Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: a Multicentre Experience

Selective minimally invasive strategy for acute superior mesenteric artery obstruction

OBJECTIVE

Acute mesenteric artery obstruction is a severe cause of acute mesenteric ischemia, associated with significant morbidity and mortality. However, there is limited guidance on choosing between traditional and minimally invasive techniques comprehensively. This study introduces a selective, minimally invasive strategy designed to improve the survival and prognosis of patients with acute superior mesenteric artery obstruction.

METHODS

In this prospective, single-arm trial conducted between 2020 and 2023, patients with acute mesenteric ischemia due to acute superior mesenteric artery obstruction were enrolled. A total of 42 patients were included, meeting the predetermined sample size. The primary outcome was the 30-day chronic intestinal failure (CIF)-free survival rate. Based on an algorithm incorporating preoperative radiographic findings, physical signs, and laboratory markers, patients were assigned to one of three therapeutic pathways: traditional laparotomy with thrombectomy, laparoscopy combined with endovascular therapy, or endovascular therapy alone.

RESULTS

The CIF-free survival rates at 30 days and 2 years were 71% (30/42) and 60%, respectively. Short-term mortality, including 30-day and in-hospital mortality, was 11.9%, indicating an improvement compared with historical cohorts. The cumulative mortality rates at 6 months, 1 year, and 2 years were 26%, 32%, and 32%, respectively. The primary and assisted patency rates at 1 year were 90% and 97%, respectively. Transition to laparotomy was required in 43% of patients undergoing laparoscopic exploration. Improved blood supply was observed in 73% of the patients who underwent two laparoscopic procedures (15 patients), and bowel resection was avoided in 40% of cases. The median durations of hospitalization and intensive care unit stay were 19 days (interquartile range, 11-31 days) and 2 days (interquartile range, 0-6 days), respectively.

CONCLUSIONS

This selective, minimally invasive strategy for managing acute mesenteric ischemia demonstrated high 30-day CIF-free survival rates and reduced short-term mortality. These findings suggest the potential advantages of this approach in improving outcomes for patients with acute mesenteric ischemia.

Long-term Outcomes of Endovascular Versus Medical Treatment for Isolated Superior Mesenteric Artery Dissection: A 10-Year Retrospective Study

PURPOSE

Isolated superior mesenteric artery dissection (IMAD) is increasing in prevalence. Both endovascular and medical treatments are frequently used, but based on studies with relatively small sample sizes and limited follow-up. This article aims to compare the long-term outcomes of medical treatment versus endovascular treatment for isolated superior mesenteric artery dissection.

MATERIALS AND METHODS

Patients who were treated for IMAD at our institution between June 2009 and March 2019 were retrospectively investigated. The primary outcomes were freedom from adverse events and the complete remodeling rate. Propensity score matching (PSM) was used to align baseline data, ensuring comparability between the two groups.

RESULTS

The study cohort comprises 226 patients with IMAD. The mean follow-up duration was 74.9 ± 28.3 months. One hundred and ninety-one patients (84.5%) received endovascular treatment, and 35 (15.5%) were treated medically. The freedom from adverse event rate was 91.8% in the endovascular group and 79.6% in the medical group at 60 months (p < 0.05) and 87.6% and 74.6%, at 120 months (p < 0.05). The complete remodeling rate was 69.3% in the endovascular group and 29.0% in the medical group (p < 0.01) at 60 months and 70.8% and 37.8%, respectively, at 120 months (p < 0.01). After propensity score matching, the freedom from adverse event rate was 91.9% versus 85.6% (p < 0.05) at 60 months and 87.8% versus 78.6% (p < 0.05) at 120 months. The complete remodeling rate was 69.8% versus 43.0% (p < 0.01) at 60 months and 71.2% in the endovascular group versus 43.0%.

CONCLUSION

The freedom from adverse event and complete remodeling rates were higher in patients with IMAD who received endovascular treatment than in those who were treated medically during long-term follow-up.

LEVEL OF EVIDENCE

Level 3, non-randomized controlled cohort/follow-up study.

Clinical characteristics and impact of pseudo-lumen blood flow on long-term vessel dilatation in spontaneous isolated dissection of superior mesenteric/celiac artery

This study aimed to identify the clinical characteristics associated with spontaneous isolated dissection of superior mesenteric artery/celiac artery (SIDSMA/SIDCA). This observational study, conducted at Toranomon Hospital, Japan between 2009 and 2020, analyzed consecutive SIDSMA/SIDCA cases based on radiology data. The study compared clinical characteristics between symptomatic and asymptomatic patients with SIDSMA/SIDCA and investigated factors related to future vessel dilatation. Among 57 cases (44 SIDSMA, 17 SIDCA, and 4 both), the majority were male (87.7%), nearly half having hypertension (43.9%) and smokers (48.9%). Of those, 17 cases (29.8%) were symptomatic; abdominal pain (94.1%), back pain (23.5%), nausea (17.6%) and fever (5.9%). The symptomatic group was younger (52.6 ± 9.4 versus 67.2 ± 7.9 years, P < 0.001), had higher systolic and mean blood pressure (142.6 ± 20.0 versus 129.5 ± 16.5 mmHg, P = 0.017; 96.1 ± 14.6 versus 88.2 ± 17.7 mmHg, P = 0.038), a higher white blood cell count (9975 ± 5032 versus 6268 ± 1991 /µL, P = 0.012), and a higher LDL cholesterol level at diagnosis (129.7 ± 21.7 versus 87.2 ± 25.6 mg/dL, P = 0.002) than the asymptomatic group. The factors associated with future vessel dilatation included the presence of pseudo-lumen flow in the dissection vessel (73.9% versus 41.4%, p = 0.019) and a larger vessel diameter (13.5 ± 2.4 mm versus 11.5 ± 2.1 mm, p = 0.005) at diagnosis after multiple adjustments, pseudo-lumen flow was a predictor of future vessel dilatation (odds ratio, 4.80; 95% confidence interval, 1.11-20.75; p = 0.036). The study revealed that only 30% of SIDSMA/SIDCA cases were symptomatic. Symptomatic cases were generally younger and exhibited higher blood pressure and elevated white blood cell counts. These findings offer valuable insights for the acute diagnosis of SIDSMA/SIDCA.

Systematic review and meta-analysis of current evidence in endograft therapy for spontaneous isolated superior mesenteric artery dissection

The role of endovascular stent therapy (EST) in the treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD) has gained momentum in recent years but remains controversial. We gathered research examining the advantages and disadvantages of EST for SISMAD patients. Primary outcomes involved both immediate and long-term results. Random or fixed effect models were used for effect size (ES) calculation with 95% confidence interval (CI) based on 50% heterogeneity threshold. Our analysis incorporated data from 21 studies including 611 SISMAD cases treated by EST. Our findings show a complication rate of approximately 1% following EST (95%CI 0.01-0.02, I2 = 0%, P = 0.97), with a bare minimum mortality rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P > 0.05) and a reintervention rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P = 0.89). We also found technique success and symptom resolution approaching 94% and 99%, respectively, in the immediate postoperative phase. In the long run, we observed a recurrence of symptoms at 3% (95%CI 0.00-0.06, I2 = 58.6%, P < 0.01), creation of new dissections at 1% (95%CI 0.00-0.02, I2 = 0%, P = 0.73), aneurysm progression at 2% (95%CI 0.00-0.03, I2 = 42.7%, P = 0.12), reintervention due to complications at 3% (95%CI 0.00-0.05, I2 = 0%, P = 0.43) and stenotic stents at 12% (95%CI 0.04-0.23, I2 = 77.5%, P < 0.01). Nevertheless, high levels of stent patency 98% (95% CI 0.97-1.00, I2 = 0%, P = 0.51) and complete remodeling 88% (95% CI 0.82-0.94, I2 = 65.5%, P < 0.05) were observed postoperatively. Overall, EST presents minimal complications and promising long-term outcomes for SISMAD, although the prevalence of stent stenosis requires further attention.

Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection

OBJECTIVE

Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable.

METHODS

A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold.

RESULTS

9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion.

CONCLUSION

EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.

Factors associated with false lumen changes in patients with superior mesenteric artery dissection

BACKGROUND

False lumen changes (FLCs) are the main reference for the prognosis judgment and treatment plan selection for type IIa superior mesenteric artery dissection (SMAD).

METHODS

For this retrospective study, 55 patients with symptomatic type IIa SMAD were included. Computational fluid dynamics (CFD) analysis was used to explore the hemodynamic basis of FLCs. Correlation and multiple linear regression analyses were performed to identify clinical, morphological and hemodynamic factors associated with FLCs.

RESULTS

The FLCs of patients with successful conservative treatment (n = 29) are significantly higher than those with failed conservative treatment (n = 26) (58.5 ± 21.1% vs 10.9 ± 17.4%, p < 0.0001). Positive correlations were seen between FLCs and the morphological parameters false lumen length (FLL)/dissection entrance length (DEL) and FLL. In terms of hemodynamic parameters, negative correlations were seen between FLCs and time-averaged wall shear stress (TAWSS), vorticity, and high areas of TAWSS and vorticity, whereas positive correlations were seen between FLCs and oscillatory shear index (OSI), relative residence time (RRT), and high areas of OSI and RRT. Multiple linear regression analysis identified symptom duration (odds ratio [OR], 0.93; 95% CI, 0.91-0.96; p < 0.0001), FLL/DEL (OR, 1.30; 95% CI, 1.01-1.67; p = 0.044), and high RRT area (OR, 2.03; 95% CI, 1.48-2.78; p < 0.0001) as predictors of FLCs.

CONCLUSION

The clinical predictor symptom duration, morphological factor FLL/DEL, and the hemodynamic factor high RRT area can serve as predictors of FLCs in patients with symptomatic type IIa SMAD.

Endovascular treatment of systematic isolated mesenteric artery dissection with a patent false lumen: Bare stents alone versus stent-assisted coiling

OBJECTIVES

Bare stent treatment and bare stent-assisted coiling treatment have not been directly compared in symptomatic isolated superior mesenteric artery dissection with a patent false lumen. Thus, we compared the early and mid-term outcomes of bare stent treatment and bare stent-assisted coiling treatment to determine the most effective remedy for patients with this condition.

METHODS

Consecutive patients diagnosed with systematic isolated superior mesenteric artery dissection with a patent false lumen admitted to the study hospital between January 2016 and December 2021 were enrolled in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed.

RESULTS

A total of 85 patients (83 men) were included. 34.1% (n = 29) adopted bare stent treatment and 65.9% (n = 56) underwent bare stent-assisted coiling treatment. The symptoms were relieved in all patients (100%) with bare stent treatment and bare stent-assisted coiling treatment. There was no significant difference in the length of hospital stay between the two endovascular treatments (p = 0.354). The cumulative complete remodeling rate was 100% in bare stent-assisted coiling treatment vs. 70.4% in bare stent treatment (p < 0.0001). The prevalence of adverse events for abdominal pain recurrence (none in BST or bare stent-assisted coiling treatment), and formation of the aneurysm (two in bare stent treatment, and none in bare stent-assisted coiling treatment) showed no significant difference at follow-up.

CONCLUSION

Both bare stent treatment and bare stent-assisted coiling treatment for symptomatic isolated superior mesenteric artery dissection with a patent false lumen have the same satisfying early outcome. In the midterm follow-up, bare stent-assisted coiling treatment has the higher cumulative complete remodeling rate which could be prioritized to treat this condition.

Isolated superior mesenteric artery dissection: An updated review of the literature

Isolated superior mesenteric artery dissection (ISMAD) is a rare but potentially life-threatening cause of acute abdominal pain. Owing to the availability of computed tomography angiography, more cases have been detected during screening for acute abdomen in recent years. With increasing knowledge of ISMAD, a better management strategy is being developed. To enhance our understanding and improve treatment outcomes of ISMAD, a systematic literature review was conducted with a focus on diagnosis and management strategies based on existing evidence.