Block 8 M

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Block 8 MM

• Ali Dadla Robert Lew
• 2/14/14

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Morbidity Mortality Conference

• It is for the department faculty and residents to
  peer review case(s) from the inpatient service.
• The primary objective is to improve overall
  patient care focusing on quality of care
  delivered, performance improvement, patient
  safety and risk management.
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Morbidity Mortality Conference

• Goals
• To review recent cases and identify areas for
  improvement for (all) clinicians involved
• Patient complications deaths are reviewed with
  the purpose of educating staff, residents and
  medical students.
• To identify system issues, which negatively
  affect patient care
• To modify behavior and judgment and to prevent
  repetition of errors leading to complications.
• To assess all six ACGME competencies and
  Institute of Medicine (IOM) Values in the quality
  of care delivered
• Conferences are non punitive and focus on the
  goal of improved and safer patient care
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Morbidity Mortality Conference

• Every Defect is a Treasure
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Every Defect is a Treasure

• Errors are due to
• Processes 80
• Individuals 20
• Translate all error into education
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Every Defect is a Treasure

• I request those that may recognize and may have
  been involved in the care of patients being
  presented not to take the discussion personally
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Hepatic artery dissection

• Robert Lew and Ali Dadla

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Objective

• Hepatic artery dissection is very rare with a few
  case reports. This was the only significant
  finding during autopsy on our patient.
• The objective is to briefly review the clinical
  features and diagnostics from those case reports
  to see how they compare to our case and whether
  the autopsy finding was incidental.

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• Isolated artery dissection outside the aorta has
  been reported mostly in the carotid and renal
  arteries
• Isolated spontaneous dissection of a splanchnic
  artery is a rare condition and most papers are
  case reports on SMA dissection with those on
  celiac and hepatic artery dissection being even
  rarer 1-6

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Splanchnic artery overview
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Celiac trunk diagram
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Risk factors

• Atherosclerotic disease
• HTN
• Prior abdominal surgeries
• Peritonitis
• Fibromuscular dysplasia
• Trauma
• Pregnancy
• Connective tissue disorder/Cystic Medial Necrosis
• Ref 1-6

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• In one study by Sparks et al who reviewed 29
  cases of SMA dissection 88 cases occurred in men
  with an average age of 55 years.6

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• Pseudoaneurysm of the hepatic artery an extremely
  rare complication of manipulation of the hepatic
  artery vasculature during abdominal surgery
• Ref E.Otah et al Visceral artery pseudoaneurysms
  following pancreatoduodenectomy Archives of
  Surgery Vol 137 no.1 pp 55-59,2002

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Symptoms

• Acute abdominal pain is the most common symptom
• Hepatic artery dissection can present as
  abdominal pain,dyspepsia or jaundice.
• Ref N.Tulsyan et al The endovascular management
  of visceral artery aneurysms and pseudoaneurysms
  Journal of vascular surgery Vol.45 no.2
  pp276-283,2007

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Imaging

• Most authors consider Contrast enhanced CT to be
  the imaging of choice but at times USG with
  Doppler imaging has identified splanchnic artery
  dissections.1-3

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Rx

• For uncomplicated asymptomatic lesion even if
  patient had abdominal pain at admission
• Anticoagulant INR 2-3/antiplatelet for 3-6 months
• Strict BP control
• Imaging surveillance Ref7

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Surgery?

• Increasing fusiform,saccular aneurysm or arterial
  rupture
• Thrombosis of true lumen
• Persistent pain besides anticoagulation
• Occlusive lesions jeopardizing the lower
  digestive tract
• Liver ischemia Ref4,6
• OptionsCoil embolization/Endovascular
  stent/simple ligation as collateral circulation
  to the liver is adequate/vascular reconstruction.

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• Of note in a study with 19 pts who had isolated
  spontaneous splanchnic artery dissection with a
  median of 2 years of follow up none had expansion
  or progression of the false lumen on f/u imaging
  with CT abdo or USG.7

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Summary

• Splanchnic artery dissections occur most commonly
  in the SMA with few case reports on Hepatic
  artery dissection
• Commonly occurs in males in the 6th decade of
  life
• Hepatic artery dissection can present as
  abdominal pain,dyspepsia and jaundice
• Treatment is mostly medical with BP control and
  possibly anticoagulation
• Surgery is indicated if there is risk of arterial
  rupture,incessant pain or ischemic damage to
  organs

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References

• 1M.F. Muller, D. Kim Spontaneous dissection
  of the hepatic artery Abdom Imaging, 20 (1995),
  pp. 462465
• 2.H. Yasuhara, H. Shigematsu, T. Muto
  Self-limited spontaneous dissection of the main
  trunk of the superior mesenteric artery J Vasc
  Surg, 27 (1998), pp. 776779
• 3. Suzuki, S. Furui, H. Kohtake, T.
  Sakamoto, M. Yamasaki, A. Furukawa et al.Isolated
  dissection of the superior mesenteric artery CT
  findings in six cases
• 4.Abdom Imaging, 29 (2004), pp. 153157J.D.
  Woolard, A.D. Ammar Spontaneous dissection of the
  celiac artery a case report J Vasc Surg, 45
  (2007), pp. 12561258
• 5.N. D'Ambrosio, B. Friedman, D. Siegel, D.
  Katz, A. Newatia, J. HinesSpontaneous isolated
  dissection of the celiac artery CT findings in
  adultsAJR Am J Roentgenol, 188 (2007), pp.
  W506W511
• 6.S.R. Sparks, J.C. Vasquez, J.J. Bergan,
  E.L. Owens Failure of nonoperative management of
  isolated superior mesenteric artery dissection
  Ann Vasc Surg, 14 (2000), pp. 105109
• 7.Isolated spontaneous dissection
  of the splanchnic arteries.T Takayama ert al
  Journal of vasular surgery Journal 48

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Thank You!