Clinical and angiographic follow-up of spontaneous isolated superior mesenteric artery dissection

Serial Follow-Up Evaluation With Computed Tomography After Conservative Medical Treatment in Patients With Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection

OBJECTIVE

There is no detailed information available about trend in the morphological change after conservative medical treatment in patients with symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD).

METHODS

We enrolled 27 consecutive patients with symptomatic SISMAD who underwent conservative medical treatment between 2006 and 2015. The long-term prognosis, natural history, and serial follow-up computed tomography (CT) findings of risk factors of rupture such as arterial diameter and false lumen enhancement were retrospectively assessed.

RESULTS

Spontaneous isolated superior mesenteric artery dissection usually developed in middle-aged men around 50 years old who had a history of smoking. Follow-up CT was performed at 1 to 6 months, 7 to 12 months, and after 12 months. Superior mesenteric artery (SMA) maximum diameter was 10.3 mm (quartile 9.5-11.3) on initial CT and expanded in 47.1% patients during 1- to 6-month follow-up, which decreased over time ( P < .001 at 7- to 12-month follow-up, P = .001 after 12-month follow-up). On the other hand, false lumen enhancements were revealed in 9 (33.3%) patients on initial CT. The size of false lumen enhancement was expanded in the longest diameter in 35.3% patients and in shortest diameter in 29.4% during 1- to 6-month follow-up. However, the size of false lumen decreased in all patients after 12-month follow-up. All patients were alive without arterial aneurysm rupture and hospital readmission during the median of 523 days (170-799) study period.

CONCLUSION

We demonstrated that both SMA maximum diameter and false lumen enhancement were transiently expanded in some patients during 6-month follow-up, but no longer expanded after 12-month follow-up. Patients with symptomatic SISMAD could be treated medically with scheduled careful follow-up CT evaluations.

Real clinical management of patients with isolated superior mesenteric artery dissection in Japan

BACKGROUND

Due to the rarity of this condition, clinical treatment and outcomes in isolated superior mesenteric artery dissection (ISMAD) patients remain unknown. The primary aim of this retrospective multicenter study was to elucidate the treatment strategies and in-hospital outcomes for ISMAD patients by using administrative data.

METHODS

We retrospectively analyzed patients that were primarily diagnosed with ISMAD using the Diagnosis Procedure Combination data collected at 141 hospitals in Japan in 2015. Patients with comorbidities that included "aneurysm" were excluded.

RESULTS

A total of 221 ISMAD without aneurysm patients (male: 90.5%; mean age: 52.5±10.1 years) were enrolled, and 95 (67.4%) of these encountered just one ISMAD case per year. We found only one (0.5%) in-hospital death and length of stay for ISMAD patients was 13.2±9.1 days. One-third of patients received antiplatelet therapy (32.1%) and anticoagulation therapies, such as heparin (38.9%) and warfarin (10.0%). A total of 146 (66.1%) patients received antihypertensive treatment (either orally or via an intravenous route) during hospitalization. Twelve (5.4%) patients underwent surgical procedures during hospitalization as follows: 4 (33.3%) patients underwent bypass surgery, 3 (25.0%) patients underwent exploratory laparotomies, 2 (16.7%) patients underwent bowel resection, 1 (8.3%) patient underwent a thrombectomy, and 2 (16.7%) patients underwent surgical angioplasties.

CONCLUSIONS

We found that conservative therapy for ISMAD patients without aneurysm is safe and is also associated with a low rate of surgical intervention in clinical practice.

Presentation, treatment, and outcomes in patients with spontaneous isolated celiac and superior mesenteric artery dissection

Spontaneous isolated celiac or superior mesenteric artery (SMA) dissection (SICMAD) is a rare clinical entity. Not much is known about the natural history and appropriate treatment. We retrospectively queried a prospectively collected institutional radiology database for all patients diagnosed with SICMAD from 1990 to 2017. We identified 42 arteries in 40 patients (83.3% male), mean age 54.8 ± 10.9 years, consisting of 24 celiac arteries and 18 SMA. SMA lesions were longer than celiac lesions (5.15 ± 3.81 vs 2.38 ± 1.40 cm, p = 0.008). Thirty-one patients had follow-up; mean follow-up was 4.9 ± 4.8 years. Morphologic improvement was seen in 20 (48%) arteries. Sakamoto IV lesions were more likely to remodel (OR: 11.26, 95% CI: 1.13, 588.26, p = 0.039), and Sakamoto II lesions less likely to remodel (OR: 0, 95% CI: 0.00, 0.93, p = 0.05). Patients received an average of 2.35 scans during follow-up. Symptom resolution occurred in all symptomatic patients, and 16% of patients had recurrence of symptoms. Follow-up CT scans revealed a stable arterial diameter for the majority of patients. In conclusion, the majority of patients with SICMAD improve with medical therapy alone. Aneurysmal dilatation is uncommon.

Conservative Management of Spontaneous Isolated Dissection of the Superior Mesenteric Artery

Purpose

We report the clinical outcomes of patients with spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated conservatively.

Materials and Methods

A retrospective review was performed in 14 patients from 2006 to 2016 with SIDSMA. Their clinical features and computed tomographic angiography (CTA) characteristics, treatment methods, and clinical outcomes were analyzed. The mean age was 53.6 (range, 41–73) years, and the mean follow-up duration was 20.6 (range, 1–54) months. Conservative management was the primary treatment if no bowel ischemia or arterial rupture was noted.

Results

The mean initial abdominal visual analog pain score was 7 (range, 5–9) in seven patients. The mean total duration of abdominal pain was 10.2 days (range, 2–42 days) in 10 patients. The mean percentage stenosis of the dissected SMA at the initial presentation was 78.8% in 14 patients. Complete obstruction of the SMA at the initial presentation was evident in 4 of the 14 patients (28.6%). Conservative management was successful in all 14 patients. None of the 14 patients developed bowel ischemia or an infarction. Abdominal pain did not recur in any patient during follow-up (mean, 20.6 months; range, 1–54 months).

Conclusion

Conservative management was successful for all SIDSMA patients, even those with severe compression of the true lumen or complete obstruction of the dissected SMA.

The Classification and Management Strategy of Spontaneous Isolated Superior Mesenteric Artery Dissection

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is an uncommon but potentially catastrophic pathology. Multiple classification schemes have been proposed for this occurrence. Although no consensus has emerged regarding which classification should be used, Li's classification scheme is more precise and complete compared to other classification systems and can be used to guide the treatment of SISMAD. Initial conservative treatment is promising, with favorable early and long-term outcomes for most patients; endovascular treatment is recommended for patients with persistent/recurrent symptoms after conservative treatment; surgical treatment should be performed without delay for patients with arterial rupture, intestinal necrosis, or failed endovascular treatment.

Spontaneous isolated dissection and atherosclerotic plaques of superior mesenteric artery: the vastly different occurrence site suggests the opposite haemodynamic aetiology

OBJECTIVE

The development of atherosclerotic plaques and spontaneous isolated dissection (SID) of the superior mesenteric artery (SMA) was considered to be related to opposite haemodynamics. The purpose of this study was to compare their occurrence sites and the morphology of the SMA to confirm the haemodynamic aetiologies.

METHODS

57 patients with SID and 64 patients with atherosclerotic plaques were compared about patient characteristics, location of SID and plaque, the distance from lesion to the aortic ostia, SMA branching angle and inlet diameter of the SMA.

RESULTS

The location of SID and plaque was very different (p < 0.001). The anterior wall was the most common entry site of SIDSMA (84.0%) but the least frequent origin site of atherosclerotic plaques (7.8%). The posterior, left and right walls were the frequent origin sites of atherosclerotic plaques (total 92.2%) but not for SIDSMA. Most plaques started from the aortic ostia, and their average distance to the aortic ostia was significantly less than the distance from the entry site to the aortic ostia of SIDSMA (p < 0.001). No significant difference was found between SIDSMA and the plaque groups in the branching angle and inlet diameter of the SMA.

CONCLUSION

The vastly different sites of SIDSMA and atherosclerotic plaque indicate their opposite haemodynamic aetiology. Advances in knowledge: By comparing the location of the two diseases, we demonstrate their different haemodynamic causes.

Endovascular treatment with flow-diverting stents of symptomatic superior mesenteric artery after dissection aneurysm

Isolated and spontaneous superior mesenteric artery dissection is a rare cause of acute abdominal pain. Whereas there is widespread consensus on conservative treatment of asymptomatic forms, revascularization would seem indicated in symptomatic complicated cases. A 73-year-old man presented with worsening epigastric pain. A computed tomography scan revealed an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The postdissection aneurysm was treated by endovascular exclusion with flow-diverting stents. The abdominal pain was completely relieved, and the patient remained asymptomatic at follow-up.

Transient ischemic jejunitis due to symptomatic isolated superior mesenteric artery dissection: case report and review of literature

Acute abdominal pain is one of the most common conditions encountered in the emergency department. The differential diagnosis of acute abdominal pain is extensive and identifying the underlying etiology can be challenging. We report a case of acute transient ischemic jejunitis due to symptomatic isolated superior mesenteric artery dissection in a patient with no cardiovascular risk factors or autoimmune diseases. Symptomatic isolated superior mesenteric artery dissection is a rare cause of acute abdominal pain usually treated in the surgical department. The patient had criteria for conservative treatment and rapidly recovered. We highlight a rare condition which should be taken into account for the differential diagnosis of acute abdominal pain.

Conservative Management of Isolated Superior Mesenteric Artery and Celiac Trunk Dissection: A Case Report and Literature Review

Isolated arterial dissection without aortic pathology has been rarely reported in mesenteric vessels. The natural history and appropriate treatment for this disease is uncertain because of the scarcity of literature which limits the data available to the clinician, resulting in management challenges. Herein, we report a rare case of a 42-year-old Tunisian man with spontaneous dissection and aneurysmal dilatation of the Celiac Artery (CA) and the Superior Mesenteric Artery (SMA) with partial thrombosis. This case was successfully managed conservatively with heparin infusion and blood pressure control and the patient remained symptom free at 15 months follow up. This case demonstrates that conservative management may be warranted in non-complicated isolated visceral arterial dissection.

Clinical presentation, management, follow-up, and outcomes of isolated celiac and superior mesenteric artery dissections

OBJECTIVE

Isolated visceral artery dissections are rare entities with no current consensus guidelines for treatment and follow-up. This study aims to evaluate the presentation, management, outcomes, and follow-up practices for patients with isolated visceral artery dissections and to compare those with and without symptoms.

METHODS

In this retrospective analysis, we identified all patients with isolated celiac artery and/or isolated superior mesenteric artery dissections at a single institution between September 2006 and December 2014. Patients with concomitant aortic dissections were excluded. Cases were stratified by symptom status. Presentation, anatomic findings, treatment, outcomes, and follow-up imaging were then compared between symptomatic and asymptomatic patients.

RESULTS

We identified 25 patients including 15 with symptoms and 10 without. There were no differences in patient comorbidities; however, symptomatic patients more frequently presented with thrombus (n = 10; 67% vs n = 1; 10%; P = .01) and inflammation (n = 8; 53% vs n = 1; 10%; P = .04), and trended toward increased stenosis (n = 12; 80% vs n = 4; 40%; P = .09) compared with asymptomatic patients. All asymptomatic patients were treated with observation alone with vessel diameter enlargement noted in 33% (n = 2) of patients on follow-up imaging. Among symptomatic patients, standard treatment included a short course of anticoagulation (mean, 4.5 months) with lifelong antiplatelet therapy. Three patients underwent operative intervention for persistent or worsening symptoms, two during the index admission and one 10 months after presentation for chronic abdominal pain. Approximately 70% (n = 17) of patients in each group had follow-up imaging (computed tomography angiography: n = 14; 56%; magnetic resonance angiography: n = 4; 16%; ultrasound: n = 13; 52%). Among patients treated nonoperatively, no patients complained of symptoms at follow-up, and 50% of those with inflammation on initial imaging had resolution. Twenty-five percent (n = 4) of patients had an increase in vessel size; however, all vessels remained less than 2 cm in maximal diameter. There were no ruptures or related deaths in either group.

CONCLUSIONS

Among patients with visceral artery dissection, no ruptures occurred but diameter enlargement was documented. This disease progression suggests that routine surveillance may be appropriate; however, transitioning early to ultrasound imaging should be considered to decrease radiation, contrast, and associated costs.

Current Understandings of Spontaneous Isolated Superior Mesenteric Artery Dissection

Spontaneous isolated superior mesenteric artery dissection (SISMAD) has been known as a rare vascular disease. However it is increasingly reported in these days with the development of advanced imaging technology. Underlying etiology, natural course or an optimal management strategy of SISMAD is not exactly known at the moment. During the past 10 years, we have had an interest in this rare vascular disease and collected clinical and image data in 100 or more patients with SISMAD. In this review article, I would like to describe my current understanding of SISMAD on the base of our recent publications in the major vascular surgery journals.

Clinical Outcomes of Anticoagulation Therapy in Patients With Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery

The aim of this study was to determine the clinical outcomes of long-term anticoagulation therapy in patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and to evaluate whether conservative treatment with anticoagulation therapy is a safe and effective treatment modality for these patients.In this single center, observational cohort study, data from a prospectively recruiting symptomatic SIDSMA registry, including demographics, risk factors of interest, clinical characteristics and outcomes, and initial and follow-up computed tomography angiography (CTA) findings, were analyzed retrospectively. During an 8-year period, a total of 52 consecutive patients who underwent conservative treatment with the use of long-term anticoagulation were included in this study. Clinical symptoms resolved within 11 days in all except 4 patients (7.7%); 3 received endovascular treatment for persistent symptoms and 1 received surgical repair. The mean duration of anticoagulation therapy was 9 (range: 3-60) months. A follow-up CTA showed complete remodeling in 20 (41.7%) patients, and the mean diameter and the incidence of false lumen thrombosis were also decreased significantly. There was no anticoagulation therapy-related mortality or morbidity except 2 (4.2%) minor bleeding complications, and no symptomatic recurrence or aggravation of the dissection occurred during the mean follow-up period of 47.5 (range: 10-97) months. The present study showed that long-term anticoagulation therapy could result in a high rate of complete remodeling during the natural course of symptomatic SIDSMA. Conservative treatment with long-term anticoagulation therapy could be an optimal treatment strategy for symptomatic SIDSMA.

One case of spontaneous isolated superior mesenteric artery dissection with abdominal pain as initial symptom

Abdominal pain is one of the most common symptoms of digestive diseases, and rare etiologies tend to be ignored. A patient with an initial symptom of abdominal pain was eventually diagnosed with spontaneous isolated superior mesenteric artery dissection. Clinicians should raise their awareness of this rare condition, summarize the characteristics of abdominal pain, and should not ignore the rare etiology of abdominal pain.

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.

The value of a new image classification system for planning treatment and prognosis of spontaneous isolated superior mesenteric artery dissection

Objective

To aid diagnosis of spontaneous isolated superior mesenteric artery dissection and planning management, we investigated the role of classification of features as observed on computed tomography angiography images.

Methods

A retrospective study was conducted, comprising computed tomography angiography images and clinical data of 28 consecutive patients with spontaneous isolated superior mesenteric artery dissection. Based on the computed tomography angiography images, a new classification for spontaneous isolated superior mesenteric artery dissection was proposed. Patients with intestinal ischemia not relieved or worsened after 10 days of conservative treatment underwent surgery or stenting. All patients were followed up with computed tomography angiography.

Results

Spontaneous isolated superior mesenteric artery dissection was categorized into five types (I–V). Type III was further divided into subtypes IIIa–IIIc. Spontaneous isolated superior mesenteric artery dissection IIIa and IV typified nine (32.1%) and seven (25%) patients, respectively. Six (21.4%) patients had aortic or branch artery abnormalities and 21 (78%) showed prior intestinal ischemia. Four (14.3%) patients had intestinal ischemia and underwent surgery or stenting.

Conclusions

Spontaneous isolated superior mesenteric artery dissection type IIIa is more likely to occur than other types. Long-term computed tomography angiography follow-up is valuable for determining treatment strategy for spontaneous isolated superior mesenteric artery dissection. Conservative therapy with anticoagulants is recommended for five days, and surgery or stenting should be considered if symptoms of intestinal ischemia are not relieved. Stent implantation provides relatively satisfactory mid-term outcome for true lumen construction of the superior mesenteric artery.

Three Case Report of Spontaneous Isolated Dissection of the Superior Mesenteric Artery-With an Algorithm Proposed for the Management

Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition, and there is still no consensus on optimal management. Here, we present three cases of SID-SMA, that were treated by surgical revascularization with urgent iliomesenteric bypass surgery without intestine resection, endovascular therapy with stent placement, and conservative management. The purpose of this study is to review these three cases and propose an algorithm for optimal management of SID-SMA.

Stent Placement for Acute Superior Mesenteric Artery Occlusion Associated with Type B Aortic Dissection

A 50-year-old man had a mesenteric ischemia related to superior mesenteric artery (SMA) occlusion associated with a type B aortic dissection. We decided to perform stent placement for the SMA and could avoid mesenteric ischemia. We think the stent placement in the SMA might be an option for the treatment of mesenteric ischemia caused by aortic dissection.

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.

Congenital incomplete fusion of superior mesenteric artery mimicking dissection

BACKGROUND

Both spontaneous SMA dissection and anatomical variants of GIT vasculature are well known entities. We present a case initially diagnosed as an SMA dissection on CT, but upon detailed review of the imaging findings was considered to be incompletely fused ventral segmental arteries--a rare anatomic variant not well described before. This finding is clinically significant, as it can mimic a vascular dissection and such a wrong diagnosis will lead to unnecessary investigation and intervention.

CASE REPORT

A 62-year-old male patient presented with abdominal pain of uncertain etiology. The initial CT revealed an abnormal appearance of the superior mesenteric artery (SMA) which was diagnosed as SMA dissection. However, the appearance of this 'dissection' was unusual and there was a mismatch between the clinical presentation and radiological findings. The scan was reviewed and a 3D reconstruction of the abdominal aortal and visceral arteries was performed. The abnormal appearance of the SMA was deemed to be from a congenital anatomical variant. A review of the embryological origin of gut vasculature provides a likely explanation for this appearance.

CONCLUSIONS

Ours is an unusual case of a developmental variant that has not been well described hitherto. Attention to the ancillary radiological signs and understanding the embryological origin of the abdominal vasculature is important to distinguish such variants from pathology.

Management of isolated superior mesenteric artery dissection

AIM: To evaluate our experience of the clinical management of spontaneous isolated superior mesenteric artery dissection (ISMAD).

METHODS: From January 2008 to July 2013, 18 patients with ISMAD were retrospectively analyzed, including 7 patients who received conservative therapy, 9 patients who received reconstruction with bare stents, and 2 patients who underwent surgical treatment. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms.

RESULTS: Intestinal ischemia-related symptoms completely resolved in 7 patients who received conservative therapy. Stent placement was successful in 9 patients. Of the 9 patients who received endovascular stenting, abdominal pain was alleviated after the procedure and gradually disappeared within 3 d. Follow-up computed tomography and computed tomography angiography were available in all patients during the first month and the first year after the procedure, which revealed patent stent and patent involved superior mesenteric artery branches with complete obliteration of the dissection lesion. In the 2 patients who underwent surgical treatment, good clinical efficacy was also observed.

CONCLUSION: ISMAD may be managed successfully in a variety of ways based on the clinical symptoms. ISMAD should be treated by conservative management as the first-line option, however, in those with bowel necrosis or imminent arterial rupture during conservative therapy, endovascular or surgical therapy is indicated.

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

Background:

Spontaneous isolated superior mesenteric artery dissection (ISMAD) is exceedingly rare. The therapeutic options range from observation to medical treatment to surgery or endovascular repair. We present our experience of the clinical management of ISMADs.

Methods:

Sixteen patients with ISMAD from January 2008 to July 2012 were retrospectively analyzed. The decision to intervene was based on anatomic suitability, patient comorbidities, and symptoms. Percutaneous endovascular reconstruction with bare stents was carried out in 7 patients in this study, for patients with persistent abdominal pain despite conservative treatment or signs of bowel ischemia. The patients were kept on antiplatelet therapy from 6 to 10 months postoperatively.

Results:

All attempted bare stent placements were successfully accomplished without any treatment-related complication. Of the 7 patients with ISMADs, 4 were treated by single stents, 2 by double overlapping stents, and 1 by triple overlapping stents. The abdominal pain alleviated after procedure and disappeared gradually within 3 days. None of the patients had ISMAD symptoms during follow-up (median, 21.7 months; range, 11-32 months). Follow-up computed tomography (CT) and CT angiography revealed patent stent and patent superior mesenteric artery (SMA) branches with complete obliteration of the dissection.

Conclusion:

Isolated SMA dissection may be managed successfully in a variety of ways based on the clinical symptoms. In this small series, percutaneous endovascular reconstruction with bare stent implantation is a feasible treatment choice with a high success rate and good clinical outcome.

Isolated dissection of the superior mesenteric artery treated using open emergency surgery

Background

Isolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts.

Methods

Two cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided.

Results

Both patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities.

Conclusion

Open surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.

Isolated dissecting aneurysms of the abdominal aorta and the superior mesenteric artery. A case report and literature review

Supracoeliac abdominal aortic dissections are rare and require complex interventions for repair. Superior mesenteric artery (SMA) dissections are also rare and even less frequently reported to involve aneurysmal change. We present the case of a 65-year-old man with a dissecting supracoeliac aortoiliac aneurysm and a separate dissecting aneurysm of the SMA The surgical intervention performed and a review of the literature on the management of SMA dissection in the endovascular era are presented.

Management strategy of isolated spontaneous dissection of the superior mesenteric artery

OBJECTIVE

Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection.

METHODS

A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years).

RESULTS

We categorized SMA dissection into the six types according to the Sakamoto's and Zerbib's classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months.

CONCLUSION

Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

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.