Robotic system-assisted endovascular treatment of a dissection-related pseudoaneurysm of the celiac axis secondary to fibromuscular dysplasia

摘要

Spontaneous celiac artery dissection caused by fibromuscular dysplasia is rare. Subsequent thrombosis and occlusion of the celiac trunk can result in intestinal ischemia and hepatic failure. We describe a case of spontaneous celiac artery dissection with an associated pseudoaneurysm caused by fibromuscular dysplasia, extending into the common hepatic artery. An endovascular intervention featuring robotic-assisted celiac artery cannulation with stent-assisted coil embolization resulted in successful treatment. Spontaneous celiac artery dissection caused by fibromuscular dysplasia is rare. Subsequent thrombosis and occlusion of the celiac trunk can result in intestinal ischemia and hepatic failure. We describe a case of spontaneous celiac artery dissection with an associated pseudoaneurysm caused by fibromuscular dysplasia, extending into the common hepatic artery. An endovascular intervention featuring robotic-assisted celiac artery cannulation with stent-assisted coil embolization resulted in successful treatment. Spontaneous celiac artery dissection caused by fibromuscular dysplasia (FMD) is a rare entity.1Olin J.W. Sealove B.A. Diagnosis, management, and future developments of fibromuscular dysplasia.J Vasc Surg. 2011; 53: 826-836Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar The condition can be asymptomatic, but the most common presenting symptom is abdominal pain.1Olin J.W. Sealove B.A. Diagnosis, management, and future developments of fibromuscular dysplasia.J Vasc Surg. 2011; 53: 826-836Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 2Neychev V. Krol E. Dietzek A. Unusual presentation and treatment of spontaneous celiac artery dissection.J Vasc Surg. 2013; 58: 491-495Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Pascual A. Bush H.S. Copley J.B. Renal fibromuscular dysplasia in elderly persons.Am J Kidney Dis. 2005; 45: e63-e66Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar We describe robotic-assisted endovascular treatment of a pseudoaneurysm secondary to spontaneous celiac artery dissection. The patient consented to the publication of this report. An 81-year-old woman presented to our institution because of abdominal pain radiating to the back for 5 months. The patient was empirically prescribed a proton pump inhibitor; however, her symptoms did not subside. She denied any history of trauma. She was normotensive and afebrile. Physical examination revealed mild epigastric tenderness. Results of laboratory tests, including a complete blood count, liver function, and metabolic profiles, were within normal limits. Computed tomography angiography revealed a spontaneous celiac artery dissection with an associated pseudoaneurysm (Fig 1). The pancreas, aorta, and superior mesenteric artery appeared normal. Given her symptoms, age, and comorbidities, angiography was performed in hopes of treating the aneurysm endovascularly. Angiography showed a spontaneous celiac artery dissection extending into the common hepatic artery (HA) with an associated 1.0- × 2.0-cm pseudoaneurysm (Fig 2). Both renal arteries were patent, but there was a typical string of beads appearance of the right renal artery and irregularities in the right HA, compatible with FMD. After selection of the celiac artery with a 5F Cobra 2 catheter, a 0.035-inch stiff wire was positioned distally in the common HA. Multiple attempts were made to advance a vascular sheath into the origin of the celiac axis (to achieve stability at the target site and to guide subsequent treatment) but failed as a result of her steeply angulated celiac axis. The decision was made to stop the procedure and to repeat with robotic assistance. During this attempt, the 9F Magellan robotic system (Hansen Medical, Mountain View, Calif) was used in combination with a 0.035-inch hydrophilic-coated guidewire (Glidewire; Terumo, Somerset, NJ) to catheterize the celiac axis. The ability to manipulate the angle and