Revascularization using arterial conduits for abdominal angina due to isolated and spontaneous dissection of the superior mesenteric artery

Small intestinal autotransplantation for spontaneous isolated superior mesenteric artery dissection: A case report

INTRODUCTION

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare differential diagnosis for patients presenting with abdominal pain. Due to limited cases reported, surgical management strategies are poorly defined.

PATIENT CONCERNS

A 54-year-old man presented to our emergency department with a 4-day history of epigastric pain combined with nausea and vomiting. The pain was dull, constant, and unbearable. It was accompanied by abdominal distention, but there was no radiating pain, chills, fever, or hematochezia. The patient did not have a history of abdominal surgeries, or tobacco or illicit drug use.

DIAGNOSIS

A contrast-enhanced computerized tomography (CT) scan demonstrated an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The middle-lower jejunum and the whole ileum were extensively dilated, and the middle jejunum was ischemic with edema.

INTERVENTIONS

Exploratory laparotomy and autologous small bowel transplantation.

OUTCOMES

The patient was successfully treated using exploratory laparotomy and intestinal autotransplantation (IATx) without bowel resection and had a stable recovery without complications.

CONCLUSION

For patients with severe mesenteric ischemia or those who fail to respond to initial conservative treatment, IATx may be a reasonable treatment strategy.

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.

Early Detection of a Rare Case: Idiopathic Spontaneous Superior Mesenteric Artery Dissection, by Duplex Ultrasonography

Spontaneous dissection of the superior mesenteric artery (SMA) without involvement of the aorta is an extremely rare condition. It could be a surgical emergency because ischaemic intestine due to artery occlusion is life-threatening and the prognosis is time-dependent. We present a 55-year-old man with a 5-day history of progressive abdominal pain. He had a negative laboratory work-up and pan-endoscopy showed multiple gastric ulcers. Despite treatment, he had persistent severe epigastric pain disproportionate to physical findings. Bedside duplex ultrasonography revealed the absence of color signal in the proximal SMA. Angiography confirmed the diagnosis of SMA dissection. Mesenteric vascular emergency including arterial dissection should be taken into consideration in patients who present with severe abdominal pain of unknown origin. Abdominal bruit may be the only vital clue but is usually difficult in the noisy emergency department. Duplex ultrasonography can be helpful to detect blood flow abnormality whenever in doubt. (Hong Kong j. emerg.med. 2015;22:189-193)

Endovascular stenting of spontaneous isolated dissection of the superior mesenteric artery: A case report and literature review

RATIONALE

Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare arterial disease that is difficult to differentiate from other diseases because of lack of specific clinical manifestation and for which there is no available optimal management strategy.

PATIENT CONCERNS

A 58-year-old male patient visited our emergency room with sudden onset of moderate-severe epigastric abdominal pain of uncertain cause.

DIAGNOSES

Computed tomography scanning showed a characteristic "double lumen sign" of the superior mesenteric artery, and further computed tomography angiography findings revealed a dissected segment of the superior mesenteric artery.

INTERVENTIONS

Conservative management was administered for 5 days, but the abdominal pain remained. Subsequently, an endovascular stent was placed in the affected superior mesenteric artery. Postoperative antiplatelet therapy was administered for 6 months.

OUTCOMES

The abdominal pain was relieved. Six months later, a follow-up of computed tomography angiography showed that the stent placed had no interval narrowing.

LESSONS

Based on our review and the illustration of this case, endovascular stenting may be a preferred rescue treatment in SID-SMA patients for whom initial conservative treatment fails.

Dissecção espontânea do tronco celíaco: qual a melhor abordagem terapêutica?

A dissecção espontânea das artérias viscerais é um evento relativamente raro. Dor abdominal súbita no epigástrio é o sintoma mais frequentemente manifestado pelos pacientes. O avanço das técnicas de exames de imagem possibilitou o diagnóstico deste evento com maior facilidade, aumentando a incidência das dissecções das artérias viscerais. O tratamento clínico conservador, a revascularização cirúrgica, e a terapia endovascular são as três possíveis opções terapêuticas. Neste artigo, relatamos os casos de dois pacientes com dissecção espontânea do tronco celíaco conduzidos de formas diversas, de acordo com a apresentação clínica e exames de imagem, além de realizar uma revisão bibliográfica sobre esta doença.

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.

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 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.

Isolated, spontaneous superior mesenteric and celiac artery dissection: case report and review of literature

Spontaneous, isolated dissection of the superior mesenteric artery (SMA) and celiac artery (CA) is rare. Although there are known risk factors, there is no particular mechanism that is common to vascular dissections. The objectives of this study were to review the current literature on diagnosis and treatment of isolated SMA and CA dissection, and to review aortic complications in giant cell arteritis, Takayasu arteritis, and polyarteritis nodosa. Giant cell arteritis, Takayasu arteritis, and polyarterteritis nodosa are vasculitides that are associated with SMA and CA dissection. An interesting aspect of this case is that the patient was a healthy person before presentation, and ultimately, did not have an underlying etiology to explain the dissection. In addition, the patient was successfully managed without operative intervention. Although there are known risk factors in patients who present with isolated, spontaneous SMA and CA dissection, the pathogenesis is still unclear. The prognosis has improved significantly with the early use of computed tomography angiography to diagnosis this entity. Although most cases require surgical intervention, there are some, as in this case, that are managed non-operatively.

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.