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Zhang B, Shen Y, Jin L, Wang J. Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection. Langenbecks Arch Surg 2024; 409:215. [PMID: 39008150 DOI: 10.1007/s00423-024-03406-9] [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] [Received: 06/11/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
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.
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Affiliation(s)
- Baoyou Zhang
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Yuexin Shen
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Ling Jin
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Jian Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, Zhejiang, 310051, China.
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Knarr J, Augustin AM, Hartung V, Krajinovic K, Kickuth R. Management of isolated dissection of the superior mesenteric artery. ROFO-FORTSCHR RONTG 2024; 196:726-734. [PMID: 38176435 DOI: 10.1055/a-2221-3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Jonas Knarr
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Anne Marie Augustin
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Viktor Hartung
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | | | - Ralph Kickuth
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
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Braet DJ, Powell CA, Maksutova M, Delbono L, Reddy S, Kim GY, Henke PK, Coleman DM, Eliason J, Corriere MA. Natural history of visceral branch artery dissections and the influence of concurrent aortic dissection on overall and intervention-free survival. J Vasc Surg 2024; 79:809-817.e2. [PMID: 38104676 DOI: 10.1016/j.jvs.2023.12.026] [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] [Received: 10/11/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
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.
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Affiliation(s)
- Drew J Braet
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Chloé A Powell
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Mariam Maksutova
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Luciano Delbono
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sonali Reddy
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Gloria Y Kim
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- Division of Vascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Jonathan Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Matthew A Corriere
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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Ji J, Xie Y, Bai Z, Deng G, Zhao G, Qin Y, Ji Z. Placement of Bare Self-Expanding Metal Stent for Isolated Superior Mesenteric Artery Dissection. Ann Vasc Surg 2023; 96:223-231. [PMID: 37230317 DOI: 10.1016/j.avsg.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/20/2023] [Accepted: 04/30/2023] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Jiajie Ji
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Yiyun Xie
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Zhibin Bai
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Gang Deng
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Guofeng Zhao
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Yonglin Qin
- Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China.
| | - Zhenling Ji
- Department of General Surgery, Zhongda Hospital, Medical School, Southeast University, Nanjing, China.
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Frey V, Engelberger RP, Psathas E. Case report: Isolated dissection of the left gastric artery: an unusual cause of acute abdominal pain. Front Cardiovasc Med 2023; 10:1240853. [PMID: 37655216 PMCID: PMC10466798 DOI: 10.3389/fcvm.2023.1240853] [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: 06/28/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023] Open
Abstract
Spontaneous and isolated dissection of the left gastric artery is a rare occurrence, with only a handful of cases reported in the medical literature. Clinical presentation may mimic more common intra-abdominal pathologies; however, it is imperative to identify this condition promptly due to its potential serious consequences. This underscores the importance of maintaining a high level of clinical suspicion and including this pathology in the differential diagnosis of patients presenting with acute abdominal symptoms. Hence, this case report aims to increase awareness among clinicians about the importance of identifying and treating this rare condition promptly. A 69-year-old female experienced severe epigastric pain while attending a yoga class, prompting her admission to the emergency department 24 h later due to the persistence of her symptoms. Following imaging work-up utilizing computed tomography angiography (CTA), she was diagnosed with a dissection of the left gastric artery. Notably, there was no associated aneurysm or any evidence of ischemia in the esophageal or gastric wall. Conservative management, including low-dose aspirin and blood pressure control, was implemented. After 6 months of follow-up, CTA demonstrated expansion of the true lumen and the absence of secondary aneurysm formation, leading to discontinuation of aspirin. The management of spontaneous dissection of visceral arteries is primarily determined by the presence of complications and organ ischemia. In the case of uncomplicated visceral artery dissections, first-line treatment comprises surveillance and antiaggregation. Nevertheless, the optimal duration of antiplatelet therapy and the necessity for long-term follow-up remain unclear. Endovascular or surgical interventions should be reserved for patients exhibiting deteriorating symptoms or complications, and the decision to pursue these interventions should be made on a case-by-case basis.
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Affiliation(s)
- V. Frey
- Department of Internal Medicine, Angiology Unit, HFR Fribourg – Cantonal Hospital, Fribourg, Switzerland
| | - R. P. Engelberger
- Department of Internal Medicine, Angiology Unit, HFR Fribourg – Cantonal Hospital, Fribourg, Switzerland
| | - E. Psathas
- Department of Surgery, Vascular Surgery Unit, HFR Fribourg – Cantonal Hospital, Fribourg, Switzerland
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Five-Year Results of Spontaneous Isolated Superior Mesenteric Artery Dissection from Two Teaching Hospitals in China. Ann Vasc Surg 2023; 92:42-48. [PMID: 36736721 DOI: 10.1016/j.avsg.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/06/2022] [Accepted: 01/13/2023] [Indexed: 02/04/2023]
Abstract
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.
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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.
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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
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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.
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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.
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Huang X, Li G, Zhang X, Chen Z, Xu M, Sun Y. Natural Course and Treatment of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection with Total True Lumen Occlusion. Vasc Endovascular Surg 2022; 57:41-47. [PMID: 36171181 DOI: 10.1177/15385744221130836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We retrospectively investigated the association between the imaging features of spontaneous isolated superior mesenteric artery dissection (SISMAD) accompanied by total true lumen occlusion and the clinical symptoms to identify the patients at high risk and establish personalized therapeutic options. METHODS Among 261 patients with SISMAD, we selected 37 with Yun's type III dissection; 35 patients underwent successful conservative management and 2 patients underwent exploratory laparotomy. After discharge, all patients were periodically followed up on an outpatient basis. We recorded patients' general condition, symptoms, time until symptom relief, imaging findings and follow-up results. RESULTS All patients experienced acute abdominal pain prior to admission, with an onset time of 29.95 ± 24.66 hours. The mean time until relief of abdominal pain in patients who received conservative treatment was 42.17 ± 38.09 hours. Correlation analysis revealed no correlation between the length of dissection or of the occluded segment and abdominal pain intensity. Pain scores were lower and time until pain relief was shorter in patients with a definite arc of Riolan (AOR) on admission than in those without an AOR. No collateral circulation was observed in the two patients who underwent exploratory laparotomy, and distal intestinal perfusion was poor in these cases. Complete and partial remodeling of the superior mesenteric artery (SMA) was observed in 6 and 16 patients, respectively at the 12-month follow-up. Although the SMA remained occluded in 12 patients, abundant collateral circulation was detected. Three patients were lost to follow-up. CONCLUSION This study highlights that conservative treatment should be attempted as first-line therapy in most patients with Yun's type III SISMAD. Complete AOR can contribute to remission of clinical symptoms during the acute stage. Poor distal blood flow of occluded vessels may serve as an important indicator for identification of patients at high risk of ischemic intestinal necrosis.
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Affiliation(s)
- Xianchen Huang
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Guanqiang Li
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Xicheng Zhang
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Zhaolei Chen
- Department of Vascular Surgery, 370089Yangzhou University Affiliated Northern Jiangsu People's Hospital, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Miao Xu
- Department of Vascular Surgery, 370089Yangzhou University Affiliated Northern Jiangsu People's Hospital, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuan Sun
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
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Wang Y, Li T, Chen Y, Liu J, Shi Q, Yang C, Huang S, Zhou C, Xiong B. Management of spontaneous isolated intramural hematoma of the superior mesenteric artery: a single-center experience. Langenbecks Arch Surg 2022; 407:1217-1224. [PMID: 34994827 DOI: 10.1007/s00423-022-02429-4] [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: 10/20/2021] [Accepted: 01/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the clinical course and optimal management for spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA). METHODS From January 2015 to October 2020, a total of 31 consecutive patients with SIHSMA were included in this study. The demographics, clinical features, treatment details, imaging information, and outcomes were reviewed. RESULTS There were 24 males and 7 females, with a mean age of 54.9 years (SD 6.9 years). Seven patients (7/31, 23%) were associated with ulcer-like projection (ULP), one patient (1/31, 3%) with intramural blood pool (IBP), and the remaining twenty-three patients (23/31, 74%) had no ULP or IBP. All patients were initially managed conservatively and underwent a median follow-up of 25.5 months (IQR 14.5, 39.9), which showed 3 patients (3/31, 10%) subsequently underwent stenting (2 within 7 days and 1 after 1.5 months), 1 patient (1/31, 3%) progressed to a localized dissection 7 months later but remained stable and asymptomatic until the time of writing, and the remaining patients (27/31, 87%) had no progression. In the present cohort, the overall survival was 100% (31/31). The free-from progression and stenting rate under conservative treatment was 87% (27/31). The invasive intervention rate was 10% (3/31). The natural complete regression rate of IMH in patients without ULP was higher than those with ULP (91% [21/23] vs. 29% [2/7], p = .003). CONCLUSION The majority of patients with SIHSMA can be managed conservatively. Patients with ULP seemed to have a lower IMH regression rate than those without ULP.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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11
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Eldine RN, Dehaini H, Hoballah J, Haddad F. Isolated Superior Mesenteric Artery Dissection: A Novel Etiology and a Review. Ann Vasc Dis 2022; 15:1-7. [PMID: 35432650 PMCID: PMC8958406 DOI: 10.3400/avd.ra.21-00055] [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: 05/13/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Rakan Nasser Eldine
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Hassan Dehaini
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Jamal Hoballah
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
| | - Fady Haddad
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut
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12
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Acosta S, Gonçalves FB. Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review. Scand J Surg 2021; 110:130-138. [PMID: 33724090 PMCID: PMC8258720 DOI: 10.1177/14574969211000546] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- S Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - F B Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central and NOVA Medical School, Lisboa, Portugal
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13
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Yang ZQ, Sun LB, Li GR, Yuan FK, Xia FF. Uncovered stent insertion for isolated superior mesenteric artery dissection. Medicine (Baltimore) 2021; 100:e24732. [PMID: 33578619 PMCID: PMC10545074 DOI: 10.1097/md.0000000000024732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/17/2020] [Accepted: 01/18/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The aim of this study is to describe our clinical outcomes in isolated superior mesenteric artery dissection (SMAD) patients that underwent uncovered stent insertion.Between January 2016 and August 2019, consecutive isolated SMAD patients at our center were treated via uncovered stent insertion. Both short- and long-term outcomes in these patients were analyzed.Over the course of the study period, 11 total isolated SMAD patients meeting the criteria for stent insertion at our hospital were treated via uncovered stent insertion. Stent placement across the SMAD site was successful in all patients, with 1 stent being used per patient. There were no instances of procedure-related complications, and the median operative duration was 60 minutes. Patency of the distal superior mesenteric artery and branches thereof was achieved in all cases. Patients experienced progressive SMAD-related symptom relief and were followed for 6 to 49 months (median: 22 months). Over this follow-up period, the obliteration of the dissection was observed within 3 months in all patients. We did not detect any instances of stent occlusion, bowel ischemia, or anti-platelet-related bleeding during the follow-up period.Uncovered stent insertion can achieve favorable short- and long-term outcomes in isolated SMAD patients.
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Affiliation(s)
| | | | - Gui-Rong Li
- Department of ICU, Binzhou People's Hospital, Binzhou
| | - Fu-Kang Yuan
- Department of Vascular Surgery, Xuzhou Institute of Cardiovascular Disease, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, Jiangsu
| | - Feng-Fei Xia
- Department of Interventional Vascular Surgery, Binzhou People's Hospital, Binzhou, China
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14
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Gao X, Xie W, Shang D, Liu J, Jin B, Xu YJ. Clinical features and management strategy of symptomatic spontaneous isolated celiac artery dissection. Vascular 2021; 29:865-873. [PMID: 33435814 DOI: 10.1177/1708538120986295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical features and management strategy for patients with symptomatic spontaneous isolated celiac artery dissection (SICAD). METHODS In this retrospective study, consecutive patients with symptomatic SICAD from two institutions were included. The demographics, clinical manifestations, comorbidities, imaging findings and treatment strategy selection were obtained from the medical records. The general epidemiological data, treatment regimens and clinical and follow-up outcomes were analysed. RESULTS Patients were divided into the conservative treatment group (group A, n = 26) and endovascular treatment group (group B, n = 11). Of these 37 patients, extent of dissection in both groups included only celiac trunk (61.54%% vs. 18.18%, p = 0.03), common hepatic artery (CHA) and splenic artery (SA) (3.85%% vs. 54.55%, p = 0.001), CHA (7.69% vs. 18.18%, p = 0.57), SA (23.08% vs. 9.09, p = 0.65) and left gastric artery (LGA) (3.85% vs. 54.55%, p = 0.99). Of note, the extension of the lesion in group A was shorter than that in group B. In addition, there were significantly more type IIb in group A than in group B (42.31% vs. 9.09%, p = 0.06) and the mean length of dissection in group A was 42.3 ± 54.71 mm which was significantly shorter than that in the group B 58.45 ± 3.71 mm (p =0.04). During a median follow-up of 11.5 months, the 1, 3, 6 and 12 month follow-ups were completed in 100% (37/37), 100% (37/37), 94.59% (35/37) and 91.19% (34/37) of patients, respectively. The cumulative rate of persistent disease stability in patients with endovascular treatment group was higher than in that conservative treatment group at the 3, 6, 9 and 12 months (50% vs. 16.67%, p = 0.001; 80% vs. 37.5%, p =0.03; 100% vs. 62.5%, p = 0.012;100% vs. 91.67%, p = 0.02 respectively). CONCLUSION Most symptomatic SICAD have a tendency to persistent disease stability after conservative treatment. Risk factors for failed conservative treatment were length of dissection and branch involvement. Furthermore, endovascular treatment was associated with a high technical success and persistent disease stability rate, which might be reserved for patients with failed conservative treatment.
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Affiliation(s)
- Xiujuan Gao
- Department of Cerebrovascular Surgery, Binzhou Medical University Hospital, Binzhou, PR China
| | - Weiping Xie
- Department of Rehabilitation Medicine, Peoplement of RehabilDingtao District, Heze City, PR China
| | - Dan Shang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Jianyong Liu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Bi Jin
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Ying Jiang Xu
- Department of Interventional Vascular Surgery, Binzhou Medical University Hospital, Binzhou, PR China.,Key Laboratory of Metabolism and Molecular Medicine, The Ministry of Education, Department of Biochemistry and Molecular Biology, Fudan University Shanghai Medical College, Shanghai, PR China
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15
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Management of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection: A Single Centre Experience with Mid Term Follow Up. Eur J Vasc Endovasc Surg 2020; 60:863-871. [PMID: 33032925 DOI: 10.1016/j.ejvs.2020.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 07/24/2020] [Accepted: 08/06/2020] [Indexed: 12/31/2022]
Abstract
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.
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16
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A Spontaneous Isolated Superior Mesenteric Artery Dissection Associated with Cocaine Abuse: A Pathomechanistic Association. Case Rep Vasc Med 2020; 2020:2514687. [PMID: 32566353 PMCID: PMC7294347 DOI: 10.1155/2020/2514687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 11/18/2022] Open
Abstract
Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare potentially fatal disease. We present a case of cocaine-related SISMAD in a patient with abdominal pain. A 38-year-old African American male with hypertension and alcohol, cocaine, and tobacco abuse presented with abdominal pain and recent cocaine use. A CT angiogram revealed SISMAD; he was treated with conservative management. Cocaine and SISMAD share similar pathophysiologic mechanisms pertaining to vascular smooth muscle cell apoptosis and increased shear stress at fixed vascular positions. Our report emphasizes the need to consider cocaine abuse in SISMAD pathophysiology, risk stratification, and treatment algorithms in future studies.
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17
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Xu L, Shao J, Zhang D, Qiu C, Wang J, Li K, Fang L, Zhang X, Lei J, Lai Z, Ma J, Yu Y, Yu X, Du F, Qi W, Chen J, Liu B. Long-term outcomes of conservative treatment and endovascular treatment in patients with symptomatic spontaneous isolated superior mesenteric artery dissection: a single-center experience. BMC Cardiovasc Disord 2020; 20:256. [PMID: 32471346 PMCID: PMC7257236 DOI: 10.1186/s12872-020-01532-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 05/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disorder, and the treatment strategies remain controversial. This study aimed to compare outcomes of conservative and endovascular treatments in symptomatic patients with SISMAD. METHODS Forty-two consecutive SISMAD patients who were admitted to a single center between October 2009 and May 2018 were enrolled in this study. Based on their symptoms, 15 had conservative treatment, and 27 had endovascular treatment. The baseline characteristics, treatments, and follow-up results of the conservative group and endovascular group were analysed. RESULTS The rates of symptom relief were 93.3% in the conservative group and 96.3% in the endovascular group. The procedure-related complications in the endovascular group included one case of pseudoaneurysm formation in the left brachial artery. During the follow-up period (median 28.5 months), a higher proportion of patients in the conservative group had symptom recurrence (42.9% in the conservative group versus 4.8% in the endovascular group, p < 0.001). Four patients in the conservative group and one patient in the endovascular group had additional endovascular intervention during follow-up. Compared with the conservative group, patients in the endovascular group had statistically significantly longer symptom-free survival (p = 0.014) and a higher rate of superior mesenteric artery (SMA) remodeling (p < 0.001). CONCLUSIONS For symptomatic SISMAD, endovascularly treated patients had a lower rate of symptom recurrence and a higher rate of SMA remodeling in the long term. Prospective, multi-center studies are needed to confirm the long-term outcomes of both treatments.
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Affiliation(s)
- Leyin Xu
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Daming Zhang
- Department of Radiology, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Chenyang Qiu
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jingjing Wang
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Kang Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lijing Fang
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xin Zhang
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jinsong Lei
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Zhichao Lai
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiangyu Ma
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yanying Yu
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiaoxi Yu
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Fenghe Du
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Wanting Qi
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Junye Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Kim H, Labropoulos N. The role of aortomesenteric angle in occurrence of spontaneous isolated superior mesenteric artery dissection. INT ANGIOL 2020; 39:125-130. [PMID: 32052950 DOI: 10.23736/s0392-9590.20.04314-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study investigated whether anatomical factors affect the occurrence of SISMAD by measuring the aortomesenteric angle (AMA). METHODS The study population is comprised of 3 distinct population; Korean SISMAD patients, two control groups from a medical checkup database of 4997 Korean and 317 Caucasian patients from 2011 to 2016. The patient group (PG) included 26 symptomatic patients and 19 Korean diagnosed with SISMAD during medical checkup. The control group was selected based on propensity score similarities calculated by using the following covariates: sex, age, body mass index, drinking, smoking, hypertension, diabetes, and cancer. We compared PG with equal numbers of two control groups comprised of Koreans (KG) and Caucasians (FG), respectively. RESULTS The mean (SD) AMA was 74.9o (17.5) (range, 45.9-110.9o) in the PG, 56.8o (19.5 (range, 10.2o -91.9o) in the FG, and 62.4o (19.1) (range, 25.4-110.8o) in the KG. A significant difference was observed between PG and the two control groups (P<0.001). The AMA in the FG was significantly more acute than the AMA in Korean patients including those in the PG and KG (P=0.001). CONCLUSIONS Large AMA is considered to be an important etiologic factor in SISMAD.
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Affiliation(s)
- Hyangkyoung Kim
- Division of Vascular and Transplantation Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Nicos Labropoulos
- Department of Surgery, Stony Brook University Medical Center, New York, NY, USA -
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19
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Fang G, Xu G, Fang Y, Yang J, Pan T, Jiang X, Dong Z, Fu W. Primary conservative treatment for peritonitis-absent symptomatic isolated dissection of the superior mesenteric artery with severely compressed true lumen. Vascular 2019; 28:132-141. [PMID: 31840566 DOI: 10.1177/1708538119892751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives The purpose of this study was to evaluate the safety and efficacy of primary conservative treatment (PCT) for peritonitis-absent symptomatic spontaneous isolated dissection of the superior mesenteric artery (S-SIDSMA) with severely compressed true lumen. Methods From January 2013 to December 2018, PCT was used in 26 cases of peritonitis-absent S-SIDSMA with severely compressed true lumen in our center based on our previous proposed treatment algorithm for S-SIDSMA. The demographics, duration from the onset to the admission, duration from the start of the conservative treatment to the alleviation of the symptoms, and in-hospital and follow-up clinical and angiographic outcomes were prospectively recorded and then analyzed. Results Among the 26 included patients, 84.6% were male. The mean age of the patients was 54.7 years. The mean duration from the onset to the admission was 3.1 days (range, 1–14 days). Symptoms in 22 patients were markedly or completely relieved during the first five-day medical treatment. Endovascular stent placement was attempted in the remaining four patients, which was successfully performed in three (75%) of them. The technical failure occurred in a patient whose compressed true lumen failed to be cannulated. Medical treatment was then continued in this patient, and his symptoms were relieved after a two-day medical treatment. During the mean follow-up period of 14.3 months, endovascular stent placement was performed in three patients due to the recurrence of the abdominal pain and the chronic intestinal ischemia. No patient showed dissection progression during the follow-up. The complete remodeling rate of the stent group was significantly higher than that of the medical group (83.3% vs. 25%, P = 0.021). Conclusions Based on our previous proposed treatment algorithm for S-SIDSMA, PCT could achieve satisfactory results both clinically and morphologically in peritonitis-absent S-SIDSMA with severely compressed true lumen.
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Affiliation(s)
- Gang Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Genying Xu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jue Yang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianyue Pan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaolang Jiang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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20
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Wei J, Yang Y, Zheng J, Chen D, Wang W, Zhao Q, Li X, Wu G. Small intestinal autotransplantation for spontaneous isolated superior mesenteric artery dissection: A case report. Medicine (Baltimore) 2019; 98:e17837. [PMID: 31764779 PMCID: PMC6882613 DOI: 10.1097/md.0000000000017837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare differential diagnosis for patients presenting with abdominal pain. Due to limited cases reported, surgical management strategies are poorly defined. PATIENT CONCERNS A 54-year-old man presented to our emergency department with a 4-day history of epigastric pain combined with nausea and vomiting. The pain was dull, constant, and unbearable. It was accompanied by abdominal distention, but there was no radiating pain, chills, fever, or hematochezia. The patient did not have a history of abdominal surgeries, or tobacco or illicit drug use. DIAGNOSIS A contrast-enhanced computerized tomography (CT) scan demonstrated an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The middle-lower jejunum and the whole ileum were extensively dilated, and the middle jejunum was ischemic with edema. INTERVENTIONS Exploratory laparotomy and autologous small bowel transplantation. OUTCOMES The patient was successfully treated using exploratory laparotomy and intestinal autotransplantation (IATx) without bowel resection and had a stable recovery without complications. CONCLUSION For patients with severe mesenteric ischemia or those who fail to respond to initial conservative treatment, IATx may be a reasonable treatment strategy.
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Affiliation(s)
| | - Yi Yang
- Department of Radiology, Xijing Hospital, The Air Force Military Medical University, Xi’an, Shaanxi, People's Republic of China
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Jia Z. Re. "Mid-Term Results of Endovascular Treatment for Spontaneous Isolated Dissection of the Superior Mesenteric Artery". Eur J Vasc Endovasc Surg 2019; 58:782. [PMID: 31422045 DOI: 10.1016/j.ejvs.2019.06.496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Zhongzhi Jia
- Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Changzhou, 213003, China.
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Jia Z, Chen W, Su H, Shi H, Xu Q, Ni G, Qi C, Gu J. Factors Associated with Failed Conservative Management in Symptomatic Isolated Mesenteric Artery Dissection. Eur J Vasc Endovasc Surg 2019; 58:393-399. [PMID: 31331723 DOI: 10.1016/j.ejvs.2019.03.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/19/2019] [Accepted: 03/29/2019] [Indexed: 12/15/2022]
Abstract
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%.
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Affiliation(s)
- Zhongzhi Jia
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China.
| | - Wenhua Chen
- Department of Interventional Radiology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Haobo Su
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongjian Shi
- Department of Interventional Radiology, Wujin Hospital Affiliated to Jiangsu University, Changzhou, China
| | - Qing Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guoqing Ni
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chunjian Qi
- Medical Research Centre, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China.
| | - Jianping Gu
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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Clinical and CT Angiographic Follow-Up Outcome of Spontaneous Isolated Intramural Hematoma of the Superior Mesenteric Artery. Cardiovasc Intervent Radiol 2019; 42:1088-1094. [PMID: 30949761 DOI: 10.1007/s00270-019-02212-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/26/2019] [Indexed: 12/30/2022]
Abstract
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.
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