Dissection of the Celiac Artery

Case

A 41-year-old man presented to our ED with a 4-day history of epigastric pain radiating to the bilateral flanks and back. His medical history was significant for hypertension, for which he was prescribed isosorbide dinitrite 30 mg four times per day; however, he reported that he did not regularly take this medication.

The patient had visited our ED 3 days earlier with the same complaint. Since his blood pressure (BP) reading at the first ED presentation was 213/141 mm Hg, he had been admitted for hypertensive urgency. The patient’s BP was controlled with antihypertensive agents during his stay, but he continued to experience epigastric pain. A basic work-up for abdominal pain was ordered, the results of which were normal. Based on these findings, the patient’s pain was attributed to gastritis, and he was discharged home with instructions to return to the ED if his pain became worse or persisted.

At both ED presentations, the patient denied experiencing any nausea, vomiting, diarrhea, or chest pain. At the second presentation, his triage BP was 158/106 mm Hg. A chest X-ray, complete blood count (CBC), basic metabolic profile (BMP), hepatic panel, and lipase evaluation were all unremarkable, with the exception of a mild increase in creatinine to 1.38 mg/dL. A point-of-care (POC) ultrasound study of the aorta was normal.

Given the patient’s recent hypertensive episode, a computed tomography angiography (CTA) of the chest and abdomen was also obtained, which revealed an isolated 4.5-cm dissection of the celiac artery (DCA) with filling defect in the hepatic artery (Figure 1).

Based on the CTA findings, a nicardipine infusion was immediately started, and the patient was admitted to the medical intensive care unit (MICU). Because his heart rate was in the range of 60 beats/min, an esmolol infusion was not required. Prior to transferring the patient to MICU, a second ultrasound study of the aorta was performed by our fellowship-trained director of emergency medicine ultrasound.

Despite the excellent views taken of the aorta, celiac trunk, and hepatic and splenic arteries (Figure 2), the dissection was not visible on either of the two ultrasound images.

In the MICU, the patient’s BP was stabilized on hospital day 2, and he was transitioned to oral antihypertensive medications. He was also started on a heparin infusion at the recommendation of vascular surgery services.

A repeat CTA of the abdomen taken on hospital day 3 showed an unchanged dissection in the celiac axis extending into the hepatic artery. The vascular surgeon recommended strict BP control, anticoagulation therapy, and a vascular surgery follow-up with a repeat CTA of the abdomen in 6 months.

On hospital day 6, repeat serial CBC, BMP, and hepatic panels revealed only slight increases in aspartate transaminase to 88 U/L and alanine aminotransferase to 117 U/L. The patient was transitioned to enoxaparin and discharged home on hospital day 6, and instructed to follow-up with his primary care physician for transition to warfarin. Unfortunately, this patient was lost to follow-up.

Discussion

Isolated DCA is a rare cause of abdominal pain. The first documented case of isolated DCA is often incorrectly attributed to Bauersfeld’s¹ 1947 case series on dissections,but that report described superior mesenteric artery dissection rather than a celiac artery dissection. Watson’s² 1956 dissection series is also incorrectly cited as the first DCA, but that series described a dissection of the splenic artery, which is a branch of the celiac artery. In a 1959 series, Foord and Lewis³ described what is most likely the first report of DCA as an incidental finding at autopsy. More frequent descriptions in recent years are thought to be due to the routine use of abdominal CTA.⁴

Dissection of the celiac artery is a rare occurrence, with less than 100 cases reported, and little evidence exists to guide its management.⁵ These dissections represent 36.8% of all visceral artery dissections,⁶ which themselves are less common than renal, carotid, and vertebral artery dissections.⁷ Dissection of visceral arteries occurs predominantly in men and more often in middle-aged patients.⁸ Risk factors for DCA are thought to mirror risk factors for dissection of other arteries, including atherosclerotic disease, hypertension, connective tissue disorders, trauma, vasculitis, and pregnancy.^9-11