shenouda m, riga c, naji y, renton s kss core surgery prize day friday 4th january 2013
TRANSCRIPT
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Shenouda M, Riga C, Naji Y, Renton S
KSS Core Surgery Prize DayFriday 4th January 2013
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Mrs X, 85 y/oPC – acute onset epigastric pain
Sharp, associated with nausea, vomiting, sweating.No haematemesis/melaena; no neck/chest painNo previous episodes
PMHx – 2 previous visceral aneurysm repairs (15y previously), HTN, recent NSTEMI
FHx – IHDSHx – lives alone, independent, active, ex-smoker (50-
pack years – stopped 6/12 previously)
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O/EAlert, orientated, GCS 15/15Stable vital signs: Temp 35.8, HR 52, BP 132/53, RR 18, SaO2 96% O/APale, 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 ischaemiaAll pulses presentNo radio-radial or radio-femoral delayCRT <2 sec in all four limbs
Neurology intact
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Basic IxUrine 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….
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CTA11 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.
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ManagementCross-matched 6 units, fluid resuscitationUrgent angiogram…
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Angiogram & EmbolisationLA, 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.
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SEGMENTAL ARTERIAL MEDIOLYSIS
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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 literatureAbdominal visceral arteries, intracranial arteriesAetiology unknown
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SEGMENTAL ARTERIAL MEDIOLYSIS
Presentation – intra-abdominal/intracranial haemorrhageasymptomatic on routine investigationspost-mortem
Diagnosis – radiological – arterial dilatation, single/multiple aneurysms,
stenoses/occlusion, dissectionhistological – surgical resection, post-mortem
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Literature review, 1976-201262 studies, 85 cases69% confirmed histologically (24% on autopsy)M:F – 1.5:1Age range 0-91 (median 57)21% had history of hypertension13% mortality before further investigation/managementOverall mortality 25%Management – open vs endovascular
SEGMENTAL ARTERIAL MEDIOLYSIS
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SummarySAM 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 surgeryCan also be a temporary measure before definite surgery at a
later stage
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ReferencesSlavin, 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.