Traumatic dissection of the coeliac artery and splenic injury following blunt trauma

Abstract

An 18-year-old male patient presented to our regional referral hospital postcollapse at home. This was about 48 hours following a 2 m fall from a mountain bike. CT scan at presentation showed a grade 3/4 laceration at the splenic lower pole with some haemoperitoneum. He was managed conservatively. However, on day 4 he developed increasing abdominal pain which prompted repeat CT abdominal angiography. This scan did not show any further active bleeding from the spleen, however, a coeliac artery dissection was discovered, which was not evident on the first scan. After liaison with the vascular surgery team at a tertiary hospital, this was treated conservatively. Coeliac artery dissection following blunt trauma is an extremely rare occurrence, with fewer than 10 cases described in the literature. To our knowledge, this is the first case of concurrent splenic injury and coeliac artery dissection following blunt trauma to be reported.

Background

Coeliac artery dissection following blunt trauma is an extremely rare occurrence, with fewer than 10 cases described in the literature.^1–6 Concurrent splenic injury and coeliac artery dissection following blunt trauma has not previously been reported in the literature. To our knowledge, we present the first known case of a patient with concurrent splenic injury and coeliac artery dissection following blunt trauma. We feel it is important to make aware that a delayed second major vessel injury can occur in cases of blunt trauma.

Case presentation

An 18-year-old male patient presented to a local hospital, 24 hours after a 2 m fall from a mountain bike with pain in his left lower chest. A chest X-ray performed was unremarkable, and he was discharged. The following day he collapsed at home and was transferred to the Emergency Department of our hospital, a major regional referral centre. After initial resuscitation and positive Focused Assessment with Sonography for Trauma (FAST), our patient was taken for a CT chest, abdomen and pelvis with both portal venous phase and arterial phase, demonstrating a large subcapsular haematoma around the spleen with grade 3/4 lower pole injury (figure 1).

Figure 1.

CT abdomen on presentation demonstrating grade 3/4 laceration at the lower pole of the spleen.

Our patient was transferred to high dependence unit with strict bed rest and twice daily haemoglobin check. He remained haemodynamically stable and his haemoglobin remained relatively stable staying above 90 g/L and he was soon transferred to the ward. However, on day 4 of his admission, he reported worsening of his abdominal pain, which prompted a repeat CT abdomen with arterial and portal venous phase to look for further splenic bleeding/pseudoaneurysm.

Investigations

The first CT scan on presentation to our hospital demonstrated a large subcapsular haematoma around the spleen and a grade 3/4 laceration at the lower pole. A moderate volume haemoperitoneum was noted. The subsequent scan on day 4 did not show any further splenic active bleeding, although there was suspicion of a small pseudoaneurysm of the spleen. More significantly, coeliac axis trunk dissection was noted (figure 2).

Figure 2.

CT abdomen on day 4 of admission demonstrating coeliac artery dissection.

On further review of the initial CT abdomen on presentation to our institution, the coeliac axis was patent with no dissection (figure 3), which suggests the development of coeliac artery dissection over the course of the hospital admission. There was adequate cross-perfusion from the superior mesenteric artery via collaterals, and liver function tests remained normal throughout.

Figure 3.

CT abdomen on presentation demonstrating a patent coeliac artery.

Treatment

His case was discussed with the vascular surgery team at the tertiary hospital for advice. It was thought that endovascular intervention may lead to further tearing of the intimal wall, and given the good collateral blood supply, it was opted for further conservative management, with a recommendation of no contact sports or extreme sports lifelong given that the coeliac artery was being perfused solely on collateral blood supply.

Given the concurrent splenic injury, antiplatelet and anticoagulation treatment would also be ill advised given the risk of rebleeding from the splenic injury site with such treatment. As such, he remained for strict bed rest and no further intervention throughout the rest of his hospital stay until discharge and for avoidance of contact sports and extreme sports with risk of blunt trauma lifelong given the risk of ischaemia given that the coeliac artery was only perfused by collateral blood supply.

Outcome and follow-up

Our patient discharged after a week’s stay in the hospital. He later re-presented to the regional hospital a week after this with more abdominal pain in the left upper quadrant, in conjunction with left shoulder pain and shortness of breath and was transferred again to our hospital. A moderate left sided plural effusion was evident on chest X-ray and CT chest, and abdomen angiography was performed which further demonstrated associated atelectasis/contusion of the left lower lobe of the lung parenchyma. Left shoulder X-ray showed no evidence of fracture. Lipase was normal and there was no evidence of traumatic pancreatitis on ultrasound abdomen or CT abdomen. No further bleed from the splenic haematoma was present at this time, and after resolution of the pain he was soon discharged, although the coeliac artery abnormality persists (figure 4).

Figure 4.

CT abdomen 1 week postdischarge demonstrating persistence of the coeliac artery dissection.

Discussion

Coeliac artery dissection following blunt trauma is an extremely rare occurrence, with fewer than 10 cases described in the literature.^1–6 The superior mesentery artery is the most common location for blunt abdominal vascular injury, while coeliac artery injury is uncommon, accounting for 1%–2% of vascular lesions.^{1 5} As such, many surgeons have not gained much experience in dealing with this injury and optimal management is contentious. Various treatments have been described, varying from no treatment, to aspirin, heparin or endovascular self-expanding stents.

Abdominal pain is a common symptom of coeliac artery dissection and often begins several days after the initial injury.⁶ The initial trauma likely resulted in mural injury without radiological abnormalities. The patient’s abdominal pain on day 4 likely resulted from evolving severity of the dissection, which ultimately became evident on CT.⁵ Coeliac artery dissection may be a delayed presentation following blunt trauma and repeat CT scan may be recommended if there is worsening of abdominal pain. We believe it is suitable to repeat CT scanning in this patient whenever he develops significant abdominal pain which does not quickly improve due to the possibility of ischaemia of organs perfused solely on collateral blood supply from the superior mesenteric artery.

Early observation is important to observe for ischaemic complications including hepatic failure or multiple organ ischaemia following coeliac artery dissection. Late aneurysmal change may also complicate coeliac artery dissection, and is detected in 6% of patients with conservatively managed spontaneous coeliac artery dissections.⁷ Repair is generally necessary when the aneurysm is over 2–3 cm in size. Most aneurysmal changes after traumatic coeliac artery dissection occur within 2 months,⁷ but they have also been detected as late as the fourth year,⁸ which highlights the importance of long-term follow-up for patients with coeliac artery dissection.⁶

To our knowledge, this is the first report of coeliac artery dissection following blunt trauma in conjunction with splenic injury. Although our patient initially was admitted to our hospital with splenic injury, the initial CT angiography showed patent coeliac trunk, and he was treated as per an isolated splenic injury. We believe that a high index of suspicion should occur if there is an increase in pain after admission and repeat CT angiography, to both look for further splenic bleeding and for other vascular injuries, which may have a delayed presentation as described in other cases in the literature.

Learning points.

• Coeliac artery dissection following blunt abdominal trauma is rare but a high index of suspicion is required, even if splenic injury is present which can account for the pain.

• Coeliac artery dissection may not be evident on initial CT abdominal angiography and repeat CT scanning may be required.

• Given the rarity of coeliac artery dissection, there is little consensus regarding treatment, ranging from no treatment, aspirin, heparin, or endovascular self-expanding stents. However, in the setting of concurrent splenic injury, aspirin or heparin would be ill advised.