Ten-year review of isolated spontaneous mesenteric arterial dissections

Comparison of clinical outcomes between medical or/and endovascular therapy in spontaneous isolated superior mesenteric artery dissection patients without bowel ischemia

OBJECTIVE

This study aims to assess the clinical results of endovascular intervention for spontaneous isolated superior mesenteric artery dissection (SISMAD) and its impact on superior mesenteric artery (SMA) remodeling in comparison to solely medical management.

METHODS

All patients with SISMAD between January 2015 and August 2023 were included. The primary endpoints were the absence of major adverse events (MAEs), including dissection-related mortality, recurrence of mesenteric ischemia symptoms, and the necessity for intervention. The secondary endpoints were stenosis or occlusion of the SMA and morphologic remodeling of the dissections.

RESULTS

A total of 217 SISMAD patients were included. In this study, 127 (58.5 %) patients received medical management alone (conservative group), and 90 (41.5 %) underwent endovascular therapy (EVT group). In the EVT group, the technical success rate was 94.4 % (85/90). During follow-up, 13 (6.0 %) patients experienced MAEs, and 1 patient in the conservative group death related to SISMAD. The patients in EVT group showed more complete remodeling than those in the conservative group (76 (84.4 %) vs 66 (52.0 %), P < .0001). Survival analysis showed that the estimated MAEs-free survival rates were97.8 %, 95.6 %, and 95.6 % in EVT group and 98.4 %, 94.5 %, 92.9 % in conservative group at one, two, and three years, respectively. No significant difference was observed in both groups.

CONCLUSION

The findings indicate that both endovascular treatment and medical management alone yield comparable rates of MAE-free survival among patients with SISMAD. Additionally, endovascular therapy exhibits a higher rate of complete remodeling and greater freedom from stenosis or occlusion of the SMA.

Systematic review and meta-analysis of current evidence in endograft therapy for spontaneous isolated superior mesenteric artery dissection

The role of endovascular stent therapy (EST) in the treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD) has gained momentum in recent years but remains controversial. We gathered research examining the advantages and disadvantages of EST for SISMAD patients. Primary outcomes involved both immediate and long-term results. Random or fixed effect models were used for effect size (ES) calculation with 95% confidence interval (CI) based on 50% heterogeneity threshold. Our analysis incorporated data from 21 studies including 611 SISMAD cases treated by EST. Our findings show a complication rate of approximately 1% following EST (95%CI 0.01-0.02, I2 = 0%, P = 0.97), with a bare minimum mortality rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P > 0.05) and a reintervention rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P = 0.89). We also found technique success and symptom resolution approaching 94% and 99%, respectively, in the immediate postoperative phase. In the long run, we observed a recurrence of symptoms at 3% (95%CI 0.00-0.06, I2 = 58.6%, P < 0.01), creation of new dissections at 1% (95%CI 0.00-0.02, I2 = 0%, P = 0.73), aneurysm progression at 2% (95%CI 0.00-0.03, I2 = 42.7%, P = 0.12), reintervention due to complications at 3% (95%CI 0.00-0.05, I2 = 0%, P = 0.43) and stenotic stents at 12% (95%CI 0.04-0.23, I2 = 77.5%, P < 0.01). Nevertheless, high levels of stent patency 98% (95% CI 0.97-1.00, I2 = 0%, P = 0.51) and complete remodeling 88% (95% CI 0.82-0.94, I2 = 65.5%, P < 0.05) were observed postoperatively. Overall, EST presents minimal complications and promising long-term outcomes for SISMAD, although the prevalence of stent stenosis requires further attention.

A rare occurrence of isolated superior mesenteric artery dissection, a case image report

Isolated spontaneous superior mesenteric artery (SMA) dissection is relatively rare. Often found incidentally on cross-sectional imaging, often managed non-operatively. We present a patient who presented with chest pain and was found to have a SMA dissection.

Gastrointestinal bleeding risk factors in type A aortic dissection post-aortic arch replacement

Background

Gastrointestinal bleeding (GIB) is a notable complication in patients diagnosed with aortic dissection (AD). We evaluated the outcomes and identified the risk factors associated with GIB in patients with AD.

Methods

A retrospective case-control study was conducted on patients diagnosed with type A aortic dissection (TAAD) who underwent total aortic arch replacement (TAAR) at our institution from July 2021 to July 2023. Comprehensive clinical data, laboratory findings, and imaging results were meticulously gathered and analyzed to identify potential risk factors linked to GIB in this patient cohort.

Results

Of the 198 AD patients who underwent TAAR, 38 (19.2%) developed postoperative GIB (GIB group), with a median interval of 7 days between surgery and bleeding onset. The GIB group exhibited significantly higher mortality (26.3% vs. 3.1%, P<0.001), prolonged intensive care unit (ICU) stay {15 [interquartile range (IQR), 8-25] vs. 7 (IQR, 5-12) days, P<0.001}, and extended duration of ventilation [168 (IQR, 120-372) vs. 71 (IQR, 34-148) hours, P<0.001] compared to the control group (n=160, 80.8%). Logistic regression analysis identified age >54 years [odds ratio (OR): 3.529], intraoperative red blood cell (RBC) transfusion >600 mL (OR: 3.865), and concomitant celiac trunk and superior mesenteric artery (SMA) hypoperfusion (OR: 15.974) as independent risk factors for GIB in AD patients.

Conclusions

GIB subsequent to TAAR in AD patients is linked to adverse prognosis. Factors such as advanced age, extensive intraoperative transfusion, and gastrointestinal (GI) perfusion abnormalities may heighten the risk of GIB in this patient population.

Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival

OBJECTIVE

Visceral branch artery dissection (VBAD) is uncommon and may occur with or without an associated aortic dissection (AD). We hypothesized that isolated VBAD would have a more benign clinical course than those with concurrent AD and compared survival outcomes stratified based on aortic involvement.

METHODS

VBAD over a 5-year period were identified using International Classification of Diseases codes. Data related to patient demographics, comorbid conditions, clinical presentation, management (including procedural interventions), and survival were obtained from medical records. Anatomic imaging studies were reviewed to characterize anatomy, including the presence or absence of concurrent AD. Overall survival and intervention-free survival were evaluated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

A total of 299 VBAD were identified, 174 of which were isolated VBAD and 125 were associated with concurrent AD. Seventy-one percent of patients were men, 77% were White, and 85% were non-Hispanic. The mean age was 61.1 ± 14.4 years. The mean follow-up was 53.2 ± 50.0 months. The estimated overall survival was 88.2% and the estimated overall intervention-free survival was 55.6% at 12 months. Isolated VBAD had better overall survival than those with concurrent AD (69.2% vs 32.4%; P < .001). Concurrent AD was also associated with inferior intervention-free survival (57.5% vs 7.3%; P < .001). Acute presentation was associated with decreased intervention-free survival (86.1% vs 13.4%; P < .001). Acute presentation was also associated with decreased overall survival in patients with isolated VBAD (60.8% vs 80.0% at 180 months; P < .001) and inferior intervention-free survival (48.4% vs 69.5% at 180 months; P < .001) in the subgroup of patients with isolated VBAD. Multivariable Cox models identified that age (hazard ratio [HR]: 1.05, standard deviation [SD]: 0.02; P = .001) was associated with inferior survival and renal dissections (HR: 3.08, SD: 0.99; P = .001) or mesenteric and renal dissections (HR: 3.39, SD: 1.44; P = .004) were associated with inferior intervention-free survival.

CONCLUSIONS

Isolated VBAD has superior overall and intervention-free survival to those associated with concurrent AD. The absence vs presence of aortic involvement is useful for risk stratification and may support tailored approaches to the frequency of imaging surveillance.

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.

Placement of Bare Self-Expanding Metal Stent for Isolated Superior Mesenteric Artery Dissection

BACKGROUND

To evaluate the safety and efficacy of placing bare self-expanding metal stent (SEMS) for treating isolated superior mesenteric artery dissection (ISMAD).

METHOD

Patients with ISMAD who received bare SEMS from January 2014 to December 2021 at the authors' center were included. Baseline characteristics, clinical manifestation, radiological findings, and treatment outcomes, including symptom relief and SMA remodeling, were analyzed.

RESULT

A total of 26 patients were included in this study. Among the patients, 25 were admitted due to persistent abdominal pain, and 1 was admitted based on computed tomography angiography (CTA) during physical examination. According to CTA scan, the percentage of stenosis was 91% (53.8-100%), and the length of dissection was 100.2 ± 8.4 mm. All patients received bare SEMS placement. The median time to symptom relief was 1 day (interquartile range, 1 3 days). The the median follow-up time of CTA was 6.8 months (range, 2-85 months), with an average of 16.2 months. Complete remodeling of the superior mesenteric artery (SMA) was recorded in 24 patients. The median time to remodeling was 3 months with an average of 4.7 months. Survival analysis indicated no significance difference in remodeling time between different ISMAD types based on Yun classification (P = 0.888) or between acute and nonacute disease (P = 0.423). Incomplete remodeling was noted in 2 patients. Distal stent occlusion without SMA-related symptoms was seen in 1 patient. Proximal stent stenosis occurred in 1 patient, and restenting was performed. The median follow-up time by telephone was 20.8 (4-91.5) months, and no intestinal ischemic symptoms were observed in any patient.

CONCLUSIONS

Bare SEMS placement can effectively relieve SMA-related symptoms in a short time and promote dissection remodeling in ISMAD. Time from symptom onset and classification of ISMAD seem not to have effects on SMA remodeling after bare SEMS placement.

Spontaneous Celiac Artery Dissection with Splenic Infarction: A Report of Two Cases

Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that is characterized by sudden onset abdominal pain, typically occurring in middle-aged men. Although its clinical course is mostly benign, it may progress to true lumen occlusion. No established therapeutic guidelines are available for SICAD associated with splenic infarction. This report describes two patients who presented with sudden onset abdominal pain and were diagnosed with SICAD with splenic infarction based on computed tomography (CT) findings. Patients were treated with bowel rest and anticoagulants. After a week of medical therapy, the abdominal pain resolved. Follow-up CT revealed no progression of the dissection flap. The patients received oral anticoagulants for 3 months and did not experience any symptom recurrence. Medical therapy with anticoagulants may be considered for patients with SICAD and splenic infarction. Associated splenic infarction itself is not an indication for endovascular or surgical intervention for SICAD.

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

OBJECTIVES

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

METHODS AND RESULTS

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

CONCLUSIONS

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

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.

Five-Year Results of Spontaneous Isolated Superior Mesenteric Artery Dissection from Two Teaching Hospitals in China

BACKGROUND

To present 5-year results of management on spontaneous isolated superior mesenteric artery dissection (SISMAD) from 2 teaching hospitals in China.

METHODS

The clinical data of 41 patients with SISMAD were retrospectively collected from 2 teaching hospitals between December 2016 and December 2021. Therapeutic methods mainly included open surgery, endovascular management, and conservative therapy. Patients' demographics, total number of WBC (White blood cell, WBC), the percentage of NEUT (Neutrophil), the level of CRP (C-reactive protein, CRP), duration of abdominal pain on admission, YOO classification of SISMAD, angle of superior mesenteric artery to abdominal aorta (ASA), length of hospital stays, and vascular remodeling rate of SMA between endovascular and conservative groups were analyzed.

RESULTS

A total of 41 patients with SISMAD were finally included in this study. Their average age was 53.4 ± 7.1 years old, ranging from 35 to 68 years old. Among these patients, 1 patient suffered emergent open surgery because of the intestinal necrosis. The other 40 patients were treated conservatively at first, but 13 of them were transitioned into endovascular management due to persistent abdominal pain. Regarding the imaging analysis, IIS and IVS types of YOO classification were more in the endovascular group (13 patients) than the conservative group (27 patients). The length of hospital stays (P = 0.003) and the vascular remodeling rate of SMA were significantly different between 2 groups (P = 0.002), while the time of abdominal pain on admission, the infection markers (WBC, CRP, NEUT) and ASA were not significantly different between the 2 groups.

CONCLUSIONS

In SISMAD, patients without any signs of peritonitis and intestinal necrosis may be treated conservatively firstly, and then transitioned into endovascular management if abdominal pain is not improved within 48 hr. IIS and IVS types of YOO classification should be alerted of this potential transition. But the optimal timing of transition required more clinical studies.

Risk factor analysis and treatment outcome of patients with spontaneous isolated celiac axis or superior mesenteric artery dissection

BACKGROUND

Spontaneous isolated mesenteric artery (celiac axis or superior mesenteric artery [SMA]) dissection (IMAD) is a rare clinical entity. The aim of the present study was to examine the patient demographics, comorbidities, clinical and radiologic features, management, and prognosis and to identify the risk factors predictive of symptoms.

METHODS

We performed a single-center, retrospective review from November 2005 to November 2021 of prospectively collected data from patients with a diagnosis of IMAD. The clinical data and radiologic images were reviewed, and statistical analysis was performed to compare the symptomatic and asymptomatic groups.

RESULTS

A total of 78 patients were identified. Of the 78 patients, 24 (31%) had had celiac dissections, 51 (65%) had had SMA dissections, and 3 (4%) had had both celiac and SMA dissections. The mean age was 57.7 years (range, 36-84 years), with a male predominance (86%). More than one half (55%) of the patients had had hypertension. In addition, 29 patients (37%) were symptomatic, and 24 (31%) had been admitted to the hospital. The symptomatic patients with celiac axis dissections were more likely to have thrombosis (P = .02), significant stenosis (P = .01) or branch extension (P = .02). The symptomatic patients with SMA dissections were more likely to have a smaller artery diameter (P = .07), a longer dissection length (P = .05), thrombosis (P < .001), significant stenosis (P < .001), or branch extension (P = .003). The symptomatic patients were more likely to have been treated with antiplatelet or anticoagulant therapy (P < .001). Only three patients had undergone an intervention. Seven patients (9%) had died of unrelated causes. The Kaplan-Meier survival analysis showed a 5-year survival rate of 96% and 10-year survival rate of 91%.

CONCLUSIONS

IMAD is an uncommon disease entity with a risk of visceral ischemia. Nonetheless, most of these patients can be treated conservatively with medication, with only a small minority requiring emergency surgery.

General features, management strategies, and outcomes of symptomatic spontaneous isolated celiac artery dissection

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.

Relationship Between Morphological Remodeling and Angiographic Types of Spontaneous Isolated Superior Mesenteric Artery Dissection After Conservative Management: Determinant Affecting Serial Radiologic Courses

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.

Spontaneous isolated celiac and splenic artery dissection with splenic infarction

Spontaneous isolated celiac artery dissection is considered an uncommon clinical condition. Rarer still is spontaneous isolated celiac and splenic artery dissection, with a total of 42 reported cases. There is no known definitive cause of visceral artery dissections, but risk factors include male sex, age in 5th or 6th decade, hypertension, and connective tissue disorders. The presentation varies, diagnosis is principally radiographic, and the mainstay of treatment is anticoagulation or antiplatelet therapy. Splenic infarction is a common finding with splenic artery dissection, although the strength of this association has not previously been reported. Herein we present a case of spontaneous isolated celiac and splenic artery dissection with splenic infarction that was successfully managed with blood pressure control and antiplatelet therapy. We review previous literature, principles of diagnosis and management, and incidence and outcomes of splenic infarction as it related to splenic artery dissection.

Current status of spontaneous isolated celiac artery dissection

BACKGROUND

This study aimed to evaluate the current status of spontaneous isolated celiac artery dissection (SICAD).

METHODS

The English-language literature published in various databases before December 2020 was reviewed. All case reports and series were included. If multiple reports came from the same hospital and covered the same period, only the most recent report was considered. The clinical characteristics, imaging features, and treatment outcome were analyzed.

RESULTS

The study enrolled 88 English language publications between January 1959 and December 2020, including 70 case reports, two case series, and 16 clinical studies. Overall, 316 cases of SICAD were reported in the studies, including 268 men and 44 women (unavailable for 4, men: women ratio: 6:1, p < 0.05). The median age was 50.5 years (range: 6-72) in men and 53.9 years (range: 41-67) in women. Most patients (83.54%, 264/316) complained about stomach pain, primarily in the epigastric region (38.61%, 122/316). The misdiagnosis rate in this study was 3.16% (10/316). The most commonly used imaging modality was computed tomography angiography (CTA), with 97.47% (308/316) cases reporting its use in diagnosis and/or management. The rate of symptom improvement with Conservative Management, with or without antithrombotic agents, was 92.45% (98/106) and 96.58% (141/146), respectively. The rate of symptom improvement after surgical recanalization was 100% (13/13). Moreover, endovascular management resulted in a 100% (50/50) symptom improvement rate.

CONCLUSION

Conservative management is the first-line treatment for SICAD. The surgical or endovascular intervention had a high technical success rate, suggesting that it should be reserved for patients who have failed conservative treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptomatic spontaneous superior mesenteric artery dissection treated with endovascular stent repair

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

Two Cases of Spontaneous Isolated Dissection of Superior Mesenteric Artery in One Night: Report of a (Noninvasive) Double Challenge

BACKGROUND Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare but potentially fatal condition. Although many cases of SID-SMA have been reported in the literature in recent years because of the increased use of contrast-enhanced computed tomography (CT) scanning, optimal management has not yet been firmly established. CASE REPORT We report 2 cases of SID-SMA that were managed with stenting and angioplasty via transfemoral access. In case 1 a 54-year-old man presented with diffuse abdominal pain without Blumberg sign. Laboratory data were unremarkable. Abdominal CT scanning revealed SID-SMA and initial bowel ischemia. The angiogram revealed a dissected true lumen of SMA with a narrowing of the ileo-colic artery managed, respectively, with self-expandable stent placement and angioplasty. In case 2, a 45-year-old man presented with severe abdominal cramping and pain of 3 days' duration. Physical examination revealed abdominal tenderness with positive Blumberg sign. Laboratory tests showed leukocytosis and increased lactate dehydrogenase. Abdominal CT scan revealed SID-SMA and initial bowel ischemia. After an SMA angiogram, 2 self-expandable stents were placed and an angioplasty was performed. Although a postprocedural angiogram showed good patency of the SMA in both patients, the first patient had a recurrence of abdominal pain after 5 days with a new narrowing tract of the SMA and more inferiorly a dissection with aneurysm of a false lumen, detected on CT scan, treated respectively with stenting and coils. CT follow-up showed successful morphological results in both patients. CONCLUSIONS In our experience, endovascular treatment of SID-SMA is safe and effective, including in cases of recurrence and postprocedural evolution.

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.

Superior Mesenteric Artery Dissection: Classical Presentation, Novel Genetic Determinants

Superior mesenteric artery dissection is a rare cause of acute abdomen. Potential etiologies include atherosclerosis, medial degeneration of the arterial wall, mycotic aneurysm, hypertension, and a variety of arteriopathies. Here, we present a case of superior mesenteric artery dissection prompting clinical genetic testing to investigate the underlying mechanisms of the vasculopathy. (Level of Difficulty: Intermediate.)

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.

The impact of endovascular treatment on clinical outcomes of stable symptomatic patients with spontaneous superior mesenteric artery dissection

OBJECTIVE

To evaluate the efficacy and clinical outcomes of endovascular treatment for superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with medical management alone after successful initial medical management.

METHODS

In this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs, a composite of dissection-related death, the recurrence of mesenteric ischemia symptoms, and a requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA.

RESULTS

A total of 94 patients with SMAD who underwent successful initial medical management (91 males; mean age, 50.4 ± 6.3 years) were enrolled in the study. Fifty-seven (60.6%) received medical management alone, and 37 (39.4%) underwent endovascular repair after initial medical management. In the endovascular group, the technical success rate was 86.5% (32 of 37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain, and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1, 3, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log rank P = .046).

CONCLUSIONS

Endovascular treatment and medical management alone result in similar MAE-free survival for patients with SMAD after successful initial medical management. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.

Isolated superior mesenteric artery dissection: CTA features and clinical relevance

PURPOSE

To determine the detailed computed tomography angiography (CTA) features of isolated superior mesenteric artery dissection (ISMAD), aiming to improve the current understanding of ISMAD.

MATERIALS AND METHODS

We retrospectively analyzed 57 patients with confirmed diagnoses of ISMAD with CTA from June 2011 to June 2018 in our hospital. The superior mesenteric artery (SMA) angle, entry site of dissection, and features of both false and true lumen were analyzed individually.

RESULTS

In general, middle-aged men with atherosclerosis (42.1%), hypertension (35.3%), or long-term smoking (33.3%) were the main populations. 80.7% of patients can be discharged successfully after conservative treatment. 87% of patients had a right (or almost right) SMA angle, and the entry site of dissection in 90% of patients occurred in the curved segment of the SMA. As a polymorphic disease, we can use the coded CTA features to delineate individual cases, including cases beyond the presenting classification systems. The diameter of the true lumen is the only different CTA feature between the conservative treatment group and the interventional treatment group (p = 0.000). The re-entry site (p = 0.501), thrombosis in the false lumen (p = 0.135), the distance between the entry site of dissection and SMA root (p = 0.133), and SMA branch involvement (p = 0.322) had no difference between the 2 groups.

CONCLUSIONS

Based on CTA analysis, the bending area, especially in the SMA with right or nearly right SMA angle, is the most vulnerable anatomical region for the occurrence of ISMAD. The diameter of true lumen is the determined CTA feature for the decision of treatment. CTA should be recommended as a standardized diagnostic and classification tool for ISMAD.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).

Clinical Features of Spontaneous Isolated Dissection of Abdominal Visceral Arteries

Background

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

Methods

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

Results

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

Conclusions

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

Mid- to Long-Term Outcomes in Management of Spontaneous Isolated Coeliac Artery Dissection (SICAD)

OBJECTIVE

Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment.

METHODS

Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed.

RESULTS

The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period.

CONCLUSION

Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.

Spontaneous superior mesenteric artery dissection following upper gastrointestinal panendoscopy: A case report and literature review

BACKGROUND

Complications associated with upper gastrointestinal (UGI) endoscopy are uncommon, and rarely involve those of cardiovascular nature. We report herein a unique case of spontaneous superior mesenteric artery dissection (SMAD) after UGI pandenoscopy.

CASE SUMMARY

A 45-year-old man who had previously undergone UGI panendoscopy and colonoscopy during a voluntary health check-up at our facility was admitted to the emergency room (ER) at the same facility due to persistent epigastric pain with radiation to the back. At the ER, the patient did not present notable abnormalities upon physical, conscious, or laboratory examinations apart from mild tenderness in the epigastric abdomen. Acute abdominal aortic dissection was suspected, and abdominal contrast-enhanced computed tomography confirmed SMAD. He was then transferred to the cardiovascular ward and treated conservatively with fasting, prostaglandin E1, and aspirin. The patient recovered and returned home soon after, and was symptom-free 6 months after discharge from the facility.

CONCLUSION

SMAD after UGI panendoscopic procedure is a previously unreported complication. Awareness of this complication and associated sequela is warranted.

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%.

Clinical and CT Angiographic Follow-Up Outcome of Spontaneous Isolated Intramural Hematoma of the Superior Mesenteric Artery

OBJECTIVES

The aim of this study was to evaluate the clinical course and vascular remodeling of spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA) after treatment.

METHODS

In this retrospective study, 24 consecutive patients with SIHSMA admitted from January 2009 through December 2016 were included in this study. The clinical characteristics, type and location of the dissection, clinical outcome and vascular remodeling were analyzed retrospectively.

RESULTS

The subjects included 21 men and three women, with a mean age of 50.58 years. The chief complaint was abdominal pain in all patients. The mean follow-up was 10.08 months. Among the 24 patients examined, two patients (8.33%) showed no obvious changes in the CT. Twenty patients were treated by conservative strategy. One case underwent exploratory laparotomy along with embolectomy and arteriotomy. Another three cases received angioplasty and stent implanting. Complete and partial remodeling was observed in 15 (62.5%) and four patients (16.67%). Three (12.5%) of the lesions had dissection remodeling and aneurysm change.

CONCLUSIONS

SIHSMA represented variable vascular remodeling, while most of the patient got a complete resolution during follow-up, and its clinical course was benign in this study. Vast majority of patients can be managed conservatively when there are no signs indicating organ ischemia.

Celiac Artery Dissection in a Young Smoker

Isolated dissection of the celiac artery (IDCA) is a rare phenomenon with unclear pathogenesis. Although several risk factors have been attributed, it is essential for clinicians to maintain this diagnosis in the list of differentials to ensure prompt implementation of diagnostic and treatment modalities. We present the case of a 37-year-old smoking male who presented with upper abdominal pain radiating to the left upper quadrant with associated nausea/vomiting, diaphoresis, and diarrhea.

Visceral Fibromuscular Dysplasia: From asymptomatic disorder to emergency

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-atherosclerotic and non-inflammatory disease of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries, mostly involving renal and cervical arteries. As a result of better and more systematic screening, it appears that involvement of the splanchnic vascular bed is more frequent than originally assumed. We review epidemiology, pathogenesis, clinical picture as well as diagnosis and treatment of visceral artery (VA) FMD. The clinical picture is very diverse, and diagnosis is based on CT-, MR- or conventional catheter-based angiography. Involvement of VAs generally occurs among patients with multi-vessel FMD. Therefore, screening for VA FMD is advised especially in renal artery (RA) FMD and in case of aneurysms and/or dissections. Treatment depends on the clinical picture. However, the level of evidence is low, and much of the common practice is extrapolated from visceral atherosclerotic disease.