Spontaneous isolated dissection of the superior mesenteric artery

Isolated Superior Mesenteric Artery Dissection: An Unusual Etiology of Epigastric Pain

Abdominal pain is a very common presentation in the emergency department (ED). The pain is often well-characterized and leads to the diagnosis, but often, the presentation is vague and nonspecific. Superior mesenteric artery (SMA) dissection is a rare cause of abdominal pain that presents with nonspecific epigastric pain and is common in males, middle age, and patients of Asian descent. A high index of suspicion is usually helpful with imaging modalities such as computer tomography (CT) scan and ultrasonography in experienced hands. A prompt diagnosis is vital to managing this disease which may range from non-surgical intervention with supportive therapy to invasive endovascular procedures and surgery. Here, we report a case of an isolated SMA dissection presenting with vague abdominal symptoms and highlight the need to explore the vascular etiology of abdominal pain as their diagnosis is often difficult and may result in irreversible bowel injury when missed.

A case report of an isolated superior mesenteric artery dissection caused by childbirth

Background

The isolated superior mesenteric artery dissection (SMAD) is a rare and sporadic cause of acute abdominal pain. It most frequently affects male patients in their fifth to sixth decades, while our patient was a young woman who delivered a baby before the onset of abdominal pain. Possible risk factors for SMAD include hypertension, arteriosclerosis, abnormalities in elastic fibres, trauma, and pregnancy. In our case, delivery was suggested as a risk factor, which has not been reported previously.

Case presentation

A 27-year-old woman complained of acute severe upper abdominal pain and vomiting for 2 days after delivery. The patient had no significant medical history. Physical examination revealed epigastric mild tenderness. All routine blood tests, blood coagulation analysis, liver function tests and abdomen computed tomography showed no remarkable findings. Computed tomography angiography revealed a marked dissection 3.5 cm below the superior mesenteric artery ostium. Since distal blood flow existed and the patient was in a puerperal state with no evidences of mesenteric ischemia, she was managed conservatively, including intestinal rest by fasting, parenteral nutritional support and antibioticis, without anticoagulants or antiplatelet agents. Fortunately, she recovered smoothly and had no recurrence.

Conclusions

SMAD is a rare and sporadic cause of acute abdominal pain that occurs in young women after delivery.

Optimal Treatment Strategy and Natural History of Isolated Superior Mesenteric Artery Dissection Based on Long-Term Follow-up CT Findings

BACKGROUND

Isolated superior mesenteric artery dissection (ISMAD) was previously considered a rare disorder; however, this condition has been increasingly diagnosed as time progressed. Although treatment regimen and treatment outcomes have become clearer, the optimal treatment strategy has not yet been well established.

MATERIALS AND METHODS

This study included 54 patients diagnosed with ISMAD by computed tomography (CT) between November 2004 and December 2017. Thirteen patients were excluded from the analysis of natural course as 6 were lost to follow-up, and 7 underwent endovascular therapy.

RESULTS

Of the 54 patients included in the study, 50 were male, and 4 were female. The mean age of the patients was 52.3 years (range 40-74). The mean follow-up duration was 18.5 months (range 1.0-131.0). Thirty-eight patients were symptomatic, and 16 were asymptomatic. All aneurysmal changes observed on follow-up CT scans were initially classified as type III or IV. Of these patients, 7 underwent endovascular therapy. The failure rate of conservative treatment was 13%.

CONCLUSIONS

Conservative treatment is safe and effective if bowel necrosis or arterial rupture is not present. Symptomatic patients classified as type III or IV on the initial CT scan should be followed up. If there is recurrent pain or aneurysmal progression, endovascular therapy should be performed.

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.

The value of CT findings for prognostic prediction of spontaneous superior mesenteric artery dissection

BACKGROUND

Spontaneous superior mesenteric artery (SMA) dissection is rare cause of acute abdomen. Time-dependent change of SMA dissection has not been established.

PURPOSE

To determine Sakamoto classification (SC) type of acute and chronic SMA dissection (aSMAD and cSMAD) to predict the treatment methods and outcome.

MATERIAL AND METHODS

From April 2003 to March 2017, unenhanced and contrast-enhanced CT were used to diagnose acute symptomatic or chronic asymptomatic SMA dissection in 25 consecutive patients without aortic dissection. Correlations between SCs and treatment methods and outcomes were investigated.

RESULTS

All 13 patients with aSMAD initially received conservative treatment. Initial SCs in aSMAD were type I = 1, type III = 9, and type IV = 3. Three of nine initial type III and two of three initial type IV changed to type I at follow-up. One of nine type III changed to type II at follow-up. Ohers did not change. One with initial type III required vascular repair, so the final SC was not available. Three patients required bowel resection. In cSMAD of 12 patients, the initial/final SC were type I and IV in ten and two patients, respectively, without change during follow-up. cSMAD was significantly older than aSMAD. The initial length of dissection of aSMAD was longer than in the cSMAD group. In aSMAD, the final length of dissection was significantly shorter than in the initial computed tomography scan.

CONCLUSION

Initial SC differed significantly between aSMAD and cSMAD. Initial SC types in aSMAD were type III and IV mainly, and changed during the observation period. In cSMAD, SC types were I and IV without change.

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

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33-85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4-18 months), 12 months (IQR, 6-19 months) and 14 months (IQR, 6-20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

Isolated Superior Mesenteric Artery Dissection: A Case Report and Literature Review

Spontaneous isolated superior mesenteric artery dissection (ISMAD) is an uncommon cause of abdominal pain. Clinical presentation ranges from an asymptomatic incidental finding to acute bowel ischemia or fatal aneurysmal super mesenteric artery (SMA) rupture. We report the case of a 58-year-old male presenting with abdominal pain. Imaging studies revealed an ISMAD without radiological evidence of bowel ischemia. The patient was successfully treated using a conservative approach including bowel rest and anticoagulation. ISMAD incidence is expected to increase with the utilization of advanced imaging modalities. Thus, an ISMAD should be suspected when other common causes of an acute abdomen have been excluded. Given the lack of evidence-based guidelines, management options include conservative treatment and anticoagulation, endovascular stenting, or open surgical repair.

Acute and Isolated Dissection of the Superior Mesenteric Artery: Presentation and follow-up with Duplex Ultrasound

Introduction

Isolated dissection of the superior mesenteric artery (SMA) is a rare and often-fatal condition. Currently, only 47 cases of SMA dissection, in the absence of aortic dissection, have been reported in the literature. This report describes a case wherein the use of duplex ultrasound (DU) established the initial diagnosis and was used aggressively in follow-up care.

Case Report

A 51-year-old man presented to the emergency department (ED) complaining of severe abdominal pain. A DU of the mesenteric vessels was normal with the exception of a focal dilatation noted near the origin of the SMA that was later confirmed by computed tomography. Two days after admission, a second DU revealed a further increase in diameter of the proximal SMA and an intimal flap present in this segment. The patient was managed conservatively and discharged. Approximately 1 year later, the patient returned to the ED complaining of nausea and diarrhea for 3 weeks. DU revealed chronic dissection of the SMA as well as a stenosis in the celiac artery and inferior mesenteric artery (IMA). A stent was placed into the origin of the IMA to ensure collateral blood flow and anticoagulant therapy was continued. Before discharge, another DU was performed, which showed a patent IMA and well-perfused proximal SMA. One week later, the patient was asymptomatic and discharged home.

Conclusions

The use of DU provided a prompt and accurate diagnosis for a rare and unsuspected abnormality in the SMA that proved to be very beneficial in follow-up management decisions.

Spontaneous Isolated Superior Mesenteric Artery Dissection

A true isolated superior mesenteric artery (SMA) dissection is a rare occurrence. The increasing use of diagnostic imaging studies has resulted in this rare disease being more recognized. A 68-year-old Caucasian female presented with sharp upper abdominal pain. Computed tomography (CT) of the abdomen showed dissection with thrombosis in the proximal SMA. Conservative management with bowel rest, blood pressure control, and anticoagulation relieved her symptoms. Follow-up CT showed stable dissection. Physicians should consider the diagnosis of isolated spontaneous SMA dissection after excluding more common causes. The optimal management pathway has not been firmly established. Conservative management with anticoagulation appears to be a safe first-line therapy in selected patients.

Conservative treatment for isolated dissection of the superior mesenteric artery: Report of two cases

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Isolated spontaneous dissection of the superior mesenteric artery is very rare condition.

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Imaging studies are effective for diagnosis.

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Common treatment strategy consists of three methods as follows; conservative therapy, endovascular treatment, and surgery.

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The etiology and the best treatment have not been established yet.

Introduction

Isolated spontaneous dissection of the superior mesenteric artery (SMA) is rare and a treatment strategy has not been established yet. In this paper, we present our experience with two cases and review the literature.

Presentation of case

Both cases were treated conservatively as they did not show signs of bowel ischemia. They were symptom free with no evidence of disease progression after a median follow-up of 3.5 years.

Discussion

There are three methods for the treatment of isolated SMA dissection; observation with medical therapy, endovascular surgery, and open surgery. Most patients with isolated SMA dissection can be treated with observation alone. Although the indications for surgery are still controversial, patients with bowel ischemia should undergo invasive treatment in the form of either endovascular or open surgery.

Conclusion

We recommend observation with medical therapy as the first choice for isolated SMA dissection. However, long term follow-up is necessary as the extent of the dissection may change over time.

Initial and Middle-Term Outcome of Treatment for Spontaneous Isolated Dissection of Superior Mesenteric Artery

Symptomatic isolated dissection of the superior mesenteric artery (SIDSMA) represents an extremely rare condition. Although various treatments including conservative treatment, endovascular stenting (ES), and surgical repair are currently available, consensus treatment guideline is absent due to scarce of SIDSMA cases. Thus, we present our experience in the treatment of SIDSMA at our single center.Fourteen cases of SIDSMA were treated with conservative treatment, catheter-directed thrombolysis (CDT), endovascular stenting (ES), or surgical repair at our center between January 2008 and January 2014. Demographics, clinical manifestations, coexisting medical conditions, imaging feature, treatments, and follow-up outcome of these patients were retrospectively collected and analyzed.For 13 patients without peritonitis, conservative treatment was given for 4 to 6 days initially. After the first observation cycle, symptoms and signs were alleviated in 8 patients, and conservative treatments were continued. The remaining 5 patients received technically and clinically successful ES (in 4) or CDT (in 1) due to worsening symptoms and signs during conservative treatment. One patient with peritonitis underwent emergency surgery, with the necrotic small intestine resected. However, the abdominal pain was not alleviated 17 days postoperatively, ES was thus performed and symptoms relieved immediately. Two weeks after ES, a new aneurysm and partial thrombosis in the distal part of the stent were found by computed tomography angiography in this patient. No intestinal infarction or mortality developed during hospitalization. Follow-up was accomplished in 11 cases, ranging from 4 to 74 months (23.5 ± 21.3). Except that one complained with mild abdominal pain, the other 10 achieved complete remission. All patients were free from new aneurysmal formation of SMA and all stents remained patent.For SIDSMA without peritonitis, conservative treatment can be provided with reasonable success rate, while ES may serve as an effective alternative once conservative treatment fails. For SIDSMA with peritonitis, open surgery remains the treatment of choice by resection of necrotic intestine and revasculization.

Three cases of spontaneous isolated dissection of the superior mesenteric artery

BACKGROUND

Spontaneous isolated superior mesenteric artery dissection is a rare disease that may cause bowel ischemia or aneurysm rupture and subsequent death. Thus, the establishment of a correct diagnosis in the early stage is quite important.

OBJECTIVE

To describe the presentation of 3 patients diagnosed with spontaneous isolated supramesenteric artery dissection and briefly summarize the diagnostic procedure, treatment, and clinical course.

CASE REPORTS

We experienced three cases of isolated mesenteric artery dissection in the past 5 years. A definitive diagnosis was obtained by abdominal spiral computed tomography in two cases and angiography in one case. All patients were provided anticoagulation therapy.

CONCLUSION

One patient died of bowel ischemia, 2 were discharged within 21 days without complications, and one was able to discontinue anticoagulation therapy 12 months after discharge. The remaining patient has continued warfarin, making it difficult to determine the end point of anticoagulation.

Clinical and radiologic course of symptomatic spontaneous isolated dissection of the superior mesenteric artery treated with conservative management

OBJECTIVE

To determine the clinical and radiological outcomes of patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated with conservative management.

METHODS

This retrospective study included 27 consecutive patients who were diagnosed with symptomatic SIDSMA and managed conservatively from April 2007 to April 2013. Twenty-six patients were treated using anticoagulation therapy, and one patient with chronic liver disease underwent observation only. For evaluation, patients were divided into two groups, those with a patent false lumen with both entry and re-entry (group I), and those with partial or complete thrombosis of the false lumen (group II). In general, the patients underwent follow-up computed tomography angiography (CTA) 1 week, 1 month, and 6 months after admission. Thereafter, they underwent annual CTAs.

RESULTS

There were five group I and 22 group II patients. During hospitalization, none of the patients needed additional endovascular or surgical intervention, and after conservative management, every patient was asymptomatic upon discharge. The mean duration of clinical follow-up was 27.3 months. There was no recurrent abdominal pain associated with SIDSMA, and no invasive procedures due to SIDSMA were needed. During a mean of 17.1 months of CTA follow-up in group I patients, serial CTAs found sustained patent false lumen and no angiographic changes in all patients. Among 22 group II patients, despite anticoagulation and symptomatic relief, CTA 1 week after admission revealed increased stenosis of the true lumen in 84.2% (16/19) of patients including six cases of progressive SMA occlusion. Five patients, including the three patients initially presenting with SMA occlusion, had no interval changes, and only one patient had improved compression of the true lumen. During a mean of 18.0 months of CTA follow-up in group II patients, serial CTAs revealed improvement in the occlusion or stenosis of the true lumen in 89% (16/18) of patients and progressive resolution of false lumen thrombosis in all patients. Aneurysmal dilatation greater than 2 cm was not detected in either group of patients during follow-up.

CONCLUSIONS

During the acute stage of SIDSMA, we found a discrepancy between the clinical and angiographic findings. The therapeutic regimen should be based on clinical symptoms, and conservative management is feasible in most cases. SMA stenosis could not be an indication for invasive treatment, because stenosis of the true lumen has been seen to improve after the acute stage of dissection.

Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification

OBJECTIVE

To explore a therapy strategy for the spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) based on morphologic classification.

METHODS

Forty-two symptomatic patients with SIDSMA presenting with abdominal pain between January 2007 and December 2012 were enrolled in this retrospective study. We proposed a new morphologic classification with subtypes depending on the patency of the true lumen and reviewed the patients' clinical features, risk factors, computed tomography images (morphologic classification, location of entry site, dissection length, and true lumen residual diameter), treatment modalities, and follow-up results.

RESULTS

Twenty-four patients received only observation treatment, seven received open surgery, and 11 received endovascular therapy. True lumen residual diameter in the observation group (46.6%) was statistically better than that in the surgery group (0%) and the endovascular group (18.3%) (P < .05). There was clinical progression in three and imaging progression in seven of the observation group, of which two patients received endovascular treatment and one patient died of bowel infarction. There were two clinical progressions and one imaging progression in the surgery group, of which two patients received additional surgery and one patient died of bowel infarction. The endovascular group obtained encouraging results with no progressions or complications.

CONCLUSIONS

Symptomatic patients with SIDSMA are at risk of progression. We suggested a morphologic classification to guide the treatment. We recommend observation treatment with close follow-up for patients with patent true lumen flow and endovascular intervention for high-risk patients with true lumen stenosis or occlusion. Surgery is indicated for patients with suspected bowel infarction or arterial rupture.

Isolated superior mesenteric artery dissection

Isolated superior mesenteric artery (SMA) dissection without involvement of the aorta and the SMA origin is unusual. We present a case of an elderly gentleman who had chronic abdominal pain, worse after meals. CT angiography, performed on a 64-slice CT scanner, revealed SMA dissection with a thrombus. A large artery of Drummond was also seen. The patient was managed conservatively.

Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review

BACKGROUND AND METHOD

The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.

CASE PRESENTATION

We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.

CONCLUSION

Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

Spontaneous dissection of the superior mesenteric artery

We describe a case of spontaneous dissection and thrombosis of the superior mesenteric artery in a 54-year-old man who presented with new onset of hypertension and epigastric pain. Initial unsuccessful treatment with catheter-directed thrombolysis was followed by surgical intervention. In cases in which an extensive intimectomy is performed, early institution of antiplatelet therapy or anticoagulation may be necessary to preserve vessel patency due to the presence of a prothrombotic surface and compromised outflow.

[Isolated spontaneous dissection of superior mesenteric artery: treated by percutaneous endovascular stent placement]

Isolated spontaneous dissection of the superior mesenteric artery (SMA) without aortic dissection is a rare cause of acute mesenteric ischemia. A sudden decrease of intestinal blood flow can lead to fatal complications such as ischemic necrosis, shock, and death. Therefore, early diagnosis and therapeutic approach before the occurrence of intestinal infarction are the most important factor to determine the patients prognosis. A 52-year-old male presented with postprandial periumbilical pain, and isolated spontaneous dissection of the superior mesenteric artery with mural thrombus was detected by abdominal computed tomography with contrast enhancement. By the percutaneous implantation of vascular metallic stent via femoral artery, he was treated successfully. We report a case of isolated spontaneous dissection of the SMA treated by a percutaneous endovascular stent replacement with a review of literature.

Endovascular treatment of spontaneous dissections of the superior mesenteric artery

BACKGROUND

Spontaneous dissection of the superior mesenteric artery (SMA) is exceedingly rare. Treatment options range from observation to anticoagulation to open surgery or endovascular repair. We present our experience to date in the management of isolated SMA dissections.

METHODS

A retrospective review of the vascular surgery and radiology databases from 1998 to 2008 was performed. In general, incidental radiologic findings of a dissection were managed expectantly. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms, and physician preference. Endovascular stents were placed using a brachial approach, with the choice of stent determined by physician preference. Patients who underwent endovascular stent placement (ESP) were maintained on antiplatelet therapy for 6 months postoperatively. Follow-up consisted of yearly office visits and adjunctive computerized tomography (CT) or magnetic resonance imaging (MRI) when clinically indicated.

RESULTS

CT or MRI imaging identified nine patients (7 men, 2 women) with an isolated SMA dissection. One patient also had a concomitant celiac artery dissection. Median age was 70 years (range, 46-73 years). Median follow-up time was 32 months (range, 13.8-62.5 months). Presentations included an incidental radiologic finding in three patients and acute onset abdominal pain in six. Treatment included expectant management in four patients, anticoagulation in two, and ESP in three. ESP was performed primarily in two patients and in a third patient after initial management with anticoagulation failed. The reduction in the diameter of the true lumen was significantly greater in patients treated with ESP vs patients who were successfully managed expectantly or with anticoagulation (F = 15.59, P < .005). No procedural complications were associated with ESP.

CONCLUSIONS

An isolated SMA dissection is a rare entity that may be managed successfully in a variety of ways based on clinical presentation. Endovascular stenting can be performed with good results and may be the preferred treatment in patients with symptomatic isolated SMA dissections.

Management of isolated spontaneous dissection of superior mesenteric artery

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Spontaneous splanchnic dissection: application and timing of therapeutic options

BACKGROUND

Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes.

METHODS

Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3).

RESULTS

All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management.

CONCLUSION

Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Spontaneous isolated superior mesenteric artery dissection: a case report and literature review with management algorithm

BACKGROUND

An isolated spontaneous superior mesenteric artery (SMA) dissection is the most frequent type of digestive artery dissection. Hepatic, splenic, left gastric, and celiac artery dissections are much less frequently observed. Dissection of the SMA is usually an extension of an aortic dissection. A true isolated SMA dissection is a relatively rare clinical cause of abdominal pathology. Only 106 cases (including the present case) of isolated spontaneous SMA dissection without associated aortic dissection were identified from the literature.

METHODS

Our vascular team managed a 56-year-old woman with spontaneous SMA dissection conservatively. Prior to the initiation of systemic anticoagulation, she underwent diagnostic laparoscopy. A repeat angiogram done at 2 months showed complete resolution of the dissection. She has been repeatedly examined for 5 years, which is the longest follow-up mentioned in the literature.

CONCLUSION

To our knowledge, this is the first case wherein laparoscopy was used to confirm the absence of mesenteric ischemia in acute presentation of SMA dissection. Using information from a review of the literature, we have designed a management protocol for this rare condition.

Three isolated superior mesenteric artery dissections: update of previous case reports, diagnostics, and treatment options

Isolated superior mesenteric artery dissection is a relatively rare vascular pathology. However, the number of recent case reports has shown an increasing incidence with the widespread use of computed tomography imaging for abdominal pain. Here we report three cases of isolated superior mesenteric artery dissection. The unique surgical option of small bowel transplantation along with successful medical management is described. A treatment algorithm for isolated superior mesenteric artery dissection is also proposed.

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

We report the case of a 38-year-old man admitted at the emergency department for abdominal pain of abrupt onset. Computed tomographic examination revealed a spontaneous isolated dissection of the superior mesenteric artery and an anevrysm of the coeliac artery caused by the arcuate ligament. Outcome was favorable under conservative medical treatment and a three months follow-up was uneventful. This observation offers the opportunity to present recent insights concerning this pathology.

Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery

OBJECTIVE

The objective of our study was to report the clinical and imaging features of isolated dissection of the superior mesenteric artery (SMA) and describe our imaging classification of this disease entity.

SUBJECTS AND METHODS

We retrospectively analyzed clinical presentation, imaging appearances and outcome of the 12 patients who were diagnosed as having spontaneous dissection of the SMA from 1991 to 2005 in our institution or its affiliated two hospitals. There were 11 males and 1 female with a mean age of 50 years (range, 43-61 years). The diagnosis of isolated dissection was established with CT within 24h of the onset.

RESULTS

We categorized SMA dissection into the following four types based on imaging appearances: type I, patent false lumen with both entry and re-entry (four patients), type II, 'cul-de-sac' shaped false lumen without re-entry (one patient), type III, thrombosed false lumen with ulcer like projection (ULP), which is defined as a localized blood-filled pouch protruding from the true lumen into the thrombosed false lumen (five patients) and type IV, completely thrombosed false lumen without ULP (two patients). One patient with type II underwent urgent surgery because of small bowel ischemia. One patient with type III underwent urgent embolotherapy for the treatment of rupture of a branch of the SMA. The remaining 10 patients were initially managed conservatively. In one of the conservatively treated patient, ULP had progressively dilated, and it was treated with stent placement and coil packing 22 months after the onset. The remaining nine patients were conservatively managed without any event during the follow-up period of 7-72 months.

CONCLUSION

Most of the patients with isolated SMA dissection can initially be managed conservatively if there are no clinical and imaging signs indicating ruptured SMA branches or bowel ischemia.

Superficial femoral artery transposition repair for isolated superior mesenteric artery dissection

Isolated dissection of the superior mesenteric artery is an uncommon event, but many new cases have been reported recently, reflecting the progress of imaging and suggesting that this pathology is not as rare as previously thought. Here we report a case of superior mesenteric artery dissection where we performed, after failure of conservative medical management, an original surgical technique for mesenteric revascularization using a superficial femoral artery transposition. To the best of our knowledge, this is the first report of the use of this technique for complex mesenteric revascularization.

Endovascular Treatment of Spontaneous Isolated Dissecting Aneurysm of the Superior Mesenteric Artery Using Stent-Assisted Coil Embolization

Spontaneous isolated dissecting aneurysm of the main trunk of the superior mesenteric artery is a rare condition. We treated a patient with this condition successfully by stent-assisted coil embolization. Intravascular stent placement may widen the indications for endovascular coiling of the aneurysmal false lumen to avoid perforation.

Successful angiographic stent-graft treatment for spontaneously dissecting broad-base pseudoaneurysm of the superior mesenteric artery

Visceral arterial aneurysm is an uncommon form of vascular disease that has a significant potential for rupture or erosion into an adjacent viscera, resulting in life-threatening hemorrhage. Superior mesenteric artery (SMA) aneurysms are especially rare, comprising only 5-8% of all visceral arterial aneurysms. Traditionally, the most common treatment for SMA aneurysms has been simple surgical ligation of the proximal and distal vessel. Herein, we report the case of a 53-year-old man with a dissecting pseudoaneurysm of the SMA, demonstrated by multi-slice computed tomography and angiography. The patient was successfully treated with percutaneous transluminal angioplasty and stenting.

Two-Graft Repair of Very Proximal Superior Mesenteric Artery Aneurysms: A Technical Note

Visceral artery aneurysms are found in only 0.2% of the general population. Among these, aneurysms of the superior mesenteric artery (SMA) are very unusual and account for only 5.5 % to 8 %. Risk of rupture or embolization is the impetus for their definitive treatment and this should be performed in acceptable candidates. These aneurysms are typically located distal to the origin of the SMA and this situation lends itself to interposition grafting as a means of both aneurysm repair and reestablishment of prograde SMA blood flow. However, SMA origin aneurysms that arise directly from the abdominal aorta add a degree of complexity because the vascular reconstruction must include the diseased visceral aorta as well as the SMA. In this article we report successful operative treatment of large aneurysms at the origin of the superior mesenteric artery using a two-graft technique in two elderly patients.

The right gastroepiploic artery as an alternative inflow source in acute mesenteric ischemia

Spontaneous and isolated dissection of the superior mesenteric artery is rare. This report describes a case treated with a new technique of right gastroepiploic artery to superior mesenteric artery bypass with a reversed saphenous vein graft, which has been patent for 6 years. This technique is an alternative approach in the setting of acute mesenteric ischemia.