An 18 year old male was presented after a high speed motor vehicle accident. The primary and secondary surveys revealed a Glasgow Coma Scale (GCS) of 15, abrasions on the chest and abdomen consistent with the seatbelt sign, and abdominal tenderness. Initial vital signs showed haemodynamic stability. A computed tomography scan (CT) of the chest, abdomen, and pelvis revealed an infrarenal abdominal aortic dissection, a peri-aortic retroperitoneal haematoma, and free fluid in the abdomen. Additionally, he also had a sternal fracture and three column fracture of the third lumbar vertebral body (L3) with bony retropulsion into the spinal canal, correlating with the level of the aortic injury. The initial CT also revealed focal narrowing of the coeliac artery (CA) at its origin, with opacification of the vessel distally, and patent superior and inferior mesenteric arteries. An emergency aortogram in the operating room confirmed an infrarenal aortic injury with active extravasation. A 23 mm x 70 mm long Endurant aortic cuff (Medtronic, Minneapolis, MN, USA) was placed, with resolution of the aortic extravasation. However, the patient continued to be hypotensive with no other obvious source of bleeding, which prompted an exploratory laparotomy. This revealed multiple small intestinal mesenteric tears and a 20 cm length of devascularised jejunum that was resected. The intra-operative examination and mesenteric Doppler evaluation confirmed adequate perfusion of the remaining small bowel. The patient improved haemodynamically, a primary bowel repair was performed, and he was transferred to the intensive care unit (ICU) for further care.
By post-operative day six, the patient's laboratory values revealed an elevated aspartate transaminase (AST; 488 U/L [normal range 4-35 U/L]) and alanine transaminase (ALT; 1 174 U/L [normal range 6-55 U/L]). Total and direct bilirubin levels were 16.5 and 11.5 mg/dL, respectively, and the international normalised ratio was 1.4. His white blood cell count (WBC) and serum lactic acid level were normal. A CT angiogram (CTA) of the abdomen and pelvis showed severe focal stenosis of the proximal CA and superior mesenteric artery (SMA) with small bowel dilation, inflammation, and evidence of liver hypoperfusion. With a diagnosis of post-traumatic dissection of visceral arteries the patient was brought to the hybrid operating room for emergency revascularisation. On table bilateral saphenous vein mapping was done with a low threshold for conversion to open bypass surgery. A mesenteric angiogram via left brachial artery access confirmed severe stenosis in the proximal SMA (Fig. 1A) and CA (Fig. 2A). A 7 x 22 mm iCAST (Atrium, Hudson, NH, USA) covered balloon expandable stent was placed in the SMA and the CA stenosis was treated with two 8 x 20 mm and 9 x 20 mm self expanding non-covered Epic nitinol stents (Boston Scientific, Marlborough, MA, USA) accommodating the tortuosity of the CA at the dissection site. Completion angiography showed an excellent radiographic result with brisk flow in the SMA and CA (Figure 1, Figure 2B). For the remainder of his hospitalisation, the patient required decompression of the lumbar spine with vertebral fusion for spinal injuries resulting from the initial accident, and a right hemicolectomy and ileostomy for a presumed iatrogenic injury at the index abdominal exploration. Sixty-nine days after presentation, he was discharged to a rehabilitation centre with normalised gut function.