[Isolated spontaneous dissection of the superior mesenteric artery: a case report]

Clinical and CT Angiographic Follow-Up Outcome of Spontaneous Isolated Intramural Hematoma of the Superior Mesenteric Artery

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.

Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis

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.

Classification of spontaneous isolated superior mesenteric artery dissection: correlation with multi-detector CT features and clinical presentation

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.

Conservative Management of Spontaneous Isolated Dissection of the Superior Mesenteric Artery

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.

Management of isolated superior mesenteric artery dissection

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.

Percutaneous Endovascular Reconstruction With Bare Stent Implantation for Isolated Superior Mesenteric Artery Dissection

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.

[Spontaneous isolated dissection of the superior mesenteric artery: an uncommon cause of acute abdomen. A case report]

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.

Management of isolated spontaneous dissection of superior mesenteric artery

PURPOSE

Our objectives were to clarify the management of isolated spontaneous dissection of the superior mesenteric artery (DSMA).

METHODS

We reviewed seven patients diagnosed as having DSMA from 2002 to 2007 (group A). Simultaneously, we analyzed 50 cases of DSMA previously reported in the literature between 2000 and 2008 (group B). In each group, clinical presentation, Sakamoto's classification, imaging appearances, need for emergent surgery, failure of medical management, and long-term outcome were analyzed.

RESULTS

In group A, according to Sakamoto's classification, there were two type I, two type II, and three type III. Two patients needed surgery (one type II, one type III). In group B, according to Sakamoto's classification, there were seven type I, five type II, 14 type III, and six type IV. Intestinal revascularization was necessary for 21 patients, especially for types II and III, while medical management was more frequent for types I and IV. We identified four indications for intestinal revascularization: acute mesenteric ischemia with mesenteric thrombosis, arterial rupture, chronic mesenteric ischemia with superior mesenteric artery (SMA) stenosis, and SMA dissecting aneurysm of at least 2 cm in diameter. If abdominal pain lasts for more than 1 week, types I and IV were able to be medically managed, whereas intestinal revascularization has to be considered in types II and III.

CONCLUSION

Patients with symptoms lasting for more than 1 week, aneurysmal dilatation more than 2 cm in diameter, and SMA stenosis are suitable candidates for surgical management.

Percutaneous endovascular treatment for isolated spontaneous superior mesenteric artery dissection: report of two cases and literature review

Isolated spontaneous superior mesenteric artery (SMA) dissection is a rare and sporadically reported condition. Therapeutic options include medical treatment, surgery, and endovascular treatment. However, the optimal treatment strategy has still not been established. We herein present two patients with acute abdomen due to isolated spontaneous SMA dissection, in whom symptoms remained despite initial anticoagulation therapy. Percutaneous endovascular treatment with stenting of the dissected main trunk to achieve complete coverage of the entry site and balloon angioplasty for the distally involved side branches were performed successfully and resulted in complete resolution of the symptoms. According to our experience and previous case reports, early (within 1 week) elective percutaneous endovascular intervention with background anticoagulation therapy is a feasible and effective treatment strategy for symptomatic patients with isolated SMA dissection.