most of the reported cases have been associated with the superior mesenteric artery , and to our knowledge , only 25 cases of the spontaneous isolated celiac artery dissection can be found in the literature ( 1 ) . of the reported cases , only 2 cases of spontaneous celiac artery dissection
awareness of the visceral artery dissection is important because of its life - threatening complications causing extensive hemorrhage or ischemia to the supplied organs .
although a review of the medical literature suggests that the natural history of spontaneous celiac artery dissection may not be fatal , it is difficult to predict .
all of the following can potentially occur : spontaneous resolution , ischemia due to occlusion of the vessel , aneurysm formation , and rupture ( 2 ) .
the management of spontaneous celiac artery dissection includes conservative medical treatment , endovascular therapy , and surgery ( 1 ) . in complicated cases ,
the optimal management of spontaneous celiac artery dissection remains controversial because this condition is rare .
the medical literature does not provide enough information to assess the superiority of one treatment over another . herein , we report 2 cases of the complicated spontaneous dissection of the celiac artery , both of which were successfully treated using an endovascular stent graft .
a 47-year - old man , who had presented with acute abdominal pain to a different healthcare facility , was transferred to our emergency room for further evaluation and treatment of dissection of the splanchnic arteries .
the patient had a history of uncomplicated dissection of the superior mesenteric artery , and had been taking anti - hypertension medication for 1 year .
however , he had stopped taking his prescription medication 10 months prior to admission to the emergency room .
on arrival to the emergency room of a local hospital , his blood pressure was 95/60 mm hg and the pulse rate was 110 beats per min .
after blood transfusion and fluid therapy in local hospital , the patient 's blood pressure had increased to 150/100 mm hg , and there were no obvious abnormalities on the physical examination or in the laboratory findings on admission to our hospital .
a contrast - enhanced ct scan showed a newly developed saccular dissecting aneurysm in the celiac artery with surrounding retroperitoneal hematoma , measuring 2.8  7.9  12.0 cm ( fig .
the dissection of the superior mesenteric artery had not changed , compared to the previous ct scan .
one day after admission , the patient 's hemoglobin level had decreased to 9.6 g / dl again , after cessation of blood transfusion .
the patient was offered a less invasive endovascular procedure to avoid surgical repair . after puncturing of his right common femoral artery , an 8f guiding catheter ( vista brite tip , cordis , miami , fl , usa )
was inserted into the orifice of the celiac artery , which allowed for celiac angiography that revealed a dissecting aneurysm at the entry point ( fig .
the proximal splenic artery was occluded , and the true lumen of the left gastric artery and common hepatic artery were narrowed by intramural hematoma .
we placed the 4 - 9  38 mm peripheral stent graft ( jostent , abbott vascular , rangendingen , germany ) , which was mounted over a 6  40 mm savvy balloon ( cordis , miami , fl , usa ) from the origin of the celiac artery to the common hepatic artery .
post - procedure angiography showed complete coverage of the dissecting aneurysm with the use of a stent graft ( fig .
follow - up ct scan , obtained 1 week after the procedure , showed a complete obliteration of the dissecting aneurysm in the celiac artery with preservation of the hepatic arterial flow and marked reduction of the retroperitoneal hematoma . although occlusion of the proximal splenic artery and proximal left gastric artery after stent graft placement persisted , no abnormalities ( i.e. , splenic infarction , gastric ischemia , or signal of irritated peritoneum ) were noted due to an abundance of collateral blood flow .
a 57-year - old man , presented with acute abdominal pain , was admitted to the emergency room . the patient had a previous medical history of spontaneous celiac artery and of the superior mesenteric artery dissection .
an abdominopelvic ct scan , obtained 3 months prior to admission , demonstrated a 7 mm - sized saccular aneurysm , with a mural hematoma along the celiac artery to the common hepatic artery and a dissection of the superior mesenteric artery with a mural hematoma ( fig .
infiltration of the fat surrounding the celiac artery was noticed as a secondary sign of acute spontaneous celiac artery dissection .
other than the acute abdominal pain , the patient was healthy and had no risk factors associated with the occurrence of visceral artery dissection .
he had been treated with an anticoagulant to prevent a thromboembolic complication for 3 months , because he had no major complication associated with the dissection of the celiac artery and superior mesenteric artery .
contrast enhanced ct revealed a progressive dissecting aneurysm along the celiac artery , which had a maximal inner diameter of 2 cm ( fig .
the aneurysm originated 2 cm distal from celiac artery orifice without compromised distal flow to the distal hepatic artery .
in addition , the patient 's previous superior mesenteric artery dissection with mural thrombus had improved completely without associated complications .
the patient was transferred to an interventional suite for endovascular treatment , because the risk of rupture was high , due to the progressive enlargement of an aneurysm sac .
celiac angiography , obtained after an insertion of the 8 fr guiding catheter ( cordis ) , showed a dissecting aneurysm , which obviously defined the celiac artery , proximal to splenic artery and left gastric artery orifice ( fig .
we placed the 4 - 9  38 mm peripheral stent graft ( jostent , abbott vascular , rangendingen .
germany ) , which was mounted over a 6 mm  40 mm savvy balloon ( cordis ) from the origin of celiac artery to the bifurcation of the common hepatic artery and the splenic artery .
there was no noticeable compromise in the blood flow to the distal hepatic artery , gastroduodenal artery , and splenic artery .
the follow - up ct scan , obtained 3 months after the procedure , showed a complete disappearance of the dissecting aneurysm .
a 47-year - old man , who had presented with acute abdominal pain to a different healthcare facility , was transferred to our emergency room for further evaluation and treatment of dissection of the splanchnic arteries .
the patient had a history of uncomplicated dissection of the superior mesenteric artery , and had been taking anti - hypertension medication for 1 year .
however , he had stopped taking his prescription medication 10 months prior to admission to the emergency room .
on arrival to the emergency room of a local hospital , his blood pressure was 95/60 mm hg and the pulse rate was 110 beats per min .
after blood transfusion and fluid therapy in local hospital , the patient 's blood pressure had increased to 150/100 mm hg , and there were no obvious abnormalities on the physical examination or in the laboratory findings on admission to our hospital .
a contrast - enhanced ct scan showed a newly developed saccular dissecting aneurysm in the celiac artery with surrounding retroperitoneal hematoma , measuring 2.8  7.9  12.0 cm ( fig .
the dissection of the superior mesenteric artery had not changed , compared to the previous ct scan .
one day after admission , the patient 's hemoglobin level had decreased to 9.6 g / dl again , after cessation of blood transfusion .
the patient was offered a less invasive endovascular procedure to avoid surgical repair . after puncturing of his right common femoral artery , an 8f guiding catheter ( vista brite tip , cordis , miami , fl , usa )
was inserted into the orifice of the celiac artery , which allowed for celiac angiography that revealed a dissecting aneurysm at the entry point ( fig .
the proximal splenic artery was occluded , and the true lumen of the left gastric artery and common hepatic artery were narrowed by intramural hematoma .
we placed the 4 - 9  38 mm peripheral stent graft ( jostent , abbott vascular , rangendingen , germany ) , which was mounted over a 6  40 mm savvy balloon ( cordis , miami , fl , usa ) from the origin of the celiac artery to the common hepatic artery .
post - procedure angiography showed complete coverage of the dissecting aneurysm with the use of a stent graft ( fig .
follow - up ct scan , obtained 1 week after the procedure , showed a complete obliteration of the dissecting aneurysm in the celiac artery with preservation of the hepatic arterial flow and marked reduction of the retroperitoneal hematoma . although occlusion of the proximal splenic artery and proximal left gastric artery after stent graft placement persisted , no abnormalities ( i.e. , splenic infarction , gastric ischemia , or signal of irritated peritoneum ) were noted due to an abundance of collateral blood flow .
a 57-year - old man , presented with acute abdominal pain , was admitted to the emergency room .
the patient had a previous medical history of spontaneous celiac artery and of the superior mesenteric artery dissection .
an abdominopelvic ct scan , obtained 3 months prior to admission , demonstrated a 7 mm - sized saccular aneurysm , with a mural hematoma along the celiac artery to the common hepatic artery and a dissection of the superior mesenteric artery with a mural hematoma ( fig .
infiltration of the fat surrounding the celiac artery was noticed as a secondary sign of acute spontaneous celiac artery dissection .
other than the acute abdominal pain , the patient was healthy and had no risk factors associated with the occurrence of visceral artery dissection .
he had been treated with an anticoagulant to prevent a thromboembolic complication for 3 months , because he had no major complication associated with the dissection of the celiac artery and superior mesenteric artery .
contrast enhanced ct revealed a progressive dissecting aneurysm along the celiac artery , which had a maximal inner diameter of 2 cm ( fig .
the aneurysm originated 2 cm distal from celiac artery orifice without compromised distal flow to the distal hepatic artery .
in addition , the patient 's previous superior mesenteric artery dissection with mural thrombus had improved completely without associated complications .
the patient was transferred to an interventional suite for endovascular treatment , because the risk of rupture was high , due to the progressive enlargement of an aneurysm sac .
celiac angiography , obtained after an insertion of the 8 fr guiding catheter ( cordis ) , showed a dissecting aneurysm , which obviously defined the celiac artery , proximal to splenic artery and left gastric artery orifice ( fig .
we placed the 4 - 9  38 mm peripheral stent graft ( jostent , abbott vascular , rangendingen .
germany ) , which was mounted over a 6 mm  40 mm savvy balloon ( cordis ) from the origin of celiac artery to the bifurcation of the common hepatic artery and the splenic artery .
there was no noticeable compromise in the blood flow to the distal hepatic artery , gastroduodenal artery , and splenic artery .
the follow - up ct scan , obtained 3 months after the procedure , showed a complete disappearance of the dissecting aneurysm .
spontaneous dissection of the celiac artery , which is not associated with aortic dissection , is extremely rare .
approximately one half of the patients with celiac artery dissection are asymptomatic , due to a good collateral flow , via the superior mesenteric artery ( 3 ) .
the symptoms are usually non - specific epigastric pain or post - prandial abdominal pain .
these symptoms are considered to be the result of the dissection itself , or to ischemic signs of the abdominal organ ( 4 ) . however
, various clinical presentations , such as liver ischemia , splenic infarction , may occur according to the involvement of the branch vessels , and life threatening hemorrhage due to a rupture of the aneurysm ( 1 , 4 ) . the initial diagnosis of the visceral artery dissection is rarely established by symptoms .
this disease entity is found incidentally during imaging studies for the purpose of evaluating other symptoms .
there have been reported cases in which the ct findings of isolated dissection of the celiac artery were described ( 4 , 5 ) .
the intimal flap with double lumen , thrombosis of false lumen or intramural hematoma , enlarged involved vessels were the findings of visceral artery dissection .
infiltration of the fat surrounding the affected vessel is a well - known secondary sign of acute spontaneous dissection of a visceral artery .
complications of the celiac artery dissection include hemorrhage or ischemic change of the distal organs , propagation of dissection into adjacent vessels , expansion of a false lumen , and the development of an aneurysm .
the hepatic artery aneurysm could be presented as a complication of the celiac artery dissection .
expansion of a false lumen may cause either a rupture or poor perfusion to the supplied organ , secondary to the mechanical compression of the true lumen flow ( 6 ) .
however , the inability to predict either regression or expansion of a false lumen mandates close , life - long follow - up .
the management of celiac artery dissection depends on the hemodynamic status of the patient , response to conservative treatment , and development of complications ( ischemia or hemorrhage ) .
in asymptomatic stable dissection , current treatment recommendations are conservative treatment with anticoagulation or antiplatelet agents under close observation to prevent thromboembolic complications .
blood pressure control is necessary to minimize the progression of a dissection ( 4 , 5 ) .
the indications for surgical or endovascular treatment include visceral ischemia , rupture of the dissection , progressing aneurysm ( 1 , 2 , 6 - 8 ) . in the era of improved radiologic intervention
, percutaneous endovascular treatment has been used as a surgical alternative with increasing frequency for the management of complicated splanchnic artery dissection because of its less invasiveness .
the specific application of any interventional technique should be tailored to the needs of the individual patient , because each technique offers different advantages and disadvantages ( 6 - 8 ) .
( 6 ) reported placement of a bare metal stent in a patient with celiac artery dissection as a treatment of poor perfusion secondary to mechanical compression of the true lumen by an expansion of the false lumen , following a failed conservative treatment .
but , there was no evidence of a rupture in that case . in our cases ,
dissection of the celiac artery resulted in a rupture of aneurysm with decreased hemoglobin level in the first case , and progressing aneurysm with high risk of rupture in the second case .
conservative treatment , including anticoagulation or placement of a bare stent , was not amenable to treat or prevent bleeding in our cases because these therapies could not limit the aneurysm .
8) reported isolated dissecting aneurysm of the celiac artery , extending into the proper hepatic artery that was successfully treated by transcatheter arterial embolization .
fortunately , in this reported case , intrahepatic branches were visualized after embolization through collateral pathways of the pancreatic arcade and epicholedochal arterial plexus from the superior mesenteric artery and dorsal pancreatic artery . however , proper collateral flow is essential for the use of transcatheter arterial embolization to treat a dissecting celiac artery to avoid organ infarction .
therefore , a stent - graft could be considered to control the bleeding from a ruptured aneurysm without the inadvertent development of complications caused by arterial embolization in poor collateral channels .
several reports have suggested the stent - graft as a valid alternative endovascular treatment for ruptured sma dissection or celiac artery aneurysm ( 9 , 10 ) . a stent - graft that better preserves the distal flow might provide a safe , efficacious alternative to coil or plug embolization . in our cases ,
the involved vessels showed a smooth curvature to allow an easy navigation of a stent graft . in the first case ,
the patient had experienced a previous dissection of the superior mesenteric artery without complications . in addition , he had been treated with anticoagulant and hypertensive medication .
the patient had discontinued anticoagulation after 6 months , and no serious complications concerning a superior mesenteric artery dissection was noted on a follow - up ct angiogram . the patient had stopped his hypertension medication arbitrarily . in addition , 10 months later , a ruptured dissecting aneurysm of the celiac artery developed with a concomitant decrease in hemoglobin .
most likely , arbitrary discontinuation of medication could explain the episode of celiac artery dissection .
we successfully treated the dissecting aneurysm of the celiac artery that had ruptured with the retroperitoneal hematoma by the use of a stent graft . in the second case , although the urgent complication had not been noticed , the progressive enlargement of the aneurysm is at the greatest risk from rupturing .
the patient was managed successfully with the placement of a stent graft . to our knowledge
, we are reporting the first case of a spontaneous celiac artery dissection treated with a stent graft .
percutaneous stent graft placement for the treatment of complicated spontaneous dissection of celiac artery is safe and feasible .
however , studies with a large group of patients and long - term follow - up will be needed to validate this procedure .
 we report 2 cases of complicated spontaneous dissection of the celiac artery , which were successfully treated by a stent graft . 
 the first patient was a 47-year - old man who presented with acute abdominal pain . 
 ct scan showed ruptured saccular aneurysm with surrounding retroperitoneal hematoma . 
 the second patient was a 57-year - old man with progressive dissecting aneurysm . 
 endovascular stent graft was placed in the celiac trunk to control bleeding , and to prevent rupture in each patient . 
 follow - up ct scans showed complete obliteration of a dissecting aneurysm . 