(A rare case of) Segmental Medial Arteriolysis
Download
Report
Transcript (A rare case of) Segmental Medial Arteriolysis
Shenouda M, Riga C, Naji Y, Renton S
KSS Core Surgery Prize Day
Friday 4th January 2013
Mrs X, 85 y/o
PC – acute onset epigastric pain
Sharp, associated with nausea, vomiting, sweating.
No haematemesis/melaena; no neck/chest pain
No previous episodes
PMHx – 2 previous visceral aneurysm repairs (15y
previously), HTN, recent NSTEMI
FHx – IHD
SHx – lives alone, independent, active, ex-smoker (50pack years – stopped 6/12 previously)
O/E
Alert, orientated, GCS 15/15
Stable vital signs: Temp 35.8, HR 52, BP 132/53, RR 18, SaO2 96% O/A
Pale, clammy, otherwise normal CVS/resp ex
Abdo: midline scar; severe
epigastric/central tenderness with
guarding. No pulsatile masses,
absent bowel sounds
Peripheral vasc:
No signs of acute ischaemia
All pulses present
No radio-radial or radio-femoral delay
CRT <2 sec in all four limbs
Neurology intact
Basic Ix
Urine NAD, ECG - SR
Bloods – Hb 9.2, WCC 16.2, Plt 183, Clot NAD, CRP <5
Cr 81, Ur 7.4, Na 141, K 4.7, Trop 0.13
Clotting, LFTs NAD
Urgent CT Angio….
CTA
11 mm aneurysm arising from a branch of the gastroduodenal
artery is seen with surrounding haematoma, suspicious for rupture.
Difficult anatomy is seen with common trunk for the celiac and SMA,
and a 10mm aneurysm in SMA trunk.
Multiple other aneurysms – 25mm splenic artery aneurysm, 14mm
aneurysm at the origin of the IMA.
Management
Cross-matched 6 units, fluid resuscitation
Urgent angiogram…
Angiogram & Embolisation
LA, R CFA puncture
Selective catheterisation of the celiac axis and then GDA
cannulated. The aneurysm was identified. Embolisation
with several microcoils proximal and distal to the
aneurysm in the GDA; complete cessation of flow within
the aneurysm.
Findings in keeping with CTA – multiple visceral
aneurysms.
Also noted multiple narrowings and irregularities in the
visceral arteries.
SEGMENTAL ARTERIAL
MEDIOLYSIS
SEGMENTAL ARTERIAL
MEDIOLYSIS
1976 –
Slavin RE, Gonzalez-Vitale JC. Segmental mediolytic
arteritis. A clinical pathologic study. Lab Interv 1976;35:23–
91.
Described 3 autopsy cases
partial or total mediolysis arterial gaps dissecting
aneurysms rupture massive haemorrhage
85 cases in literature
Abdominal visceral arteries, intracranial arteries
Aetiology unknown
SEGMENTAL ARTERIAL
MEDIOLYSIS
Presentation –
intra-abdominal/intracranial haemorrhage
asymptomatic on routine investigations
post-mortem
Diagnosis –
radiological – arterial dilatation, single/multiple aneurysms,
stenoses/occlusion, dissection
histological – surgical resection, post-mortem
SEGMENTAL ARTERIAL
MEDIOLYSIS
Literature review, 1976-2012
62 studies, 85 cases
69% confirmed histologically (24% on autopsy)
M:F – 1.5:1
Age range 0-91 (median 57)
21% had history of hypertension
13% mortality before further investigation/management
Overall mortality 25%
Management – open vs endovascular
Summary
SAM is a rare diagnosis of unknown aetiology
May be asymptomatic or present with massive haemorrhage
Treatment usually restricted to symptomatic cases
Endovascular embolisation can prevent the need for major
surgery
Can also be a temporary measure before definite surgery at a
later stage
References
Slavin, RE. Gonzalez-Vitale, JC. Segmental mediolytic
arteritis: a clinical pathologic study. Lab Invest 1976;
35:23–29.
Michael, M. Widmer, U. Wildermuth, et al. Segmental
arterial mediolysis: CTA findings at presentation and
follow-up. AJR Am J Roentgenol 2006; 187:1463-9
Tameo, MN. Dougherty, MJ. Calligaro, KD. Spontaneous
dissection with rupture of the superior mesenteric artery
from segmental arterial mediolysis. J Vasc Surg
2011;53:1107-12.