A Case of Spontaneous Isolated Celiac Artery Dissection with Pseudoaneurysm Formation
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1 A Case of Spontaneous Isolated Celiac Artery Dissection with Pseudoaneurysm Formation John Kim MS3, Lamar Moree M.D., Michael Muehlberger M.D. 1 University of Central Florida College of Medicine, 2 Orlando Regional Medical Center
2 Financial Disclosure Nothing to disclose
3 Initial Presentation 49 yo male presented with abdominal pain for 5 days Constant epigastric pain with radiation to the back Exacerbated by food consumption 7/10 in intensity Acute onset after a strenuous bike ride PMH: Nephrolithiasis Surgical: Knee arthroscopy Social: Smoking status: Cigars 1-2/wk; denies cigarettes Alcohol: 2-3 drinks/wk Illicit drugs use: denies cocaine or any illicit drugs use
4 Physical Exam and Labs VS: T 98.2, BP 139/95, HR 49, RR 20, O2 99% on room air Gen: alert, no acute distress CV: RRR; no murmurs, rubs, or gallops. Normal S1 and S2. No S3 or S4. Resp: Clear bilaterally Abd: Tender to palpation in epigastric region; Soft, non-distended; No pulsatile mass; (+) BS Labs: CBC, renal function, and troponin WNL
5 Imaging CT Abdomen and Pelvis Focal dissection of celiac artery Pseudoanuerysm involving ostium of the celiac artery
6 Imaging Ultrasound Celiac artery size: 1.4cm Velocity at celiac artery: 147 cm/s No evidence of dynamic intimal flap
7 Spontaneous isolated celiac artery dissection <100 cases reported in the literature in the past 14 years No large prospective studies No clear guidelines for management Clinical presentation + Lesions on imaging studies Isolated case reports and systemic reviews Medical therapy vs. Endovascular vs. Surgical Complications: Aneurysm > thromboembolic events Extension > stenosis/occlusion > compromised distal perfusion Rupture of visceral artery
8 Systematic review of 596 cases of MAD 88 cases of isolated celiac artery dissection Treatment: 1) 26 cases-???- did not report treatment 2) 51 cases- Medical therapy 6 failed- 1 due to aneurysmal dilatation 3) 6 cases- Primary endovascular therapy 3 due to ruptured aneurysms 4) 5 cases- Surgery 3 due to ruptured aneurysms Guidelines for elective treatment of non-ruptured aneurysm? Conservative vs. Intervention 6/11 (55%) cases
9 Retrospective study- correlation of clinical characteristics with serial imaging findings treated by conservative management 6 cases of isolated celiac dissection with aneurysm 5 patients- Conservative management Asymptomatic on routine follow up [mean=16mo; range 5-32 mo] 1 patient- Endovascular stent Persistent abdominal pain All 6 patients F/U CT: preservation of distal perfusion; regression of false lumen; no progression of aneurysm
10 Management and Follow-up Initial management Clopidogrel 75mg x 3 months Percocet 5mg/325mg PRN Follow-up (at 3 months) No abdominal pain; BP=128/21 Ultrasound (at 3 months) No dissection flap, stenosis, thrombus No growth of aneurysm Aspirin 81mg Resumed bike riding; max HR:150 6 months Annually
11 Summary Optimal management of spontaneous isolated celiac artery dissection with pseudoaneurysm formation Factors to take into consideration: Hemodynamic status Involved vessels Response to conservative treatments Development of complications Goals of medical treatment: Blood pressure control Anticoagulation or anti-platelet therapy Analgesic Rama Krishnan R S, Murali K, Madan R, Francis G. CT imaging findings and endovascular management of isolated spontaneous dissecting aneurysm of celiac artery. Indian J Radiol Imaging [serial online] 2013 [cited 2017 Apr 28];23:234-7.
12 References Garrett HE, Jr. Options for treatment of spontaneous mesenteric artery dissection. Journal of Vascular Surgery.59(5): e1432 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. Feb 2011;36(1): Rama Krishnan R S, Murali K, Madan R, Francis G. CT imaging findings and endovascular management of isolated spontaneous dissecting aneurysm of celiac artery. Indian J Radiol Imaging [serial online] 2013 [cited 2017 Apr 28];23:234-7.
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