1
|
Pratesi C, Esposito D, Martini R, Novali C, Zaninelli A, Annese AL, Baggi P, Bellosta R, Bianchini Massoni C, Bonardelli S, Carriero S, Cervelli R, Chisci E, Cioni R, Corvino F, DE Cobelli F, Fanelli F, Fargion AT, Femia M, Freyrie A, Gaggiano A, Gallitto E, Gennai S, Giampalma E, Giurazza F, Grego F, Guazzarotti G, Ierardi AM, Kahlberg AL, Mascia D, Mezzetto L, Michelagnoli S, Nardelli F, Niola R, Lenti M, Perrone O, Piacentino F, Piffaretti G, Pulli R, Puntel G, Puppini G, Rossato D, Rossi M, Silingardi R, Sirignano P, Squizzato F, Tipaldi MA, Venturini M, Veraldi GF, Vizzuso A, Allievi S, Attisani L, Fino G, Ghirardini F, Manzo P, Migliari M, Steidler S, Miele V, Taurino M, Orso M, Cariati M. Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM). THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:49-63. [PMID: 38037721 DOI: 10.23736/s0021-9509.23.12809-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.
Collapse
Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy -
| | - Romeo Martini
- Department of Angiology, San Martino Hospital, Belluno, Italy
| | - Claudio Novali
- Department of Vascular Surgery, GVM Maria Pia Hospital, Turin, Italy
| | | | - Antonio L Annese
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Paolo Baggi
- Department of Vascular Surgery, ASST Spedali Civili, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | | | | | - Serena Carriero
- Department of Diagnostic and Interventional Radiology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosa Cervelli
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Emiliano Chisci
- Department of Vascular Surgery, S. Giovanni di Dio Hospital, Florence, Italy
| | - Roberto Cioni
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Fabio Corvino
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Francesco DE Cobelli
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Fabrizio Fanelli
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Marco Femia
- Department of Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Antonio Freyrie
- Department of Vascular Surgery, University Hospital of Parma, Parma, Italy
| | - Andrea Gaggiano
- Department of Vascular Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefano Gennai
- Department of Vascular Surgery, Baggiovara Hospital, Modena, Italy
| | - Emanuela Giampalma
- Department of Diagnostic and Interventional Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Francesco Giurazza
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Franco Grego
- Department of Vascular Surgery, University Hospital of Padua, Padua, Italy
| | - Giorgia Guazzarotti
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Anna M Ierardi
- Department of Diagnostic and Interventional Radiology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Daniele Mascia
- Department of Vascular Surgery, San Raffaele Hospital, Milan, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, Verona, Italy
| | | | - Floriana Nardelli
- Department of Diagnostic and Interventional Radiology, Città della Salute e della Scienza, Turin, Italy
| | - Raffaella Niola
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Massimo Lenti
- Department of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Orsola Perrone
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | | | - Raffaele Pulli
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Gino Puntel
- Department of Diagnostic and Interventional Radiology, University Hospital of Verona, Verona, Italy
| | - Giovanni Puppini
- Department of Diagnostic and Interventional Radiology, University Hospital of Verona, Verona, Italy
| | - Denis Rossato
- Department of Diagnostic and Interventional Radiology, Città della Salute e della Scienza, Turin, Italy
| | - Michele Rossi
- Department of Diagnostic and Interventional Radiology, Sant'Andrea University Hospital, Rome, Italy
| | | | | | | | - Marcello A Tipaldi
- Department of Diagnostic and Interventional Radiology, Sant'Andrea University Hospital, Rome, Italy
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | - Gian F Veraldi
- Department of Vascular Surgery, University Hospital of Verona, Verona, Italy
| | - Antonio Vizzuso
- Department of Diagnostic and Interventional Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Sara Allievi
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Luca Attisani
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Gianluigi Fino
- Department of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | | | - Paola Manzo
- Department of Vascular Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Baggiovara Hospital, Modena, Italy
| | - Stephanie Steidler
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Vittorio Miele
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Maurizio Taurino
- Department of Vascular Surgery, Sant'Andrea University Hospital, Rome, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche, Perugia, Italy
| | - Maurizio Cariati
- Department of Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, Milan, Italy
| |
Collapse
|
2
|
Shang T, Zhou HJ, Wang YS, Qiu C, Chen TC, Sun J, Lu T, Wu Z, Zhang H, Li Z, Li DL. Mid-term Results of the Treatment of Isolated Dissection of the Celiac Artery: A Comparative Analysis of Endovascular Versus Conservative Therapy. J Endovasc Ther 2024; 31:80-88. [PMID: 35852451 DOI: 10.1177/15266028221112254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA. METHODS Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed. RESULTS A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10-85 months) and 44.0 (range, 9-80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001). CONCLUSIONS EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required. CLINICAL IMPACT Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery.
Collapse
Affiliation(s)
- Tao Shang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hua-Ji Zhou
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Vascular Surgery, Ping Hu People's Hospital, Jiaxing, China
| | - Yi-Shu Wang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian-Chi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Sun
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No.2 Hospital), Ningbo, China
| | - Tian Lu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dong-Lin Li
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
3
|
Wu H, Tang B, Zhang H, Ran K, Chen Y, Luo H. Endovascular treatment of systematic isolated mesenteric artery dissection with a patent false lumen: Bare stents alone versus stent-assisted coiling. Sci Prog 2023; 106:368504231214959. [PMID: 38116780 PMCID: PMC10664444 DOI: 10.1177/00368504231214959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
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.
Collapse
Affiliation(s)
- Huan Wu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Ran
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
4
|
Volumetric Analysis of Progressive Remodeling of Isolated Mesenteric Artery Dissection Treated by Conservative Therapy. J Vasc Interv Radiol 2023; 34:445-453. [PMID: 36400121 DOI: 10.1016/j.jvir.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/18/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To characterize remodeling of conservatively treated isolated mesenteric artery dissection (IMAD) using 3-dimensional (3D) volumetric analysis. MATERIAL AND METHODS Patients with Type I/II (classification of Yun) treated by conservative therapy between January 2018 and January 2020 were prospectively included. Semiautomatic morphological analysis of the superior mesenteric artery (SMA) included volumetric measurements of the true lumen (TL), false lumen (FL), and overall lumen (OL) and 3D aortomesenteric angles from computed tomography angiography data at admission (T0), 1 month (T1), and 12 months (T12). The SMA morphology of patients with IMAD (n = 15, mean age 53 years ± 7; 87% men) was also compared with that of control individuals (n = 51, mean age 56 years ± 4; 94% men). RESULTS A significant reduction in OL volume was observed (P <.001), whereas TL volume remained stable (P =.23). The TL/OL volume ratio significantly increased over time (P =.001) from 53% at T1 to 78% at T12. Aortomesenteric 3D angles at 2, 4, and 6 cm from the ostium showed a progressive decrease toward values observed in the control group (P =.013, P =.002, and P =.027, respectively). At T12, 5 patients (33%) had complete remodeling, and aneurysmal change was observed in 2 patients (<20 mm). Smoking and SMA angle at a distance of 6 cm from the ostium (T0) were the only factors affecting remodeling negatively at T12. CONCLUSIONS One-year remodeling in IMAD followed an overall decrease in OL volume related to a decrease in FL volume. Smokers and patients with larger SMA angles at baseline showed poorer remodeling. Spontaneous arterial remodeling in IMAD might favor conservative therapy.
Collapse
|
5
|
Ben Abdallah I, Huguet A, Nuzzo A, Mirault T, Roussel A, El Batti S, Ronot M, Castier Y, Corcos O. Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre. Eur J Vasc Endovasc Surg 2022; 64:656-664. [PMID: 36075544 DOI: 10.1016/j.ejvs.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 08/17/2022] [Accepted: 08/28/2022] [Indexed: 01/11/2023]
Abstract
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.
Collapse
Affiliation(s)
- Iannis Ben Abdallah
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Department of Vascular and Thoracic Surgery, Hôpital Bichat, APHP, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP; Inserm, UMR_S 1140, Fondation Carpentier, Paris, France.
| | - Audrey Huguet
- SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP
| | - Alexandre Nuzzo
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP
| | - Tristan Mirault
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; National Reference Centre for Rare Vascular Diseases, FAVA-MULTI, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Arnaud Roussel
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, APHP, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP
| | - Salma El Batti
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Inserm, UMR_S 1140, Fondation Carpentier, Paris, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Maxime Ronot
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP; Department of Radiology, Hôpital Beaujon, APHP, Clichy, France
| | - Yves Castier
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Department of Vascular and Thoracic Surgery, Hôpital Bichat, APHP, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP
| | - Olivier Corcos
- Université Paris Cité and Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales, i.e., Intestinal Stroke Centre), Hôpitaux Beaujon/Bichat, APHP
| |
Collapse
|
6
|
Yuan Z, Hu G, Sheng S, You Y, Wang J. Management Strategy and Radiologic Outcomes of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection Based on Angiographic Classification: The Follow-Up Experience in a Single Center. J Endovasc Ther 2022:15266028221133700. [PMID: 36346065 DOI: 10.1177/15266028221133700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To investigate the demographics, clinical features, radiologic measurement, treatment, and outcomes of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) according to computed tomography (CT) classification. METHODS This retrospective study included 201 patients diagnosed with symptomatic SISMAD from November 2014 to December 2020. Symptomatic spontaneous isolated superior mesenteric artery dissection was categorized into four types based on CT images by Yun's angiographic classification. Their clinical characteristics, images features, treatment methods, and radiological outcomes were comparatively analyzed by CT angiographic types. RESULTS SISMADs were categorized into type I (13.9%) patent false lumen (FL) with both entry and re-entry; type IIa (37.3%), blind pouch of FL; type IIb (43.3%), thrombosed FL; and type III (5.5%), and the occlusion of superior mesenteric artery (SMA). Type IIb, the most common SISMAD, showed the largest true lumen (TL) residual diameter and the lowest percentage of TL stenosis. Type III positioned most proximally to SMA origin and had the maximum dissection length. Symptomatic spontaneous isolated superior mesenteric artery dissections underwent conservative (75.1%), endovascular (22.4%), and surgical (2.5%) treatment. Conservative treatment was more frequent in type I (85.7%) and type IIb (83.9%) than in type IIa (65.3%) and type III (45.5%). Endovascular intervention was more commonly utilized in type IIa (32.0%) and type III (36.4%) than in type I (14.3%) and type IIb (14.9%). Conservative patients achieved FL vanishment/shrinkage (57.8%), stabilization (26.6%), and enlargement (15.6%). After conservative treatment, type I showed angiographic FL stabilization; type IIa achieved FL shrinkage (48.1%), stabilization (22.2%), and enlargement (29.6%); type IIb exhibited FL vanishment/shrinkage (92.0%) and enlargement (8.0%). Cumulative rate of stent patency was 92.3% during 6-year follow-up. CONCLUSIONS Conservative management with close follow-up is initially provided especially for types I and IIb. Morphological stabilization is more frequent in type I of patent FL with entry and re-entry. False lumen vanishment or shrinkage was more likely to occur in type IIb due to the thrombus absorption. Endovascular intervention has excellent long-term in-stent patency and is predominantly utilized in types IIa and III. Blood flow sustained into a blind-ending FL causes the TL compression and stenosis in type IIa. Type III with the occlusion of SMA has the high risk of bowel ischemia. CLINICAL IMPACT According to Yun's angiographic classification of spontaneous isolated superior mesenteric artery dissection (SISMAD), type I (13.9%) has patent true and false lumen and the morphological pattern is maintained stable; type IIa (37.3%) possesses a patent blind-ending false lumen which might shrink, remain unchanged, or enlarge; and endovascular intervention is suggested when conservative treatment failed; type IIb (43.3%) recovers spontaneously due to the absorption of false lumen thrombus and conservative treatment is preferentially considered; type III (5.5%) with the occlusion of main trunk carries a high risk of bowel necrosis, early endovascular intervention is proposed, and open surgery might be necessary.
Collapse
Affiliation(s)
- Zihui Yuan
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guofu Hu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shi Sheng
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun You
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Wang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
Sun J, Wang L, Que Y, Li H, Wu K, Yuan D, Xiong J, Wang W. Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: a Multicentre Experience. Eur J Vasc Endovasc Surg 2022; 64:507-514. [PMID: 36038050 DOI: 10.1016/j.ejvs.2022.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 08/13/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Isolated mesenteric artery dissection (IMAD) is an increasingly diagnosed disease. However, multicentre studies to support clinical decision making are limited. This multicentre retrospective study aimed to investigate the characteristics, treatment options, and outcomes of IMAD. METHODS Data from consecutively enrolled patients with IMAD between October 2009 and May 2021 at three hospitals were collected retrospectively. One hundred and ninety uncomplicated symptomatic IMAD patients were divided into two groups: conservative (n = 141) and operative (n = 49). The costs, length of hospital stay, factors affecting outcomes, symptom relief, and complete remodelling of superior mesenteric artery (SMA) were analysed between the two groups. RESULTS Compared with patients who received operative treatment, patients receiving conservative treatment had shorter hospital stays (8.2 ± 4.6 vs. 11.9 ± 6.4 day, p < .020) and lower hospital costs (14 900 ± 1 048 vs. 60 400 ± 7 733 yuan, p < .001). In contrast, patients receiving operative treatment showed higher complete SMA remodelling (95.9% vs. 51.8%, p < .001). The cumulative rate of symptom relief was similar between the groups (p = .71). The rates were 78% vs. 79%, 87% vs. 87%, 89% vs. 87% at one, 12, and 60 months in the conservative and operative groups, respectively. Further subgroup analysis showed that endovascular treatment of IMAD had the advantage of shorter hospital stays than open surgery (10.7 ± 4.5 vs. 25.2 ± 9.4 days, p < .010). Univariable analysis showed that Sakamoto type II was associated with failed complete SMA remodelling (odds ratio 0.34; 95% confidence intervals 0.13 - 0.91; p = .031). CONCLUSION IMAD patients achieved good long term survival and symptom relief regardless of the treatment. Sakamoto type II IMAD is a risk factor for failed complete SMA remodelling. Although endovascular treatment provided a higher rate of complete SMA remodelling, the conservative group had statistically significantly shorter hospital stays, lower hospital costs, and similar cumulative rates of symptom relief. Therefore, this study supports conservative treatment as the main strategy for uncomplicated symptomatic IMAD patients.
Collapse
Affiliation(s)
- Jinjian Sun
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lei Wang
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yifu Que
- Department of Vascular and Endovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, Beijing, China
| | - Hou Li
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kemin Wu
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, Beijing, China; Department of Vascular and Endovascular Surgery, Hainan Hospital, Chinese PLA General Hospital, Sanya, Hainan, China.
| | - Wei Wang
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| |
Collapse
|
8
|
Zhou F, Zheng Z, Pan Y. General features, management strategies, and outcomes of symptomatic spontaneous isolated celiac artery dissection. Front Surg 2022; 9:972276. [PMID: 36338634 PMCID: PMC9635887 DOI: 10.3389/fsurg.2022.972276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that has not been fully investigated and reported, and very little is known regarding its prognosis and management. Here, we aimed to provide more evidence on the management strategy and outcome for symptomatic SICAD based on the experience of a single center. Methods From January 2018 to December 2021, a total of consecutive 51 patients with symptomatic SICAD were retrospectively included in this study. These patients had been selectively treated with conservative treatment (n = 31) or endovascular treatment (n = 20). Baseline data, imaging findings, treatment strategy, outcomes, and follow-up data have been described and analyzed. Results The mean age of the patients was 53.2 ± 9.6 years, 44 (86.3%) were male, and 36 (70.6%) had hypertension. The median length of stay was 10.0 days. The complete remission rate was 92.2% on discharge. The median follow-up time was 21.0 months. A secondary intervention was required for two patients during follow-up in the conservative group, wherein one underwent a stent placement three months after discharge because of progression of symptoms and extension of dissection, and the other required intervention one month after discharge because of symptomatic progression. No secondary intervention was required in the endovascular group. Occasional and mild relapse of symptoms occurred in two patients in both the conservative and endovascular groups, with no secondary intervention. The length of dissection (25.5 ± 11.8 mm vs. 19.1 ± 7.4 mm, P = 0.022) and complete remodeling rate (85.7% vs. 15.4%, P < 0.001) in the endovascular group were greater than that in the conservative group. Conclusion Patients with symptomatic SICAD who were selectively treated with conservative treatment or endovascular treatment had satisfactory early and medium-term outcomes. Endovascular treatment showed significant advantages in the complete remodeling of the celiac artery and presented with a lower rate of secondary intervention. Moreover, it was found to be a safe and effective remedy for failed conservative treatment.
Collapse
|
9
|
Qiu C, Wu Z, He Y, Tian L, Zhu Q, Shang T, Zhang H, Li D. Endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery. Cochrane Database Syst Rev 2022; 9:CD014703. [PMID: 36074662 PMCID: PMC9455746 DOI: 10.1002/14651858.cd014703.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) occurs when a tear in the inner layer of the superior mesenteric artery (SMA) allows blood to flow between the layers of the SMA, forcing the layers apart, and creating two lumens. Abdominal pain is the most prevalent clinical manifestation. Other people may have no symptoms or experience nausea, vomiting, diarrhea, or blood in their stools. For people with SIDSMA who are not suspected of intestinal necrosis or intra-abdominal bleeding, medical treatment and endovascular therapy are the main treatment options. There is no consensus on the optimum first-line management strategy. OBJECTIVES To evaluate the benefits and harms of endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021. SELECTION CRITERIA We planned to include all randomized controlled trials (RCTs) which compared endovascular therapy and medical treatments for SIDSMA. We planned to exclude studies where participants were treated with open surgery. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were endovascular intervention rate and recurrent abdominal pain. Our secondary outcomes were open surgery rate, remodeling rate of SMA, new aneurysm formation of SMA, SMA occlusion, new dissection of SMA, death, symptom relief rate and complications of endovascular therapy. We planned to use GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We did not identify any RCTs to include in any analysis. AUTHORS' CONCLUSIONS We were not able to include any RCTs that compared endovascular therapy versus medical treatment in people with SIDSMA. High-quality RCTs that evaluate the benefits and harms of these interventions are needed to help determine the optimal strategy for managing SIDSMA.
Collapse
Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lu Tian
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qianqian Zhu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tao Shang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
10
|
Yuan Z, Sheng S, You Y, Li D, Wei Q, Yan K, Wang J. Relationship Between Morphological Remodeling and Angiographic Types of Spontaneous Isolated Superior Mesenteric Artery Dissection After Conservative Management: Determinant Affecting Serial Radiologic Courses. Front Cardiovasc Med 2022; 9:945141. [PMID: 35872891 PMCID: PMC9300881 DOI: 10.3389/fcvm.2022.945141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To monitor the radiological courses of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) after conservation, clarify the relationship between its morphological change and initial imaging classification, and identify these factors that affect dissection remodeling. Methods Eighty-nine conservative patients with SISMAD who underwent periodic follow-up of computed tomography angiography (CTA) were enrolled. Initial morphologic classification, imaging features and dissection remodeling were analyzed retrospectively. Logistic regression was used to identify predictors for remodeling. Receiver operating characteristics were performed for cutoff threshold. Results Zerbib classification was adapted and initial CT appearance divided eighty-nine patients into: type I (15.7%), patent false lumen (FL) with both entry and re-entry; type II (37.1%), “cul-de-sac” shaped FL without re-entry; type III (27.0%), thrombosed FL with ulcer-like-projection (ULP); type IV (18%), intramural hematoma; type V (0%), dissecting aneurysm; and type VI (2.2%), total or partial occlusion of superior mesenteric artery (SMA). Follow-up CTA revealed complete remodeling (33.7%), partial remodeling (16.9%), no change (25.8%), type change (13.5%) and dissection progression (10.1%). There was no dissection-related mortality. Type I (92.9%) sustained patent FL and no angiographic change. Type II showed partial remodeling (42.4%), no change (27.3%) and dissection progression (27.3%), and the length of FL enhancement positively predicted dissection progression with the cutoff of 40.3 millimeters. Type III achieved complete remodeling (58.3%) or evolved into type II (41.7%), and the distance between SMA orifice and ULP negatively predicted type change with the cutoff of 23.5 millimeters. Type IV (87.5%) achieved complete remodeling due to hematoma absorption. One patient underwent stent placement for the evolution of ULP into an enlarged blind-ending FL 2 months after conservation. Conclusion After conservation, patent FL with a distal re-entry is no morphological change, FL thrombosis tends to be resolved, and the “cul-de-sac” shaped FL without re-entry is partially shortened, no change or progressively dilated. FL enhancement length ≥ 40.3 millimeters is a predictor for the blinding-end FL enlargement. Thrombosed FL with ULP evolves into a patent “cul-de-sac” shaped FL when the distance between SMA orifice to ULP is less than 23.5 millimeters. A careful follow-up is necessary for the lesions with demonstrated predictors.
Collapse
Affiliation(s)
- Zihui Yuan
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shi Sheng
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun You
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Defu Li
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Wei
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Hepatobiliary and Gastrointestinal Surgery, Hankou Hospital, Wuhan, China
| | - Kai Yan
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Hepatobiliary and Gastrointestinal Surgery, Hankou Hospital, Wuhan, China
| | - Jian Wang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Jian Wang,
| |
Collapse
|
11
|
Lei Y, Liu J, Lin Y, Li H, Song W, Li Z, Huang W, Chen S. Clinical characteristics and misdiagnosis of spontaneous isolated superior mesenteric artery dissection. BMC Cardiovasc Disord 2022; 22:239. [PMID: 35610570 PMCID: PMC9131659 DOI: 10.1186/s12872-022-02676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare disease with a potentially fatal pathology. Due to the lack of specificity of clinical characteristics and laboratory tests, misdiagnosis and missed diagnosis are often reported. Therefore, the aim of this study was to investigate the clinical characteristics and misdiagnosis of SISMAD. Methods In a registry study from January 2013 to December 2020, 110 patients with SISMAD admitted to the First Affiliated Hospital of Wenzhou Medical University were enrolled. Descriptive methods were used to analyse clinical characteristics, laboratory data, diagnostic method or proof, misdiagnosed cases, plain computed tomography (CT) findings and dissection features. To study the relationship between dissection features and treatment modality, the selected patients were classified into the conservative group (n = 71) and the non-conservative group (n = 39). The Chi-square test and Student’s t-test were used to compare the conservative and non-conservative groups. Results One hundred ten patients with SISMAD, including 100 (90.9%) males and 10 (9.1%) females, with a mean age of 52.4 ± 7.6 years, were enrolled in the study. Relevant associated comorbidities included a history of hypertension in 43 cases (39.1%), smoking in 46 cases (41.8%), and alcohol consumption in 34 cases (30.9%). One hundred four patients (94.5%) presented with abdominal pain. Abnormalities in the C-reactive protein lever, white blood cells count and D-dimer lever were the 3 most common abnormal findings. There were 32 misdiagnosis or missed diagnosis. Fourteen cases were misdiagnosed because of insufficient awareness. Twelve cases were misdiagnosed because of disease features. Twenty cases were misdiagnosed as SMA embolism. Among them, There were 15 cases of Yun type IIb SISMAD. Sixty-six patients underwent plain CT. The maximum SMA diameter was 12.1 (11.3–13.1) mm, and the maximum SMA diameter was located on the left renal vein (LRV) plane in 68.2% of cases. Dissection features observed on contrast-enhanced CT (CECT), CT angiography (CTA), or digital subtraction angiography (DSA) showed that there were 70 cases (63.6%) of Yun type IIb SISMAD, the maximum SMA diameter was 13.0 ± 2.4 mm, the location of the maximum SMA diameter was on the LRV plane in 64.5% of cases, and 7.3% of cases were complicated with intestinal obstruction, including bowel necrosis in 3.6% of cases. There were differences between the conservative group and non-conservative groups in the residual true lumen diameter or degree of true lumen stenosis and the presence of intestinal obstruction or bowel necrosis (all P < 0.05). Conclusion For SISMAD, misdiagnosis and missed diagnosis were usually caused by insufficient awareness and disease features. SISMAD should be considered in the differential diagnosis of patients presenting with unexplained abdominal pain, especially males, patients in the 5th decade of life, patients with hypertension, and patients with an enlarged SMA diameter or a maximum SMA diameter located on the LRV plane on plain CT. Mesenteric CTA or CECT should be recommended for the investigation of these conditions.
Collapse
Affiliation(s)
- Yuanli Lei
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Jinying Liu
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Yi Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Huiping Li
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Wenxing Song
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhangping Li
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Weijia Huang
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Shouquan Chen
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China.
| |
Collapse
|
12
|
Lei YL. Value of superior-mesenteric-artery-diameter/superiormesenteric-vein-diameter on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection. World J Emerg Med 2022; 13:202-207. [DOI: 10.5847/wjem.j.1920-8642.2022.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022] Open
|
13
|
Choke E, Tay JS. SISMAD: Leave Alone or Stent? Eur J Vasc Endovasc Surg 2020; 60:872. [PMID: 32962918 DOI: 10.1016/j.ejvs.2020.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore.
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore
| |
Collapse
|