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

Clinical characteristics and impact of pseudo-lumen blood flow on long-term vessel dilatation in spontaneous isolated dissection of superior mesenteric/celiac artery

This study aimed to identify the clinical characteristics associated with spontaneous isolated dissection of superior mesenteric artery/celiac artery (SIDSMA/SIDCA). This observational study, conducted at Toranomon Hospital, Japan between 2009 and 2020, analyzed consecutive SIDSMA/SIDCA cases based on radiology data. The study compared clinical characteristics between symptomatic and asymptomatic patients with SIDSMA/SIDCA and investigated factors related to future vessel dilatation. Among 57 cases (44 SIDSMA, 17 SIDCA, and 4 both), the majority were male (87.7%), nearly half having hypertension (43.9%) and smokers (48.9%). Of those, 17 cases (29.8%) were symptomatic; abdominal pain (94.1%), back pain (23.5%), nausea (17.6%) and fever (5.9%). The symptomatic group was younger (52.6 ± 9.4 versus 67.2 ± 7.9 years, P < 0.001), had higher systolic and mean blood pressure (142.6 ± 20.0 versus 129.5 ± 16.5 mmHg, P = 0.017; 96.1 ± 14.6 versus 88.2 ± 17.7 mmHg, P = 0.038), a higher white blood cell count (9975 ± 5032 versus 6268 ± 1991 /µL, P = 0.012), and a higher LDL cholesterol level at diagnosis (129.7 ± 21.7 versus 87.2 ± 25.6 mg/dL, P = 0.002) than the asymptomatic group. The factors associated with future vessel dilatation included the presence of pseudo-lumen flow in the dissection vessel (73.9% versus 41.4%, p = 0.019) and a larger vessel diameter (13.5 ± 2.4 mm versus 11.5 ± 2.1 mm, p = 0.005) at diagnosis after multiple adjustments, pseudo-lumen flow was a predictor of future vessel dilatation (odds ratio, 4.80; 95% confidence interval, 1.11-20.75; p = 0.036). The study revealed that only 30% of SIDSMA/SIDCA cases were symptomatic. Symptomatic cases were generally younger and exhibited higher blood pressure and elevated white blood cell counts. These findings offer valuable insights for the acute diagnosis of SIDSMA/SIDCA.

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

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

Secondary Hemorrhagic Shock Due to Spontaneous Isolated Dissection of the Superior Mesenteric Artery Branch

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition, particularly when complicated by hemorrhagic shock. This case report describes the discovery of SIDSMA in an 88-year-old woman through CT angiography. The patient initially presented with acute abdominal pain, nausea, and diarrhea, which later progressed to hemorrhagic shock. After fluid resuscitation, the patient underwent successful endovascular treatment.

The management of spontaneous isolated celiac artery dissection: A case report and literature review

OBJECTIVES

Spontaneous isolated celiac artery dissection (SICAD) without associated aortic dissection is a rare disease. Complications are ischemia, aneurysm formation, and rupture. Different treatment options have been reported for managing SICAD, including conservative management, endovascular intervention, and open surgery. Despite the increased recognition of this disease, there are no consensus guidelines on management of this condition. To improve the knowledge and treatment of this disease, a case of SICAD was reported.

METHODS AND RESULTS

We describe the case of a 57-year-old woman with SICAD whose symptoms improved after endovascular treatment when conservative treatment failed and systematically analyze the management strategy for patients with SICAD.

CONCLUSIONS

SICAD is a rare disease and has no universally agreed upon guidelines for treatment. Most patients can be first treated conservatively for dissection with strict blood pressure control, antithrombotic therapy, and intensive surveillance. For SICAD patients with aneurysms located in the celiac trunk, stent grafts can be used in such patients without affecting the branch blood supply.

Long-term outcome of spontaneous isolated superior mesenteric artery dissection in different angiographic types

OBJECTIVE

This study aimed to compare the follow-up and outcomes of spontaneous isolated superior mesenteric artery dissection (SISMAD) in different angiographic types and to determine the optimal therapeutic options for SISMAD patients.

METHODS

This is a retrospective study of 61 SISMAD patients between December 2010 and January 2019 in a single center. Data analysis consisted of demographics, clinical data, radiology review, treatment, follow-up, and outcomes.

RESULTS

A total of 61 SISMAD patients were reviewed in this study. Median age was 53 (quartile, 47.5-63.0), 90.2% were males with hypertension (50.8%), dyslipidaemia (54.1%), and smoking history (60.7%). Among all, 43 patients underwent periodic follow-up of computed tomography (CT) angiography for follow-up analysis. 11 (25.6%) patients showed "No Change" during follow-up, including 6 type I patients. 23 patients (53.5%) were "Partially Remodelled" and 18 of them were type II patients. 7 "Completely Remodelled" patients (16.3%) were all in type II group. Two type III patients (4.6%) died after the emergent surgical intervention within 30 days.

CONCLUSIONS

Different SISMAD angiographic types present with variant progression. Type I SISMAD may be inclined to remain "unchanged." Type II SISMAD shows a clear trend to remodeling, especially type IIb patients. The progression of type III SISMAD varies in the extent of collateral bypasses.

Conservative management of spontaneous isolated superior mesenteric artery dissection: A case report

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare and potentially fatal cause diagnosis presenting with acute abdominal; however, because of its rarity, the pathogenic factors of SISMAD remain unknown and no clear cause has been found. Moreover, there is a lack of evidence-based treatment guidelines.

Isolated Spontaneous Mesenteric Artery Dissection: A Rare Entity

Isolated spontaneous dissection of the mesenteric artery in the absence of involvement of the aorta or its branches is an uncommon vascular entity. It is generally seen in males and presents with gastrointestinal symptoms due to mesenteric ischemia. However, asymptomatic cases are increasingly being diagnosed due to increased use of computed tomography (CT) angiography. The course is usually self-limiting, and conservative management with bowel rest, strict blood pressure control, anticoagulants, sedatives for pain, and close observation usually suffices. Surgery or endovascular stenting is usually reserved for those exhibiting bowel ischemia or impending rupture. We report a case of a young female with isolated spontaneous mesenteric artery dissection with thrombus, which did not improve with medical therapy and was managed promptly by surgery due to the presence of bowel ischemia.

Symptomatic spontaneous superior mesenteric artery dissection treated with endovascular stent repair

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare condition in which patients develop an isolated dissection of the superior mesenteric artery without traumatic or iatrogenic causes. We present the case of a 52-year-old woman who presented with SISMAD and underwent endovascular stenting as her symptoms failed to respond to medical management. We also spend the bulk of the report discussing the current literature on management of SISMAD.

Revascularization of Isolated Superior Mesenteric Artery Dissection for Post-Mesenteric Infarction Exudative Enteropathy: The Contribution of a Multidisciplinary Care Teamwork

BACKGROUND

Isolated dissection of the superior mesenteric artery (SMA) is increasingly diagnosed; the conservative treatment appears to be the best option when blood supply is maintained. However, some patients require a more invasive attitude, due to acute or chronic ischemic complication. Multidisciplinary care within a health-care network improves medical and surgical support. We present a case of chronic complication of isolated SMA dissection requiring a revascularization, followed by bowel resection.

CASE PRESENTATION

A 49-year-old man presented abdominal pain secondary to necrotizing enterocolitis of unknown cause. An isolated small bowel resection with immediate restoration of continuity was first performed to remove the necrotic tissue. The patient developed post-ischemic exudative enteropathy and small intestinal bacterial overgrowth (SIBO). Re-examination of the first computed tomography (CT) scan revealed an isolated dissection of the SMA that had not been diagnosed. The patient was then successfully treated by superior mesenteric revascularization, and after recovering, he underwent small bowel resection for chronic ischemia.

CONCLUSIONS

SMA revascularization has to be performed in case of SMA dissection complicated of bowel ischemia. Enteropathy is a rare complication of chronic mesenteric ischemia requiring digestive and vascular management in a dedicated health-care team.

A Spontaneous Isolated Superior Mesenteric Artery Dissection Associated with Cocaine Abuse: A Pathomechanistic Association

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare potentially fatal disease. We present a case of cocaine-related SISMAD in a patient with abdominal pain. A 38-year-old African American male with hypertension and alcohol, cocaine, and tobacco abuse presented with abdominal pain and recent cocaine use. A CT angiogram revealed SISMAD; he was treated with conservative management. Cocaine and SISMAD share similar pathophysiologic mechanisms pertaining to vascular smooth muscle cell apoptosis and increased shear stress at fixed vascular positions. Our report emphasizes the need to consider cocaine abuse in SISMAD pathophysiology, risk stratification, and treatment algorithms in future studies.

Clinical Features of Spontaneous Isolated Dissection of Abdominal Visceral Arteries

Background

Spontaneous isolated dissection of abdominal visceral arteries without aortic dissection is rare and its pathology and prognosis are not yet clear; therefore, therapeutic strategies for this disease have not been established. The present multi-institution investigational study analyzed the clinical features of patients with spontaneous isolated dissection of abdominal visceral arteries.

Methods

A total of 36 patients diagnosed as spontaneous isolated dissection of abdominal visceral arteries from January 2010 to October 2016 were enrolled. The medical data of the patients were retrospectively reviewed. Imaging characteristics were evaluated. Spontaneous isolated dissection of abdominal visceral arteries was detected on upper abdominal computed tomography examination in almost patients, and was detected on magnetic resonance imaging in one patient.

Results

Of the 36 cases, 26 cases involved the superior mesenteric artery dissection, nine involved the celiac artery, two involved the splenic artery, one involved the common hepatic artery, one involved the gastroduodenal artery and one involved the left gastric artery. Among the 36 patients, 20 had hypertension and 14 were current smokers. Additionally, only one patient had diabetes and four patients had dyslipidemia. Moreover, 32 cases complained of pain including abdominal pain and back pain, one had cough and three had no symptoms. Of the 36 patients, 34 cases (94.4%) were treated conservatively, and two (5.6%) required intravascular treatment. All patients were discharged without complications.

Conclusions

Our findings indicate that hypertension and smoking might be closely involved in the pathogenesis of spontaneous isolated dissection of abdominal visceral arteries, whereas dyslipidemia and diabetes might be less involved. Additionally, few asymptomatic patients were accidentally diagnosed, indicating that the absence of symptoms cannot be used to rule out the presence of this disease. Randomized clinical trials cannot be performed because a considerable number of cases are required. Therefore, detailed descriptions of clinical features, as provided in our report, are important.

Long-Term Outcomes of Spontaneous Isolated Superior Mesenteric Artery Dissection

Spontaneous isolated dissection of the superior mesenteric artery (SMAD) is not still well known. We retrospectively analyzed our 30 patients with SMAD to elucidate the treatment strategy and long-term follow-up outcomes. Due to severe abdominal symptom we performed a stents deployment and surgical reconstructive surgery for each one case. Anerysmectomy and bypass surgery was performed for a patient with aneurysmal change. Other 27 patients were managed conservatively. SMAD patients had only two vascular events (renal infarction and graft occlusion), and showed good prognosis for 6-146 (mean 69) months follow-up. We found that there is a few SMAD patients necessary of invasive management at acute phase and that most patients are safely conservatively treated with good prognosis. (This is a translation of J Jpn Coll Angiol 2018; 58: 195-199.).

Primary conservative treatment for peritonitis-absent symptomatic isolated dissection of the superior mesenteric artery with severely compressed true lumen

Objectives

The purpose of this study was to evaluate the safety and efficacy of primary conservative treatment (PCT) for peritonitis-absent symptomatic spontaneous isolated dissection of the superior mesenteric artery (S-SIDSMA) with severely compressed true lumen.

Methods

From January 2013 to December 2018, PCT was used in 26 cases of peritonitis-absent S-SIDSMA with severely compressed true lumen in our center based on our previous proposed treatment algorithm for S-SIDSMA. The demographics, duration from the onset to the admission, duration from the start of the conservative treatment to the alleviation of the symptoms, and in-hospital and follow-up clinical and angiographic outcomes were prospectively recorded and then analyzed.

Results

Among the 26 included patients, 84.6% were male. The mean age of the patients was 54.7 years. The mean duration from the onset to the admission was 3.1 days (range, 1–14 days). Symptoms in 22 patients were markedly or completely relieved during the first five-day medical treatment. Endovascular stent placement was attempted in the remaining four patients, which was successfully performed in three (75%) of them. The technical failure occurred in a patient whose compressed true lumen failed to be cannulated. Medical treatment was then continued in this patient, and his symptoms were relieved after a two-day medical treatment. During the mean follow-up period of 14.3 months, endovascular stent placement was performed in three patients due to the recurrence of the abdominal pain and the chronic intestinal ischemia. No patient showed dissection progression during the follow-up. The complete remodeling rate of the stent group was significantly higher than that of the medical group (83.3% vs. 25%, P = 0.021).

Conclusions

Based on our previous proposed treatment algorithm for S-SIDSMA, PCT could achieve satisfactory results both clinically and morphologically in peritonitis-absent S-SIDSMA with severely compressed true lumen.

Early Detection of Superior Mesenteric Artery Dissection by Ultrasound: Two Case Reports

Superior mesenteric artery (SMA) dissection is a rare disease. Most of the cases are diagnosed through contrast-enhanced computed tomography. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. We present two case reports: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through contrast-enhanced computed tomography.

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.

Classification of spontaneous isolated superior mesenteric artery dissection: correlation with multi-detector CT features and clinical presentation

PURPOSE

The purpose of the study is to propose a computed tomography (CT) classification of spontaneous isolated superior mesenteric artery dissection (SISMAD) correlated with clinical presentation METHODS: We retrospectively reviewed CT images of 40 patients with SISMAD at our institution from 2006 to 2015 and proposed a new classification: type I, patent false lumen with both entry and re-entry; type II, patent false lumen without re-entry; type III, completely or partially thrombosed false lumen; and type IV, thrombosed false lumen with ulcer-like projection. Additionally, we included a subtype (S) at each type when there was either a long segment of dissection and/or significant true lumen stenosis. CT features were statistically analyzed using Fisher's exact and Mann-Whitney test.

RESULTS

The CT findings classified patients as type I (15%), type II (12.5%), type III (35%), and type IV (37.5%). Of the 40 patients, 25 (62.5%) were symptomatic. There was a significantly different proportion of each type between symptomatic and asymptomatic patients (p = 0.005). There were 25 patients with subtype (S); no type I or II, 12 type III, and 13 type IV. The symptomatic patients showed longer dissection tendency and more severe true lumen stenosis (78% vs. 53%, p = 0.000) compared with asymptomatic patients.

CONCLUSION

The proposed multi-detector CT classification of SISMAD correlates with clinical presentation. This new classification could be helpful for treatment planning.

Spontaneous Celiac Artery Dissection Presenting With Splenic Infarction: A Case Report

Spontaneous isolated celiac artery dissection (SICAD) is extremely rare. We herein report a case of a 43-year-old male with no known history of cardiovascular disease who presented to the emergency department (ED) with sudden onset severe epigastric abdominal pain without a known trigger. Abdominal computed tomography (CT) scan showed a focal dissection and irregular enhancement of the celiac trunk with associated splenic artery embolus and large splenic infarct. The patient was successfully treated conservatively with blood pressure control, antiplatelet and anticoagulation therapy.

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)

Ten-year review of isolated spontaneous mesenteric arterial dissections

OBJECTIVE

Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition; however, it has been increasingly noted incidentally on diagnostic imaging. The purpose of this study was to examine the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissection (SMAD). We hypothesized that most SMADs can be treated nonoperatively.

METHODS

This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes.

RESULTS

A total of 77 patients were found to have CA dissection, SMA dissection, or both in the absence of aortic dissection diagnosed on computed tomography or magnetic resonance imaging. The average age was 56 years (range, 26-86 years), 80% were male, and 10 patients (13%) had underlying connective tissue disorders. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients; 33 (43%) presented with isolated CA dissection, and 30 (39%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up. One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 73 patients were managed nonoperatively; 40 (52%) were treated with a short course of anticoagulation, 23 (30%) were treated with antiplatelet therapy, and 10 (13%) were treated with observation alone. No other late interventions or recurrences were noted during a mean follow-up of 21 months.

CONCLUSIONS

Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Only a small number of patients require surgical revascularization for bowel ischemia.

Comparison of CTA and DSA in the diagnosis of superior mesenteric artery dissecting aneurysm

Objective

To compare computed tomography arteriography (CTA) and digital subtraction arteriography (DSA) in the diagnosis of superior mesenteric artery dissecting aneurysm (SMADA).

Methods

All SMADA patients who underwent CTA and DSA at one of two medical centers between May, 2007 and April, 2017 were identified. The accuracy of CTA and DSA for the depiction of morphologic characteristics of SMADA was analyzed.

Results

Fourteen patients (12 men; mean age, 55.1 ± 6.4 years) were included in this study. The mean diameter of the dissecting aneurysm was 3.78 ± 1.53 mm on CTA and 3.81 ± 1.54 mm on DSA ( p = 0.96). The luminal stenosis was 0.52 ± 0.27 on CTA and 0.35 ± 0.23 on DSA ( p = 0.09). The thrombosed false lumen was visualized on CTA in 79% (11/14) of patients but in no patients on DSA ( p < 0.001). The entry points of the dissection were visualized on CTA in 64.3% (9/14) of patients and on DSA in 100% (14/14) of patients ( p = 0.041); CTA and DSA did not visualize re-entry points in any patients. The intimal flap was visualized on CTA in 71.4% (10/14) of patients and on DSA in 78.6% (11/14) of patients ( p > 0.05). Branch vessel involvement was visualized in 7.1% (1/14) of patients on CTA but in no patients on DSA ( p > 0.05).

Conclusions

CTA can be used in place of DSA for the diagnosis of SMADA. Although CTA may exaggerate the degree of luminal stenosis and is weak in depicting the entry points of SMADA, this modality more accurately depicts the thrombosed false lumen and branch vessel involvement.

Spontaneous isolated dissection of the superior mesenteric artery and aneurysm formation resulting from segmental arterial mediolysis: a case report

Background

Spontaneous isolated dissection of the superior mesenteric artery (SMA) can lead to bowel ischemia, aneurysm rupture, or even death. Studies have suggested that mechanical or hemodynamic stress on the vascular wall of the SMA may be a contributor, but its pathogenesis is unclear.

Case presentation

A 57-year-old Japanese man with a history of untreated hypertension and hyperuricemia was admitted to our hospital with the sudden onset of severe epigastric pain. Laboratory findings showed elevated white blood cell count and C-reactive protein, and contrast-enhanced computed tomography (CT) of the abdomen demonstrated arterial dissection with luminal stenosis and aneurysm formation at the distal portion of the SMA after the branching of the jejunal artery, and intravenous nicardipine was administered. The patient’s epigastric pain resolved spontaneously but recurred on day 6 of his hospital stay. Contrast-enhanced abdominal CT revealed an enlarged aneurysm with wall thinning. Because of the risk of aneurysm rupture, the decision was made to perform aneurysmectomy and bowel resection on day 6. Histologic examinations revealed two separate dissecting lesions: one latent and the other resulting in aneurysm formation. Both lesions showed characteristics of segmental arterial mediolysis (SAM) with lack of arterial media, absence of internal and external elastic laminae and intimal proliferation.

Conclusions

Histologic findings in the present case suggest that mechanical or hemodynamic stress on the vascular wall and SAM-related vascular vulnerability may concomitantly contribute to the onset of isolated SMA dissection.

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.

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.

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.

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.

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 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.

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.

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).

Approaches to the management of spontaneous isolated visceral artery dissection

BACKGROUND

Spontaneous isolated celiac and superior mesenteric artery dissection without aortic dissection is a rare disease. Recently, an increasing number of cases have been diagnosed and the prognosis has improved significantly because of technical progress in computed tomography (CT). However, management approaches vary from conservative treatment or endovascular repair to open surgery. This study analyzed the clinical findings of patients with spontaneous visceral artery dissection, and attempted to illuminate how to manage these cases.

MATERIALS AND METHODS

From June 2005 to February 2012, a total of 17 patients were diagnosed with spontaneous isolated visceral artery dissection in the authors' hospital (4 celiac arteries, 12 superior mesenteric arteries, and 1 inferior mesenteric artery) based on CT findings. The clinical characteristics, Sakamoto's classification, imaging appearance, and early outcomes of these patients were retrospectively compared.

RESULTS

The mean age of the patients was 51.47 ± 8.65 years (range, 39-73 years) and the mean follow-up period was 35.18 ± 25.55 months (range, 1-79 months). Fifteen (88.2%) patients had abdominal pain and no ischemic changes of the bowel. The dissections initiated at a mean distance of 13.04 ± 10.41 mm (range, 4.00-43.39 mm) from the origin of the artery, with a mean length of 53.39 ± 28.06 mm (range, 10.00-108.46 mm). There were 4 type I (23.8%), 1 type II (5.9%), 9 type III (52.9%), and 3 type IV (17.6%) dissections according to Sakamoto's classification. Treatments included observation without anticoagulation treatment in 3 patients (17.6%), anticoagulation treatment in 12 (70.6%), and endovascular stenting in 2 (11.8%). The disease stabilized in all patients during follow-up.

CONCLUSIONS

If bowel perfusion is not compromised and patency is well compensated by collateral circulation, most patients can be managed conservatively with or without anticoagulation treatment. However, patients must be monitored closely and followed up regularly for early detection of progression.

A case report of aneuysmectomy after thrombo-intimectomy for spontaneous isolated superior mesenteric artery dissection

A 53 year-old man was admitted with acute onset of severe abdominal pain, and we performed emergent thrombectomy and intimectomy for acute, complete occlusion of superior mesenteric artery (SMA) due to its spontaneous dissection. However, 4 months later the operated part of the SMA enlarged due to aneurysm and the patient was treated by aneuysmectomy and iliac-mesenteric bypass using a saphenous vein. Aggressive treatment such as surgical or endovascular procedure is necessary for severe ischemia due to SMA dissection.

Isolated celiac and superior mesenteric artery dissection identified with MDCT: imaging findings and clinical course

OBJECTIVE

Isolated celiac or superior mesenteric artery (SMA) dissection is a rare entity in the absence of aortic dissection. Our objective was to detail imaging and clinical course of celiac and or SMA dissections.

METHODS

We conducted a retrospective search from 2004 to 2010 using "celiac and/or SMA dissection" keywords. Analysis of medical record and imaging at diagnosis and follow-up was performed. Dissections for any reason without aortic dissection were included.

RESULTS

Twenty-four celiac and 18 SMA dissections were detected in 38 patients. One third of the dissections diagnosed with interactive multiplanar reconstruction/maximum intensity projection (MIP)/3-dimensional (3D) rendering were missed on standard imaging planes. No patients had bowel ischemia or died. Eighty-four percent of the patients were observed, 2 patients received anticoagulation, 2 patients received surgical repair, and 3 patients received stenting. Twenty-three of 25 cases treated with observation exhibited no change or improvement/resolution (2/25) with 20.9-month mean follow-up.

CONCLUSION

Most isolated celiac and SMA dissections were asymptomatic/incidental, supporting observation and surveillance with intervention reserved for vascular compromise. Interactive multiplanar reconstruction/maximum intensity projection/3D rendering can increase diagnostic sensitivity.

Spontaneous rupture of a middle colic artery aneurysm arising from superior mesenteric artery dissection: Diagnosis by color Doppler ultrasonography and CT angiography

Both middle colic artery (MCA) aneurysm and spontaneous dissection of the superior mesenteric artery (SMA) are rare. We report the first case of concomitancy of both conditions, diagnosed by ultrasonography and CT angiography. A 56-year-old man with abrupt abdominal pain and hypovolemic shock was diagnosed initially with ruptured MCA aneurysm by color Doppler ultrasonography. Computed tomography and angiography confirmed MCA aneurysm and showed that it was arising from the false lumen of an SMA dissection and was probably associated with segmental arterial mediolysis. The MCA aneurysm was treated successfully by transcatheter coil embolization, and the SMA dissection was treated conservatively.