CT imaging findings and endovascular management of isolated spontaneous dissecting aneurysm of celiac artery
A 45-year-old man presented to our emergency department with sudden onset of sharp epigastric pain. He gave history of hospital admission elsewhere, 6 months back for similar complaint. Upper gastrointestinal (GI) endoscopy performed at that time revealed peptic ulcer, and since then, he had been on antacids. His medical history was also remarkable except for uncontrolled hypertension. At presentation, his blood pressure was 180/100 mm Hg. Routine blood tests and basic metabolic profile including liver, cardiac enzymes, and serum amylase/lipase levels were normal. Emergency ultrasound performed on him did not reveal any significant abnormality. So, a biphasic contrast-enhanced CT of the abdomen was performed on a GE Light Speed Discovery 750 HD, 64-slice scanner, using oral contrast and 80 ml of non-ionic iodinated contrast material 350 mg I/ml, injected at the rate of 3 ml/s. Arterial phase images of the upper abdomen were obtained using smart prep technique followed by portal venous phase acquisition of whole abdomen at 50 s from the start of contrast injection.\nThe CT study revealed celiac artery aneurysm of 1.4 cm, approximately 0.8 cm from its origin with focal dissection as evidenced by true lumen and thrombosed false lumen. The caliber of the true lumen was severely compromised [Figures and ]. Distal propagation of the dissection and mural thrombus into the ostia-proximal hepatic and splenic arteries was seen which were occluded. The left gastric artery was originating from the celiac axis, proximal to the dissecting aneurysm and was normal. Replaced left hepatic artery from left gastric artery was seen as a normal variant. Fat infiltration was seen surrounding the celiac axis and proximal hepatic and splenic arteries []. This finding is a sign of dissection acuity and indicates predisposition toward progressive extension of dissection into adjacent vessels. The abdominal aorta and its other major branches were normal with no stenosis or aneurysm or dissection. There was no evidence of organ or bowel infarction. Subsequent Digital subtraction angiogram performed with therapeutic intent confirmed the CT findings []. Also, superior mesenteric artery injection showed retrograde filling of the hepatic and splenic arteries via the anterior, posterior pancreaticoduodenal arcades and the gastroduodenal artery [].\nSevere abdominal pain present in spite of good collateral flow indicates dissection to be the cause of pain, rather than intestinal ischemia. Also, in view of peri-celiac fat infiltration on CT and the complicating aneurysm with inherent potential risk of rupture, it was decided to treat him either with endovascular stent grafting or coil embolization. Stent grafting can be done if there is good landing zone of 2 cm on either side of the aneurysm. In our case, stent graft would have compromised the flow through the left gastric artery originating just proximal to the aneurysm. Also, in view of the good collateral flow to the hepatic and splenic arteries from superior mesenteric artery, it was decided to occlude the aneurysm distal to left gastric origin to prevent rebleed. Transarterial embolization was performed and the aneurysm was packed with detachable micro coils (Covidien, Ireland). Post coil embolization angiogram [] showed that the parent artery was obliterated except for its proximal portion with left gastric origin and that the intrahepatic branches were supplied through collateral pathways and the replaced left hepatic artery. His initial pain subsided gradually, and he was symptom free during discharge.