Segmental arterial mediolysis of left gastric artery: a case report and review of pathology

Abstract

BackgroundSegmental arterial mediolysis (SAM) is a rare non inflammatory vascular disease that can present with massive haemorrhage, which may lead to death without prompt surgical intervention.Case presentationA 60 years old Aboriginal female presented with life threatening, spontaneous intra-abdominal bleeding requiring an emergency laparotomy. The source of bleeding was found to be ruptured left gastric artery. A total gastrectomy was performed as a damage control procedure. A staged Roux-en-Y oesophago-jejunostomy with Hunt Lawrence pouch reconstruction was undertaken thirty six hours later. Histopathological findings revealed evidence of non-inflammatory segmental vascular damage with microaneurysm, consistent with segmental arterial mediolysis.ConclusionPrompt resuscitation and surgical intervention can decrease the morbidity and mortality in this rare clinical entity.

Spontaneous hemoperitoneum resulting from segmental arterial mediolysis

“…SAM involves an initial injurious phase followed by a reparative phase to the affected vessels. Although the exact etiology is unknown, it is thought to be catalyzed by a vasospastic event, such as hypoxemia, pulmonary hypertension, vasopressor administration, recent anesthesia, and so on, which injures the vessel resulting in lysis and degeneration of the outer arterial wall [2] . The medial layer subsequently tears from the adventitia and gaps form between the intima and the damaged internal elastic lamina [3] .…”

“…This is followed by a reparative phase where granulation tissue forms in the gaps and is replaced with fibrotic tissue in an effort to restore normal vessel architecture [4] . Secondary dissection can occur during the reparative phase [2] . Vessel walls become weakened to the point of impending arterial rupture.…”

Segmental arterial mediolysis, a vasculitis mimic: Case report and review of literature

“…Intra-abdominal vasculature is most commonly involved including mesenteric, gastric, splenic, and pancreatic arteries [3] . Involvement of renal, coronary and cranial vessels has been reported as well [5][6][7][8][9] . PAN and FMD may be the closest differential diagnoses of SAM.…”

Segmental arterial mediolysis: Literature review focused on radiologic findings and management

“…Previously, SAM was thought to be a variant or a precursor of FMD. 1,3,17,22 The morphologic appearance of FMD resembles that of the reparative phase of SAM. 1 ever, a recent study shows that FMD is not solely caused by SAM but represents a group of arterial disorders with diverse etiologies.…”