Jpn J Radiol (2009) 27:430–437
DOI 10.1007/s11604-009-0366-8
ORIGINAL ARTICLE
Imaging findings and management of isolated dissection of
the visceral arteries
Hiroyuki Tokue · Yoshito Tsushima · Keigo Endo
Received: February 22, 2009 / Accepted: August 16, 2009
© Japan Radiological Society 2009
Abstract
Purpose. To describe clinical and computed tomography
(CT) findings of isolated dissection of the visceral arter-
ies (IDVA).
Materials and methods. We retrospectively analyzed
clinical presentation and abdominal CT findings of 38
patients who were diagnosed as having an IDVA. IDVA
were classified into three types based on CT findings:
patent false lumen with re-entry (type I), patent false
lumen without re-entry (type II), and completely throm-
bosed false lumen (type III).
Results. The dissection was located in the superior mes-
enteric artery (SMA) in 27 patients, celiac artery (CA)
in 6, CA to splenic artery in 2, and common hepatic
artery (CHA), CA to CHA, and inferior mesenteric
artery (IMA) in 1 patient each. The dissection was clas-
sified into type I in 8 patients, type II in 12, and type III
in 18. Surgical treatment was performed in 1 patient with
type II SMA dissection because of bowel ischemia,
although the remaining 37 patients were managed con-
servatively. Two cases with type II showed a progressive
enlargement of the false lumen in follow-up CT. Increased
density of the fat tissue around the affected visceral
artery was more commonly seen in symptomatic patients
compared to asymptomatic ones (P < 0.01).
H. Tokue (*) · Y. Tsushima · K. Endo
Department of Diagnostic and Interventional Radiology,
Gunma University Hospital, 3-39-22 Showa-machi, Maebashi
371-8511, Japan
Tel. +81-27-220-8401; Fax +81-27-220-8409
e-mail: tokue@s2.dion.ne.jp
Conclusion. Based on our observation, patients with
IDVA can be managed conservatively when there are no
signs indicating organ ischemia.
Key words Isolated dissection · Visceral artery ·
Superior mesenteric artery (SMA) · Celiac artery ·
Computed tomography (CT)
Introduction
Isolated dissection of the visceral artery, which is not
associated with aortic dissection, is a relatively rare con-
dition. The superior mesenteric artery (SMA) is most
commonly affected, followed by the celiac artery (CA)
or common hepatic artery (CHA).1,2 The initial manifes-
tation is usually acute abdominal pain, which is sus-
pected to be the result of ischemic change of abdominal
organs or intraperitoneal hemorrhage secondary to
simultaneous rupture of the affected artery. The dissec-
tion itself may also be related to the symptom, because
inflammatory response around the dissected visceral
artery stimulates the visceral nerve plexus.3 Etiological
factors include arteriosclerosis, arterial media degenera-
tion, trauma, mycosis, arteriopathies, periarterial inflam-
mation in association with cholecystitis or pancreatitis,
fibromuscular hyperplasia, and pregnancy. In many
cases, however, no definitive pathogenesis was con-
firmed,4 and the clinical and imaging findings, and out-
comes, of this life-threatening disease, have not been
fully understood.
We investigated clinical and computed tomography
(CT) findings of isolated dissection of the visceral arter-
ies and proposed our CT classification, which may be
associated with clinical course and outcome.
Jpn J Radiol (2009) 27:430–437 431

Materials and methods
We retrospectively reviewed the clinical presentation,
CT findings, and outcomes of 38 patients who were diag-
nosed as having an isolated dissection of the visceral
arteries from 2004 to 2008 in our hospital. Case search
was performed by one of the authors on the computer-
based reporting system of the radiology department
using the keyword “dissection” and its Japanese name,
and 38 patients with 38 visceral artery dissections but
without aortic dissection were discovered.
In all 38 patients, unenhanced and contrast-enhanced
CT of the whole abdomen were performed. In our hos-
pital, contrast-enhanced CT has been performed after an
intravenous bolus injection of 100 ml nonionic iodinated
contrast media (iopamidol, 300 mg I/ml; Iopamiron,
Bayer Yakuhin, Tokyo, Japan) at a rate of 3 ml/s. Scan-
ning was initiated approximately 30 or 60 s after the
initiation of the bolus injection of contrast media.
All patients underwent CT examination by 8- or 64-
multidetector computed tomography (MDCT).
The diagnosis of visceral artery dissection was made
when one of the following signs was observed on CT: (a)
an intimal flap was identified in the artery and a false
lumen was enhanced (double-barreled dissection), or (b)
a crescent-shaped area along the wall of the visceral
artery was identified and it was not enhanced (dissection
with thrombosed false lumen). Disease location was clas-
sified into SMA, CA, CHA, CA to splenic artery, CA to
CHA, and inferior mesenteric artery (IMA). Isolated
visceral arterial dissections were classified into three
types based on CT findings: type I, patent false lumen
with re-entry; type II, patent false lumen without re-
entry; and type III, completely thrombosed false
lumen.
Any associated findings were also investigated, such
as an increased density of the fat tissue around the
affected arteries (dirty fat sign), hematoma, bowel wall
thickening (edema), lack of bowel wall enhancement,
and solid organ infarction. If necessary, three-dimen-
sional CT images or thin-slice CT data were reviewed.
Also, we reviewed more detailed analysis of CT images
in cases with SMA dissection, including extension of
dissection (proximal or distal), branch vessel involve-
ment, degree of luminal stenosis, and bowel wall
enhancement.
Data were expressed by mean ± standard deviation
(SD). The Student t test and χ2 test were used for statisti-
cal analyses, and a P value < 0.05 was considered sig-
nificant. Our institutional review board did not need
informed consent of the patients in such a retrospective
analysis.
Results
Patient characteristics and CT findings of the 38 patients
(32 men, 6 women; age, 61 ± 11 years old; range, 39–78)
with 38 isolated visceral artery dissections are summa-
rized in Table 1. Twenty-four patients were asymptom-

Table 1. Patient characteristics and computed tomography (CT) findings of the 38 patients
with 38 isolated visceral artery dissections
Type of dissection

Patient characteristics and CT findings Type I Type II Type III P value

No. of patients (male/female) 8 (8/0) 12 (9/3) 18 (15/3) 0.32

Age (mean ± SD) 62 ± 12 60 ± 12 62 ± 10 0.80
No. of symptomatic patients 2 (25%) 7 (58%) 5 (28%) 0.17
Associated diseases
Systemic hypertension 3 3 5 0.82
Hyperlipidemia 0 3 0 0.03
Diabetes mellitus 0 3 1 0.31
Cardiac disease 0 3 4 0.11
Occlusive vascular disease 3 2 1 0.13
Disease location
SMA 7 5 15 0.08
CA or/and its branches 1 6 3
IMA 0 1 0
Positive dirty fat sign 1 (13%) 5 (42%) 3 (17%) 0.20
Changes in CT findings in follow-up CT 0.29
No change 8 7 16
Shrinkage of the false lumen 0 3 2
Expansion of the false lumen 0 2 0
Follow-up months (mean ± SD) 27 ± 14 11 ± 14 23 ± 19 0.06
SMA, superior mesenteric artery; IMA, inferior mesenteric artery
432 Jpn J Radiol (2009) 27:430–437

a b

Fig. 1. A 46-year-old man with acute abdominal pain and an iso- mal splenic artery (arrows) with dirty fat sign around the celiac
lated celiac artery (CA) dissection (type I). a Enhanced computed axis (arrowheads). b Three-dimensional volume rendering image
tomography (CT) showed extension of dissection into the proxi- showed entry and re-entry sites (arrows)

Table 2. Comparison between symptomatic and asymptomatic patients

Clinical symptoms at the initial
diagnosis of the dissection

Symptomatic Asymptomatic P value

No of patients (male/female) 14 (11/3) 24 (21/3) 0.47

Age (mean ± SD, years) 52 ± 10 66 ± 7 0.99
Disease location 0.07
CA and its branches 6 4
SMA 7 20
IMA 1 0
Positive dirty fat sign 7 (50%) 2 (8%) <0.01
Changes in CT findings in follow-up CT <0.01
No change 7 24
Shrinkage of the false lumen 5 0
Expansion of the false lumen 2 0
Follow-up months (mean ± SD) 14 ± 17 23 ± 18 0.94
CA, celiac artery; SD, standard deviation

atic when the diagnosis of the visceral artery dissection
was made, and they were incidentally discovered by
enhanced CT scans that were performed for other pur-
poses. In 14 symptomatic patients, the diagnosis of
an isolated visceral artery dissection was made with
enhanced CT within 24 h of the onset, and their initial
complaints were acute severe abdominal pain in 12 and
vague abdominal pain in 2. Eleven patients (29%) had
systemic hypertension, 7 (18%) had cardiac disease, 6
(16%) had occlusive vascular disease, 4 (11%) had dia-
betes mellitus, and 3 (8%) had hyperlipidemia. There was
no significant differences in these patients’ characteris-
tics among dissection types.
Isolated visceral artery dissection was delineated at
SMA in 27 patients, CA in 6, CA to splenic artery in 2,
and CHA, CA to CHA, and IMA in 1 each. On an
enhanced CT, an intimal flap was identified in 20 patients
(53%; types I and II; Figs. 1–3) and false lumen was
completely thrombosed in 18 patients (47%; type III;
Figs. 4, 5). In all of the 20 patients with type I or II dis-
section, an entry was confirmed at 1–6 cm distal from
the root of the visceral artery.
Increased density of the fat tissue around the affected
visceral artery (dirty fat sign) was observed in nine
patients (24%). This sign was more commonly seen in
symptomatic patients (P < 0.01) compared to asymp-
tomatic ones (Table 2), and was seen in all three cases
of dissection extending into the adjacent splenic or prox-
imal hepatic arteries.
In one 64-year-old female patient with symptomatic
type II SMA dissection (Fig. 6), the small bowel was
partially dilated and its wall was not enhanced, sugges-
tive of bowel ischemia. She underwent an urgent lapa-
rotomy, and her postoperative course was uneventful
Jpn J Radiol (2009) 27:430–437 433

Fig. 2. A 52-year-old woman

with acute abdominal pain
and an isolated superior
mesenteric artery (SMA)
dissection (type II). a
Enhanced CT showed a false
lumen with an aneurysm-like
outpouching (arrow). b
Conventional angiography
confirmed the findings
(arrow). c, d After 1 month,
the outpouching was
expanded (arrowhead).
However, the patient was
conservatively followed up
because there was no sign of
bowel ischemia.
Subsequently, the false
lumen had shrunk (not a c
shown)

b d

during the follow-up period of 30 months. Twenty-eight
patients (74%) were initially managed conservatively
without any medication, and 9 patients (24%) were
managed with antihypertensive drugs. A 45-year-old
male patient with acute abdominal pain showed type II
CA dissection, which extended to the splenic artery
resulting in splenic infarction (see Fig. 3). However, this
patient was conservatively managed. The mean follow-
up duration after the initial diagnosis of the visceral
artery dissection was 20 ± 18 months (range, 2–60), and
all patients were alive at the time of the last follow-up.
Follow-up CT studies showed no morphological
changes in 31 visceral artery dissections (82%). The
expansion of the false lumen was observed in two patients
with type II dissections (5%) despite a relatively short
follow-up. These patients did not receive anticoagulant
therapy. In three patients with type II dissection and two
patients with type III dissection, shrinkage of the false
lumen was observed (see Table 1). Three patients showed
a change in type during the follow-up period (see Table
3, Figs. 4, 5).
Table 4 presents detailed analysis of CT images and
outcome in 27 cases with isolated SMA dissection: 17
(63%) were proximal entry site, 18 (67%) were branch
vessel involvement, 11 (41%) were lumen stenosis, and
26 (96%) were bowel wall enhancement. Given the low
434 Jpn J Radiol (2009) 27:430–437

sample size, we were unable to perform a statistical anal-

ysis to find a correlation between CT characteristics with
isolated SMA and outcomes.

Discussion

From our results, we concluded it may be better to

a
b
Fig. 3. A 45-year-old man with acute abdominal pain and an iso-
lated CA dissection (type II). a Enhanced CT showed an isolated
dissection of the CA to the splenic artery. There was a partial
infarction of the spleen (arrowhead). The splenic arterial branches
at the hilum were poorly enhanced. b After 3 weeks, enhanced CT
showed a narrowed true lumen, which was compressed by an
expanded false lumen (arrows). Subsequently, the false lumen had
thrombosed
manage carefully the patients with type II dissection,
because expansion of false lumen was seen only in the
type II dissections, and one patient with type II SMA
dissection required surgical intervention because of
bowel ischemia. Dirty fat sign was more commonly seen
in symptomatic patients; thus, this finding may be indic-
ative for an acute inflammatory process.
Although isolated visceral artery dissection has been
considered very rare,1–7 the recent extended utilization of
high-resolution vascular imaging modalities may con-
tribute to the increase in recent reports, and we suspect
that the incidence may have been underestimated in the
past. Enhanced CT has been reported to be useful for
the initial diagnosis and follow-up because the longitu-
dinal orientation of the visceral artery, which is perpen-
dicular to the scanning plane, minimizes the partial
volume effect and allows exact evaluation of the arterial
wall.1–7 Additionally, this imaging modality may also
show concomitant findings such as intraabdominal hem-
orrhage and bowel ischemia.5 There have been many
single case reports about the treatment of isolated vis-
ceral artery dissection, but only a few large-scale studies
have been conducted (see Table 5):1,4,6,8,9 there have been
some cases that required surgical intervention (10
patients; 12%), although many cases were treated con-
servatively (88%). Surgical cases consisted of arterial
ruptures (n = 3), enlarging diameter of the dissected
artery (n = 2), large dissecting aneurysm (n = 2), bowel
ischemia (n = 1), occlusion of true lumen (n = 1), and
persistent symptoms despite medical treatment (n = 1).
We classified visceral artery dissection into three
types: type I dissection may initially be managed conser-

Table 3. Three patients who showed a change in type of the dissection during the follow-up
period
Patient Age Interval between two CT
number (years) Sex Initial diagnosis Follow-up CT imagings (weeks)

1 78 F Type II (IMA) → Type III 13

2 50 M Type III (SMA) → Type I 3
3 52 M Type III (SMA) → Type II 27
Another patient (Fig. 6) underwent urgent laparotomy because of bowel ischemia
Jpn J Radiol (2009) 27:430–437 435

Fig. 4. A 52-year-old man

with acute abdominal pain
and an isolated SMA
dissection (type III).
a Enhanced CT showed an
SMA dissection with a
completely thrombosed false
lumen. The true lumen was
occluded and compressed by
the expanded thrombosed
false lumen (arrows). b
Conventional angiography
showed occlusion of the
SMA (arrowhead), and the
distal part of SMA was
perfused by the collateral a
circulation via the right colic
artery to the ileocolic artery.
The patient was followed up
conservatively because there
were no signs of bowel
ischemia. c Seven months
later, enhanced CT showed
recanalization of the false
lumen (arrow)

b c

Fig. 5. A 50-year-old man

with acute abdominal pain
and an isolated SMA
dissection (type III). a
Enhanced CT showed a
thrombosed false lumen with
dirty fat sign around the
SMA axis (arrow). b After 3
weeks, enhanced CT showed
recanalization of the false
lumen (arrowhead). During
the follow-up period of 14
months, his abdominal pain
did not recur, and the CT
finding did not change

a b
436 Jpn J Radiol (2009) 27:430–437

vatively, because all our patients with type I dissection

a thrombosis of a true lumen.9 In type II dissection, there
b were observed in follow-up CT. Sakamoto et al.9 claimed
Fig. 6. A 64-year-old woman with acute abdominal pain and an
isolated SMA dissection (type II). a Enhanced CT showed type II
dissection of the SMA (arrow). b Enhanced CT also showed para-
lytic ileus and bowel ischemia (arrowheads). She underwent urgent
laparotomy
(two of them had abdominal pain) were able to be con-
servatively managed, and the false lumens did not show
any morphological changes in CT findings during a
follow-up period. These results were consistent with the
previously reported cases.9 However, follow-up CT may
be recommended for the early recognition of possible
progressive dilatation of false lumen, and long-term
anticoagulation therapy may be necessary to prevent
were two patients in whom the blind-ending false lumen
had been enlarged in the follow-up period (see Figs. 2,
3). Although these cases might be conservatively
managed, we suspected that more careful attention
should be given. In fact, one patient with type II SMA
dissection showed bowel ischemia, leading to an emer-
gency operation. In two patients with type III dissection,
imaging classification has been changed during the
follow-up period: recanalizations of the false lumens
that long-term follow-up may not be necessary for SMA
dissection with thrombosed false lumen because these
had resolved in a relatively short time and did not recur.
However, our cases suggested the necessity of follow-up
CT, even when the false lumen is totally thrombosed.

Table 4. CT characteristics and outcomes of 27 patients with isolated SMA dissection

Outcome of false lumen No change or shrinkage Expansion or surgical treatment

No. (male/female) 25 (25/0) 2 (1/1)

Mean age ± SD (years) 62 ± 11 58 ± 8
Location of entry site
Zone 1 (proximal) 2 0
Zone 2 (proximal) 15 0
Zone 3 (distal) 8 2
Branch vessel involvement 17 1
Luminal stenosis 10 1
Bowel wall enhancement 25 1
Location of entry site: zone 1, SMA segment from the orifice to 1 cm proximal to the SMA
curvature; zone 2, SMA segment from 1 cm proximal to 1 cm distal to the SMA curvature;
zone 3, distal to zone 2

Table 5. Summary of previously reported cases of isolated visceral artery dissection

No. of patients Mean age Disease location: No. of symptomatic Surgical Mean follow-up
Studies (male/female) (years) CA/SMA or IMA patients treatment (months)

Our study 38 (32/6) 61 10/28 14 1 20

Takayama et al.4 19 (17/2) 58 8/13a 7 1 21
D’Ambrosio et al.8 6 (6/0) 59 6/0 5 0 9
Sakamoto et al.9 12 (11/1) 50 0/12 12 3 40
Suzuki et al.6 6 (4/2) 58 0/6 5 2 5
Glehen et al.1 5 (3/2) 54 5/0 4 3 14
Total 86 — 29/59 (55%) 47 10 (12%) —
a
Two patients had dissections at both CA and SMA
Jpn J Radiol (2009) 27:430–437
In our study, the dirty fat sign was commonly seen in
symptomatic patients, suggestive of an acute inflamma-
tory process, as previously reported.5,6 The increased
attenuation of the fat is nonspecific as it can be caused
by malignant neoplasm, inflammation, or other vascular
disorders.8 However, an active inflammatory process
may stimulate the visceral nerve plexus, and it may be
logical that this sign was more commonly seen in the
symptomatic patients.
Surgical treatment has been recommended for (a) a
fusiform or saccular aneurysm with increasing diameter,
(b) thrombosis of the true lumen of the dissection site,
(c) persistent symptoms despite anticoagulation, (d)
occlusive lesions jeopardizing the lower digestive tract,
or (e) arterial complications such as rupture or liver
ischemia.1 Takeda et al.7 claimed that the involvement
of the hepatic artery is an indication for surgery or
transcatheter embolization because of high mortality.
However, dissection of visceral artery is a dynamic
process, and optimal management is still somewhat con-
troversial. In our study only 1 of 38 patients required
surgical intervention (Fig. 6); thus, emergent interven-
tion may not be mandatory even in symptomatic patients
without evidence of acute bowel ischemia or hemor-
rhage. Recently, conservatively treated cases with favor-
able outcome have been increasingly reported with strict
blood pressure control, but long-term results have not
been obtained.6,8
Conclusion
Based on our observation, most cases of visceral artery
dissection were able to be managed conservatively when
there were no clinical or imaging signs indicating bowel
ischemia. However, in cases of dissections that have a
437
false lumen without re-entry (type II), careful attention
and follow-up CT studies are recommended. The dirty
fat sign suggestive of active inflammatory process was
commonly seen in the symptomatic patients. Imaging
classification may play an important role in clinical
management.
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