Spontaneous celiac artery dissection: a rare vascular cause of abdominal pain

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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, non‐opioid analgesia. Repeat CT angiography of the abdomen was repeated at day 7, which showed stable appearances of the celiac 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 absence concomitant abdominal aortic dissection. It is a rare phenomenon, with only 34 cases reported between 1958 and 2012.1 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 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
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 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.

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