Clinical Outcomes of Conservative Treatment in Patients with Symptomatic Isolated Spontaneous Renal Artery Dissection and Comparison with Superior Mesenteric Artery Dissection

Midterm Results of the Conservative, Bare Stent, and Bare Stent-Assisted Coiling Treatments for Symptomatic Isolated Superior Mesenteric Artery Dissection

BACKGROUND

We compared the early and midterm (31, 3-63 months) outcomes of conservative treatment, bare stent treatment (BST), and bare stent-assisted coiling treatment (BSACT) to determine the most effective treatment for patients with symptomatic isolated superior mesenteric artery dissection (SISMAD).

METHODS

Consecutive patients with SISMAD admitted to the study hospital between January 2016 and December 2021 were included in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed.

RESULTS

A total of 121 patients were included in the study (23 with conservative treatment, 42 with BST, and 56 with BSACT). Symptoms were relieved in 91.3% of conservative patients, whereas all patients (100%) with BST or BSACT had symptom relief (P = 0.035). There was no significant difference in the length of hospital stay between the 2 endovascular treatments (P = 0.9051), but hospital stay was significantly shorter compared to conservative treatment (P < 0.0001). The cumulative rate of complete remodeling was 100% for BSACT versus 46.3% for BST (P < 0.0001) versus 42.9% for conservative patients (P < 0.0001). There were no significant differences between the last 2 groups (P = 0.3925). The prevalence of adverse events for abdominal pain recurrence and aneurysm formation was also significantly lower in the BSACT group at follow-up.

CONCLUSIONS

BSACT for SISMAD has a preferable early outcome. The cumulative complete remodeling rate and the event-free survival rate are satisfactory at midterm follow-up. BSACT is an effective approach for SISMAD.

Endovascular treatment of systematic isolated mesenteric artery dissection with a patent false lumen: Bare stents alone versus stent-assisted coiling

OBJECTIVES

Bare stent treatment and bare stent-assisted coiling treatment have not been directly compared in symptomatic isolated superior mesenteric artery dissection with a patent false lumen. Thus, we compared the early and mid-term outcomes of bare stent treatment and bare stent-assisted coiling treatment to determine the most effective remedy for patients with this condition.

METHODS

Consecutive patients diagnosed with systematic isolated superior mesenteric artery dissection with a patent false lumen admitted to the study hospital between January 2016 and December 2021 were enrolled in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed.

RESULTS

A total of 85 patients (83 men) were included. 34.1% (n = 29) adopted bare stent treatment and 65.9% (n = 56) underwent bare stent-assisted coiling treatment. The symptoms were relieved in all patients (100%) with bare stent treatment and bare stent-assisted coiling treatment. There was no significant difference in the length of hospital stay between the two endovascular treatments (p = 0.354). The cumulative complete remodeling rate was 100% in bare stent-assisted coiling treatment vs. 70.4% in bare stent treatment (p < 0.0001). The prevalence of adverse events for abdominal pain recurrence (none in BST or bare stent-assisted coiling treatment), and formation of the aneurysm (two in bare stent treatment, and none in bare stent-assisted coiling treatment) showed no significant difference at follow-up.

CONCLUSION

Both bare stent treatment and bare stent-assisted coiling treatment for symptomatic isolated superior mesenteric artery dissection with a patent false lumen have the same satisfying early outcome. In the midterm follow-up, bare stent-assisted coiling treatment has the higher cumulative complete remodeling rate which could be prioritized to treat this condition.

Acute Renal Infarction Due to Symptomatic Isolated Spontaneous Renal Artery Dissection: A Rare and Fatal Disease

OBJECTIVE

To report demographics and clinical, laboratory, and imaging features of acute renal infarction (ARI) due to symptomatic isolated spontaneous renal artery dissection (SISRAD) and to analyze outcomes after the initial therapy for SISRAD.

METHODS

Thirteen patients with ARI due to SISRAD between January 2016 and March 2021 were enrolled in this retrospective study. We reviewed the demographics, clinical, laboratory, and imaging features (location of the infarct kidney, the branch artery involved by dissection, true lumen stenosis, false lumen thrombosis, and aneurysm), treatment modalities, and follow-up results; analyzed the difference between SISRAD and other causes of ARI; and propose an appropriate therapy strategy for SISRAD based on our data and literature.

RESULT

Patients with ARI due to SISRAD were mostly young men (43 [24-53] years; 12/13 [92%]). No patients had atrial fibrillation or acute kidney injury at admission (0/13). All 13 patients received conservative treatment as the initial treatment. Sixty-two percent (8/13) of patients progressed, and 88% (7/8) of them had dissection aneurysm on the admission computed tomographic angiography (CTA) image. Seventy-five percent (6/8) of patients underwent endovascular intervention as follows, stent placement in 1 patient, renal artery embolization in 1, and stent placement with embolization in 4. Two patients with disease progression died: 1 during the conservative treatment period and 1 after the stent placement. Thirty-eight percent (5/13) of patients in remission continued to receive conservative treatment, none of whom had dissection aneurysm on the admission CTA.

CONCLUSION

Symptomatic isolated spontaneous renal artery dissection is a rare and fatal disease. For young ARI patients with no previous history of tumors and cardiogenic diseases, CTA examination is recommended to exclude SISRAD. Dissection aneurysm seems to be a risk of progression for SISRAD in this series. Conservative treatment, a recognized initial treatment, has a good effect on patients without dissection aneurysm, and we recommend endovascular intervention as the initial treatment for the patient with dissection aneurysm at admission. Multicenter clinical studies are needed to explore a more-appropriate treatment for patients with SISRAD.

CLINICAL IMPACT

This article report the related factors, risks, demographics and laboratory data of Acute renal infarction (ARI) due to Symptomatic isolated spontaneous renal artery dissection (SISRAD) and explore a better initial therapy strategy for SISRAD. It will help improve the effectiveness of SISRAD treatment and reduce the mortality rate from this rare but lethal disease.

Isolated superior mesenteric artery dissection: An updated review of the literature

Isolated superior mesenteric artery dissection (ISMAD) is a rare but potentially life-threatening cause of acute abdominal pain. Owing to the availability of computed tomography angiography, more cases have been detected during screening for acute abdomen in recent years. With increasing knowledge of ISMAD, a better management strategy is being developed. To enhance our understanding and improve treatment outcomes of ISMAD, a systematic literature review was conducted with a focus on diagnosis and management strategies based on existing evidence.

Clinical characteristics, treatment and outcomes of patients with spontaneous renal artery dissections

OBJECTIVES

The natural history and optimal management of spontaneous renal artery dissections (SRADs) are poorly understood. We compared baseline characteristics, presentation, management, and outcomes between patients with symptomatic versus asymptomatic SRADs.

METHODS

We performed a retrospective review of medical charts for patients diagnosed with SRAD at a single, tertiary care center. Patients were identified using billing codes. Patient demographics, medical history, clinical presentation, treatment, and follow up were recorded. We compared patients based on presence or absence of symptoms at the time of SRAD diagnosis.

RESULTS

A total of 125 patients were included; 73 (58.4%) patients had symptoms at the time of SRAD diagnosis. Symptomatic patients were younger at the time of diagnosis (47.4 vs. 54.3 years, p = 0.008) and more likely male (74.0% vs. 44.2%, p = 0.005). Most patients received medical therapy (93.2% vs. 82.6%, p = 0.32). Endovascular therapy utilization was low in both groups (8.2% vs. 7.7%, p = 0.9). Outcomes between the two groups were comparable; renal function remained stable, and mortality was rare.

CONCLUSION

Most patients who presented with SRAD were treated with medical therapy alone and usually experienced a benign course. Further studies are needed to understand the pathophysiology and natural history of renal artery dissections.

Analysis of safety and efficacy of conservative treatment and endovascular treatment in patients with spontaneous isolated mesenteric artery dissection

Background

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease with abdominal pain as the main clinical manifestation, but its optimal treatment strategy has not yet been determined. Based on this, this study explored a safe and effective treatment method by analyzing and comparing the safety and efficacy of conservative treatment and endovascular treatment in SISMAD patients.

Methods

The clinical and imaging data and treatment effects of 85 patients with SISMAD who were admitted to the General Surgery Department of the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from January 2008 to December 2020 were retrospectively analyzed. Two groups were treated, the data of patients in conservative treatment group and endovascular treatment group were analyzed, and a safe and effective treatment method for SISMAD was discussed.

Results

The mean follow-up time was 36.58 ± 25.03 months. The success rate of interventional operation was 86.11% (31/36), and the operation failed because the guide wire could not enter the true lumen in four cases. One case was terminated due to poor physical condition of the patient who could not tolerate surgery. There were no significant differences in gender, body mass index, clinical manifestations, and past history between conservative treatment and endovascular treatment (P > 0.05), but in age, superior mesenteric artery-distal aorta angle, distance from the superior mesenteric artery opening to dissection, dissection length, and true lumen stenosis. There was a statistical difference between the two groups in the rate and Yun classification (P < 0.05).

Conclusions

Conservative treatment is effective for most symptomatic SISMAD patients, and close monitoring is required; for patients with persistent symptoms and severe true lumen stenosis (especially Yun classification type III), endovascular treatment is preferred; endovascular treatment is mainly based on endovascular bare stent placement. Patients receiving stent implantation may suffer from stent stenosis or occlusion in the long term, and most of them have no obvious symptoms of intestinal ischemia; the prognosis is good.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre

OBJECTIVE

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC).

METHODS

All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI).

RESULTS

Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun et al., IMADs were reported as follows: type I (n = 7, 20%), type IIa (n = 6, 18%), type IIb (n = 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n = 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n = 3; type III, n = 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n = 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n = 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n = 4; stenting, n = 1) and or bowel resection (early, n = 3; late, n = 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention.

CONCLUSION

Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Spontaneous renal artery dissection: an elusive diagnosis

Spontaneous renal artery dissection is a rare condition with an often non-specific presentation, resulting in a challenging diagnosis for clinicians. This is the case of a 39-year-old man who presented with an acute-onset right flank pain, mild neutrophilia and sterile urine. CT of abdomen and pelvis showed a patchy hypodense area in the right kidney originally thought to represent infection. He was treated as an atypical pyelonephritis with antibiotics and fluids. When his symptoms failed to improve, a diagnosis of renal infarction was considered and CT angiogram of the aorta revealed a spontaneous renal artery dissection. He was managed conservatively with systemic anticoagulation, antihypertensive treatment and analgesia and discharged home with resolution of his symptoms and normal renal function.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Renal Outcome and New-Onset Renal and Extrarenal Dissections in Patients With Nontrauma Renal Artery Dissection Associated With Renal Infarction

[Figure: see text].

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

Background and Aims:

There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited.

Material and Methods:

The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis.

Results and Conclusions:

Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

Management of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection: A Single Centre Experience with Mid Term Follow Up

OBJECTIVE

This study aimed to report a single centre management experience and mid term outcomes for symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD).

METHODS

This was a retrospective observational study. Between 1 August 2012, and 30 June 2018, consecutive patients with symptomatic SISMAD were included. Patient demographics, clinical symptoms, comorbidities, risk factors, and dissection characteristics were obtained. The treatment regimens and clinical and follow up outcomes were reviewed and analysed. A chi square test, Fisher's exact test, or one way analysis of variance was used to compare variables between the groups. Binary logistic regression was used to determine predictive factors for failed conservative treatment. The cumulative rate of complete dissection remodelling was calculated using a Kaplan-Meier curve.

RESULTS

Sixty-two patients (mean age, 56.0 ± 9.3 years) were included. Patients at risk of intestinal ischaemia or dissecting aneurysm rupture were considered to be high risk patients (Group 1, n = 16) and received primary endovascular treatment. The remaining patients were considered low risk (Group 2, n = 46) and received primary conservative treatment. Symptom relief was observed in 82.6% of patients in Group 2. Finally, failed conservative treatment was observed in 50% of the low risk patients. Dissection length ≥50 mm was an independent risk factor for failed conservative treatment (p = .019; OR 4.68, 95% CI 1.29-16.98). During a median follow up of 30.5 months (interquartile range, 17.5, 58.3), patients with stents had a higher complete dissection remodelling rate than those without stents.

CONCLUSION

This study found that conservative treatment showed satisfactory symptom resolution for low risk SISMAD patients. Endovascular stenting was associated with a high technical success and dissection remodelling rate. This treatment modality might be reserved for patients with high risk SISMAD or failed conservative treatment. In addition, a dissection length ≥50 mm was a risk factor for failed conservative treatment.

Factors Associated with Failed Conservative Management in Symptomatic Isolated Mesenteric Artery Dissection

OBJECTIVE

The aim of this study was to assess factors associated with conservative management failure in patients with symptomatic isolated mesenteric artery dissection.

METHODS

Patients with symptomatic isolated mesenteric artery dissection who underwent conservative therapy as first line treatment between February 2010 and May 2018 were included in this retrospective study. Conservative management failure was defined as the persistence or aggravation of symptoms and signs, increasing aneurysmal dilation, or new appearance of a dissecting aneurysm after conservative management. Univariable and multivariable analyses were performed to identify risk factors for failure of conservative management.

RESULTS

A total of 123 patients (115 men, 8 women, mean age, 53.7 ± 6.1 years) were included in this study. Conservative management was successful in 89 (72.4%) patients but failed in the remaining 34 (27.6%) patients. Of the 89 for whom conservative management was successful, all of the symptoms were eliminated (n = 81) or relieved (n = 8) within 3.8 ± 0.7 days after conservative management. All of the 34 patients in whom conservative management failed underwent successful endovascular stenting. Failure of conservative management was associated with type II IMADs as defined by the Sakamoto classification (meaning that there is an entry tear, but no re-entry, and still no thrombosis of false lumen, odds ratio: 33.76; 95% confidence interval 8.65-131.85; p < .001) and with ≥90% luminal stenosis (odds ratio 40.70; 95% confidence interval: 3.76-440.07; p < .01).

CONCLUSIONS

Conservative management can be used successfully in most patients with symptomatic isolated mesenteric artery dissection. Risk factors for failed conservative treatment were type II IMADs and degree of luminal stenosis ≥90%.

Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery

Introduction

Isolated dissection of the superior mesenteric artery (SMA) is rare and remains the most common reason for aneurysmal degeneration of the vessel. The treatment is challenging and not standardised. The purpose of this report is to demonstrate that coiling of the false lumen is a good alternative for dissecting SMA aneurysms.

Report

A 50 year old male presented with a 3.3 cm dissecting aneurysm of the SMA and epigastric pain of moderate severity. More than 50% of the ileal arteries arose from the collapsed true lumen. Via transfemoral access the true lumen was catheterised. An open cell balloon expandable stent was deployed at the proximal and a closed cell self expandable stent at the distal end of the dissection flap. Through the cells of the first stent a microcatheter was advanced into the false lumen and 33 coils were deployed into the aneurysm sac. A stent graft was deployed within the first stent leading to the total exclusion of the aneurysm. Follow up at three months was uneventful and the patency was assessed by contrast enhanced ultrasound.

Discussion

Coiling of the false aneurysm is a good alternative for dissecting SMA aneurysms, where no other open surgical or endovascular options are applicable.

•

Spontaneous isolated SMA dissection is the most frequent type of visceral artery dissection.

•

Spontaneous isolated SMA dissection is the most frequent cause of SMA dissecting aneurysms.

•

Treatment of SMA dissecting aneurysms remains controversial.

•

Coiling of the false lumen and stenting of the true lumen is an effective method of treatment.