Real clinical management of patients with isolated superior mesenteric artery dissection in Japan

Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection

OBJECTIVE

Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable.

METHODS

A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold.

RESULTS

9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion.

CONCLUSION

EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.

Conservative versus stent treatment for spontaneous isolated superior mesenteric artery dissection after the failure of initial 3 days' conservative treatment: A 10-year follow-up study

OBJECTIVES

To compare the safety and effectiveness of conservative and stent treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) patients after the failure of initial 3 days' conservative treatment.

METHODS

All newly diagnosed SISMAD patients between 2013 and 2017 were retrospectively reviewed. After the failure of 3 days' conservative treatment, all patients were recommended for stent treatment, but some patients refused to choose it. Their demographic, radiologic, and clinical data were compared.

RESULTS

57 patients were not improved after initial 3 days' conservative treatment. Among them, 19 patients were chose to receive stent placement and 38 patients were continually treated with conservative treatment. The median follow-up time was 92.0 (range 62.7-120.4) months. There were no bowel ischemia and arterial rupture. No significant difference was observed in clinical complete recovery (Conservative 31/38 vs Stent 12/19, p =.19) and hospitalization time (Conservative 8.3 ± 1.7 days vs Stent 7.2 ± 1.5 days, p =.59) between conservative and stent treatment groups. Significant statistical differences were found in radiological complete remodeling (6/38 vs 16/19, p < .01) and hospitalization expense (8662 ± 2886 China Yuan vs 32,935 ± 11,767 China Yuan, p < .01) between these two groups.

CONCLUSIONS

Although undergoing the failure of initial 3 days' conservative treatment, continue conservative treatment still is safe and effective for SISMAD patients. Stent placement could be chosen as an alternative treatment, especially for patients potentially with bowel ischemia or arterial rupture.

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.

Spontaneous isolated superior mesenteric artery dissection: A case report and brief analysis

This case report describes the clinical presentation, diagnostic approach, and treatment strategies for a 58-year-old male patient diagnosed with spontaneous isolated superior mesenteric artery dissection (SISMAD). The patient presented with suddenonset abdominal pain and was diagnosed with SISMAD using computed tomography angiography (CTA). SISMAD is a rare but potentially serious condition that can lead to bowel ischemia and other complications. Management options include surgery, endovascular therapy and conservative management with anticoagulation and close observation. The patient was managed conservatively with antiplatelet therapy and close follow-up. During hospitalization, he received antiplatelet therapy and was closely monitored for signs of bowel ischemia or other complications. The patients' symptoms gradually improved over time, and he was eventually discharged on oral mono- antiagreggation therapy. Clinical follow-up showed a significant symptimatic improvement. Conservative management with antiplatelet therapy was chosen due to the absence of bowel ischemia signs and overall stable clinical condition of patient. This report emphasizes the importance of prompt recognition and management of SISMAD to prevent potentially life-threatening complications. Conservative management with antiplatelet therapy can be a safe and effective treatment option for SISMAD, especially in cases without evidence of bowel ischemia or other complications.

Endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery

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.

Isolated Superior Mesenteric Artery Dissection: A Novel Etiology and a Review

Isolated superior mesenteric artery dissection (ISMAD) is a rare pathology with multifactorial etiology. The aim of this article is to provide a narrative review of the latest literature about ISMAD. Case reports, series, and recent meta-analyses were included. This review is introduced with a brief case report of a rare etiology of ISMAD, followed by a discussion of its etiology, clinical presentation, diagnosis, classification, and treatment, and we report a new cause of ISMAD, that is, blunt abdominal trauma. The etiology of ISMAD is multifactorial, consisting of anatomic, genetic, and systemic components. ISMAD is more common among middle-aged males and in East Asia. Its clinical presentation ranges from asymptomatic to mesenteric ischemia, albeit mortality remains <1%. It is diagnosed and classified mostly by computed tomography angiography, and there are five classification systems for ISMAD, though traumatic etiology may be added. The treatment of ISMAD is mostly conservative, with a success rate exceeding 90%. Endovascular stenting is second line, reserved so far for failed medical management, though its role is expanding to include earlier management of symptomatic patients, while open surgical repair is left for acute mesenteric ischemia with bowel compromise.

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.

Safety and efficacy of conservative, endovascular bare stent and endovascular coil assisting bare stent treatments for patients diagnosed with spontaneous isolated superior mesenteric artery dissection

Introduction

Isolated dissection of visceral artery organs is very infrequently reported and when it occurs it mostly affects the superior mesenteric artery (SMA) with abdominal pain as the commonest presenting symptom. However, the best therapeutic strategy in symptomatic patients has not yet been established.

Aim

To evaluate the safety and efficacy of conservative, endovascular bare stent and endovascular coil assisting bare stent treatments for patients diagnosed with spontaneous isolated superior mesenteric artery dissection (SISMAD).

Material and methods

We reviewed patients who had SISMAD and received conservative, bare stent and coil assisting bare stent as a primary treatment between 2014 and 2018. Patient demographics, symptoms, angiographic findings and treatment outcomes were analyzed.

Results

A total of 62 patients was found to have SISMAD among whom 83.9% (n = 52) were male and 16% (n = 10) were female with the mean age of 52.55 ±7.22 years, range 33–77. 22.6% (n = 14) received conservative, 62.9% (n = 39) endovascular bare stent and 14. Four percent (n = 9) endovascular coil assisting bare stent treatment. The success rate in primary treatment was conservative 78.5% (n = 11), bare stent 97.4% (n = 38), coil assisting bare stent 100% (n = 9). The mean follow-up duration (months) was 28.76 ±12.87.

Conclusions

Endovascular bare stent placement is a safe, effective, and successful treatment in the management of symptomatic SISMAD. The diagnostic imaging result is a key point for planning appropriate treatment especially in patients with tapered vessels, longer dissection lesion, and dissection aneurysm where coil assisting bare stent shows good results. Conservative treatment should be given priority for the asymptomatic patient, but close monitoring is highly recommended.

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.).