Celiac dissection after blunt abdominal trauma complicated by acute hepatic failure: Case report and review of literature

Abstract

Injuries of the abdominal visceral vessels are uncommon but devastating entities resulting in extremely high rates of mortality. The most common cause of abdominal vascular injuries is penetrating trauma, accounting for 90% to 95% of these injuries. In contrast, blunt trauma accounts for 5% to 10% of all abdominal vascular lesions. Although traumatic injury to the celiac artery is among the rarest of all vascular injuries, mortality can be as high as 75%. We report a 66-year-old patient who sustained multiple injuries in a motor vehicle crash. The initial whole-body computed tomography (CT) scan revealed a combination of severe brain injury and bilateral thoracic lesions. On day 6 after the accident, the patient's clinical situation deteriorated rapidly. At this time, the abdominal arterial CT scan showed a dissection of the celiac artery. Therapeutic anticoagulation was not feasible because of the intracranial hemorrhage. Also the patient's clinical situation worsened so rapidly that interventional therapy, including surgical and endovascular treatment, could not be performed. Finally, the patient died of fulminant hepatic failure, therefore not surviving a potentially treatable injury. The diagnosis of celiac artery dissection in this patient was significantly delayed because the initial trauma CT protocol did not include an arterial phase of the abdominal vessels.

Isolated Dissection of the Celiac Artery after Blunt Trauma: A Case Report and Review of Literature

“…Isolated CA injury, which is an injury to the CA without concomitant aortic injury, is the least common among all abdominal arterial injuries. To date, only 8 reports of isolated CA injury following blunt trauma have been reported [2][3][4][5][6][7][8][9]. These cases, except for 1 case without a detailed description, are summarized, along with our two cases, in Table 1.…”

“…More than half of the reported patients had elevated liver enzymes, but this is of low diagnostic value because mild elevations of the hepatic enzymes are also commonly associated with liver contusion or muscle injuries after blunt abdominal trauma. However, an acute elevation of liver enzymes in a patient with known traumatic CA dissection should warrant further evaluation, because it may be a sign of liver necrosis from hepatic artery involvement [4]. Among all reported cases of traumatic CA dissection, 4 showed involvement of branches of the CA (splenic artery and common hepatic artery, n=3 and common hepatic artery only, n=1).…”

“…Even in the rare cases where thrombosis accompanying CA dissection has caused partial splenic infarct, pancreatitis, or liver dysfunction, the patients have been managed successfully with conservative measures [16,17]. However, close observation is important because two lethal ischemic complications, fulminant hepatic failure after traumatic CA dissection [4], and multiple organ ischemia leading to septic shock after spontaneous CA dissection [19], have been reported. Late aneurysmal change is another feared complication, and is detected in 6% of patients with conservatively managed spontaneous CA dissections [10].…”

An uncommon cause of abdominal pain following blunt abdominal trauma

“…In the majority of cases, traumatic injury to the coeliac artery is associated with injury to other intra-abdominal organs, including the small bowel, duodenum, pancreas, colon or stomach. Only a few cases of isolated blunt traumatic injury to the coeliac axis have been reported [2][3][4][5]. The intimate anatomical relationship of the coeliac axis to the median arcuate ligament has been proposed as a factor contributing to isolated coeliac artery injury secondary to blunt trauma.…”

Pancreatic transection from blunt trauma associated with vascular and biliary lesions: A case report

“…Our effort to maintain the continuity of the hepatic artery was justified by the transitory postoperative rise of hepatic enzymes, which returned to the normal range after stenting of the anastomosis. Moreover, a case of unrecognised hepatic artery dissection, having as a consequence a fatal fulminate hepatic failure, was recently reported [15] . Alternative techniques of revascularization by means of a prosthetic conduit should be avoided if possible, because septic complications are frequent in the postoperative course.…”