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.