Isolated Spontaneous Visceral Artery Dissections: A Case Series

Spontaneous isolated visceral artery dissections (IVADs) are rare but increasingly recognized since the advent of abdominal computed tomography angiograms in the diagnosis of acute-onset abdominal pain. Several case reports and case series in the literature discuss this problem with limited follow-up. The management of symptomatic patients with IVADs varies depending on the extent of vascular compromise, and treatment algorithms often involve surgical intervention. However, the long-term results of expectant management of IVADs are largely unknown. We present three cases of spontaneous celiac artery dissection and two cases of superior mesenteric artery dissection in middle-aged men (mean age, 48.4 years). All patients presented with hypertension and acute epigastric abdominal pain without evidence of peritoneal irritation. One patient had a single episode of hematochezia that did not require transfusion. Another two patients had several episodes of nonbloody bilious emesis associated with the abdominal pain. All cases were diagnosed by computed tomography angiography of the abdomen and pelvis (Figs 1 and 2). The patients were managed expectantly with concomitant oral anticoagulation in two of the five patients. All patients had spontaneous resolution of their symptoms. A mean follow-up of 45.8 months (range, 13-66 months) is available, with yearly surveillance mesenteric duplex ultrasound imaging showing no evidence of aneurysmal degeneration of the false lumen or elevated peak systolic velocities suggestive of stenosis. Furthermore, no patient required surgical intervention during the follow-up period. This small case series suggests that properly selected symptomatic patients with IVADs can be managed safely with careful observation; however, the therapeutic role of oral anticoagulation in IVADs is not fully understood. Long-term follow-up in this small case series suggests that these patients do not develop any clinically significant long-term sequela. Furthermore, they do not require surgical revascularization even several years after spontaneous visceral artery dissection.Fig 2Abdominal computed tomography scan shows the celiac artery intimal flap (arrow) with perfusion of the false lumen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)