Management of symptomatic spontaneous isolated visceral artery dissection: is emergent intervention mandatory?

Spontaneous dissection of a visceral artery without associated aortic dissection is rare, although more cases have recently been reported because of the advancement of diagnostic techniques. The risk factors, causes, and natural history of spontaneous isolated visceral artery dissection are unclear. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed; however, there is no consensus on the optimal management. We present three cases of spontaneous and isolated dissection of visceral arteries. Dissection involved the superior mesenteric artery in one and the celiac artery in two. All three patients presented with acute abdominal pain but lacked any peritoneal irritation. The patients were treated nonoperatively with anticoagulants or antiplatelets. No surgical or endovascular intervention was performed. Follow-up imaging studies demonstrated improvement of the dissection in two patients and no change in one patient. All patients were symptom-free over a mean follow-up of 17 months. Nonoperative treatment with close observation is an acceptable strategy in the management of spontaneous isolated dissection of visceral arteries. Emergent intervention is not mandatory in symptomatic patients without evidence of acute bowel ischemia or hemorrhage.

Rupture of an abdominal aortic aneurysm following nonaccidental blunt abdominal trauma.

A 78-year-old woman presented to our trauma center with an initial, erroneous history of a ground-level fall. Further investigation revealed that the patient had been assaulted by her husband immediately prior to presentation. The initial abdominal examination was benign, and the patient was hemodynamically stable. The patient was found to have a large subdural hematoma (SDH). Following open evacuation of the SDH, the patient developed ongoing hemodynamic instability. Further evaluation with computed tomography of the abdomen and pelvis uncovered the diagnosis of a 6 cm abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. The patient underwent emergent repair of the ruptured AAA. There were no other significant intra-abdominal injuries, and the patient had an uneventful recovery. This case highlights the need for thorough evaluation of the trauma patient and recognition of the possibility of coexistent AAA in the elderly trauma patient. We believe that this is the first reported case of a ruptured AAA following nonaccidental blunt abdominal trauma.

Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization.

Mobile thrombus of the thoracic aorta is an uncommon pathology with potentially catastrophic complications. Recurrent spontaneous distal embolization may also occur from an ulcerated thrombus of the abdominal aorta. The simultaneous presence of a mobile thrombus in the thoracic aorta and ulcerated thrombus of the abdominal aorta is extremely rare and poses a significant treatment dilemma. Although various approaches have been reported, there is no standard treatment. Direct replacement of the thoracoabdominal aorta is extremely morbid, while continued embolization despite anticoagulation mandate intervention. We herein present the first case report of successful treatment of symptomatic mobile/ulcerated thrombi of the thoracic and abdominal aorta using staged endovascular stent graft repair. Successful treatment of the thoracic component with a thoracic aortic graft (TAG, Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.) was followed one week later by exclusion of the infrarenal aortic lesion with a bifurcated stent graft. Endovascular stent graft exclusion of mobile/ulcerated thoracic and abdominal aortic thrombi is a minimal invasive operation. It can be employed as an alternative procedure in treatment of aortic thrombus with embolization in high risk patients. Long-term follow-up will be necessary to assess the durability of this technique.

A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization.

In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.

Chronic ergot toxicity presenting with bilateral external iliac artery dissection and lower extremity rest pain.

Chronic use of ergot alkaloids has been recognized as a rare cause of lower extremity ischemia. Most patients with ergot toxicity present with symptoms of lower extremity claudication. Herein we present a woman with bilateral lower extremity rest pain and a history of chronic ergot use for migraine headaches. Arteriography demonstrated extensive pruning of the distal arterial tree along with bilateral external iliac artery dissections - a finding that is not often associated with young, normotensive patients with chronic ergot toxicity. This patient was treated with endovascular stenting of the dissections along with cessation of ergot. Her symptoms improved markedly, and follow-up arteriography 6 weeks later demonstrated resolution of the iliac dissections along with restoration of nearly normal lower extremity runoff vessels. Discontinuation of ergot-containing products and cessation of tobacco and caffeine use is the cornerstone of therapy in chronic ergot toxicity. The association of ergot toxicity and iliac dissection has not been previously described. Endovascular or surgical interventions may be considered in patients with ergot toxicity for specific indications or those whose symptoms progress despite conservative management.

Major lower extremity amputation in an academic vascular center.

Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.