Clinical characteristics of spontaneous isolated visceral artery dissection

The management of spontaneous isolated celiac artery dissection: A case report and literature review

OBJECTIVES

Spontaneous isolated celiac artery dissection (SICAD) without associated aortic dissection is a rare disease. Complications are ischemia, aneurysm formation, and rupture. Different treatment options have been reported for managing SICAD, including conservative management, endovascular intervention, and open surgery. Despite the increased recognition of this disease, there are no consensus guidelines on management of this condition. To improve the knowledge and treatment of this disease, a case of SICAD was reported.

METHODS AND RESULTS

We describe the case of a 57-year-old woman with SICAD whose symptoms improved after endovascular treatment when conservative treatment failed and systematically analyze the management strategy for patients with SICAD.

CONCLUSIONS

SICAD is a rare disease and has no universally agreed upon guidelines for treatment. Most patients can be first treated conservatively for dissection with strict blood pressure control, antithrombotic therapy, and intensive surveillance. For SICAD patients with aneurysms located in the celiac trunk, stent grafts can be used in such patients without affecting the branch blood supply.

Imaging of the Inferior Mesenteric Vasculature

The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) supply and drain blood from the distal colon and rectum, respectively. Routinely imaged at cross-sectional imaging of the abdomen and pelvis, these vessels play a vital role in gastrointestinal tract health but may be neglected due to their diminutive caliber relative to other mesenteric vessels and potential lack of inclusion in routine search patterns. The authors describe and illustrate normal and abnormal appearances of the IMA and IMV and findings that are diagnostic of primary vascular abnormalities or can offer diagnostic clues. After the embryologic features, normal anatomy, and anatomic variants of the IMA and IMV are reviewed, various manifestations of IMA and IMV abnormalities, such as aneurysm and pseudoaneurysm, stenosis, occlusion, dissection, hemorrhage, arteriovenous malformations and fistulas, tumoral invasion, vasculitis, and perivascular lymphatic dilatation, are explored with use of case examples. The role of the IMA and IMV as collateral vasculature, including the clinical scenarios of superior mesenteric arterial occlusion, aortic endoleak, and portosystemic venous shunt, are discussed. Finally, diagnostic clues that the inferior mesenteric vessels and adjacent soft tissues can provide, including mesenteric venous gas, compression or displacement from bowel volvulus or internal hernias, lymphadenopathy, and venous flow artifacts, are highlighted. The authors provide a comprehensive reference for radiologists who evaluate the IMA and IMV on cross-sectional images and shine a spotlight on these neglected but important vessels. ©RSNA, 2024 Supplemental material is available for this article.

Fluoroquinolone Use Preceding Visceral Artery Dissection: A Case Series

Fluoroquinolones (FQ), commonly prescribed antibiotics, may trigger aortic and carotid dissections. We report three successive cases of visceral artery dissection: one patient with celiac trunk dissection and two with dissection of the superior mesenteric artery. These events occurred up to 4 months after 7 to 14 days of FQ treatment (2 cases of ofloxacin, 1 of norfloxacin). There was no other apparent cause of dissection. These dissections were isolated, apart from a minimal aortic dissection separate from the visceral arterial dissection in one case. A case series cannot certify the relationship between dissection and FQ, but it can be hypothesized. The association between fluoroquinolone use and higher occurrence of aneurysm and dissection remains discussed in aortic syndrome. The potential link between FQ and visceral artery dissection is even less described but should be reported in the absence of previous cases in the literature. The pathophysiological theory is the induction of overexpression of some matrix metalloproteinases and a decrease of their inhibitors, provoking a dysregulation in collagen synthesis and degradation of the extracellular matrix.

A case report of Spontaneous celiac artery dissection treated by endovascular intervention

Spontaneous celiac artery dissection is uncommon. Abdominal pain is a common clinical presentation. Conservative medical treatments, endovascular interventions, and open surgery are used to treat spontaneous celiac artery dissection. A 49-year-old male patient visited our hospital, with back and subxiphoid pain that had persisted for 11 hours. He has been smoking 40 cigarettes a day for 20 years. The blood pressure was 180/100mmHg. Aortic computed tomography angiography (CTA) images revealed dissection of the celiac artery, common hepatic artery, left hepatic artery, right hepatic artery, and splenic artery. Urapidil hydrochloride and isosorbide dinitrate were administered to lower the blood pressure to approximately 110/70 mmHg. However, the back and subxiphoid pain persisted without relief. Angiography was performed and a vascular stent (BARD, LIFE STENT, VASCULAR, 8 × 60) was implanted into the celiac artery without involving the branches. Pain was immediately relieved after interventional therapy. The patient was discharged after 4 days. A subsequent aortic CTA after 10 months confirmed that the celiac artery dissection had still not reoccurred.

Comparison of clinical outcomes between medical or/and endovascular therapy in spontaneous isolated superior mesenteric artery dissection patients without bowel ischemia

OBJECTIVE

This study aims to assess the clinical results of endovascular intervention for spontaneous isolated superior mesenteric artery dissection (SISMAD) and its impact on superior mesenteric artery (SMA) remodeling in comparison to solely medical management.

METHODS

All patients with SISMAD between January 2015 and August 2023 were included. The primary endpoints were the absence of major adverse events (MAEs), including dissection-related mortality, recurrence of mesenteric ischemia symptoms, and the necessity for intervention. The secondary endpoints were stenosis or occlusion of the SMA and morphologic remodeling of the dissections.

RESULTS

A total of 217 SISMAD patients were included. In this study, 127 (58.5 %) patients received medical management alone (conservative group), and 90 (41.5 %) underwent endovascular therapy (EVT group). In the EVT group, the technical success rate was 94.4 % (85/90). During follow-up, 13 (6.0 %) patients experienced MAEs, and 1 patient in the conservative group death related to SISMAD. The patients in EVT group showed more complete remodeling than those in the conservative group (76 (84.4 %) vs 66 (52.0 %), P < .0001). Survival analysis showed that the estimated MAEs-free survival rates were97.8 %, 95.6 %, and 95.6 % in EVT group and 98.4 %, 94.5 %, 92.9 % in conservative group at one, two, and three years, respectively. No significant difference was observed in both groups.

CONCLUSION

The findings indicate that both endovascular treatment and medical management alone yield comparable rates of MAE-free survival among patients with SISMAD. Additionally, endovascular therapy exhibits a higher rate of complete remodeling and greater freedom from stenosis or occlusion of the SMA.

Multi-modal imaging for the diagnosis of spontaneous visceral artery dissection: A case report

BACKGROUND

Spontaneous visceral artery dissection (SVAD) is a rare condition that affects the visceral arteries, such as the celiac, superior mesenteric, and inferior mesenteric arteries, without involving the aorta. Organ ischemia or hemorrhage from vessel rupture can occur in SVAD; therefore, prompt detection and management is essential. Contrast-enhanced computed tomography (CECT) has been used to diagnose most of the previous cases, but few studies have explored the potential of contrast-enhanced ultrasound (CEUS) for early detection of this disease.

CASE SUMMARY

A 53-year-old male presented with complaints of poor appetite and abnormal liver function for the past 6 months. He had previously undergone transabdominal splenectomy, esophagogastric devascularization, and cholecystectomy for gallstones and severe portal hypertension. Liver ultrasound was performed in our department to assess liver status. An abnormal hepatic artery spectrum was observed, and dissection involving both the celiac artery and the common hepatic artery was observed. A CEUS was then performed and clearly showed the entry site of the intimal tear and the false lumen, and dissection was subsequently confirmed by CECT. The patient was asymptomatic; therefore, treatment to control the blood pressure was provided, and follow-up was recommended. After 6 months of follow-up, the celiac artery was found to be dilated with an adherent thrombus visible in the wall, and the common hepatic artery was occluded with the presence of collateralization. Despite these findings, no significant changes in liver function were observed.

CONCLUSION

Multi-modal imaging is effective in diagnosing SVAD, and conservative treatment is a choice for asymptomatic patients.

Management of Spontaneous Isolated Celiac Artery Dissection

BACKGROUND

Spontaneous isolated celiac artery dissection (SICAD) is uncommon, with very few series reported in the literature. The present study aims to describe the clinical characteristics and treatment outcomes of patients with SICAD treated at a single Chilean institution over 20 years.

METHODS

A retrospective review of all patients from a single academic hospital with SICAD diagnosed between January 2003 and March 2023 was performed. Conservative treatment included antiplatelets, anticoagulation, or both. The normal size of a celiac artery in our population was 7.9 ± 0.79 mm in females and 8.3 ± 1.08 mm in males. We defined a celiac artery with a diameter equal to or more than 12.5 mm as an aneurysmal celiac artery.

RESULTS

The cohort included 27 patients; 77.8% (n = 21) were males. The median age was 51.0 years (range: 38-84 years). Fourteen (51.8%) patients presented with aneurysmal dilatation. Fourteen (51.8%) patients were treated with antiplatelets, 6 (22.2%) patients with anticoagulation, and 7 (25.9%) with anticoagulation and antiplatelets. One patient was treated with endovascular therapy due to a pseudoaneurysm of the celiac artery detected 10 days after conservative treatment with antiplatelets. The median length of hospital stay was 5 days (range: 2-14 days). Complete remodeling was seen in 6 (22.2%) patients, partial remodeling in 10 (37.0%) patients, and no change was seen in 8 (26.9%) patients. Three (11.5%) patients were lost to follow-up. There were no significant differences between treatments and remodeling outcomes (P = 0.729). The median celiac artery diameter of patients with aneurysmal dilatation was 13.5 mm (range: 12.5-20.5 mm). Systemic arterial hypertension was found more commonly in patients who presented with aneurysmal dilatation than in patients without (87.5% vs. 12.5%, respectively, P = 0.016). Mean follow-up was 41.5 months and median follow-up was 16 months (range: 6-204 months).

CONCLUSIONS

Most patients with SICAD can be treated conservatively with excellent outcomes. Hypertension was more commonly found in patients with SICAD and aneurysmal dilatation.

Multimodal Study of the Superior Mesenteric Artery Wall

BACKGROUND

To quantitatively analyze histological and fiber structure of the superior mesenteric artery (SMA) wall and to further explore the possible relationship between the architecture and histology changes of vessel wall and the occurrence of related diseases.

METHODS

Histological and fiber structure analysis were performed on SMA specimens obtained from 22 cadavers. The SMA specimens were divided into initial, curved, and distal segments, and each segment was separated into the anterior and posterior walls.

RESULTS

From the initial to the curved to the distal segment, the ratio of elastin decreased (31.4% ± 6.0%, 21.1% ± 5.8%, 18.6% ± 4.7%, respectively; P < 0.001), whereas the ratio of smooth muscle actin (24.5% ± 8.7%, 30.5% ± 6.8%, 36.1% ± 7.3%, respectively; P < 0.001) increased. Elastic fiber longitudinal amplitude of angular undulation was highest in the initial segment [7° (3.25°, 15°)] and lowest in the curved segment [2° (1°, 5°)]. In SMA curved segment, the anterior wall, when compared with the posterior wall, demonstrated a lower ratio of elastin (19.0% ± 5.8% vs. 23.3% ± 5.0%; P = 0.010) and collagen (41.4% ± 12.3% vs. 49.0% ± 10.2%; P = 0.032), a lower elastic fiber longitudinal amplitude of angular undulation [1° (1°, 5°) vs. 3° (2°, 5.25°); P = 0.013], a lower average fiber diameter (8.06 ± 0.36 pixels vs. 8.45 ± 0.50 pixels; P = 0.005), and a lower average segment length (17.96 ± 1.59 pixels vs. 20.05 ± 2.33 pixels; P = 0.001).

CONCLUSIONS

SMA wall structure varies along the circumferential and axial directions, the presence of dense undulated elastic fiber protects the SMA initial segment of from dissection and aneurysm, but highly cross-linked collagen fiber here increases the likelihood of plaque formation. In the anterior wall of the curved segment, lower elastin and collagen content, lower elastic fiber undulation, and higher degree of collagen fiber cross-linking leads to the occurrence of SMA dissection and aneurysm. In the distal segment, high levels of vascular smooth muscle cells and bundles of long collagen fiber offer protection against the development of SMA-related diseases.

Differentiating between segmental arterial mediolysis and other arterial vasculopathies to establish an early diagnosis - a systematic literature review and proposal of new diagnostic criteria

Segmental arterial mediolysis (SAM) is a rare vascular disease, characterized by acute but transient vulnerability of the wall of medium-sized arteries. The most characteristic feature of SAM is its biphasic course: an injurious phase marked by acute weakness of the arterial wall leading to acute dissection and/or hemorrhage, followed by a reparative phase in which granulation tissue and fibrosis restore the injured arterial wall. Residual stenosis, aneurysms, and/or arterial wall irregularities may remain visible on future imaging studies. Differentiating between SAM and other arterial vasculopathies is difficult due to its similarities with many other vascular diseases, such as vasculitis, fibromuscular dysplasia, inherited connective tissue disorders, and isolated visceral artery dissection. In this systematic review, we provide an overview on SAM, with an emphasis on the differential diagnosis and diagnostic work-up. We propose new diagnostic criteria to help establish a prompt diagnosis of SAM, illustrated by case examples from our multidisciplinary vascular clinic.

From Fibromuscular Dysplasia to Arterial Dissection and Back

Fibromuscular dysplasia (FMD) is an idiopathic and systemic non-inflammatory and non-atherosclerotic arterial disease. Fifteen to 25% of patients with FMD present with arterial dissection in at least one arterial bed. Conversely, a substantial number of patients with renal, carotid, and visceral dissection have underlying FMD. Also, while few patients with FMD develop coronary artery dissection, lesions suggestive of multifocal FMD have been reported in 30-80% of patients with spontaneous coronary artery dissection (SCAD), and the relation between these two entities remains controversial. The frequent association of FMD with arterial dissection, both in coronary and extra-coronary arteries raises a number of practical and theoretical questions: (i) Are FMD and arterial dissections two different facets of the same disease or distinct though related entities? (ii) Is SCAD just a manifestation of coronary FMD or a different disease? (iii) What is the risk and which are predictive factors of developing arterial dissection in a patient with FMD? (iv) What proportion of patients who experienced an arterial dissection have underlying FMD, and does this finding influence the risk of subsequent arterial complications? In this review we will address these different questions using fragmentary, mostly cross-sectional evidence derived from large registries and studies from Europe and the United States, as well as arguments derived from demographics, clinical presentation, imaging, and when available histology and genetics. From there we will derive practical consequences for nosology, screening and follow-up.

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.

The pathogenesis of superior mesenteric artery dissection: An in-depth study based on fluid-structure interaction and histology analysis

OBJECTIVE

To explore the role of hemodynamic factors in the occurrence of superior mesenteric artery (SMA) dissection (SMAD) using a fluid-structure interaction (FSI) simulation method, and to identify histopathologic changes occurring in the wall of the SMA.

METHODS

A total of 122 consecutive patients diagnosed with SMAD and 122 controls were included in this study. Hemodynamic factors were calculated using a FSI simulation method. Additionally, SMA specimens obtained from 12 cadavers were stained for histological quantitative analysis.

RESULTS

The mean aortomesenteric angle (59.7° ± 21.4° vs 48.2° ± 16.8°; p < .001) and SMA maximum curvature (0.084 ± 0.078 mm^-1 vs 0.032 ± 0.023 mm^-1; p < .001) were higher in SMAD patients than the controls. Larger aortomesenteric angles and SMA curvatures were associated with higher and more concentrated wall shear stress at anterior wall of the SMA curve segment, co-located with the dissection origins. The mean thickness of media (325.18 ± 44.87 µm vs 556.92 ± 138.32 µm; p = .003) was thinner in the anterior wall of the SMA curve than in the posterior wall. The area fractions of elastin (17.96% ± 3.36% vs 27.06% ± 4.18%; p = .002) and collagen (45.43% ± 6.89% vs 55.57% ± 7.57%; p = .036) were lower in anterior wall of the SMA curve than in posterior wall.

CONCLUSION

Increased aortomesenteric angle and SMA curvature are risk factors for SMAD. Both of these factors can cause local hemodynamic abnormalities, which can lead to histopathologic changes in anterior wall of SMA.

Pitfall of isolated superior mesenteric artery dissection with normal D-dimer level

A 51-year-old man with untreated hypertension developed sudden-onset epigastric pain. Despite a normal D-dimer level, abdominal contrast-enhanced computed tomography revealed superior mesenteric artery dissection. Abdominal contrast-enhanced computed tomography is mandatory when examining patients with sudden-onset abdominal pain, even those with a normal D-dimer level.

Diagnosis of spontaneous isolated superior mesenteric artery dissection with ultrasound: A case report

BACKGROUND

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease that originates from the superior mesenteric artery, without the presence of aortic and other arterial dissections. Most cases are diagnosed using contrast-enhanced computed tomography (CECT), whereas the application of ultrasound is less common.

CASE SUMMARY

Here, we report a case of SISMAD with sudden epigastric pain that worsened as the main symptom after eating. The patient had a long history of hypertension with unknown blood pressure control but no history of smoking or alcohol consumption. This case was initially diagnosed using ultrasound and the results were later confirmed by CECT. After admission, the patient fasted, followed by parenteral nutrition support and fluid supplementation to maintain electrolyte and acid–base balance. Metoprolol succinate sustained-release tablets and aspirin were given as nonoperative treatments. After 1 wk, the symptoms improved, and the patient was discharged. During telephone follow-up, the patient did not develop similar symptoms.

CONCLUSION

Whether ultrasound can be used as a routine and noninvasive imaging method for the diagnosis of SISMAD needs further exploration.

Current status of spontaneous isolated celiac artery dissection

BACKGROUND

This study aimed to evaluate the current status of spontaneous isolated celiac artery dissection (SICAD).

METHODS

The English-language literature published in various databases before December 2020 was reviewed. All case reports and series were included. If multiple reports came from the same hospital and covered the same period, only the most recent report was considered. The clinical characteristics, imaging features, and treatment outcome were analyzed.

RESULTS

The study enrolled 88 English language publications between January 1959 and December 2020, including 70 case reports, two case series, and 16 clinical studies. Overall, 316 cases of SICAD were reported in the studies, including 268 men and 44 women (unavailable for 4, men: women ratio: 6:1, p < 0.05). The median age was 50.5 years (range: 6-72) in men and 53.9 years (range: 41-67) in women. Most patients (83.54%, 264/316) complained about stomach pain, primarily in the epigastric region (38.61%, 122/316). The misdiagnosis rate in this study was 3.16% (10/316). The most commonly used imaging modality was computed tomography angiography (CTA), with 97.47% (308/316) cases reporting its use in diagnosis and/or management. The rate of symptom improvement with Conservative Management, with or without antithrombotic agents, was 92.45% (98/106) and 96.58% (141/146), respectively. The rate of symptom improvement after surgical recanalization was 100% (13/13). Moreover, endovascular management resulted in a 100% (50/50) symptom improvement rate.

CONCLUSION

Conservative management is the first-line treatment for SICAD. The surgical or endovascular intervention had a high technical success rate, suggesting that it should be reserved for patients who have failed conservative treatment.

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

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.

Clinical features and management strategy of symptomatic spontaneous isolated celiac artery dissection

OBJECTIVES

The aim of this study was to evaluate the clinical features and management strategy for patients with symptomatic spontaneous isolated celiac artery dissection (SICAD).

METHODS

In this retrospective study, consecutive patients with symptomatic SICAD from two institutions were included. The demographics, clinical manifestations, comorbidities, imaging findings and treatment strategy selection were obtained from the medical records. The general epidemiological data, treatment regimens and clinical and follow-up outcomes were analysed.

RESULTS

Patients were divided into the conservative treatment group (group A, n = 26) and endovascular treatment group (group B, n = 11). Of these 37 patients, extent of dissection in both groups included only celiac trunk (61.54%% vs. 18.18%, p = 0.03), common hepatic artery (CHA) and splenic artery (SA) (3.85%% vs. 54.55%, p = 0.001), CHA (7.69% vs. 18.18%, p = 0.57), SA (23.08% vs. 9.09, p = 0.65) and left gastric artery (LGA) (3.85% vs. 54.55%, p = 0.99). Of note, the extension of the lesion in group A was shorter than that in group B. In addition, there were significantly more type IIb in group A than in group B (42.31% vs. 9.09%, p = 0.06) and the mean length of dissection in group A was 42.3 ± 54.71 mm which was significantly shorter than that in the group B 58.45 ± 3.71 mm (p =0.04). During a median follow-up of 11.5 months, the 1, 3, 6 and 12 month follow-ups were completed in 100% (37/37), 100% (37/37), 94.59% (35/37) and 91.19% (34/37) of patients, respectively. The cumulative rate of persistent disease stability in patients with endovascular treatment group was higher than in that conservative treatment group at the 3, 6, 9 and 12 months (50% vs. 16.67%, p = 0.001; 80% vs. 37.5%, p =0.03; 100% vs. 62.5%, p = 0.012;100% vs. 91.67%, p = 0.02 respectively).

CONCLUSION

Most symptomatic SICAD have a tendency to persistent disease stability after conservative treatment. Risk factors for failed conservative treatment were length of dissection and branch involvement. Furthermore, endovascular treatment was associated with a high technical success and persistent disease stability rate, which might be reserved for patients with failed conservative treatment.

Clinical Manifestations of Symptomatic Spontaneous Dissection of the Celiac and Superior Mesenteric Arteries

Purpose

Spontaneous isolated dissection of the celiac artery (SID-CA) and superior mesenteric artery (SID-SMA) are rare vascular diseases with similar presentation, yet comparative studies have not been reported. In this study, we compared their characteristics with the aim of providing insights into their etiology.

Methods

Materials and Patients diagnosed with symptomatic SID-CA and SID-SMA between July 2009 and December 2018 were included. Demographics, clinical presentation, radiologic findings, treatment strategies, and outcomes were analyzed.

Results

Twenty-one patients with SID-CA and 40 patients with SID-SMA were compared. Demographics and initial abdominal pain characteristics were similar, but pain severity was significantly higher and associated mean fasting time was significantly longer in patients with SID-CA than in those with SID-SMA (fasting time 3.2 vs 2.1 days, P=0.001). Most patients were successfully treated conservatively without recurrent pain or aneurysmal dilatation, but 33.3% patients with SID-CA and 17.5% with SID-SMA required endovascular intervention. More favorable remodeling in terms of dissection regression on follow-up computed tomography was found after stenting, where patients with SID-CA showed better remodeling than those with SID-SMA. The overall median follow-up period was 22-31 months, while for patients with stent insertion, it was 55-77 months, and no stent occlusions were found during this period.

Conclusion

Patients with SID-CA presented with severer and longer-duration abdominal pain than those with SID-SMA. Stenting in both groups showed good long-term patency and favorable remodeling, with a higher regression rate for SID-CA. Based on our results, patients with SID-CA may benefit more from active endovascular intervention.

The impact of endovascular treatment on clinical outcomes of stable symptomatic patients with spontaneous superior mesenteric artery dissection

OBJECTIVE

To evaluate the efficacy and clinical outcomes of endovascular treatment for superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with medical management alone after successful initial medical management.

METHODS

In this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs, a composite of dissection-related death, the recurrence of mesenteric ischemia symptoms, and a requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA.

RESULTS

A total of 94 patients with SMAD who underwent successful initial medical management (91 males; mean age, 50.4 ± 6.3 years) were enrolled in the study. Fifty-seven (60.6%) received medical management alone, and 37 (39.4%) underwent endovascular repair after initial medical management. In the endovascular group, the technical success rate was 86.5% (32 of 37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain, and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1, 3, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log rank P = .046).

CONCLUSIONS

Endovascular treatment and medical management alone result in similar MAE-free survival for patients with SMAD after successful initial medical management. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.

Superior Mesenteric Artery Dissection After Lumbar Puncture

We hereby present a case of iatrogenic dissection of the superior mesenteric artery dissection in a 63-year-old female undergoing a lumbar puncture (LP). She presented with severe diffused abdominal pain accompanied by lower back pain, nausea and vomiting a few hours after undergoing an LP due to ongoing headaches. Abdominal CT showed evidence of hemoperitoneum. She was then transferred to another facility and while in route received one unit of packed red blood cellsdue to drop in hemoglobin levels from 15 to 11 gm/dl. Physicians should consider the possibility of arterial variations and the level at which spinal tap is performed during interventions. Acute abdominal pain is a significant, common complaint that should be appropriately investigated.

The role of aortomesenteric angle in occurrence of spontaneous isolated superior mesenteric artery dissection

BACKGROUND

This study investigated whether anatomical factors affect the occurrence of SISMAD by measuring the aortomesenteric angle (AMA).

METHODS

The study population is comprised of 3 distinct population; Korean SISMAD patients, two control groups from a medical checkup database of 4997 Korean and 317 Caucasian patients from 2011 to 2016. The patient group (PG) included 26 symptomatic patients and 19 Korean diagnosed with SISMAD during medical checkup. The control group was selected based on propensity score similarities calculated by using the following covariates: sex, age, body mass index, drinking, smoking, hypertension, diabetes, and cancer. We compared PG with equal numbers of two control groups comprised of Koreans (KG) and Caucasians (FG), respectively.

RESULTS

The mean (SD) AMA was 74.9o (17.5) (range, 45.9-110.9o) in the PG, 56.8o (19.5 (range, 10.2o -91.9o) in the FG, and 62.4o (19.1) (range, 25.4-110.8o) in the KG. A significant difference was observed between PG and the two control groups (P<0.001). The AMA in the FG was significantly more acute than the AMA in Korean patients including those in the PG and KG (P=0.001).

CONCLUSIONS

Large AMA is considered to be an important etiologic factor in SISMAD.

Clinical Features of Spontaneous Isolated Dissection of Abdominal Visceral Arteries

Background

Spontaneous isolated dissection of abdominal visceral arteries without aortic dissection is rare and its pathology and prognosis are not yet clear; therefore, therapeutic strategies for this disease have not been established. The present multi-institution investigational study analyzed the clinical features of patients with spontaneous isolated dissection of abdominal visceral arteries.

Methods

A total of 36 patients diagnosed as spontaneous isolated dissection of abdominal visceral arteries from January 2010 to October 2016 were enrolled. The medical data of the patients were retrospectively reviewed. Imaging characteristics were evaluated. Spontaneous isolated dissection of abdominal visceral arteries was detected on upper abdominal computed tomography examination in almost patients, and was detected on magnetic resonance imaging in one patient.

Results

Of the 36 cases, 26 cases involved the superior mesenteric artery dissection, nine involved the celiac artery, two involved the splenic artery, one involved the common hepatic artery, one involved the gastroduodenal artery and one involved the left gastric artery. Among the 36 patients, 20 had hypertension and 14 were current smokers. Additionally, only one patient had diabetes and four patients had dyslipidemia. Moreover, 32 cases complained of pain including abdominal pain and back pain, one had cough and three had no symptoms. Of the 36 patients, 34 cases (94.4%) were treated conservatively, and two (5.6%) required intravascular treatment. All patients were discharged without complications.

Conclusions

Our findings indicate that hypertension and smoking might be closely involved in the pathogenesis of spontaneous isolated dissection of abdominal visceral arteries, whereas dyslipidemia and diabetes might be less involved. Additionally, few asymptomatic patients were accidentally diagnosed, indicating that the absence of symptoms cannot be used to rule out the presence of this disease. Randomized clinical trials cannot be performed because a considerable number of cases are required. Therefore, detailed descriptions of clinical features, as provided in our report, are important.

Primary conservative treatment for peritonitis-absent symptomatic isolated dissection of the superior mesenteric artery with severely compressed true lumen

Objectives

The purpose of this study was to evaluate the safety and efficacy of primary conservative treatment (PCT) for peritonitis-absent symptomatic spontaneous isolated dissection of the superior mesenteric artery (S-SIDSMA) with severely compressed true lumen.

Methods

From January 2013 to December 2018, PCT was used in 26 cases of peritonitis-absent S-SIDSMA with severely compressed true lumen in our center based on our previous proposed treatment algorithm for S-SIDSMA. The demographics, duration from the onset to the admission, duration from the start of the conservative treatment to the alleviation of the symptoms, and in-hospital and follow-up clinical and angiographic outcomes were prospectively recorded and then analyzed.

Results

Among the 26 included patients, 84.6% were male. The mean age of the patients was 54.7 years. The mean duration from the onset to the admission was 3.1 days (range, 1–14 days). Symptoms in 22 patients were markedly or completely relieved during the first five-day medical treatment. Endovascular stent placement was attempted in the remaining four patients, which was successfully performed in three (75%) of them. The technical failure occurred in a patient whose compressed true lumen failed to be cannulated. Medical treatment was then continued in this patient, and his symptoms were relieved after a two-day medical treatment. During the mean follow-up period of 14.3 months, endovascular stent placement was performed in three patients due to the recurrence of the abdominal pain and the chronic intestinal ischemia. No patient showed dissection progression during the follow-up. The complete remodeling rate of the stent group was significantly higher than that of the medical group (83.3% vs. 25%, P = 0.021).

Conclusions

Based on our previous proposed treatment algorithm for S-SIDSMA, PCT could achieve satisfactory results both clinically and morphologically in peritonitis-absent S-SIDSMA with severely compressed true lumen.

Mid- to Long-Term Outcomes in Management of Spontaneous Isolated Coeliac Artery Dissection (SICAD)

OBJECTIVE

Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment.

METHODS

Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed.

RESULTS

The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period.

CONCLUSION

Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.

Necessity of revascularization for acute mesenteric ischemia in symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery

Objectives

We evaluated the necessity of revascularization for acute mesenteric ischemia in symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery.

Methods

This retrospective study included 28 consecutive, symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery treated at our hospital between December 2005 and December 2017. Patients with concomitant aortic dissection were excluded. We reviewed the patients’ clinical presentation; laboratory evaluations; computed tomography findings, including the true lumen residual ratio (i.e., the minimum true lumen size compared to the diameter of the transverse section of the dissected artery) at the time of admission; the number of patients who were suspected of having bowel ischemia; and the number of patients who required surgical or endovascular treatment and their outcomes. Additionally, to evaluate the true lumen residual ratio in symptomatic patients with bowel ischemia, the true lumen residual ratio in those with abnormal laboratory data were compared with that in those without abnormal laboratory data. Initial true lumen residual ratio values were also compared with final values. Furthermore, we assessed the clinical details of patients who had bowel necrosis. Categorical variables were compared using the χ2 test or Fisher’s exact test, and continuous values were presented as either the mean ± standard deviation or median (interquartile range 25–75%). Variables were analyzed using Student’s t-test or the Mann–Whitney U test.

Results

The patients’ age ranged between 41 and 85 years, and 25 were men. Although nine patients were suspected of having acute mesenteric ischemia, only one underwent bowel resection. None of the patients had an indication for revascularization. The true lumen residual ratio of the nine patients with abnormal laboratory data were significantly lower than those of the 19 without abnormal laboratory data (10 [0–25]% vs. 40 [20–50]%, p = 0.005). The patient who underwent bowel resection had a true lumen residual ratio of 10%; however, there was no obvious abnormal laboratory data suggestive of bowel necrosis. Dissections were managed conservatively in all patients. True lumen residual ratio increased from initial value of 30 (10–48)% to 98 (60-100)%at the final imaging study ( p < 0.0001). There were no adverse events related to the mesenteric circulation during the follow-up period of 2–11 years.

Conclusions

Reintervention is rarely required for spontaneous isolated dissection of the superior mesenteric artery, even in symptomatic patients, and spontaneous resolution of the luminal compromise is the rule.

Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery

Introduction

Isolated dissection of the superior mesenteric artery (SMA) is rare and remains the most common reason for aneurysmal degeneration of the vessel. The treatment is challenging and not standardised. The purpose of this report is to demonstrate that coiling of the false lumen is a good alternative for dissecting SMA aneurysms.

Report

A 50 year old male presented with a 3.3 cm dissecting aneurysm of the SMA and epigastric pain of moderate severity. More than 50% of the ileal arteries arose from the collapsed true lumen. Via transfemoral access the true lumen was catheterised. An open cell balloon expandable stent was deployed at the proximal and a closed cell self expandable stent at the distal end of the dissection flap. Through the cells of the first stent a microcatheter was advanced into the false lumen and 33 coils were deployed into the aneurysm sac. A stent graft was deployed within the first stent leading to the total exclusion of the aneurysm. Follow up at three months was uneventful and the patency was assessed by contrast enhanced ultrasound.

Discussion

Coiling of the false aneurysm is a good alternative for dissecting SMA aneurysms, where no other open surgical or endovascular options are applicable.

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Spontaneous isolated SMA dissection is the most frequent type of visceral artery dissection.

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Spontaneous isolated SMA dissection is the most frequent cause of SMA dissecting aneurysms.

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Treatment of SMA dissecting aneurysms remains controversial.

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Coiling of the false lumen and stenting of the true lumen is an effective method of treatment.

Diagnostic value of color Doppler sonography for spontaneous isolated superior mesenteric artery dissection

The present study aimed to evaluate the clinical significance of color Doppler sonography (CDS) in the diagnosis of spontaneous isolated superior mesenteric artery dissection (SISMAD). The ultrasonographic images of 19 patients with SISMAD confirmed by computed tomography angiography (CTA) were retrospectively analyzed and the ultrasonographic features were summarized. The paired t-test was used to statistically analyze the differences in parameters determined by CTA vs. CDS, including the minimal inner diameter (MID), cross-sectional area (CSA), diameter and area stenosis rate, and flow rate of the true lumen. Of the 19 patients, 18 (94.7%) were diagnosed with SISMAD with correct classification by CDS. There was no significant difference between CTA and CDS with regard to minimal ID, CSA, diameter stenosis and area stenosis rate, and flow rate of the true lumen (all P>0.05). CDS was indicated to be an effective imaging modality for the diagnosis of SISMAD.

Vascular Genetics: Presentations, Testing, and Prognostics

PURPOSE OF REVIEW

Numerous studies have begun to unravel the genetic basis of not only aortic disease but also other forms of commonly encountered vascular diseases. The goal of this review is to provide clinicians a reference to help identify and diagnose different types of vascular disease with a genetic underpinning.

RECENT FINDINGS

Ongoing studies have identified numerous genes involved in the TGF-β signaling pathway that are also associated with thoracic aortic aneurysm and dissection, and it is possible to test for pathogenic variants in these genes in the clinical setting using commercially available genetic testing panels. Additional studies have begun to identify genetic variants associated with an increased risk of bicuspid aortic valve, abdominal aortic aneurysm, and fibromuscular dysplasia. With increased availability of low-cost genetic testing, clinicians are now able to not only definitively diagnose some vascular syndromes but also provide information on the risk of disease in other family members, as well as provide guidance in terms of family planning. As the cost of genetic testing continues to drop with the benefit of increasing insurance coverage, genetic data will increasingly become part of clinical care for many patients with vascular disease.

Spontaneous Isolated Superior Mesenteric Artery Dissection Requiring Emergent Surgery

A 52-year-old man with a history of hypertension was referred to our hospital due to persistent abdominal pain. Abdominal palpation revealed remarkable rigidity and rebound tenderness all over the abdomen. Enhanced computed tomography demonstrated the superior mesenteric artery (SMA) dissection with a complete obstruction at the middle part of the SMA. Intraoperative findings showed significant necrosis in the most small intestine and surgical resection was performed. Emergent operation is warranted once abdominal pain becomes uncontrollable or intestinal necrosis is suspected. Physicians should pay careful attention to patients' symptoms and repeatedly perfume physical examinations.