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Kratovska A, Ponomarjova S, Ivanova P, Ligers A, Mohammadian R. Spontaneous isolated superior mesenteric artery dissection: A case report and brief analysis. Radiol Case Rep 2023; 18:3179-3183. [PMID: 37434612 PMCID: PMC10331304 DOI: 10.1016/j.radcr.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 07/13/2023] Open
Abstract
This case report describes the clinical presentation, diagnostic approach, and treatment strategies for a 58-year-old male patient diagnosed with spontaneous isolated superior mesenteric artery dissection (SISMAD). The patient presented with suddenonset abdominal pain and was diagnosed with SISMAD using computed tomography angiography (CTA). SISMAD is a rare but potentially serious condition that can lead to bowel ischemia and other complications. Management options include surgery, endovascular therapy and conservative management with anticoagulation and close observation. The patient was managed conservatively with antiplatelet therapy and close follow-up. During hospitalization, he received antiplatelet therapy and was closely monitored for signs of bowel ischemia or other complications. The patients' symptoms gradually improved over time, and he was eventually discharged on oral mono- antiagreggation therapy. Clinical follow-up showed a significant symptimatic improvement. Conservative management with antiplatelet therapy was chosen due to the absence of bowel ischemia signs and overall stable clinical condition of patient. This report emphasizes the importance of prompt recognition and management of SISMAD to prevent potentially life-threatening complications. Conservative management with antiplatelet therapy can be a safe and effective treatment option for SISMAD, especially in cases without evidence of bowel ischemia or other complications.
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Affiliation(s)
- Aina Kratovska
- Department of Interventional Radiology, Riga East University Hospital; Riga Stradins University, Department of Radiology, Latvia
| | - Sanita Ponomarjova
- Department of Interventional Radiology, Riga East University Hospital; Riga Stradins University, Department of Radiology, Latvia
| | - Patricija Ivanova
- Department of Vascular Surgery and Interventional Radiology, Riga East University Hospital, Latvia
| | - Arturs Ligers
- Department of Vascular Surgery and Interventional Radiology, Riga East University Hospital, Latvia
| | - Reza Mohammadian
- Department of Interventional Radiology, Riga East University Hospital; Riga Stradins University, Department of Radiology, Latvia
- Department of Radiology, Riga East University Hospital, Riga Stradins University, Hippocrates St, 2, Riga, LV-1038, Latvia
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2
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Bang JH, Choi JB, Lee BC, Kim DH, Jung HJ. Conservative Treatment in Two Patients With Spontaneous Hepatic Artery Dissection. Vasc Endovascular Surg 2022; 57:60-63. [PMID: 36162935 DOI: 10.1177/15385744221130848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spontaneous dissection of the hepatic artery is a rare finding for which there is no specific treatment algorithm. Even though endovascular treatment and surgery have been used to treat other visceral artery dissections, these approaches can be challenging in the case of hepatic artery dissection because it is difficult to access the hepatic artery. CASE SUMMARY 2 patients with spontaneous dissection of the hepatic artery were admitted due to epigastric pain. Although the liver function test results were normal, and there were no complications such as bleeding, shock, or ischemia in other organs, a subsequent computed tomography scan directly revealed the spontaneous dissection of the hepatic artery in both patients. The patients were treated with anticoagulants without surgery. Because it is difficult to perform surgery or endovascular treatment on the hepatic artery, we focused on preventing the progression of hepatic artery dissection and the formation of a new thrombus in the dissection. CONCLUSION Considering the risk of surgical treatment for the hepatic artery and the condition of the patients, medical treatment with anticoagulants may be considered as an initial treatment and provide more benefits than surgical treatment.
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Affiliation(s)
- Jun Hyung Bang
- Department of Surgery, Biomedical Research Institute, 220312Pusan National University Hospital, Busan, Korea
| | - Jung Bum Choi
- Department of Surgery, Biomedical Research Institute, 220312Pusan National University Hospital, Busan, Korea
| | - Byoung Chul Lee
- Department of Surgery, Biomedical Research Institute, 220312Pusan National University Hospital, Busan, Korea
| | - Dae Hwan Kim
- Department of Surgery, Biomedical Research Institute, 220312Pusan National University Hospital, Busan, Korea
| | - Hyuk Jae Jung
- Department of Surgery, Biomedical Research Institute, 220312Pusan National University Hospital, Busan, Korea
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3
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Lei YL. Value of superior-mesenteric-artery-diameter/superiormesenteric-vein-diameter on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection. World J Emerg Med 2022; 13:202-207. [DOI: 10.5847/wjem.j.1920-8642.2022.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022] Open
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Eldine RN, Dehaini H, Hoballah J, Haddad F. Isolated Superior Mesenteric Artery Dissection: A Novel Etiology and a Review. Ann Vasc Dis 2022; 15:1-7. [PMID: 35432650 PMCID: PMC8958406 DOI: 10.3400/avd.ra.21-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022] Open
Abstract
Isolated superior mesenteric artery dissection (ISMAD) is a rare pathology with multifactorial etiology. The aim of this article is to provide a narrative review of the latest literature about ISMAD. Case reports, series, and recent meta-analyses were included. This review is introduced with a brief case report of a rare etiology of ISMAD, followed by a discussion of its etiology, clinical presentation, diagnosis, classification, and treatment, and we report a new cause of ISMAD, that is, blunt abdominal trauma. The etiology of ISMAD is multifactorial, consisting of anatomic, genetic, and systemic components. ISMAD is more common among middle-aged males and in East Asia. Its clinical presentation ranges from asymptomatic to mesenteric ischemia, albeit mortality remains <1%. It is diagnosed and classified mostly by computed tomography angiography, and there are five classification systems for ISMAD, though traumatic etiology may be added. The treatment of ISMAD is mostly conservative, with a success rate exceeding 90%. Endovascular stenting is second line, reserved so far for failed medical management, though its role is expanding to include earlier management of symptomatic patients, while open surgical repair is left for acute mesenteric ischemia with bowel compromise.
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Affiliation(s)
- Rakan Nasser Eldine
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Hassan Dehaini
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Jamal Hoballah
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Fady Haddad
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
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Feng Q, Zhao J, Zang L, Chen Y, Li S. A case report of an isolated superior mesenteric artery dissection caused by childbirth. BMC Gastroenterol 2021; 21:428. [PMID: 34774024 PMCID: PMC8590309 DOI: 10.1186/s12876-021-01994-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 10/26/2021] [Indexed: 12/15/2022] Open
Abstract
Background The isolated superior mesenteric artery dissection (SMAD) is a rare and sporadic cause of acute abdominal pain. It most frequently affects male patients in their fifth to sixth decades, while our patient was a young woman who delivered a baby before the onset of abdominal pain. Possible risk factors for SMAD include hypertension, arteriosclerosis, abnormalities in elastic fibres, trauma, and pregnancy. In our case, delivery was suggested as a risk factor, which has not been reported previously. Case presentation A 27-year-old woman complained of acute severe upper abdominal pain and vomiting for 2 days after delivery. The patient had no significant medical history. Physical examination revealed epigastric mild tenderness. All routine blood tests, blood coagulation analysis, liver function tests and abdomen computed tomography showed no remarkable findings. Computed tomography angiography revealed a marked dissection 3.5 cm below the superior mesenteric artery ostium. Since distal blood flow existed and the patient was in a puerperal state with no evidences of mesenteric ischemia, she was managed conservatively, including intestinal rest by fasting, parenteral nutritional support and antibioticis, without anticoagulants or antiplatelet agents. Fortunately, she recovered smoothly and had no recurrence. Conclusions SMAD is a rare and sporadic cause of acute abdominal pain that occurs in young women after delivery.
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Affiliation(s)
- Qian Feng
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China.
| | - Jingrun Zhao
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Lina Zang
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Yuanyuan Chen
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Senlin Li
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
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He Q, Yu F, Fu Y, Yang B, Huo R, Xian R, Liu S, Liang K, Tang G. Evaluation of isolated abdominal visceral artery dissection with multi-scale spiral computed tomography: a retrospective case series. J Cardiothorac Surg 2021; 16:61. [PMID: 33781323 PMCID: PMC8008608 DOI: 10.1186/s13019-021-01428-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate the role of multi-slice spiral computed tomography (MSCT) angiography in the diagnosis of spontaneous isolated visceral artery dissection (SIVAD). Methods Twenty-seven patients with abdominal SIVAD were included in the study. The MSCT scans of the patients were subjected to various post-processing techniques to visualize the visceral artery wall. Clinical features including arterial dissection, thrombosis, dissection length, true/false lumen, and complications were recorded. Results Type I, IIa, and IIb SIVADs were observed in 11, 6, and 10 patients, respectively. Superior mesenteric artery (SMA) dissection was the most common (n = 16), followed by abdominal aortic dissection (n = 6), splenic artery dissection (n = 2), renal artery dissection (n = 2), and splenic artery dissection (n = 1). One patient with SMA dissection suffered small intestine ischemia, 1 with splenic artery dissection had splenic infarction, and 1 patient with left renal artery dissection experienced renal infarction. The false lumen was bigger than the true lumen in 20 patients, with 9 patients having thrombus. The true lumen was bigger than the false lumen in 7 patients. Conclusions MSCT angiography is a valuable technique in the diagnosis and treatment of patients with SIVAD. Patients with abdominal pain suspected due to SIVAD should be examined with MSCT angiography for early detection of SIVAD.
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Affiliation(s)
- Qizhou He
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China.
| | - Fei Yu
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Yajun Fu
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Bin Yang
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Ran Huo
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Rong Xian
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Shulan Liu
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Kali Liang
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Guangcai Tang
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou, 64600, Sichuan, China
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Acosta S, Gonçalves FB. Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review. Scand J Surg 2021; 110:130-138. [PMID: 33724090 PMCID: PMC8258720 DOI: 10.1177/14574969211000546] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Aims: There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited. Material and Methods: The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis. Results and Conclusions: Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.
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Affiliation(s)
- S Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - F B Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central and NOVA Medical School, Lisboa, Portugal
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8
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Detecting isolated superior mesenteric artery dissection with computed tomography. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.826766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tan Z, Jin Q, Fan W, Han P, Li X. Clinical implications of perivascular fat stranding surrounding spontaneous isolated superior mesenteric artery dissection on computed tomography. Exp Ther Med 2020; 21:34. [PMID: 33262820 DOI: 10.3892/etm.2020.9466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/09/2020] [Indexed: 12/28/2022] Open
Abstract
Patients with spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) usually present with acute or chronic abdominal pain and are admitted to the emergency or digestive diseases department to undergo auxiliary examinations, typically abdominal plain CT or contrast-enhanced CT (CECT). Plain CT is the most crucial examination in emergency radiology. An enlarged SMA diameter and perivascular fat stranding (PFS) on plain CT, though non-specific, may be the only indications for SISMAD. These results may be easily overlooked and the diagnosis of SISMAD may be missed. However, PFS around the SMA on CT may be the only indicator of the possible presence of SISMAD, particularly during the early stage when there are no massive changes in the vascular wall. The present study aimed to determine whether PFS surrounding the SMA on CT may help with the diagnosis of SISMAD by indicating the requirement for further examination. The data of 161 consecutive patients with SMA dissection who underwent abdominal CECT or underwent SMA CT angiography (CTA) after abdominal plain CT between February 2015 and February 2018 were retrospectively reviewed. SMA diameter, classification, PFS, complications, comorbidities and treatments were analyzed. The results demonstrated that SISMAD with PFS was significantly associated with admission type (emergency), clinical manifestations (abdominal pain), diagnostic modality and dissection subtype. On plain CT, PFS surrounding the SMA may be a marker for SISMAD, particularly in the emergency setting, and indicates the requirement for CTA examination.
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Affiliation(s)
- Zhengwu Tan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Qianna Jin
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Wenliang Fan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Ping Han
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Xin Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
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Kawahigashi T, Kawabe T, Iijima H, Takagi M, Noda T, Watanabe K. Isolated Superior Mesenteric Artery Dissection Mimicking Impending Rupture of Abdominal Aortic Aneurysm. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925464. [PMID: 33006961 PMCID: PMC7540907 DOI: 10.12659/ajcr.925464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 66-year-old Final Diagnosis: Isolated superior mesenteric artery dissection Symptoms: Abdominal and back pain Medication:— Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Teiko Kawahigashi
- Department of Emergency Medicine, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Takashi Kawabe
- Department of Emergency Medicine, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Hirokazu Iijima
- Department of Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Mutsuo Takagi
- Department of Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Tomohiro Noda
- Department of Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
| | - Kazunao Watanabe
- Department of Surgery, Tokyo Nishi Tokushukai Hospital, Tokyo, Japan
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Xu Y, Gao X, Shang D, Liu J, Jin B, Chen W. Outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection with conservative management. Vascular 2020; 29:45-53. [PMID: 32611279 DOI: 10.1177/1708538120918415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the computed tomography follow-up outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection (IMAD) after conservative management. METHODS In this retrospective study, 130 consecutive patients with symptomatic IMAD from three institutions were enrolled from January 2011 to December 2019. The general epidemiological data, clinical manifestations, first-episode symptoms, imaging findings, and treatment strategy selection were analyzed from the medical records. RESULTS Among 130 patients diagnosed with symptomatic IMAD, positive remodeling of the SMA was achieved in 75.38% (98/130), and negative remodeling of the SMA was achieved in 24.62% (32/130). In the positive remodeling group, complete remodeling was achieved 39.23% (51/130) (type I 6 patients, type IIa 10 patients, type IIb 35 patients), in which type IIb was the most (p = 0.004). Moreover, of the 32 patients in whom negative remodeling of the SMA was achieved, significant differences were observed between the type IIa with respect to dissecting aneurysm formation (p = 0.04).Of the seven factors analyzed with a logistic regression model identified three factors significantly associated with negative remodeling: length of dissection (Waldχ2 13.331; OR 6.945; 95% CI 2.762-10.498; p = 0.014), true lumen residual diameter (TLRD) (Waldχ2 9.626; OR 7.85; 95% CI 1.892-19.063; p = 0.022), and branch involvement (Waldχ2 11.812; OR 7.247; 95% CI 1.245-14.830; p = 0.011). CONCLUSION The prognosis of most symptomatic IMAD has a tendency to positive remodeling after conservative management, in which the initial type IIb classification is common. In contrast, risk factors for negative remodeling were type IIa, length of dissection, TLRD, and branch involvement. Patients with these morphological characteristics may not benefit from conservative management.
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Affiliation(s)
- Yingjiang Xu
- Department of Interventional Vascular Surgery, Binzhou Medical University Hospital, Binzhou, PR China.,Key Laboratory of Metabolism and Molecular Medicine, The Ministry of Education, Department of Biochemistry and Molecular Biology, Fudan University Shanghai Medical College, Shanghai, PR China
| | - Xiujuan Gao
- Department of Cerebrovascular Neurosurgery, Binzhou Medical University Hospital, Binzhou, PR China
| | - Dan Shang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Jianyong Liu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Bi Jin
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Wei Chen
- Department of Interventional Vascular, Shengli Oilfield Central Hospital, Dongying, PR China
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12
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Ghodasara N, Liddell R, Fishman EK, Johnson PT. High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know. Radiographics 2020; 39:559-577. [PMID: 30844348 DOI: 10.1148/rg.2019180131] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ©RSNA, 2019.
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Affiliation(s)
- Nevil Ghodasara
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Robert Liddell
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Elliot K Fishman
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Pamela T Johnson
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
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13
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Wei J, Yang Y, Zheng J, Chen D, Wang W, Zhao Q, Li X, Wu G. Small intestinal autotransplantation for spontaneous isolated superior mesenteric artery dissection: A case report. Medicine (Baltimore) 2019; 98:e17837. [PMID: 31764779 PMCID: PMC6882613 DOI: 10.1097/md.0000000000017837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare differential diagnosis for patients presenting with abdominal pain. Due to limited cases reported, surgical management strategies are poorly defined. PATIENT CONCERNS A 54-year-old man presented to our emergency department with a 4-day history of epigastric pain combined with nausea and vomiting. The pain was dull, constant, and unbearable. It was accompanied by abdominal distention, but there was no radiating pain, chills, fever, or hematochezia. The patient did not have a history of abdominal surgeries, or tobacco or illicit drug use. DIAGNOSIS A contrast-enhanced computerized tomography (CT) scan demonstrated an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The middle-lower jejunum and the whole ileum were extensively dilated, and the middle jejunum was ischemic with edema. INTERVENTIONS Exploratory laparotomy and autologous small bowel transplantation. OUTCOMES The patient was successfully treated using exploratory laparotomy and intestinal autotransplantation (IATx) without bowel resection and had a stable recovery without complications. CONCLUSION For patients with severe mesenteric ischemia or those who fail to respond to initial conservative treatment, IATx may be a reasonable treatment strategy.
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Affiliation(s)
| | - Yi Yang
- Department of Radiology, Xijing Hospital, The Air Force Military Medical University, Xi’an, Shaanxi, People's Republic of China
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Jang JH, Cho BS, Ahn HY, Lee S, Kim H, Kim CN. Optimal Treatment Strategy and Natural History of Isolated Superior Mesenteric Artery Dissection Based on Long-Term Follow-up CT Findings. Ann Vasc Surg 2019; 63:179-185. [PMID: 31626943 DOI: 10.1016/j.avsg.2019.08.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Isolated superior mesenteric artery dissection (ISMAD) was previously considered a rare disorder; however, this condition has been increasingly diagnosed as time progressed. Although treatment regimen and treatment outcomes have become clearer, the optimal treatment strategy has not yet been well established. MATERIALS AND METHODS This study included 54 patients diagnosed with ISMAD by computed tomography (CT) between November 2004 and December 2017. Thirteen patients were excluded from the analysis of natural course as 6 were lost to follow-up, and 7 underwent endovascular therapy. RESULTS Of the 54 patients included in the study, 50 were male, and 4 were female. The mean age of the patients was 52.3 years (range 40-74). The mean follow-up duration was 18.5 months (range 1.0-131.0). Thirty-eight patients were symptomatic, and 16 were asymptomatic. All aneurysmal changes observed on follow-up CT scans were initially classified as type III or IV. Of these patients, 7 underwent endovascular therapy. The failure rate of conservative treatment was 13%. CONCLUSIONS Conservative treatment is safe and effective if bowel necrosis or arterial rupture is not present. Symptomatic patients classified as type III or IV on the initial CT scan should be followed up. If there is recurrent pain or aneurysmal progression, endovascular therapy should be performed.
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Affiliation(s)
- Je-Ho Jang
- Department of Surgery, Eulji Medical Center, Daejeon, South Korea
| | - Byung Sun Cho
- Department of Surgery, Eulji Medical Center, Daejeon, South Korea.
| | - Hye Young Ahn
- Eulji University College of Nursing, Daejeon, South Korea
| | - Seulgi Lee
- Department of Surgery, Eulji Medical Center, Daejeon, South Korea
| | - Hyeyoung Kim
- Department of Surgery, Eulji Medical Center, Daejeon, South Korea
| | - Chang Nam Kim
- Department of Surgery, Eulji Medical Center, Daejeon, South Korea
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Cheng M, Lee KY, Kwok PCH. Endovascular Management of Isolated Spontaneous Superior Mesenteric Artery Dissecting Aneurysm. EJVES Short Rep 2019; 44:33-37. [PMID: 31485492 PMCID: PMC6715789 DOI: 10.1016/j.ejvssr.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 07/13/2019] [Accepted: 07/17/2019] [Indexed: 11/22/2022] Open
Abstract
Objectives The aim is to present the technique of successful management of a superior mesenteric artery (SMA) dissecting aneurysm by a purely endovascular approach. Methods This was a single centre case report. Results Isolated spontaneous SMA dissecting aneurysm is rare, and previously was usually treated by an open or hybrid approach. This is a single centre case report of the successful management of a SMA dissecting aneurysm by a purely endovascular approach. Conclusions A pure endovascular approach is feasible and effective in the management of isolated SMA dissecting aneurysm, which is a rare but life threatening condition. Isolated spontaneous superior mesenteric artery (SMA) dissecting aneurysm is rare. SMA dissecting aneurysm is life-threatening. SMA dissecting aneurysm was previously usually treated by open or hybrid approach. Management of SMA dissecting aneurysm with pure endovascular approach is effective.
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Affiliation(s)
- Mina Cheng
- Department of Surgery, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Kin-Yan Lee
- Department of Surgery, Queen Elizabeth Hospital, Kowloon, Hong Kong
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16
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Clinical and CT Angiographic Follow-Up Outcome of Spontaneous Isolated Intramural Hematoma of the Superior Mesenteric Artery. Cardiovasc Intervent Radiol 2019; 42:1088-1094. [PMID: 30949761 DOI: 10.1007/s00270-019-02212-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/26/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical course and vascular remodeling of spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA) after treatment. METHODS In this retrospective study, 24 consecutive patients with SIHSMA admitted from January 2009 through December 2016 were included in this study. The clinical characteristics, type and location of the dissection, clinical outcome and vascular remodeling were analyzed retrospectively. RESULTS The subjects included 21 men and three women, with a mean age of 50.58 years. The chief complaint was abdominal pain in all patients. The mean follow-up was 10.08 months. Among the 24 patients examined, two patients (8.33%) showed no obvious changes in the CT. Twenty patients were treated by conservative strategy. One case underwent exploratory laparotomy along with embolectomy and arteriotomy. Another three cases received angioplasty and stent implanting. Complete and partial remodeling was observed in 15 (62.5%) and four patients (16.67%). Three (12.5%) of the lesions had dissection remodeling and aneurysm change. CONCLUSIONS SIHSMA represented variable vascular remodeling, while most of the patient got a complete resolution during follow-up, and its clinical course was benign in this study. Vast majority of patients can be managed conservatively when there are no signs indicating organ ischemia.
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Yoshida R, Yoshizako T, Maruyama M, Takinami Y, Shimojo Y, Tamaki Y, Kitagaki H. The value of CT findings for prognostic prediction of spontaneous superior mesenteric artery dissection. Acta Radiol 2019; 60:542-548. [PMID: 29950110 DOI: 10.1177/0284185118786056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spontaneous superior mesenteric artery (SMA) dissection is rare cause of acute abdomen. Time-dependent change of SMA dissection has not been established. PURPOSE To determine Sakamoto classification (SC) type of acute and chronic SMA dissection (aSMAD and cSMAD) to predict the treatment methods and outcome. MATERIAL AND METHODS From April 2003 to March 2017, unenhanced and contrast-enhanced CT were used to diagnose acute symptomatic or chronic asymptomatic SMA dissection in 25 consecutive patients without aortic dissection. Correlations between SCs and treatment methods and outcomes were investigated. RESULTS All 13 patients with aSMAD initially received conservative treatment. Initial SCs in aSMAD were type I = 1, type III = 9, and type IV = 3. Three of nine initial type III and two of three initial type IV changed to type I at follow-up. One of nine type III changed to type II at follow-up. Ohers did not change. One with initial type III required vascular repair, so the final SC was not available. Three patients required bowel resection. In cSMAD of 12 patients, the initial/final SC were type I and IV in ten and two patients, respectively, without change during follow-up. cSMAD was significantly older than aSMAD. The initial length of dissection of aSMAD was longer than in the cSMAD group. In aSMAD, the final length of dissection was significantly shorter than in the initial computed tomography scan. CONCLUSION Initial SC differed significantly between aSMAD and cSMAD. Initial SC types in aSMAD were type III and IV mainly, and changed during the observation period. In cSMAD, SC types were I and IV without change.
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Affiliation(s)
- Rika Yoshida
- Department of Radiology, Shimane University, Faculty of Medicine, Shimane, Japan
| | - Takeshi Yoshizako
- Department of Radiology, Shimane University, Faculty of Medicine, Shimane, Japan
| | - Minako Maruyama
- Department of Radiology, Shimane University, Faculty of Medicine, Shimane, Japan
| | - Yoshikazu Takinami
- Department of Emergency, Shimane University Faculty of Medicine, Shimane, Japan
| | - Yoshihide Shimojo
- Department of Acute care surgery, Shimane University Faculty of Medicine, Shimane, Japan
| | - Yukihisa Tamaki
- Department of Radiation Oncology, Shimane University, Faculty of Medicine, Shimane, Japan
| | - Hajime Kitagaki
- Department of Radiology, Shimane University, Faculty of Medicine, Shimane, Japan
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Ou J, Hu H, Wu Z, Zhao H, Wang C, Rao M, Li Z, Liu J. A modified endovascular technique for treating spontaneous isolated superior mesenteric artery dissection and the early to medium-term outcomes. Heliyon 2019; 5:e01354. [PMID: 30923773 PMCID: PMC6423502 DOI: 10.1016/j.heliyon.2019.e01354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/07/2019] [Accepted: 03/12/2019] [Indexed: 01/30/2023] Open
Abstract
Purpose The spontaneous isolated dissection of superior mesenteric artery (SIDSMA) is a rare medical condition and the treatment remains controversial. This study is to present our refined technique with a Flexor introducer to facilitate stent advancement and its early to medium-term outcomes. Methods A total of 16 patients diagnosed with SIDSMA and repaired with endovascular stenting from January 2012 to December 2017 were retrospectively identified. All patients were male, and the average age was 56 years old (range from 48 to 72 years old). Diagnosis was preoperatively confirmed using computed tomography angiography and their morphologic features were measured. A long Flexor introducer was delivered to the true lumen of dissected superior mesenteric artery prior to coaxially advancing a stent. Patient demographics, endovascular procedures and postoperative outcomes were collected for analysis. Results Total technical success was 87.5%. Endovascular attempt was unsuccessful in two patients with extensive thrombus, and the guidewire failed to pass through the true lumen. The remaining 14 SMA dissections were successfully repaired with the modified method. Four patients were repaired using bare stents and 10 with covered stents. The average operative duration was 44 ± 18 minutes. Abdominal pain was relieved postoperatively in all cases except one patient with no identified reasons. The median follow-up duration was 17 months (2–63 months). No procedure- or dissection-related symptoms was present during follow up, and postoperative computed tomography angiography showed all stented SMAs were patent. Conclusions Coaxial delivery of stents within the introducer can yield high technical success and good clinical outcomes in early to medium term. Extensive thrombus inside SIDSMA is the exclusive cause for endovascular failure with this technique.
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Ullah W, Mukhtar M, Abdullah HM, Ur Rashid M, Ahmad A, Hurairah A, Sarwar U, Figueredo VM. Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis. Korean Circ J 2019; 49:400-418. [PMID: 31074212 PMCID: PMC6511528 DOI: 10.4070/kcj.2018.0429] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/11/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022] Open
Abstract
The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33-85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4-18 months), 12 months (IQR, 6-19 months) and 14 months (IQR, 6-20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.
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Affiliation(s)
- Waqas Ullah
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA.
| | - Maryam Mukhtar
- Department of Internal Medicine, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Hafez Mohammad Abdullah
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, SD, USA
| | - Mamoon Ur Rashid
- Department of Internal Medicine, Florida Hospital Orlando, Orlando, FL, USA
| | - Asrar Ahmad
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA
| | - Abu Hurairah
- Department of Gastroenterology, Advent Health Orlando, FL, USA
| | - Usman Sarwar
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, PA, USA
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Yoo J, Lee JB, Park HJ, Lee ES, Park SB, Kim YS, Choi BI. Classification of spontaneous isolated superior mesenteric artery dissection: correlation with multi-detector CT features and clinical presentation. Abdom Radiol (NY) 2018; 43:3157-3165. [PMID: 29550960 DOI: 10.1007/s00261-018-1556-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of the study is to propose a computed tomography (CT) classification of spontaneous isolated superior mesenteric artery dissection (SISMAD) correlated with clinical presentation METHODS: We retrospectively reviewed CT images of 40 patients with SISMAD at our institution from 2006 to 2015 and proposed a new classification: type I, patent false lumen with both entry and re-entry; type II, patent false lumen without re-entry; type III, completely or partially thrombosed false lumen; and type IV, thrombosed false lumen with ulcer-like projection. Additionally, we included a subtype (S) at each type when there was either a long segment of dissection and/or significant true lumen stenosis. CT features were statistically analyzed using Fisher's exact and Mann-Whitney test. RESULTS The CT findings classified patients as type I (15%), type II (12.5%), type III (35%), and type IV (37.5%). Of the 40 patients, 25 (62.5%) were symptomatic. There was a significantly different proportion of each type between symptomatic and asymptomatic patients (p = 0.005). There were 25 patients with subtype (S); no type I or II, 12 type III, and 13 type IV. The symptomatic patients showed longer dissection tendency and more severe true lumen stenosis (78% vs. 53%, p = 0.000) compared with asymptomatic patients. CONCLUSION The proposed multi-detector CT classification of SISMAD correlates with clinical presentation. This new classification could be helpful for treatment planning.
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Affiliation(s)
- Jeongin Yoo
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Jong Beum Lee
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea.
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Yang Soo Kim
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Byung Ihn Choi
- Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
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21
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Daoud H, Abugroun A, Subahi A, Khalaf H. Isolated Superior Mesenteric Artery Dissection: A Case Report and Literature Review. Gastroenterology Res 2018; 11:374-378. [PMID: 30344810 PMCID: PMC6188040 DOI: 10.14740/gr1056w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/08/2018] [Indexed: 12/13/2022] Open
Abstract
Spontaneous isolated superior mesenteric artery dissection (ISMAD) is an uncommon cause of abdominal pain. Clinical presentation ranges from an asymptomatic incidental finding to acute bowel ischemia or fatal aneurysmal super mesenteric artery (SMA) rupture. We report the case of a 58-year-old male presenting with abdominal pain. Imaging studies revealed an ISMAD without radiological evidence of bowel ischemia. The patient was successfully treated using a conservative approach including bowel rest and anticoagulation. ISMAD incidence is expected to increase with the utilization of advanced imaging modalities. Thus, an ISMAD should be suspected when other common causes of an acute abdomen have been excluded. Given the lack of evidence-based guidelines, management options include conservative treatment and anticoagulation, endovascular stenting, or open surgical repair.
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Affiliation(s)
- Hussein Daoud
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave., Chicago, IL 60657, USA
| | - Ashraf Abugroun
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave., Chicago, IL 60657, USA
| | - Ahmed Subahi
- Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, MI, USA
| | - Habeeb Khalaf
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave., Chicago, IL 60657, USA
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Liu B, Chu C, Fan X, Ding W, Wu X. Endovascular stent placement for isolated superior mesenteric artery dissection with intestinal ischaemia. VASA 2018; 48:73-78. [PMID: 30227782 DOI: 10.1024/0301-1526/a000738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Isolated superior mesenteric artery dissection (ISMAD) is rare, especially when associated with intestinal ischaemia. We report our clinical experience managing this condition. PATIENTS AND METHODS Medical records from 22 patients with ISMAD and intestinal ischaemia were retrospectively analysed. Conservative treatment was given to all patients as first line therapy. Subsequently, 15 patients received endovascular stent placement and three patients received endovascular stent placement plus intestinal resection and anastomosis. RESULTS After conservative treatment, the symptoms of three patients were remarkably relieved; however, a repeat contrast CT showed that stenosis was aggravated. Hence, endovascular stent placement was performed in all 15 patients. Enteral nutrition was successfully restored in 12 patients. Three patients showed signs of chronic intestinal ischaemia, including peritonitis and ileus. These patients underwent intestinal resection and anastomosis. Enteral nutrition was restored at postoperative week two. No signs of intestinal ischaemia recurred during two-years of follow-up. CONCLUSIONS We recommend endovascular stent placement as a feasible, effective, and minimally invasive procedure in patients with ISMAD and symptoms of intestinal ischaemia.
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Affiliation(s)
- Baochen Liu
- a These authors contributed equally to this paper
| | - Chengnan Chu
- a These authors contributed equally to this paper
| | - Xinxin Fan
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiwei Ding
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xingjiang Wu
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Kimura Y, Kato T, Inoko M. Outcomes of Treatment Strategies for Isolated Spontaneous Dissection of the Superior Mesenteric Artery: A Systematic Review. Ann Vasc Surg 2018; 47:284-290. [DOI: 10.1016/j.avsg.2017.07.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/04/2017] [Accepted: 07/18/2017] [Indexed: 02/07/2023]
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24
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Wen D, Wang Z, Yu J, Zhang W, Yang X, He H, Zhang X, Lin Y, An R, Zheng M, Xu J. Endovascular Stent-Graft Repair of Spontaneous Isolated Dissection of the Superior Mesenteric Artery. Cardiovasc Intervent Radiol 2018; 41:692-698. [DOI: 10.1007/s00270-018-1889-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/22/2018] [Indexed: 10/18/2022]
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Kim H, Park H, Park SJ, Park BW, Hwang JC, Seo YW, Cho HR. Outcomes of Spontaneous Isolated Superior Mesenteric Artery Dissection Without Antithrombotic Use. Eur J Vasc Endovasc Surg 2018; 55:132-137. [DOI: 10.1016/j.ejvs.2017.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 11/08/2017] [Indexed: 12/19/2022]
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Chang C, Hsieh T, Fan C, Lin M, Huang C, Sun J. Early Detection of a Rare Case: Idiopathic Spontaneous Superior Mesenteric Artery Dissection, by Duplex Ultrasonography. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Spontaneous dissection of the superior mesenteric artery (SMA) without involvement of the aorta is an extremely rare condition. It could be a surgical emergency because ischaemic intestine due to artery occlusion is life-threatening and the prognosis is time-dependent. We present a 55-year-old man with a 5-day history of progressive abdominal pain. He had a negative laboratory work-up and pan-endoscopy showed multiple gastric ulcers. Despite treatment, he had persistent severe epigastric pain disproportionate to physical findings. Bedside duplex ultrasonography revealed the absence of color signal in the proximal SMA. Angiography confirmed the diagnosis of SMA dissection. Mesenteric vascular emergency including arterial dissection should be taken into consideration in patients who present with severe abdominal pain of unknown origin. Abdominal bruit may be the only vital clue but is usually difficult in the noisy emergency department. Duplex ultrasonography can be helpful to detect blood flow abnormality whenever in doubt. (Hong Kong j. emerg.med. 2015;22:189-193)
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Affiliation(s)
- Cj Chang
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Th Hsieh
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Cm Fan
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Ms Lin
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Cc Huang
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
| | - Jt Sun
- Far Eastern Memorial Hospital, Department of Emergency Medicine, New Taipei City, Taiwan
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Jia Z, Huang Y, Shi H, Tang L, Shi H, Qian L, Jiang G. Comparison of CTA and DSA in the diagnosis of superior mesenteric artery dissecting aneurysm. Vascular 2017; 26:346-351. [PMID: 29105573 DOI: 10.1177/1708538117739540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective To compare computed tomography arteriography (CTA) and digital subtraction arteriography (DSA) in the diagnosis of superior mesenteric artery dissecting aneurysm (SMADA). Methods All SMADA patients who underwent CTA and DSA at one of two medical centers between May, 2007 and April, 2017 were identified. The accuracy of CTA and DSA for the depiction of morphologic characteristics of SMADA was analyzed. Results Fourteen patients (12 men; mean age, 55.1 ± 6.4 years) were included in this study. The mean diameter of the dissecting aneurysm was 3.78 ± 1.53 mm on CTA and 3.81 ± 1.54 mm on DSA ( p = 0.96). The luminal stenosis was 0.52 ± 0.27 on CTA and 0.35 ± 0.23 on DSA ( p = 0.09). The thrombosed false lumen was visualized on CTA in 79% (11/14) of patients but in no patients on DSA ( p < 0.001). The entry points of the dissection were visualized on CTA in 64.3% (9/14) of patients and on DSA in 100% (14/14) of patients ( p = 0.041); CTA and DSA did not visualize re-entry points in any patients. The intimal flap was visualized on CTA in 71.4% (10/14) of patients and on DSA in 78.6% (11/14) of patients ( p > 0.05). Branch vessel involvement was visualized in 7.1% (1/14) of patients on CTA but in no patients on DSA ( p > 0.05). Conclusions CTA can be used in place of DSA for the diagnosis of SMADA. Although CTA may exaggerate the degree of luminal stenosis and is weak in depicting the entry points of SMADA, this modality more accurately depicts the thrombosed false lumen and branch vessel involvement.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, The Affiliated Changzhou No. 2 People’s Hospital with Nanjing Medical University, Changzhou, China, 213003
- *Contributed equally to this study
| | - Youhua Huang
- Department of Interventional Radiology, Wujin people’s Hospital, Jiangsu University, Changzhou, China, 213003
- *Contributed equally to this study
| | - Hongjian Shi
- Department of Interventional Radiology, Wujin people’s Hospital, Jiangsu University, Changzhou, China, 213003
| | - Liming Tang
- Department of Gastrointestinal Surgery, The Affiliated Changzhou No. 2 People’s Hospital with Nanjing Medical University, Changzhou, China, 213003
| | - Haifeng Shi
- Department of Radiology, The Affiliated Changzhou No. 2 People’s Hospital with Nanjing Medical University, Changzhou, China, 213003
| | - Liulan Qian
- Department of Scientific Teaching Section, The Affiliated Changzhou No. 2 People’s Hospital with Nanjing Medical University, Changzhou, China, 213003
| | - Guomin Jiang
- Department of Interventional Radiology, The Affiliated Changzhou No. 2 People’s Hospital with Nanjing Medical University, Changzhou, China, 213003
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Conservative Management of Spontaneous Isolated Dissection of the Superior Mesenteric Artery. Gastroenterol Res Pract 2017; 2017:9623039. [PMID: 28791045 PMCID: PMC5534304 DOI: 10.1155/2017/9623039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/08/2017] [Indexed: 02/03/2023] Open
Abstract
Purpose We report the clinical outcomes of patients with spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated conservatively. Materials and Methods A retrospective review was performed in 14 patients from 2006 to 2016 with SIDSMA. Their clinical features and computed tomographic angiography (CTA) characteristics, treatment methods, and clinical outcomes were analyzed. The mean age was 53.6 (range, 41–73) years, and the mean follow-up duration was 20.6 (range, 1–54) months. Conservative management was the primary treatment if no bowel ischemia or arterial rupture was noted. Results The mean initial abdominal visual analog pain score was 7 (range, 5–9) in seven patients. The mean total duration of abdominal pain was 10.2 days (range, 2–42 days) in 10 patients. The mean percentage stenosis of the dissected SMA at the initial presentation was 78.8% in 14 patients. Complete obstruction of the SMA at the initial presentation was evident in 4 of the 14 patients (28.6%). Conservative management was successful in all 14 patients. None of the 14 patients developed bowel ischemia or an infarction. Abdominal pain did not recur in any patient during follow-up (mean, 20.6 months; range, 1–54 months). Conclusion Conservative management was successful for all SIDSMA patients, even those with severe compression of the true lumen or complete obstruction of the dissected SMA.
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Nishi M, Sueta D, Miyazaki T, Sakamoto K, Yamamoto E, Izumiya Y, Tsujita K, Kojima S, Kaikita K, Ikeda O, Yamashita Y, Hokimoto S. Simultaneous Idiopathic Dissections of the Coronary and Superior Mesenteric Arteries. Intern Med 2017; 56:1363-1367. [PMID: 28566599 PMCID: PMC5498200 DOI: 10.2169/internalmedicine.56.8043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 49-year-old man complained of sudden upper abdominal pain but was not given a definitive diagnosis. The day after he was discharged, he noticed left chest pain. An in-depth electrocardiogram indicated acute myocardial infarction, and emergent coronary angiography revealed 99% stenosis of his left coronary artery. An intravascular ultrasound revealed spontaneous coronary artery dissection (SCAD), and the lesion was successfully stented. In an atherosclerosis screening, superior mesenteric artery dissection (SMAD) was confirmed, after which the lesion was successfully stented. This case suggests that SCAD and SMAD might have similar pathological backgrounds.
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Affiliation(s)
- Masato Nishi
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Takashi Miyazaki
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical Sciences, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Japan
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Funahashi H, Shinagawa N, Saitoh T, Takeda Y, Iwai A. Conservative treatment for isolated dissection of the superior mesenteric artery: Report of two cases. Int J Surg Case Rep 2016; 26:17-20. [PMID: 27429179 PMCID: PMC4954935 DOI: 10.1016/j.ijscr.2016.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/01/2016] [Accepted: 07/05/2016] [Indexed: 11/30/2022] Open
Abstract
Isolated spontaneous dissection of the superior mesenteric artery is very rare condition. Imaging studies are effective for diagnosis. Common treatment strategy consists of three methods as follows; conservative therapy, endovascular treatment, and surgery. The etiology and the best treatment have not been established yet.
Introduction Isolated spontaneous dissection of the superior mesenteric artery (SMA) is rare and a treatment strategy has not been established yet. In this paper, we present our experience with two cases and review the literature. Presentation of case Both cases were treated conservatively as they did not show signs of bowel ischemia. They were symptom free with no evidence of disease progression after a median follow-up of 3.5 years. Discussion There are three methods for the treatment of isolated SMA dissection; observation with medical therapy, endovascular surgery, and open surgery. Most patients with isolated SMA dissection can be treated with observation alone. Although the indications for surgery are still controversial, patients with bowel ischemia should undergo invasive treatment in the form of either endovascular or open surgery. Conclusion We recommend observation with medical therapy as the first choice for isolated SMA dissection. However, long term follow-up is necessary as the extent of the dissection may change over time.
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Affiliation(s)
- Hitoshi Funahashi
- Division of Surgery, JA Mie Komono Public Welfare Hospital, 75 Fukumura, Komono-cho, Mie 5101234, Japan.
| | - Naoya Shinagawa
- Division of Surgery, JA Mie Komono Public Welfare Hospital, 75 Fukumura, Komono-cho, Mie 5101234, Japan.
| | - Takaaki Saitoh
- Division of Surgery, JA Mie Komono Public Welfare Hospital, 75 Fukumura, Komono-cho, Mie 5101234, Japan.
| | - Yoshihide Takeda
- Division of Surgery, JA Mie Komono Public Welfare Hospital, 75 Fukumura, Komono-cho, Mie 5101234, Japan.
| | - Akihiko Iwai
- Division of Surgery, JA Mie Komono Public Welfare Hospital, 75 Fukumura, Komono-cho, Mie 5101234, Japan.
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Chen ZL, Zhang XC, Pan GR, Sun Y, Xu M, Li XQ. Clinical Features and Therapeutic Options for Isolated Visceral Artery Dissection. Ann Vasc Surg 2016; 30:227-35. [DOI: 10.1016/j.avsg.2015.07.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/09/2015] [Accepted: 07/22/2015] [Indexed: 01/20/2023]
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Tomita K, Obara H, Sekimoto Y, Matsubara K, Watada S, Fujimura N, Shibutani S, Nagasaki K, Hayashi S, Harada H, Asami A, Uchida N, Kakefuda T, Kitagawa Y. Evolution of Computed Tomographic Characteristics of Spontaneous Isolated Superior Mesenteric Artery Dissection During Conservative Management. Circ J 2016; 80:1452-9. [DOI: 10.1253/circj.cj-15-1369] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Koichi Tomita
- Department of Surgery, Keio University School of Medicine
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine
| | | | | | | | - Naoki Fujimura
- Department of Surgery, Keio University School of Medicine
| | - Shintaro Shibutani
- Department of Surgery (Vascular Surgery), Saiseikai Yokohamashi Tobu Hospital
| | | | - Shinobu Hayashi
- Department of Surgery (Vascular Surgery), Saiseikai Yokohamashi Tobu Hospital
| | - Hirohisa Harada
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital
| | | | | | | | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine
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Li Z, Ding H, Shan Z, Du J, Yao C, Chang G, Wang S. Initial and Middle-Term Outcome of Treatment for Spontaneous Isolated Dissection of Superior Mesenteric Artery. Medicine (Baltimore) 2015; 94:e2058. [PMID: 26559313 PMCID: PMC4912307 DOI: 10.1097/md.0000000000002058] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Symptomatic isolated dissection of the superior mesenteric artery (SIDSMA) represents an extremely rare condition. Although various treatments including conservative treatment, endovascular stenting (ES), and surgical repair are currently available, consensus treatment guideline is absent due to scarce of SIDSMA cases. Thus, we present our experience in the treatment of SIDSMA at our single center.Fourteen cases of SIDSMA were treated with conservative treatment, catheter-directed thrombolysis (CDT), endovascular stenting (ES), or surgical repair at our center between January 2008 and January 2014. Demographics, clinical manifestations, coexisting medical conditions, imaging feature, treatments, and follow-up outcome of these patients were retrospectively collected and analyzed.For 13 patients without peritonitis, conservative treatment was given for 4 to 6 days initially. After the first observation cycle, symptoms and signs were alleviated in 8 patients, and conservative treatments were continued. The remaining 5 patients received technically and clinically successful ES (in 4) or CDT (in 1) due to worsening symptoms and signs during conservative treatment. One patient with peritonitis underwent emergency surgery, with the necrotic small intestine resected. However, the abdominal pain was not alleviated 17 days postoperatively, ES was thus performed and symptoms relieved immediately. Two weeks after ES, a new aneurysm and partial thrombosis in the distal part of the stent were found by computed tomography angiography in this patient. No intestinal infarction or mortality developed during hospitalization. Follow-up was accomplished in 11 cases, ranging from 4 to 74 months (23.5 ± 21.3). Except that one complained with mild abdominal pain, the other 10 achieved complete remission. All patients were free from new aneurysmal formation of SMA and all stents remained patent.For SIDSMA without peritonitis, conservative treatment can be provided with reasonable success rate, while ES may serve as an effective alternative once conservative treatment fails. For SIDSMA with peritonitis, open surgery remains the treatment of choice by resection of necrotic intestine and revasculization.
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Affiliation(s)
- Zilun Li
- From the Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University (ZL, ZS, CY, GC, SW); Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Sciences (HD); and Department of Medical Record Management, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (JD)
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Aimi M, Amano C, Yoshida R, Matsubara T, Mikami H, Izumi D, Okimoto E, Ishimura N, Ishihara S, Kinoshita Y. Isolated Superior Mesenteric Artery Dissection with Small Intestine Ischemia. Case Rep Gastroenterol 2015; 9:341-6. [PMID: 26600771 PMCID: PMC4649733 DOI: 10.1159/000441384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Superior mesenteric artery (SMA) dissection without aortic dissection is a rare condition, and its diagnosis is considered to be difficult. Intestinal infarction is a severe complication of the disease, which may require resection of the intestine. We present a case of isolated SMA dissection. A 53-year-old man experienced sudden pain in the abdomen while playing Japanese pinball and was admitted to our hospital due to acute abdominal symptoms of uncertain cause. Enhanced CT revealed a defect of the root of the SMA, while angiography and intravascular ultrasound findings showed dissection of the SMA wall. Conservative treatment was chosen at the time, while a part of the small intestine was eventually resected because of progressive ischemia. Although SMA dissection is a rare occurrence in cases with acute abdominal symptoms, awareness of the condition is important for differential diagnosis.
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Affiliation(s)
- Masahito Aimi
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Chika Amano
- Department of Functional Pathology, Shimane University School of Medicine, Izumo-shi, Japan
| | - Rika Yoshida
- Department of Radiology, Shimane University School of Medicine, Izumo-shi, Japan
| | - Takeshi Matsubara
- Department of Digestive Surgery, Shimane University School of Medicine, Izumo-shi, Japan
| | - Hironobu Mikami
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Daisuke Izumi
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Eiko Okimoto
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Norihisa Ishimura
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Shunji Ishihara
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
| | - Yoshikazu Kinoshita
- Second Department of Internal Medicine, Shimane University School of Medicine, Izumo-shi, Japan
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Three cases of spontaneous isolated dissection of the superior mesenteric artery. J Emerg Med 2015; 48:e111-6. [PMID: 25641410 DOI: 10.1016/j.jemermed.2014.12.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 11/11/2014] [Accepted: 12/21/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spontaneous isolated superior mesenteric artery dissection is a rare disease that may cause bowel ischemia or aneurysm rupture and subsequent death. Thus, the establishment of a correct diagnosis in the early stage is quite important. OBJECTIVE To describe the presentation of 3 patients diagnosed with spontaneous isolated supramesenteric artery dissection and briefly summarize the diagnostic procedure, treatment, and clinical course. CASE REPORTS We experienced three cases of isolated mesenteric artery dissection in the past 5 years. A definitive diagnosis was obtained by abdominal spiral computed tomography in two cases and angiography in one case. All patients were provided anticoagulation therapy. CONCLUSION One patient died of bowel ischemia, 2 were discharged within 21 days without complications, and one was able to discontinue anticoagulation therapy 12 months after discharge. The remaining patient has continued warfarin, making it difficult to determine the end point of anticoagulation.
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Chahal-Kummen M, Jørgensen JJ. En mann i 70-årene med hypertensjon og akutte brystsmerter. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:1260-2. [DOI: 10.4045/tidsskr.14.1550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Lv PH, Zhang XC, Wang LF, Chen ZL, Shi HB. Management of isolated superior mesenteric artery dissection. World J Gastroenterol 2014; 20:17179-17184. [PMID: 25493033 PMCID: PMC4258589 DOI: 10.3748/wjg.v20.i45.17179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 07/20/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate our experience of the clinical management of spontaneous isolated superior mesenteric artery dissection (ISMAD).
METHODS: From January 2008 to July 2013, 18 patients with ISMAD were retrospectively analyzed, including 7 patients who received conservative therapy, 9 patients who received reconstruction with bare stents, and 2 patients who underwent surgical treatment. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms.
RESULTS: Intestinal ischemia-related symptoms completely resolved in 7 patients who received conservative therapy. Stent placement was successful in 9 patients. Of the 9 patients who received endovascular stenting, abdominal pain was alleviated after the procedure and gradually disappeared within 3 d. Follow-up computed tomography and computed tomography angiography were available in all patients during the first month and the first year after the procedure, which revealed patent stent and patent involved superior mesenteric artery branches with complete obliteration of the dissection lesion. In the 2 patients who underwent surgical treatment, good clinical efficacy was also observed.
CONCLUSION: ISMAD may be managed successfully in a variety of ways based on the clinical symptoms. ISMAD should be treated by conservative management as the first-line option, however, in those with bowel necrosis or imminent arterial rupture during conservative therapy, endovascular or surgical therapy is indicated.
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Lü PH, Zhang XC, Wang LF, Shi HB. Percutaneous Endovascular Reconstruction With Bare Stent Implantation for Isolated Superior Mesenteric Artery Dissection. Vasc Endovascular Surg 2014; 48:406-11. [PMID: 25232023 DOI: 10.1177/1538574414543275] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Spontaneous isolated superior mesenteric artery dissection (ISMAD) is exceedingly rare. The therapeutic options range from observation to medical treatment to surgery or endovascular repair. We present our experience of the clinical management of ISMADs. Methods: Sixteen patients with ISMAD from January 2008 to July 2012 were retrospectively analyzed. The decision to intervene was based on anatomic suitability, patient comorbidities, and symptoms. Percutaneous endovascular reconstruction with bare stents was carried out in 7 patients in this study, for patients with persistent abdominal pain despite conservative treatment or signs of bowel ischemia. The patients were kept on antiplatelet therapy from 6 to 10 months postoperatively. Results: All attempted bare stent placements were successfully accomplished without any treatment-related complication. Of the 7 patients with ISMADs, 4 were treated by single stents, 2 by double overlapping stents, and 1 by triple overlapping stents. The abdominal pain alleviated after procedure and disappeared gradually within 3 days. None of the patients had ISMAD symptoms during follow-up (median, 21.7 months; range, 11-32 months). Follow-up computed tomography (CT) and CT angiography revealed patent stent and patent superior mesenteric artery (SMA) branches with complete obliteration of the dissection. Conclusion: Isolated SMA dissection may be managed successfully in a variety of ways based on the clinical symptoms. In this small series, percutaneous endovascular reconstruction with bare stent implantation is a feasible treatment choice with a high success rate and good clinical outcome.
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Affiliation(s)
- Peng-Hua Lü
- Department of Radiology, First Hospital Affiliated to Nanjing Medical University, Nanjing, China
- Department of Interventional Radiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Xi-Cheng Zhang
- Department of Vascular Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Li-Fu Wang
- Department of Interventional Radiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Hai-Bin Shi
- Department of Radiology, First Hospital Affiliated to Nanjing Medical University, Nanjing, China
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Wagenhäuser MU, Sagban TA, Witte M, Duran M, Schelzig H, Oberhuber A. Isolated dissection of the superior mesenteric artery treated using open emergency surgery. World J Emerg Surg 2014; 9:47. [PMID: 25140196 PMCID: PMC4137619 DOI: 10.1186/1749-7922-9-47] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 08/07/2014] [Indexed: 11/14/2022] Open
Abstract
Background Isolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts. Methods Two cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided. Results Both patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities. Conclusion Open surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.
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Affiliation(s)
- Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
| | - Tolga Atilla Sagban
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
| | - Mareike Witte
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Moorenstraße.5, 40225 Düsseldorf, Germany
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Wall ML, Newman JE, Slaney PL, Vijayaragahavan S, Downing R. Isolated dissecting aneurysms of the abdominal aorta and the superior mesenteric artery. A case report and literature review. Ann Vasc Surg 2014; 28:1937.e5-8. [PMID: 25111950 DOI: 10.1016/j.avsg.2014.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 06/25/2014] [Accepted: 07/21/2014] [Indexed: 11/25/2022]
Abstract
Supracoeliac abdominal aortic dissections are rare and require complex interventions for repair. Superior mesenteric artery (SMA) dissections are also rare and even less frequently reported to involve aneurysmal change. We present the case of a 65-year-old man with a dissecting supracoeliac aortoiliac aneurysm and a separate dissecting aneurysm of the SMA The surgical intervention performed and a review of the literature on the management of SMA dissection in the endovascular era are presented.
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Affiliation(s)
- Michael L Wall
- Department of Vascular Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester Royal Hospital, Worcester, UK.
| | - Jeremy E Newman
- Department of Vascular Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester Royal Hospital, Worcester, UK
| | - Penelope L Slaney
- Department of Interventional Radiology, Worcestershire Acute Hospitals NHS Trust, Worcester Royal Hospital, Worcester, UK
| | - Santosh Vijayaragahavan
- Department of Interventional Radiology, Worcestershire Acute Hospitals NHS Trust, Worcester Royal Hospital, Worcester, UK
| | - Richard Downing
- Department of Vascular Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester Royal Hospital, Worcester, UK
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Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg 2014; 59:1433-9.e1-2. [DOI: 10.1016/j.jvs.2014.01.040] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 01/10/2014] [Accepted: 01/19/2014] [Indexed: 01/17/2023]
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Daghfous A, Bouzaidi K, Rezgui Marhoul L. [Spontaneous isolated dissection of the superior mesenteric artery: an uncommon cause of acute abdomen. A case report]. Rev Med Interne 2014; 36:131-4. [PMID: 24630867 DOI: 10.1016/j.revmed.2013.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 09/13/2013] [Accepted: 11/22/2013] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Isolated spontaneous dissection of the superior mesenteric artery is the most common digestive artery dissection. It is a rare cause of acute abdomen. Only a few hundred cases have been reported in the literature. CASE REPORT We report a 40-year-old man with a past medical history of high blood pressure who presented abdominal pain that was related to a spontaneous dissection of the superior mesenteric artery. Computed tomography revealed an isolated dissection of superior mesenteric artery. There were no evidence of bowel ischemia. We decided a conservative treatment and the outcome was favorable, without recurrent symptoms or disease progression. CONCLUSION Based on this case report, we discuss the etiology of this vascular lesion and the contribution of computed tomography in the diagnosis, the therapeutic strategy and the follow-up of spontaneous dissection of superior mesenteric artery.
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Affiliation(s)
- A Daghfous
- Service d'imagerie médicale, centre traumatologie et des grands brûlés de Tunis, avenue du Grand Maghreb, Nabeul 8000, Tunisie.
| | - K Bouzaidi
- Service d'imagerie médicale, hôpital MT Maâmouri, Nabeul, Tunisie
| | - L Rezgui Marhoul
- Service d'imagerie médicale, centre traumatologie et des grands brûlés de Tunis, avenue du Grand Maghreb, Nabeul 8000, Tunisie
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Park UJ, Kim HT, Cho WH, Kim YH, Miyata T. Clinical course and angiographic changes of spontaneous isolated superior mesenteric artery dissection after conservative treatment. Surg Today 2014; 44:2092-7. [DOI: 10.1007/s00595-014-0849-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 11/05/2013] [Indexed: 10/25/2022]
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44
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Kim HK, Jung HK, Cho J, Lee JM, Huh S. Clinical and radiologic course of symptomatic spontaneous isolated dissection of the superior mesenteric artery treated with conservative management. J Vasc Surg 2013; 59:465-72. [PMID: 24080130 DOI: 10.1016/j.jvs.2013.07.112] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/23/2013] [Accepted: 07/27/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the clinical and radiological outcomes of patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated with conservative management. METHODS This retrospective study included 27 consecutive patients who were diagnosed with symptomatic SIDSMA and managed conservatively from April 2007 to April 2013. Twenty-six patients were treated using anticoagulation therapy, and one patient with chronic liver disease underwent observation only. For evaluation, patients were divided into two groups, those with a patent false lumen with both entry and re-entry (group I), and those with partial or complete thrombosis of the false lumen (group II). In general, the patients underwent follow-up computed tomography angiography (CTA) 1 week, 1 month, and 6 months after admission. Thereafter, they underwent annual CTAs. RESULTS There were five group I and 22 group II patients. During hospitalization, none of the patients needed additional endovascular or surgical intervention, and after conservative management, every patient was asymptomatic upon discharge. The mean duration of clinical follow-up was 27.3 months. There was no recurrent abdominal pain associated with SIDSMA, and no invasive procedures due to SIDSMA were needed. During a mean of 17.1 months of CTA follow-up in group I patients, serial CTAs found sustained patent false lumen and no angiographic changes in all patients. Among 22 group II patients, despite anticoagulation and symptomatic relief, CTA 1 week after admission revealed increased stenosis of the true lumen in 84.2% (16/19) of patients including six cases of progressive SMA occlusion. Five patients, including the three patients initially presenting with SMA occlusion, had no interval changes, and only one patient had improved compression of the true lumen. During a mean of 18.0 months of CTA follow-up in group II patients, serial CTAs revealed improvement in the occlusion or stenosis of the true lumen in 89% (16/18) of patients and progressive resolution of false lumen thrombosis in all patients. Aneurysmal dilatation greater than 2 cm was not detected in either group of patients during follow-up. CONCLUSIONS During the acute stage of SIDSMA, we found a discrepancy between the clinical and angiographic findings. The therapeutic regimen should be based on clinical symptoms, and conservative management is feasible in most cases. SMA stenosis could not be an indication for invasive treatment, because stenosis of the true lumen has been seen to improve after the acute stage of dissection.
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Affiliation(s)
- Hyung-Kee Kim
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Hee Kyung Jung
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jayun Cho
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jong-Min Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Seung Huh
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, South Korea.
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Li N, Lu QS, Zhou J, Bao JM, Zhao ZQ, Jing ZP. Endovascular stent placement for treatment of spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg 2013; 28:445-51. [PMID: 24070572 DOI: 10.1016/j.avsg.2013.01.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 01/08/2013] [Accepted: 01/10/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition often associated with a poor prognosis. The goal of this study is to assess the efficacy of endovascular treatment of SIDSMA with stenting and investigate the possible therapeutic mechanisms involved. METHODS This is a retrospective review of all patients undergoing endovascular treatment of SIDSMA from January 2009 to December 2011. Patient demographics, history, clinical presentation, laboratory tests, image characteristics, endovascular treatments, and follow-up outcome were analyzed. RESULTS Twenty-four patients with symptoms were treated. All except 1 patient (23 of 24, 96%) underwent successful stent placement (16 with single stent and 7 with overlapping stents). A total of 30 stents (4 balloon-expanded and 26 self-expanding) were placed during the procedures. In the perioperative period and during follow-up, symptom relief was achieved in 20 (83%) patients, and abdominal pain remained unchanged in 4 (17%). No death or serious complications occurred. The median length of hospital stay and follow-up was 3.25 ± 2.23 days (range 2-7 days) and 13.15 ± 8.27 months (range 6-23 months), respectively. Computed tomography angiography (CTA) performed 6 months postoperatively revealed stent patency in 23 cases (100%), false lumen patency in 5 cases (22%), and new development of dissection in the SMA distal to the stent in 1 case (4%). No significant differences were observed in the incidence of false lumen patency between patients treated with a single stent and those treated with overlapping stents, and between patients with and without symptom relief (P > 0.05 for both). CONCLUSIONS For symptomatic SIDSMA patients without intra-abdominal hemorrhage and intestinal infarction, endovascular stent placement is a feasible treatment choice with a high success rate and good clinical outcome. Overlapping stenting may be proposed for patients with aneurysmal dilation. False lumen patency may occur in some cases during follow-up, but it does not affect improvement of SIDSMA symptoms.
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Affiliation(s)
- Nan Li
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qing-Sheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jun-Min Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Qing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zai-Ping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
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46
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Luan J, Li X. Computed Tomography Imaging Features and Classification of Isolated Dissection of the Superior Mesenteric Artery. Eur J Vasc Endovasc Surg 2013; 46:232-5. [DOI: 10.1016/j.ejvs.2013.04.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 04/30/2013] [Indexed: 12/31/2022]
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47
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Vasodilator and endovascular therapy for isolated superior mesenteric artery dissection. J Vasc Surg 2013; 57:1612-20. [DOI: 10.1016/j.jvs.2012.11.121] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/22/2022]
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48
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Jia Z, Zhao J, Tian F, Li S, Wang K, Wang Y, Jiang L, Jiang G. Initial and Middle-term Results of Treatment for Symptomatic Spontaneous Isolated Dissection of Superior Mesenteric Artery. Eur J Vasc Endovasc Surg 2013; 45:502-8. [DOI: 10.1016/j.ejvs.2013.01.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
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49
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Galastri FL, Nasser F, Affonso BB, Amorim JED, Travassos FB. Dissecção espontânea do tronco celíaco: qual a melhor abordagem terapêutica? J Vasc Bras 2013. [DOI: 10.1590/s1677-54492013000100014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A dissecção espontânea das artérias viscerais é um evento relativamente raro. Dor abdominal súbita no epigástrio é o sintoma mais frequentemente manifestado pelos pacientes. O avanço das técnicas de exames de imagem possibilitou o diagnóstico deste evento com maior facilidade, aumentando a incidência das dissecções das artérias viscerais. O tratamento clínico conservador, a revascularização cirúrgica, e a terapia endovascular são as três possíveis opções terapêuticas. Neste artigo, relatamos os casos de dois pacientes com dissecção espontânea do tronco celíaco conduzidos de formas diversas, de acordo com a apresentação clínica e exames de imagem, além de realizar uma revisão bibliográfica sobre esta doença.
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Affiliation(s)
| | - Felipe Nasser
- Universidade de São Paulo; Hospital Israelita Albert Einstein, Brasil
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50
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Pang P, Jiang Z, Huang M, Zhou B, Zhu K, Shan H. Value of endovascular stent placement for symptomatic spontaneous isolated superior mesenteric artery dissection. Eur J Radiol 2013; 82:490-6. [DOI: 10.1016/j.ejrad.2012.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 09/11/2012] [Accepted: 09/16/2012] [Indexed: 11/28/2022]
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