Isolated superior mesenteric artery dissection in a patient without risk factors or aortic dissection

Spontaneous Isolated Superior Mesenteric Artery Dissection With Thrombosis: A Case Report of a Rare Presentation of Acute Abdominal Pain

Spontaneous isolated superior mesenteric artery dissection is a very rare vascular disease that involves the superior mesenteric artery or its branches, with an incidence as low as 0.08%. The majority of cases occur in patients of Asian descent. Due to advances in imaging modalities, particularly abdominal computed tomography angiography, the diagnosis of this disease has been increasing. Herein, we present a rare case of spontaneous isolated superior mesenteric artery dissection with thrombosis in a young male patient with no past medical history. The importance of this disease as a differential diagnosis for acute abdominal pain is emphasized.

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.

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.

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.

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.

Spontaneous superior mesenteric artery (SMA) dissection: an unusual cause of abdominal pain

A 44-year-old woman presented to our Emergency Department with a 4-day history of severe, sharp left upper quadrant abdominal pain associated with nausea and vomiting. She had been seen 3 days prior at another Emergency Department, and had a negative work-up including a normal non-contrast computed tomography (CT) scan of the abdomen/pelvis for possible kidney stone. Vital signs were: temperature 36.3°C (97.3°F), pulse 100 beats/min, respiratory rate 18 breaths/min, and blood pressure 141/80 mm Hg. Physical examination was remarkable for marked tenderness in the left upper and middle quadrants and voluntary guarding. Bowel sounds were normal. Although laboratory studies were normal, a CT scan of the abdomen/pelvis with intravenous contrast suggested a superior mesenteric artery dissection. This was confirmed with arteriography. The clinical presentation, diagnostic evaluation, and management of superior mesenteric artery dissection are reviewed.