Isolated spontaneous celiac artery dissection is uncommon, and the diagnosis is rarely considered in patients who have acute abdominal pain. Our search of the Medline database yielded 33 reported cases.1–24
The superior mesenteric artery seems to be affected more often than the hepatic, splenic, left gastric, or celiac arteries.8
The first reported case of spontaneous celiac artery dissection was described in 1959.3
Only 13 cases were reported before 2001.8
Although the subsequent 20 cases might seem to be an unusual clustering of infrequent events, we believe that the introduction of multislice CTA for the diagnosis of abdominal pain accounts for the disparity.18
Spontaneous arterial dissection is 5 times more common in men than in women, and the average age of the patients is approximately 55 years.6
Accordingly, the spontaneous celiac artery dissection in our 41-year-old female patient is unusual. Spontaneous celiac artery dissection has typically been associated with hypertension, arteriosclerosis, degeneration of the arterial wall, trauma, pregnancy, and arteriopathy; however, no definite cause was found in many cases.1,7,8,14,19,21,24
Two patients had symptomatic dissection related to weightlifting,8,24
so microtrauma caused by a sudden increase in abdominal pressure or a significant surge in adrenergic hormones might have played a role.
The most common presenting symptom is the sudden onset of severe epigastric or hypochondrial pain. Most patients' physical examinations have yielded normal results except for epigastric tenderness. We found one report similar to ours: spontaneous celiac artery dissection with associated pancreatitis that was secondary to some degree of pancreatic ischemia.1
Magnetic resonance imaging, ultrasonography, and conventional angiography have been used in the diagnosis of splanchnic artery dissections; however, CTA is considered to be the imaging technique of choice.6,8
This method yields details of the mesenteric vasculature regardless of a patient's body mass or anatomic variants. In addition, CTA can display luminal borders and extraluminal disease in 3 dimensions.25
The natural progression of spontaneous celiac artery dissection is not fully understood. Severe sequelae include splenic infarction, intraperitoneal hemorrhage, and intestinal ischemia.6,8,12
It is debated whether surgical or endovascular treatment is better for uncomplicated but symptomatic spontaneous dissection. Patients with an incidentally detected celiac artery dissection should undergo CTA monitoring on a regular basis if medical therapy rather than corrective action is preferred.1,6,10,18,25
Surgery—once the treatment of choice when medical therapy failed5
—has progressively given way to endovascular treatment.1
No published data support the superiority of either treatment. Conservative medical management might be appropriate for asymptomatic patients in whom there are no signs of ruptured celiac artery branches or bowel ischemia1,6,14,18,19
secondary to compression of the true lumen.25
Medical management consists of anticoagulative therapy. Continuous heparin administration is recommended while the patient is fasting or until the abdominal pain abates.1,6,14,18,19
Therapy can later be changed to oral warfarin until improvement is evident.11
If the need for anticoagulative therapy exceeds 6 months, we recommend that an invasive strategy be considered, because lifelong warfarin therapy has no proven benefit in patients with celiac artery dissection.
Some authors have advocated antiplatelet therapy during the acute stage of spontaneous dissection,1,13,24
because subendothelial injury can trigger thrombosis. Strict blood pressure control might prevent propagation of the dissection.13
A goal of optimal long-term conservative management is to identify a trigger, such as malperfusion or rupture, that would indicate the need for operative or endovascular intervention before adverse sequelae occur.18
Persistent or recurrent symptoms should raise suspicion of an undetected propagation of the dissection, expansion of the false lumen, or ischemia.
Endovascular intervention has been successful in treating spontaneous dissection of the superior mesenteric artery.9
We found 3 instances in which stenting was used to treat celiac artery dissection. Intervention respectively involved the use of a self-expanding stent (WALLSTENT®; Boston Scientific Corporation; Natick, Mass),18
a balloon-expandable bare-metal stent (Genesis®, Cordis),18
and a covered stent for a possible contained rupture.1
There are also reports of balloon fenestration17
and transcatheter embolization with coils.20
As with our patient, all the patients who underwent endovascular stenting had minimal sequelae, a complete resolution of symptoms, and no reported stenosis or progression of the dissection upon follow-up examination. However, the reported cases are too few and the follow-up periods too brief to yield definitive conclusions.
Potential advantages of stenting versus surgery include shorter hospital stays, less need for anticoagulation, and reduced radiation exposure from serial imaging. Potential disadvantages include stent thrombosis, restenosis, and procedure-related sequelae such as access-site complications. We would reserve surgical intervention for lesions that are inaccessible through an endovascular approach or for patients in whom angiography is contraindicated. Otherwise, stenting appears to be feasible as a primary treatment in patients with uncomplicated spontaneous celiac artery dissection.