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

Conservative Versus Endovascular Treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection: A Clinical and Imaging Follow-up Study

PURPOSE

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disease, the treatment strategies for which remain debated. This retrospective study aimed to compare the outcomes of conservative and endovascular treatments in patients with SISMAD.

MATERIALS AND METHODS

Fifty-eight patients with SISMAD confirmed by computed tomography angiography admitted to our hospital between November 2017 and May 2021 and received confirmed conservative (n=43) or endovascular (n=15) treatment. The patient demographics, imaging analysis, and follow-up results were analyzed and compared.

RESULTS

The cohort included 54 males and 4 females with a mean age of 52 years. Abdominal pain was the major complaint (49/58, 84.5%), followed by chest pain (2/58, 3.4%). The mean follow-up was 9.1±7.9 months. The 2 main Sakamoto types were type III (27/58, 46.6%) and type IV (16/58, 27.6%). Most patients in both groups had angle 1 (aortomesenteric angle) and angle 2 (superior mesenteric artery [SMA] course) of over 80°. About 67.3% of patients had long length of dissection (>60 mm). The median distance between the SMA root and the dissection entry site was 1.5 cm, mostly (84.5% of the patients) in the curved segment of the SMA. Telephone follow-ups found that most patients survived pain-free, and none underwent intestinal resection. Only 4 patients, 2 in each group, had recurrent abdominal pain during follow-up and received stenting treatment to achieve complete vascular remodeling. Importantly, we found that the conservative and endovascular therapies achieved similar high remodeling rates (94% and 100%, respectively; p=0.335). The conservative group achieved satisfying vascular remodeling (partial, 35%; complete, 59%), making it as safe and effective a treatment as endovascular therapy.

CONCLUSIONS

Initial conservative management is safe and effective in patients with SISMAD. A high technical success rate and favorable short-term outcomes were associated with endovascular procedures as secondary interventions. It would be helpful to conduct large-scale, prospective, randomized controlled trials with long-term follow-up for SISMAD.

CLINICAL IMPACT

1. This research provided more detail clinical information, such as evaluation of abdominal pain and measurements of SMA angles, which is all relevant to treatment. 2. What's more, the most surprising results of follow-up part shown that conservative treatment could reached the remodeling rate as high as endovascular treatment, which was relatively low in other studies. It helps us share our treatment experience with clinicians. 3. In addition, we get limited knowledge about this rare disease, it's encouraging us to do more researches based on the results we had.

Management Strategy and Radiologic Outcomes of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection Based on Angiographic Classification: The Follow-Up Experience in a Single Center

PURPOSE

To investigate the demographics, clinical features, radiologic measurement, treatment, and outcomes of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) according to computed tomography (CT) classification.

METHODS

This retrospective study included 201 patients diagnosed with symptomatic SISMAD from November 2014 to December 2020. Symptomatic spontaneous isolated superior mesenteric artery dissection was categorized into four types based on CT images by Yun's angiographic classification. Their clinical characteristics, images features, treatment methods, and radiological outcomes were comparatively analyzed by CT angiographic types.

RESULTS

SISMADs were categorized into type I (13.9%) patent false lumen (FL) with both entry and re-entry; type IIa (37.3%), blind pouch of FL; type IIb (43.3%), thrombosed FL; and type III (5.5%), and the occlusion of superior mesenteric artery (SMA). Type IIb, the most common SISMAD, showed the largest true lumen (TL) residual diameter and the lowest percentage of TL stenosis. Type III positioned most proximally to SMA origin and had the maximum dissection length. Symptomatic spontaneous isolated superior mesenteric artery dissections underwent conservative (75.1%), endovascular (22.4%), and surgical (2.5%) treatment. Conservative treatment was more frequent in type I (85.7%) and type IIb (83.9%) than in type IIa (65.3%) and type III (45.5%). Endovascular intervention was more commonly utilized in type IIa (32.0%) and type III (36.4%) than in type I (14.3%) and type IIb (14.9%). Conservative patients achieved FL vanishment/shrinkage (57.8%), stabilization (26.6%), and enlargement (15.6%). After conservative treatment, type I showed angiographic FL stabilization; type IIa achieved FL shrinkage (48.1%), stabilization (22.2%), and enlargement (29.6%); type IIb exhibited FL vanishment/shrinkage (92.0%) and enlargement (8.0%). Cumulative rate of stent patency was 92.3% during 6-year follow-up.

CONCLUSIONS

Conservative management with close follow-up is initially provided especially for types I and IIb. Morphological stabilization is more frequent in type I of patent FL with entry and re-entry. False lumen vanishment or shrinkage was more likely to occur in type IIb due to the thrombus absorption. Endovascular intervention has excellent long-term in-stent patency and is predominantly utilized in types IIa and III. Blood flow sustained into a blind-ending FL causes the TL compression and stenosis in type IIa. Type III with the occlusion of SMA has the high risk of bowel ischemia.

CLINICAL IMPACT

According to Yun's angiographic classification of spontaneous isolated superior mesenteric artery dissection (SISMAD), type I (13.9%) has patent true and false lumen and the morphological pattern is maintained stable; type IIa (37.3%) possesses a patent blind-ending false lumen which might shrink, remain unchanged, or enlarge; and endovascular intervention is suggested when conservative treatment failed; type IIb (43.3%) recovers spontaneously due to the absorption of false lumen thrombus and conservative treatment is preferentially considered; type III (5.5%) with the occlusion of main trunk carries a high risk of bowel necrosis, early endovascular intervention is proposed, and open surgery might be necessary.

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.

Open thrombectomy, patch angioplasty, and retrograde stenting for isolated superior mesenteric artery dissection

Isolated superior mesenteric artery dissection without aortic involvement is an exceptionally rare event. Nonoperative management remains the first-line therapy. However, surgical interventions can be indicated in the event of bowel ischemia. In the present report, we describe a case of complicated isolated superior mesenteric artery dissection treated with a hybrid approach.

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.

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.

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.

Hybrid repair of symptomatic superior mesenteric artery dissection, utilizing open septectomy

We present a case of acute isolated superior mesenteric artery dissection with symptomatic bowel malperfusion requiring surgical intervention. We recommend clinicians and surgeons maintain a high clinical suspicion for mesenteric ischemia in patients presenting with isolated superior mesenteric artery dissection and describe a hybrid open surgical/endovascular approach that can safely be utilized in patients requiring intervention.

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.

Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival

OBJECTIVE

Visceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement.

METHODS

VBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

A total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P < .001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P < .001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P < .001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P < .001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P < .001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P = .001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P = .001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P = .004) were associated with inferior intervention-free survival.

CONCLUSIONS

Isolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance.

A comparative study on the transbrachial and transfemoral approaches for the treatment of superior mesenteric artery lesions

BACKGROUND

Superior Mesenteric Artery (SMA) lesions present a significant challenge in endovascular surgery. Both the transbrachial (TBA) and the transfemoral (TFA) approaches have been employed for the treatment of these lesions, but the comparative effectiveness of these methods remains unclear.

MATERIALS AND METHODS

A retrospective analysis was conducted on patients who underwent TBA and TFA at a tertiary center between June 2020 and February 2023. Key parameters including technical success, procedural details, and complication rates were examined.

RESULTS

In a study of 99 patients, 66 underwent Transfemoral Approach (TFA) and 33 underwent Transbrachial Approach (TBA). No significant age or gender differences were noted between groups. TFA procedures were longer (90.0 vs 63.5 min, p = 0.002) and had higher fluoroscopy times (59.0 vs 43.0 min, p = 0.02) and selective SMA times (366.0 vs 245.0 min, p = 0.038) compared to TBA, especially with a smaller aortomesenteric angle (<90°). Technical success rates were high in both groups (TFA 97%, TBA 93.9%, p = 0.60). Complication rates were similar between groups, with no significant predictors for access site complications identified.

CONCLUSION

Both the TBA and the TFA are effective for the treatment of SMA lesions, with TBA potentially offering advantages in terms of efficiency and patient recovery, particularly in cases with certain anatomy. No significant differences in complication rates were found between the two groups. Further research, including prospective randomized trials, is needed to confirm these findings.

Conservative versus stent treatment for spontaneous isolated superior mesenteric artery dissection after the failure of initial 3 days' conservative treatment: A 10-year follow-up study

OBJECTIVES

To compare the safety and effectiveness of conservative and stent treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) patients after the failure of initial 3 days' conservative treatment.

METHODS

All newly diagnosed SISMAD patients between 2013 and 2017 were retrospectively reviewed. After the failure of 3 days' conservative treatment, all patients were recommended for stent treatment, but some patients refused to choose it. Their demographic, radiologic, and clinical data were compared.

RESULTS

57 patients were not improved after initial 3 days' conservative treatment. Among them, 19 patients were chose to receive stent placement and 38 patients were continually treated with conservative treatment. The median follow-up time was 92.0 (range 62.7-120.4) months. There were no bowel ischemia and arterial rupture. No significant difference was observed in clinical complete recovery (Conservative 31/38 vs Stent 12/19, p =.19) and hospitalization time (Conservative 8.3 ± 1.7 days vs Stent 7.2 ± 1.5 days, p =.59) between conservative and stent treatment groups. Significant statistical differences were found in radiological complete remodeling (6/38 vs 16/19, p < .01) and hospitalization expense (8662 ± 2886 China Yuan vs 32,935 ± 11,767 China Yuan, p < .01) between these two groups.

CONCLUSIONS

Although undergoing the failure of initial 3 days' conservative treatment, continue conservative treatment still is safe and effective for SISMAD patients. Stent placement could be chosen as an alternative treatment, especially for patients potentially with bowel ischemia or arterial rupture.

Mid-term Results of the Treatment of Isolated Dissection of the Celiac Artery: A Comparative Analysis of Endovascular Versus Conservative Therapy

OBJECTIVES

Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA.

METHODS

Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed.

RESULTS

A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10-85 months) and 44.0 (range, 9-80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001).

CONCLUSIONS

EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required.

CLINICAL IMPACT

Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery.

A useful modality of CT angiography image to identify medical emergency in isolated celiac artery dissection type I: A case report with longest follow-up and literature review

Symptomatic isolated celiac artery (CA) dissection (SICAD) is an extremely rare form of visceral artery dissection. It is diagnosed by a contrast abdominal computed tomography (CT) scan showing a CA dissection (CAD). There are 4 types of CAD: Type I-IV. Type I has entry and re-entry and no true luminal narrowing. All types other than type I have entry and re-entry. They have true lumen compression and true lumen constriction due to false lumen. We report a case with the longest follow-up, 120 months after symptom onset, without evidence of CAD exacerbation. A 56-year-old man presented with a sudden onset of abdominal and back pain. He had a past medical history of left pneumothorax, pulmonary tuberculosis at the age of 23, and hypertension on medication since the age of 46. On physical examination, he had mild muscle rebound tenderness in the epigastric region. The curved multiplanar reconstruction (MPR) of the urgent 3-dimensional contrast-enhanced abdominal computed tomography angiography (CTA) showed an isolated celiac artery dissection type I. Given the risk of emergency surgery for total occlusion of the CA, conservative management with analgesics during hospitalization resolved the abdominal pain, and the patient was discharged 3 days later. Subsequently, a total of 5 CTAs were performed over 120 months, but no worsening of CA arterial dissection and CA occlusion findings were observed. In type I SICAD cases, arterial dissection, and CA occlusion may progress, in which case emergency stenting or endovascular treatment may be indicated, and close follow-up such as CTA is required.

Placement of Bare Self-Expanding Metal Stent for Isolated Superior Mesenteric Artery Dissection

BACKGROUND

To evaluate the safety and efficacy of placing bare self-expanding metal stent (SEMS) for treating isolated superior mesenteric artery dissection (ISMAD).

METHOD

Patients with ISMAD who received bare SEMS from January 2014 to December 2021 at the authors' center were included. Baseline characteristics, clinical manifestation, radiological findings, and treatment outcomes, including symptom relief and SMA remodeling, were analyzed.

RESULT

A total of 26 patients were included in this study. Among the patients, 25 were admitted due to persistent abdominal pain, and 1 was admitted based on computed tomography angiography (CTA) during physical examination. According to CTA scan, the percentage of stenosis was 91% (53.8-100%), and the length of dissection was 100.2 ± 8.4 mm. All patients received bare SEMS placement. The median time to symptom relief was 1 day (interquartile range, 1 3 days). The the median follow-up time of CTA was 6.8 months (range, 2-85 months), with an average of 16.2 months. Complete remodeling of the superior mesenteric artery (SMA) was recorded in 24 patients. The median time to remodeling was 3 months with an average of 4.7 months. Survival analysis indicated no significance difference in remodeling time between different ISMAD types based on Yun classification (P = 0.888) or between acute and nonacute disease (P = 0.423). Incomplete remodeling was noted in 2 patients. Distal stent occlusion without SMA-related symptoms was seen in 1 patient. Proximal stent stenosis occurred in 1 patient, and restenting was performed. The median follow-up time by telephone was 20.8 (4-91.5) months, and no intestinal ischemic symptoms were observed in any patient.

CONCLUSIONS

Bare SEMS placement can effectively relieve SMA-related symptoms in a short time and promote dissection remodeling in ISMAD. Time from symptom onset and classification of ISMAD seem not to have effects on SMA remodeling after bare SEMS placement.

Spontaneous Celiac Artery Dissection with Splenic Infarction: A Report of Two Cases

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that is characterized by sudden onset abdominal pain, typically occurring in middle-aged men. Although its clinical course is mostly benign, it may progress to true lumen occlusion. No established therapeutic guidelines are available for SICAD associated with splenic infarction. This report describes two patients who presented with sudden onset abdominal pain and were diagnosed with SICAD with splenic infarction based on computed tomography (CT) findings. Patients were treated with bowel rest and anticoagulants. After a week of medical therapy, the abdominal pain resolved. Follow-up CT revealed no progression of the dissection flap. The patients received oral anticoagulants for 3 months and did not experience any symptom recurrence. Medical therapy with anticoagulants may be considered for patients with SICAD and splenic infarction. Associated splenic infarction itself is not an indication for endovascular or surgical intervention for SICAD.

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.

Five-Year Results of Spontaneous Isolated Superior Mesenteric Artery Dissection from Two Teaching Hospitals in China

BACKGROUND

To present 5-year results of management on spontaneous isolated superior mesenteric artery dissection (SISMAD) from 2 teaching hospitals in China.

METHODS

The clinical data of 41 patients with SISMAD were retrospectively collected from 2 teaching hospitals between December 2016 and December 2021. Therapeutic methods mainly included open surgery, endovascular management, and conservative therapy. Patients' demographics, total number of WBC (White blood cell, WBC), the percentage of NEUT (Neutrophil), the level of CRP (C-reactive protein, CRP), duration of abdominal pain on admission, YOO classification of SISMAD, angle of superior mesenteric artery to abdominal aorta (ASA), length of hospital stays, and vascular remodeling rate of SMA between endovascular and conservative groups were analyzed.

RESULTS

A total of 41 patients with SISMAD were finally included in this study. Their average age was 53.4 ± 7.1 years old, ranging from 35 to 68 years old. Among these patients, 1 patient suffered emergent open surgery because of the intestinal necrosis. The other 40 patients were treated conservatively at first, but 13 of them were transitioned into endovascular management due to persistent abdominal pain. Regarding the imaging analysis, IIS and IVS types of YOO classification were more in the endovascular group (13 patients) than the conservative group (27 patients). The length of hospital stays (P = 0.003) and the vascular remodeling rate of SMA were significantly different between 2 groups (P = 0.002), while the time of abdominal pain on admission, the infection markers (WBC, CRP, NEUT) and ASA were not significantly different between the 2 groups.

CONCLUSIONS

In SISMAD, patients without any signs of peritonitis and intestinal necrosis may be treated conservatively firstly, and then transitioned into endovascular management if abdominal pain is not improved within 48 hr. IIS and IVS types of YOO classification should be alerted of this potential transition. But the optimal timing of transition required more clinical studies.

Analysis of safety and efficacy of conservative treatment and endovascular treatment in patients with spontaneous isolated mesenteric artery dissection

Background

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease with abdominal pain as the main clinical manifestation, but its optimal treatment strategy has not yet been determined. Based on this, this study explored a safe and effective treatment method by analyzing and comparing the safety and efficacy of conservative treatment and endovascular treatment in SISMAD patients.

Methods

The clinical and imaging data and treatment effects of 85 patients with SISMAD who were admitted to the General Surgery Department of the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from January 2008 to December 2020 were retrospectively analyzed. Two groups were treated, the data of patients in conservative treatment group and endovascular treatment group were analyzed, and a safe and effective treatment method for SISMAD was discussed.

Results

The mean follow-up time was 36.58 ± 25.03 months. The success rate of interventional operation was 86.11% (31/36), and the operation failed because the guide wire could not enter the true lumen in four cases. One case was terminated due to poor physical condition of the patient who could not tolerate surgery. There were no significant differences in gender, body mass index, clinical manifestations, and past history between conservative treatment and endovascular treatment (P > 0.05), but in age, superior mesenteric artery-distal aorta angle, distance from the superior mesenteric artery opening to dissection, dissection length, and true lumen stenosis. There was a statistical difference between the two groups in the rate and Yun classification (P < 0.05).

Conclusions

Conservative treatment is effective for most symptomatic SISMAD patients, and close monitoring is required; for patients with persistent symptoms and severe true lumen stenosis (especially Yun classification type III), endovascular treatment is preferred; endovascular treatment is mainly based on endovascular bare stent placement. Patients receiving stent implantation may suffer from stent stenosis or occlusion in the long term, and most of them have no obvious symptoms of intestinal ischemia; the prognosis is good.

Risk factor analysis and treatment outcome of patients with spontaneous isolated celiac axis or superior mesenteric artery dissection

BACKGROUND

Spontaneous isolated mesenteric artery (celiac axis or superior mesenteric artery [SMA]) dissection (IMAD) is a rare clinical entity. The aim of the present study was to examine the patient demographics, comorbidities, clinical and radiologic features, management, and prognosis and to identify the risk factors predictive of symptoms.

METHODS

We performed a single-center, retrospective review from November 2005 to November 2021 of prospectively collected data from patients with a diagnosis of IMAD. The clinical data and radiologic images were reviewed, and statistical analysis was performed to compare the symptomatic and asymptomatic groups.

RESULTS

A total of 78 patients were identified. Of the 78 patients, 24 (31%) had had celiac dissections, 51 (65%) had had SMA dissections, and 3 (4%) had had both celiac and SMA dissections. The mean age was 57.7 years (range, 36-84 years), with a male predominance (86%). More than one half (55%) of the patients had had hypertension. In addition, 29 patients (37%) were symptomatic, and 24 (31%) had been admitted to the hospital. The symptomatic patients with celiac axis dissections were more likely to have thrombosis (P = .02), significant stenosis (P = .01) or branch extension (P = .02). The symptomatic patients with SMA dissections were more likely to have a smaller artery diameter (P = .07), a longer dissection length (P = .05), thrombosis (P < .001), significant stenosis (P < .001), or branch extension (P = .003). The symptomatic patients were more likely to have been treated with antiplatelet or anticoagulant therapy (P < .001). Only three patients had undergone an intervention. Seven patients (9%) had died of unrelated causes. The Kaplan-Meier survival analysis showed a 5-year survival rate of 96% and 10-year survival rate of 91%.

CONCLUSIONS

IMAD is an uncommon disease entity with a risk of visceral ischemia. Nonetheless, most of these patients can be treated conservatively with medication, with only a small minority requiring emergency surgery.

A rare and unusual cause of acute abdominal pain: A case of spontaneous isolated dissection of the celiac trunk

Spontaneous dissection of the celiac trunk is a rare and uncommon cause of acute abdominal pain. Risk factors, natural history and optimal treatment are still unclear due to the rarity of the disorder. Therapeutic strategies and follow-up procedures are based on limited observations, and the absence of guidelines warrants a patient-tailored approach. We report the case of a 50-year-old woman who presented to our emergency department for epigastric pain, nausea, and vomiting resulting from a spontaneous dissection of the celiac trunk, successfully treated endovascular technique.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre

OBJECTIVE

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC).

METHODS

All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI).

RESULTS

Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun et al., IMADs were reported as follows: type I (n = 7, 20%), type IIa (n = 6, 18%), type IIb (n = 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n = 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n = 3; type III, n = 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n = 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n = 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n = 4; stenting, n = 1) and or bowel resection (early, n = 3; late, n = 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention.

CONCLUSION

Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

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.

General features, management strategies, and outcomes of symptomatic spontaneous isolated celiac artery dissection

Objectives

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that has not been fully investigated and reported, and very little is known regarding its prognosis and management. Here, we aimed to provide more evidence on the management strategy and outcome for symptomatic SICAD based on the experience of a single center.

Methods

From January 2018 to December 2021, a total of consecutive 51 patients with symptomatic SICAD were retrospectively included in this study. These patients had been selectively treated with conservative treatment (n = 31) or endovascular treatment (n = 20). Baseline data, imaging findings, treatment strategy, outcomes, and follow-up data have been described and analyzed.

Results

The mean age of the patients was 53.2 ± 9.6 years, 44 (86.3%) were male, and 36 (70.6%) had hypertension. The median length of stay was 10.0 days. The complete remission rate was 92.2% on discharge. The median follow-up time was 21.0 months. A secondary intervention was required for two patients during follow-up in the conservative group, wherein one underwent a stent placement three months after discharge because of progression of symptoms and extension of dissection, and the other required intervention one month after discharge because of symptomatic progression. No secondary intervention was required in the endovascular group. Occasional and mild relapse of symptoms occurred in two patients in both the conservative and endovascular groups, with no secondary intervention. The length of dissection (25.5 ± 11.8 mm vs. 19.1 ± 7.4 mm, P = 0.022) and complete remodeling rate (85.7% vs. 15.4%, P < 0.001) in the endovascular group were greater than that in the conservative group.

Conclusion

Patients with symptomatic SICAD who were selectively treated with conservative treatment or endovascular treatment had satisfactory early and medium-term outcomes. Endovascular treatment showed significant advantages in the complete remodeling of the celiac artery and presented with a lower rate of secondary intervention. Moreover, it was found to be a safe and effective remedy for failed conservative treatment.

Spontaneous celiac artery dissection treated by balloon angioplasty

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition, defined as dissection of the celiac artery without aortic involvement. Because of its low prevalence, most studies have been limited to case reports and case series. We have described the case of a 44-year-old woman who had presented with symptomatic SICAD that had resulted in compromised flow to the hepatic arteries and was successfully treated with balloon angioplasty. Angioplasty alone might be effective for cases of extensive false lumen thrombosis in SICAD for immediate flow restoration to the true lumen, expediting positive remodeling.

Endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery

BACKGROUND

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) occurs when a tear in the inner layer of the superior mesenteric artery (SMA) allows blood to flow between the layers of the SMA, forcing the layers apart, and creating two lumens. Abdominal pain is the most prevalent clinical manifestation. Other people may have no symptoms or experience nausea, vomiting, diarrhea, or blood in their stools. For people with SIDSMA who are not suspected of intestinal necrosis or intra-abdominal bleeding, medical treatment and endovascular therapy are the main treatment options. There is no consensus on the optimum first-line management strategy.

OBJECTIVES

To evaluate the benefits and harms of endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021.

SELECTION CRITERIA

We planned to include all randomized controlled trials (RCTs) which compared endovascular therapy and medical treatments for SIDSMA. We planned to exclude studies where participants were treated with open surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were endovascular intervention rate and recurrent abdominal pain. Our secondary outcomes were open surgery rate, remodeling rate of SMA, new aneurysm formation of SMA, SMA occlusion, new dissection of SMA, death, symptom relief rate and complications of endovascular therapy. We planned to use GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We did not identify any RCTs to include in any analysis.

AUTHORS' CONCLUSIONS

We were not able to include any RCTs that compared endovascular therapy versus medical treatment in people with SIDSMA. High-quality RCTs that evaluate the benefits and harms of these interventions are needed to help determine the optimal strategy for managing SIDSMA.

Relationship Between Morphological Remodeling and Angiographic Types of Spontaneous Isolated Superior Mesenteric Artery Dissection After Conservative Management: Determinant Affecting Serial Radiologic Courses

Objective

To monitor the radiological courses of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) after conservation, clarify the relationship between its morphological change and initial imaging classification, and identify these factors that affect dissection remodeling.

Methods

Eighty-nine conservative patients with SISMAD who underwent periodic follow-up of computed tomography angiography (CTA) were enrolled. Initial morphologic classification, imaging features and dissection remodeling were analyzed retrospectively. Logistic regression was used to identify predictors for remodeling. Receiver operating characteristics were performed for cutoff threshold.

Results

Zerbib classification was adapted and initial CT appearance divided eighty-nine patients into: type I (15.7%), patent false lumen (FL) with both entry and re-entry; type II (37.1%), “cul-de-sac” shaped FL without re-entry; type III (27.0%), thrombosed FL with ulcer-like-projection (ULP); type IV (18%), intramural hematoma; type V (0%), dissecting aneurysm; and type VI (2.2%), total or partial occlusion of superior mesenteric artery (SMA). Follow-up CTA revealed complete remodeling (33.7%), partial remodeling (16.9%), no change (25.8%), type change (13.5%) and dissection progression (10.1%). There was no dissection-related mortality. Type I (92.9%) sustained patent FL and no angiographic change. Type II showed partial remodeling (42.4%), no change (27.3%) and dissection progression (27.3%), and the length of FL enhancement positively predicted dissection progression with the cutoff of 40.3 millimeters. Type III achieved complete remodeling (58.3%) or evolved into type II (41.7%), and the distance between SMA orifice and ULP negatively predicted type change with the cutoff of 23.5 millimeters. Type IV (87.5%) achieved complete remodeling due to hematoma absorption. One patient underwent stent placement for the evolution of ULP into an enlarged blind-ending FL 2 months after conservation.

Conclusion

After conservation, patent FL with a distal re-entry is no morphological change, FL thrombosis tends to be resolved, and the “cul-de-sac” shaped FL without re-entry is partially shortened, no change or progressively dilated. FL enhancement length ≥ 40.3 millimeters is a predictor for the blinding-end FL enlargement. Thrombosed FL with ULP evolves into a patent “cul-de-sac” shaped FL when the distance between SMA orifice to ULP is less than 23.5 millimeters. A careful follow-up is necessary for the lesions with demonstrated predictors.

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.

Haemosuccus Pancreaticus Caused by Splenic Artery Aneurysm Derived From Isolated Spontaneous Coeliac Artery Dissection: Two Case Reports

Objective

Case report

Conclusion

•

Haemosuccus pancreaticus (HP) is a rare cause of gastrointenstinal bleeding.

•

Splenic artery aneurysms derived from ISCAD may cause HP.

•

Treatment for HP may be delayed due to difficulty in diagnosis.

Comparison of Superior Mesenteric Artery Remodeling and Clinical Outcomes between Conservative or Endovascular Treatment in Spontaneous Isolated Superior Mesenteric Artery Dissection

The aim of this study was to analyze the superior mesenteric artery (SMA) remodeling after initial conservative or endovascular treatment with a standardized definition and midterm outcomes in patients with spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). This retrospective study enrolled patients with SIDSMA from January 2007 to August 2019. All patients were treated initially with conservative treatment. If they failed the medical treatment, they were converted to interventional treatment. The morphological endpoint was determined by the standardized SMA remodeling, and the clinical endpoints were determined by the in-hospital mortality, hospital stay, and the bowel-related mid-term mortality. A total of 34 consecutive patients with SIDSMA were identified. Twenty-three (67.6%) and eleven (33.4%) patients underwent conservative and interventional treatments, respectively. Clinical features and morphologic changes on CTA were available in 25 (73.5%) patients during the median follow-up of 23.3 months. Standardized SMA remodeling was significantly (p < 0.05) better in patients undergoing endovascular stenting, especially in patients with Yun's IIb classification. There was no mesenteric ischemia or SMA aneurysm during follow-up period. Patients with SIDSMA can be treated safely with initial conservative treatment. However, significant portions of patients will require endovascular intervention due to the persistent symptoms. Clinically endovascular stenting could be performed successfully, and SMA remodeling was satisfactory during the mid-term follow-up.

Aneurysmal celiac trunk dissection caused by median arcuate ligament syndrome successfully treated by endovascular technique: a case report

Median arcuate ligament syndrome (MALS) is a chronic pathogenic process, resulting from the compression of the celiac axis by fibrous attachments of the diaphragmatic crura which named median arcuate ligament. In clinical, isolated spontaneous superior mesenteric artery (SMA) is common. Whereas, isolated celiac trunk (CA) dissection is rare, it is usually associated with aortic dissection. In this case report, the CA is not only dissected, but also the aneurysm formed. Because the long-time compression of the MALS, relative narrowing of the celiac artery causes the high pressure at the beginning of the CA and that may contribute to the aneurysmal celiac trunk dissection (ACTD). This case described a male patient who underwent hypertension and abdominal pain as their main clinical manifestation. Contrast-enhanced computed tomography angiography (CTA) showed that a slightly stenosed root of the celiac artery during inhalation and severe stenosis of the root during expiration. Moreover, a small intimal tear at the site of celiac artery proximal end with nonruptured aneurysmal dilation located on the celiac trunk. After our carefully examinations, the patient was diagnosed as ACTD caused by MALS. And we applied endovascular technique-stenting in this case. It could not only cover the dissection, but also could obstruct the aneurysm. The patient was in a stable condition after management of ACTD by stenting. Stenting is a safe and effective treatment for ACTD caused by MALS.

Multiple Spontaneous Visceral Arterial Dissections in a Patient With Tolosa-Hunt Syndrome on Corticosteroid Therapy

Multiple spontaneous visceral arterial dissections are an infrequent occurrence. The etiology, risk factors and natural history of these dissections have not been elucidated, and the optimal therapeutic strategy has not been established. We report a rare case of multiple spontaneous visceral arterial dissections involving the celiac artery, splenic artery, superior mesenteric artery, and right renal artery in a patient with Tolosa-Hunt syndrome on short-term corticosteroid therapy. The patient was subjected to conservative treatment and endovascular repair, achieving good clinical and radiological outcomes during the long-term follow-up period.

Antithrombotic therapy has no beneficial effect in conservative treatment of spontaneous isolated superior mesenteric arterial dissection

Purpose

Initial conservative treatment with selective endovascular or surgical intervention has shown successful outcomes in the treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD). However, the benefits of antithrombotic therapy as a part of conservative treatment have not been clarified. This study aimed to investigate the clinical course of SISMAD patients and determine differences in clinical outcomes between the antithrombotic and no-antithrombotic groups.

Methods

We retrospectively reviewed 79 cases of SISMAD that were treated conservatively from January 2004 to December 2019 at Chonnam National University Hospital. Clinical outcomes, including the length of hospital stay, pain resolution time, image remodeling, and maximal remodeling time, were compared between the antithrombotic and no-antithrombotic groups.

Results

There were 30 patients in the no-antithrombotic group and 49 patients in the antithrombotic group. There was no significant difference in clinical characteristics between the 2 groups, except for dyslipidemia (P = 0.011). The follow-up period (32.6 months vs. 14.6 months, P = 0.009) and imaging follow-up period (31.6 months vs. 13.9 months, P = 0.011) were longer in the antithrombotic group than in the no-antithrombotic group. The length of hospital stay (5.1 days vs. 7.7 days, P = 0.002) was significantly shorter in the no-antithrombotic group than in the antithrombotic group because patients in the antithrombotic group required longer hospitalization for warfarin titration.

Conclusion

In patients with SISMAD, conservative treatment without antithrombotic therapy may have clinical benefits such as decreased length of hospital stay compared with conservative treatment with antithrombotic therapy.

Uncovered stent insertion for isolated superior mesenteric artery dissection

ABSTRACT

The aim of this study is to describe our clinical outcomes in isolated superior mesenteric artery dissection (SMAD) patients that underwent uncovered stent insertion.Between January 2016 and August 2019, consecutive isolated SMAD patients at our center were treated via uncovered stent insertion. Both short- and long-term outcomes in these patients were analyzed.Over the course of the study period, 11 total isolated SMAD patients meeting the criteria for stent insertion at our hospital were treated via uncovered stent insertion. Stent placement across the SMAD site was successful in all patients, with 1 stent being used per patient. There were no instances of procedure-related complications, and the median operative duration was 60 minutes. Patency of the distal superior mesenteric artery and branches thereof was achieved in all cases. Patients experienced progressive SMAD-related symptom relief and were followed for 6 to 49 months (median: 22 months). Over this follow-up period, the obliteration of the dissection was observed within 3 months in all patients. We did not detect any instances of stent occlusion, bowel ischemia, or anti-platelet-related bleeding during the follow-up period.Uncovered stent insertion can achieve favorable short- and long-term outcomes in isolated SMAD patients.

Natural History of Unruptured Visceral Artery Aneurysms Due to Segmental Arterial Mediolysis and Efficacy of Transcatheter Arterial Embolization: A Retrospective Multiinstitutional Study in Japan

OBJECTIVE. The purpose of this study was to clarify the natural history of unruptured visceral artery aneurysms due to segmental arterial mediolysis and the efficacy of transcatheter arterial embolization. MATERIALS AND METHODS. Patients with a pathologic or clinical diagnosis of visceral artery aneurysms due to segmental arterial mediolysis between 2005 and 2015 were enrolled. For patients with clinical diagnoses, images were collected and assessed by central radiologic review. To clarify the natural history of unruptured aneurysms, the morphologic changes were assessed. The efficacy and safety of transcatheter arterial embolization for aneurysms due to segmental arterial mediolysis were evaluated. RESULTS. Forty-five patients with 123 aneurysms due to segmental arterial mediolysis were enrolled. Among the 123 aneurysms, 70 unruptured aneurysms were evaluated for natural history. Forty-five of the 70 (64%) aneurysms had no change in morphology. Among the other 25 aneurysms, nine (13% of the 70) were reduced in size, 13 (19%) disappeared, and three (4%) were newly found at follow-up. Aneurysms of the middle colic artery were ruptured in 10 of 11 (91%) cases. Transcatheter arterial embolization was performed on 45 aneurysms and was successful in all cases but caused slight arterial injury in three cases (6.7%). CONCLUSION. At initial diagnosis, unruptured aneurysms due to segmental arterial mediolysis are likely to be stable or to resolve, but the risk of rupture of aneurysms of the middle colic artery appears high. Transcatheter arterial embolization is a useful treatment, but careful manipulation is necessary.

Asymptomatic hepatic artery dissection early after living-donor liver transplantation with simultaneous splenectomy: two case reports

Background

Hepatic artery dissection after liver transplantation is an uncommon morbidity. The onset mechanism and management for this disorder remain unclear. The present report describes the cases of two patients with hepatic artery dissection after living-donor liver transplantation (LDLT) with simultaneous splenectomy and provides new insight into the onset mechanism of this disorder.

Case presentation: Case 1

A 51-year-old man with liver cirrhosis caused by hepatitis B virus underwent LDLT with a right lobe graft and splenectomy simultaneously. The recipient’s right hepatic artery had partial dissection at the anastomosis site; therefore, his left hepatic artery was anastomosed. Contrast-enhanced computed tomography (CT) on postoperative day (POD) 27 showed dissection from his celiac artery to his left hepatic artery with bleeding in the false lumen. There was a risk of rupture of the false lumen; therefore, emergency interventional radiology and coil embolization of the false lumen were performed. The patient was doing well at 6 months after LDLT.

Case 2

A 58-year-old woman with liver cirrhosis caused by primary biliary cholangitis underwent LDLT with a left lobe graft and splenectomy simultaneously. Her hepatic artery had a dissection that extended from her left hepatic artery to the proper hepatic artery. The gastroduodenal artery was anastomosed. Contrast-enhanced CT on POD 8 revealed dissection from the celiac artery to the common hepatic artery as well as a pseudoaneurysm at the celiac artery. We managed the patient with conservative treatment and performed daily follow-ups with Doppler ultrasonography examination and serial contrast-enhanced CT. At the time of writing this report, the patient was doing well at 34 months after LDLT.

Conclusions

Patients who have an intimal dissection at the anastomosis site and/or simultaneous splenectomy are at a higher risk of hepatic artery dissection. Most patients with asymptomatic hepatic artery dissections can be treated conservatively. Blood flow in the intrahepatic artery should be checked frequently using Doppler ultrasonography or contrast-enhanced CT soon after diagnosis.

Management of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection: A Single Centre Experience with Mid Term Follow Up

OBJECTIVE

This study aimed to report a single centre management experience and mid term outcomes for symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD).

METHODS

This was a retrospective observational study. Between 1 August 2012, and 30 June 2018, consecutive patients with symptomatic SISMAD were included. Patient demographics, clinical symptoms, comorbidities, risk factors, and dissection characteristics were obtained. The treatment regimens and clinical and follow up outcomes were reviewed and analysed. A chi square test, Fisher's exact test, or one way analysis of variance was used to compare variables between the groups. Binary logistic regression was used to determine predictive factors for failed conservative treatment. The cumulative rate of complete dissection remodelling was calculated using a Kaplan-Meier curve.

RESULTS

Sixty-two patients (mean age, 56.0 ± 9.3 years) were included. Patients at risk of intestinal ischaemia or dissecting aneurysm rupture were considered to be high risk patients (Group 1, n = 16) and received primary endovascular treatment. The remaining patients were considered low risk (Group 2, n = 46) and received primary conservative treatment. Symptom relief was observed in 82.6% of patients in Group 2. Finally, failed conservative treatment was observed in 50% of the low risk patients. Dissection length ≥50 mm was an independent risk factor for failed conservative treatment (p = .019; OR 4.68, 95% CI 1.29-16.98). During a median follow up of 30.5 months (interquartile range, 17.5, 58.3), patients with stents had a higher complete dissection remodelling rate than those without stents.

CONCLUSION

This study found that conservative treatment showed satisfactory symptom resolution for low risk SISMAD patients. Endovascular stenting was associated with a high technical success and dissection remodelling rate. This treatment modality might be reserved for patients with high risk SISMAD or failed conservative treatment. In addition, a dissection length ≥50 mm was a risk factor for failed conservative treatment.

Spontaneous Isolated Celiac Artery Dissection: A Case Report

Introduction

Abdominal pain is a common chief complaint that can represent a wide breadth of diagnoses, ranging from benign to life-threatening. As our diagnostic tools become more sophisticated, we are able to better identify more causes of potentially life-threatening diseases. One such disease that is relatively unfamiliar to clinicians is spontaneous isolated celiac artery dissection (SICAD).

Case Report

We describe a case of a 46-year-old man who presented to our emergency department with a chief complaint of abdominal pain and was found to have a SICAD and was successfully treated with anticoagulation, antihypertensives, and observation.

Conclusion

It is important for emergency physicians to keep this potentially life-threatening condition in mind and to know the appropriate first steps once identified.

Long-term outcomes of conservative treatment and endovascular treatment in patients with symptomatic spontaneous isolated superior mesenteric artery dissection: a single-center experience

BACKGROUND

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disorder, and the treatment strategies remain controversial. This study aimed to compare outcomes of conservative and endovascular treatments in symptomatic patients with SISMAD.

METHODS

Forty-two consecutive SISMAD patients who were admitted to a single center between October 2009 and May 2018 were enrolled in this study. Based on their symptoms, 15 had conservative treatment, and 27 had endovascular treatment. The baseline characteristics, treatments, and follow-up results of the conservative group and endovascular group were analysed.

RESULTS

The rates of symptom relief were 93.3% in the conservative group and 96.3% in the endovascular group. The procedure-related complications in the endovascular group included one case of pseudoaneurysm formation in the left brachial artery. During the follow-up period (median 28.5 months), a higher proportion of patients in the conservative group had symptom recurrence (42.9% in the conservative group versus 4.8% in the endovascular group, p < 0.001). Four patients in the conservative group and one patient in the endovascular group had additional endovascular intervention during follow-up. Compared with the conservative group, patients in the endovascular group had statistically significantly longer symptom-free survival (p = 0.014) and a higher rate of superior mesenteric artery (SMA) remodeling (p < 0.001).

CONCLUSIONS

For symptomatic SISMAD, endovascularly treated patients had a lower rate of symptom recurrence and a higher rate of SMA remodeling in the long term. Prospective, multi-center studies are needed to confirm the long-term outcomes of both treatments.