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Purpose of review: Spontaneous and isolated visceral artery dissections (VAD) are rare but potentially life-threatening conditions that occur when there is a tear or separation of the inner lining of the blood vessels that supply the organs of the abdomen. This includes the celiac artery, superior mesenteric artery (SMA), and renal arteries leading to ischemia and infarction of the affected organs. We will discuss the natural history of VAD and management options with a focus on recent literature. Recent findings: Recent case series and meta-analyses indicate that VAD is a condition with overall low mortality that can be managed conservatively with observation, antiplatelet therapy, and/or anticoagulation. Few patients will require revascularization via endovascular and surgical intervention. Additionally, emerging data suggests that systematic imaging to evaluate for multiple artery aneurysm, dissection, and/or fibromuscular dysplasia (FMD) may help to prognosticate the patient's risk for additional dissection events or identify those that will benefit from further evaluation with genetic testing for heritable arteriopathy. Summary: For a majority of VAD patients, the available data suggest that symptoms resolve and dissections heal with medical management alone. In cases of on-going ischemia or symptoms, revascularization can be done safely and effectively. Patients should undergo evaluation for other signs and symptoms of systemic arteriopathy with imaging, and if appropriate genetic testing for heritable arteriopathies. [ABSTRACT FROM AUTHOR]

Fibromuscular dysplasia (FMD) is a vascular disease characterized by abnormal arterial wall architecture, usually visualized angiographically as the classic “string of beads” sign. We present the diagnostic dilemma of a 51-year-old woman admitted for a spontaneous renal infarct, with initial examination and investigations equivocal. She was consequently assessed for thromboembolic and vasculitic disease, before proceeding to digital subtraction angiography (DSA). This invasive method elucidated an area of focal FMD, previously not seen on computed tomography angiography (CTA). This is unusual due to CTA's high sensitivity and specificity but could be attributed to the less common subtype of FMD which requires combined imaging modalities to arrive at a diagnosis. Hence, there may be a role for the dual use of CTA and DSA in young patients presenting with a spontaneous renal infarct in the absence of other diagnoses.

Visceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement. VBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models. A total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P <.001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P <.001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P <.001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P <.001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P <.001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P =.001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P =.001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P =.004) were associated with inferior intervention-free survival. Isolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance. [ABSTRACT FROM AUTHOR]

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A strange case of renal colicWe present a case of a 42-year-old man with aortic and renal artery dissections presenting with symptoms of renal colic. The patient went twice to the emergency department during a 2-day period due to severe pain originating in the right flank and radiating both inferiorly and anteriorly. The patient's initial presentation can be misleading since the symptoms fit with the features of a renal colic. Ultrasound, a first-line examination for evaluation of vascular injuries, and Computed Tomography scans confirmed the appropriate diagnosis. A high degree of suspicion, an early identification, and surgical intervention can help reduce the high incidence of mortality in these cases. In all cases of loin pain, especially in the elderly patient, the possibility of a leaking abdominal aneurysm must be considered. Aortic dissection is a surgical emergency associated with very high morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Renal artery dissection is a condition that has been associated with traumatic injuries and connective tissue disorders. It has been managed in the past by multiple methods because there is no standard treatment, including vascular intervention with angioplasty and stenting, anticoagulation/antiplatelet therapy, and hypertension management.Case Presentation: We present a case of a spontaneous renal artery dissection in a 55-year-old white man with no traditional risk factors who presented twice to our emergency department in a 2-day period with different symptoms; on his first presentation he presented with symptoms consistent with renal colic and on the second visit he presented with symptoms consistent with aortic dissection.Conclusions: Our patient was treated with endovascular stent placement by interventional radiology, heparin infusion, and admission to our medical intensive care unit. Our review here highlights the varied management of this diagnosis for which there is no standard treatment and decisions are made in conjunction with consultants. [ABSTRACT FROM AUTHOR]

Background Spontaneous renal artery dissection (SRAD) is a rare entity of unknown etiology. We aimed to study the clinical course and outcomes and compare the characteristics of patients with SRAD with those of the general population. Methods All cases of isolated renal artery dissection diagnosed at the University of Michigan Hospitals between January 2000 and July 2012 were identified by the ICD-9 code. Cases were matched by age, gender and race with individuals from the 2009–2010 National Health and Nutrition Examination Survey (NHANES). Characteristics and awareness of comorbid conditions were compared. Information about the clinical course after diagnosis was retrieved from the case group to ascertain their outcomes. Results Overall, 17 patients with SRAD with a mean age of 38.6 years (SD = 8.3) were identified. Eleven patients were male and 14 were white. The most common presenting symptom was excruciating sudden-onset flank pain ipsilateral to the site of dissection. Fibromuscular dysplasia, Ehlers–Danlos and polyarteritis nodosa were present in 4, 4 and 1 patients, respectively. After adjusting in a multivariable model, the case group was more likely to report history of hypertension, cancer and connective tissue disorders (P < 0.001), and less likely to have obesity (BMI ≥30 kg/m2) compared with the general population. Supportive medical treatment, endovascular intervention and surgery were required in 8, 5 and 4 cases, respectively. After discharge from the hospital, hypertension was adequately controlled in all the patients but one. Conclusion SRAD may be part of a syndrome having multi-organ involvement. With appropriate medical or surgical management, long-term clinical outcome appears favorable. [ABSTRACT FROM AUTHOR]

We present a case of bilateral renal artery dissection, with the related computed tomographic images, caused by blunt torso trauma. Discussion includes the etiologies of this type of injury, the diagnostic modalities, and treatment options. [ABSTRACT FROM PUBLISHER]

A 38-year-old, previously healthy man presented with flank pain after competing in a marathon. Initial laboratory tests and urinalysis were essentially normal. Both contrast enhanced—computed tomography and magnetic resonance angiography showed an infarcted region of the left lower kidney without renal artery dissection. Thromboembolism was suspected, but further testing was negative. The diagnosis of renal artery dissection was established by angiogram, showing dissection of the segmental branch. The patient remained normotensive, maintained normal renal function, and had resolution of pain symptoms prior to discharge. On the basis of our experience and review of the literature, renal artery dissection occurs in otherwise healthy men and often goes undiagnosed. The management strategy tends to be conservative unless the patient develops progressive decline in renal function or worsening hypertension, with an excellent prognosis. This case also shows the importance of discussing the pros and cons of extreme physical exertion with all patients. [ABSTRACT FROM AUTHOR]

A 31-year-old, previously normotensive healthy man developed right flank pain and was admitted to a medical service. Right renal infarction was suspected by enhanced abdominal computed tomography (CT) and arteriography. Fourteen days after the onset, he was transferred to the Oita University Hospital, Oita, Japan. Renal angiography revealed an isolated renal artery dissection causing renal atrophy due to main stem narrowing of the right renal artery. Renogram and renal scintigram with99mTc-diethylene triamine pentaacetic acid revealed a remarkable decline in the glomerular filtration rate and almost no uptake in the right kidney. Four months later, in spite of our belief that functional recovery could not be expected, intravenous pyelography and enhanced abdominal CT scans revealed a functioning right kidney that had spontaneously recovered from the renal artery dissection through conservative management. [ABSTRACT FROM AUTHOR]

Spontaneous renal artery dissection is rare and may be misdiagnosed because its clinical presentation is confusing. Diagnosis is usually made by intra-arterial angiography. We report a case where a spontaneous renal artery dissection was initially misdiagnosed as a renal abscess. Diagnosis was made later with helical CT for suspicion of renal artery stenosis in a patient with recent onset of hypertension. This unusual case shows that helical CT can be useful for non-invasive diagnosis of renal artery dissection. [ABSTRACT FROM AUTHOR]

Objective: To describe a rare case of a renal artery dissection presenting as new-onset hypertension and severe flank pain during an IVF/intracytoplasmic sperm injection (ICSI) cycle. Design: Case report. Setting: Private, university-affiliated infertility clinic. Patient(s): A previously healthy 39-year-old woman with secondary infertility undergoing her second IVF/ICSI cycle. Intervention(s): Renal artery angioplasty and medical management with multiple antihypertensive agents. Institutional review board approval was not applicable and therefore not obtained. Main Outcome Measure(s): Control of hypertension. Result(s): The patient presented with severe flank pain and new-onset severe hypertension on day 5 of ovarian stimulation for IVF/ICSI. At that time her estrogen level was 685 pmol/L. An ultrasound examination showed evidence for infarction of the upper pole of the right kidney, and an angiogram revealed a right renal artery dissection. Blood pressure was eventually controlled after renal artery angioplasty and initiation of multiple antihypertensive agents. Conclusion(s): This is the first report of a renal artery dissection presenting during ovarian stimulation for IVF/ICSI. There were no hemodynamic or serum estrogen changes that could explain a link between the IVF process and the renal artery dissection. [Copyright &y& Elsevier]