Endovascular management of an acute type B aortic dissection in a patient with fibromuscular dysplasia

Clinical characteristics and misdiagnosis of spontaneous isolated superior mesenteric artery dissection

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.

Spontaneous Coronary Artery Dissection in a Patient with a Family History of Fatal Ascending Aortic Dissection: Case Report and Discussion of Diseases Causing Both Presentations

Background

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Aortic dissection and SCAD share common aetiologies such as a fibromuscular dysplasia (FMD), Marfan, Ehlers Danlos, and more rarely systemic lupus erythematosus and Loeys-Dietz; however, SCAD has never been known to have a familial association with aortic dissection.

Case Summary

This case report describes a 48-year-old woman suffering from SCAD who had a mother who died from ascending aortic dissection in her 50s.

Discussion

This is the first case report to our knowledge of a patient with SCAD with a first-degree relative with aortic dissection. Our case is interesting in that it shows that if predisposition to arterial dissection was inherited from mother to daughter, one of them suffered an extremely rare manifestation of their underlying disease. It also shows that a high index of suspicion is needed for SCAD in the presence of a patient with ACS and a family history of dissection elsewhere in the arterial tree.