous CA dissection led to preservation of distalperfusion with ongoing regression of false lumen in 5 of 8patients, and clinical symptoms in 7 patients disappearedwithin 14 days. There was no dissection-related mortalityor morbidity.

Arterial dissection occurs when disruption of the in-tima allows blood to extravasate between layers of thevessel wall. The resulting intramural hematoma usuallyextends distally and can lead to acute stenosis or occlusion,and later to aneurysm formationwith an increased risk forthromboembolic events. Although it is known that riskfactors for arterial dissection include hypertension, preg-nancy, trauma, atheroma, cystic medial necrosis, fibro-muscular dysplasia, and previous abdominal surgery,which can weaken the vessel wall [3], spontaneous dissec-tions of the artery usually occur free of coexisting vasculardisease, and the pathogenesis is poorly understood [4, 24].

Spontaneous dissections of the visceral artery withoutassociated aortic dissection are extremely rare. In theearly literature, these were diagnosed by autopsy [5].However, increasing reports of visceral artery dissectionshave been published in recent years because ofadvancement in diagnostic imaging technology. Most ofthe reported cases have been associated with the SMA,and reports of the CA are even rarer [1–23]. Approxi-mately one half of the patients with CA dissection areasymptomatic, which in part may be explained by thegood collateral flow via the SMA [6, 7]. This could alsoaccount for the very few reported cases in comparisonwith SMA dissection [7]. The most common presentingsymptom in patients with CA dissection is abdominal

80 S. Oh et al.: Imaging findings of CA dissection

pain of sudden onset [8, 9]. Spontaneous CA dissections,like trauma-related dissections, are initially painful forhours to days, as a consequence of the artery separationitself [4]. However, because of its unique anatomiccharacteristics, various clinical presentations may occuraccording to extent of dissection and involvement ofbranch vessels. The CA is the first branch of theabdominal aorta; it is short, about 1/2 inch long, andthick. After passing almost horizontally forward 1/2inch, it trifurcates into the left gastric, the splenic and thehepatic arteries [25]. In this study, involvement of branchvessels was noted in 7 of 8 patients: splenic artery in 2and both splenic and common hepatic arteries in 5. Themost common clinical manifestation was acute left flankpain in four patients, presenting with splenic infarctionrelated to the splenic artery dissection on contrast-enhanced dynamic CT scan.

Conventional angiography has long been consideredthe gold standard for diagnosing arterial dissection, butit is invasive and associated with possible complications[8, 10]. As the resolution of CT scanners has improved,contrast-enhanced dynamic CT scan has become one ofthe most useful diagnostic modalities for assessing thevisceral artery dissections, and provides details concern-ing the course of the dissection and its extension intosmaller branches of the arterial tree [8–12]. CT scan alsoallows for follow-up comparisons and measurements ofthe extent of the disease [10]. In the reported literature,the contrast-enhanced dynamic CT scan has been shownto be an accurate and less invasive alternative to angi-ography for the diagnosis and follow-up serial images ofarterial dissection [8, 10, 13].

Dissection is a dynamic process, and the naturalhistory of this process is difficult to predict. Acute signs

Fig. 1. Serial axial reconstructed contrast-enhanced com-puted tomography images of a 39-year-old man with symp-tomatic spontaneous celiac artery (CA) dissection. A Initialimages show dissection (arrows) of the CA and the commonhepatic artery with preservation of the hepatic arterial flow(curved arrows). B At 6 days’ follow-up, this patient presentswith deterioration of liver function and images show progres-sion of the dissection (arrows) to the distal common hepatic

artery and the splenic artery with nearly complete occlusion ofthe common hepatic artery (curved arrow). C At 1 month’sfollow-up, images show disappearance of the dissection withimproved arterial flow in the common hepatic artery (curvedarrows). Note the improved but residual dissection in the CA(arrow). D At 1 year’s follow-up, images show normalization ofthe common hepatic artery (curved arrows) with residualdissection in the splenic artery (arrow).

S. Oh et al.: Imaging findings of CA dissection 81

of hemorrhage and liver ischemia are considered poorprognostic features [13]. Although serious complications,including ischemia, aneurysm formation, and rupturehave been reported [13, 14], the literature review and ourown experience suggest that the natural history of thisprocess may not be as dismal as it was once believed[8–10, 15].

The optimal management of CA dissection remainscontroversial because of rarity of this condition and maydepend on hemodynamic status, involved vessels, re-sponse to conservative treatments, and development ofcomplications [3, 5, 9, 15, 16]. Previous reports havedemonstrated that treatment strategy for this conditionincludes conservative medical therapy, endovascular stentplacement, and surgery [6, 9, 17]. Although both endo-vascular techniques and open surgery have been utilizedwith success for patients with complicated dissection, inuncomplicated cases with stable hemodynamics, the lit-erature supports conservative management in combina-tion with close observation [8–10, 15]. The goals ofmedical treatment include blood pressure control tominimize the progression of the dissection and adminis-tration of an anticoagulant immediately after the diag-nosis to induce the healing of the dissection withdissolution of the mural hematoma and to preventthromboembolic complications [10]. There is currently noagreement on the duration of anticoagulation therapy,but it seems appropriate that treatment be continued untilfollow-up CT scan shows resolution or satisfactorily im-proved images.

In this study, involvement of branch vessels was notuncommon in patients with CA dissection on contrast-enhanced dynamic CT scan and all patients showedvarious clinical manifestations related to the involvedbranch vessels. Full anticoagulation was carried outimmediately after the diagnosis in 7 of 8 patients. Allpatients except one with endovascular stent placementwere asymptomatic after successful conservative man-agement, and follow-up CT scan showed preservation ofdistal perfusion without expanding false lumen. Surgicalintervention should be reserved for hemodynamicallyunstable patients and patients with serious complica-tions, on whom conservative management fails to stopprogression of the dissection or symptoms. In stablecases, conservative management coupled with close fol-low-up may be appropriate.

References

1. Gobble RM, Brill ER, Rockman CB, et al. (2009) Endovasculartreatment of spontaneous dissections of the superior mesentericartery. J Vasc Surg 50:1326–1332

2. Takach TJ, Madjarov JM, Holleman JH, et al. (2009) Spontaneoussplanchnic dissection: application and timing of therapeuticoptions. J Vasc Surg 50:557–563

3. Suchak AA, Reich D, Ritchie W (2007) Traumatic isolated dis-section of the celiac artery. AJR Am J Roentgenol 189:W373–W374

4. Cho YP, Ko GY, Kim HK, et al. (2009) Conservative managementof symptomatic spontaneous isolated dissection of the superiormesenteric artery. Br J Surg 96:720–723

5. Nagai T, Torishima R, Uchida A, et al. (2004) Spontaneous dis-section of the superior mesenteric artery in four cases treated withanticoagulation therapy. Intern Med 43:473–478

6. Woolard JD, Ammar AD (2007) Spontaneous dissection of theceliac artery: a case report. J Vasc Surg 45:1256–1258

7. Nordanstig J, Gerdes H, Kocys E (2009) Spontaneous isolateddissection of the celiac trunk with rupture of the proximal splenicartery: a case report. Eur J Vasc Surg 37:194–197

8. Wang J-L, Hsieh M-J, Lee C-H, et al. (2010) Celiac artery dissec-tion presenting with abdominal and chest pain. Am J Emerg Med28:111.e3–111.e5

9. Ozaki N, Wakita N, Yamada A, et al. (2010) Spontaneous dis-section of the splanchnic arteries. Interact CardioVasc Thorac Surg10:656–658

10. Polylin V, Hile C, Cambell D (2008) Medical management ofspontaneous celiac artery dissection: case report and literature re-view. Vasc Endovascular Surg 42:62–64

11. Hyodoh H, Hyodoh K, Takahashi K, et al. (1996) Three-dimen-sional CT imaging of an isolated dissecting aneurysm of the supe-rior mesenteric artery. Abdom Imaging 21:515–516

12. Subhas G, Gupta A, Nawalany M, et al. (2009) Spontaneous iso-lated superior mesenteric artery dissection: a case report and liter-ature review with management algorithm. Ann Vasc Surg 23:788–798

13. Glehen O, Feugier P, Aleksic Y, et al. (2001) Spontaneous dissec-tion of the celiac artery. Ann Vasc Surg 15:687–692

14. Batsis JA, Arora AS (2005) Celiac artery dissection: an uncommoncause of abdominal pain and weight loss. Clin GastroenterolHepatol 3:30

15. Zhang WW, Killeen JD, Chiriano J, et al. (2009) Management ofsymptomatic spontaneous isolated visceral artery dissection: isemergent intervention mandatory? Ann Vasc Surg 23:90–94

16. Cormier F, Ferry J, Artru B, et al. (1992) Dissecting aneurysms ofthe main trunk of the superior mesenteric artery. J Vasc Surg15:424–430

17. Takayama T, Miyata T, Shirakawa M, et al. (2008) Isolatedspontaneous dissection of the splanchnic arteries. J Vasc Surg48:329–333

18. Vignati PV, Welch JP, Ellison L, et al. (1992) Acute mesentericischemia caused by isolated superior mesenteric artery dissection.J Vasc Surg 16:109–112

19. Lenung DA, Schneider E, Kubik-Huch R, et al. (2000) Acutemesenteric ischemia caused by spontaneous isolated dissection ofthe superior mesenteric artery: treatment by percutaneous stentplacement. Eur Radiol 10:1916–1919

20. Sachdev U, Baril DT, Ellozy SH, et al. (2006) Management ofaneurysms involving branches of the celiac and superior mesentericarteries: a comparison of surgical and endovascular therapy. J VascSurg 44:718–724

21. Sakamoto I, Ogawa Y, Sueyoshi E, et al. (2007) Imaging appear-ances and management of isolated spontaneous dissection of thesuperior mesenteric artery. Eur J Radiol 64:103–110

22. Amabile P, Ouaissi M, Cohen S, et al. (2009) Conservative treat-ment of spontaneous and isolated dissection of mesenteric arteries.Ann Vasc Surg 23:738–744

23. D Ambrosio N, Friedman B, Siegel D, et al. (2007) Spontaneousisolated dissection of the celiac artery: CT findings in adults. AJRAm J Roentgenol 188:506–511

24. Hare WSC, Kincaid-Smith P (1970) Dissecting aneurysm of therenal artery. Radiology 97:255–263

25. Masselli G, Picarelli A, Gualdi G (2010) Celiac disease: MRenterography and contrast enhanced MRI. Abdom Imaging 35:399–406

82 S. Oh et al.: Imaging findings of CA dissection