1. Block 8 M&M Ali Dadla & Robert Lew 2/14/14 Ali Dadla & Robert Lew 2/14/14

2. 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

3. 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 Morbidity & Mortality Conference

4. Every Defect is a Treasure 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

5. 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

6. 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

8. Hepatic artery dissection Robert Lew and Ali Dadla

9. 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.

10. 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]

11. Splanchnic artery overview

12. Celiac trunk diagram

13. Risk factors: Atherosclerotic disease HTN Prior abdominal surgeries Peritonitis Fibromuscular dysplasia Trauma Pregnancy Connective tissue disorder/Cystic Medial Necrosis Ref [1-6]

14. 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]

15. 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

16. 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

17. 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]

19. 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 Ref[7]

20. 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 Ref[4,6] Options:Coil embolization/Endovascular stent/simple ligation as collateral circulation to the liver is adequate/vascular reconstruction.

21. 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]

22. Summary Splanchnic artery dissections occur most commonly in the SMA with few case reports on Hepatic artery dissection Commonly occurs in males in the 6 th 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

23. References 1M.F. Muller, D. Kim Spontaneous dissection of the hepatic artery Abdom Imaging, 20 (1995), pp. 462–465 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. 776–779 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. 153–157J.D. Woolard, A.D. Ammar Spontaneous dissection of the celiac artery: a case report J Vasc Surg, 45 (2007), pp. 1256–1258 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. W506–W511 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. 105–109 7.Isolated spontaneous dissection of the splanchnic arteries.T Takayama ert al Journal of vasular surgery Journal 48

24. Thank You!