Clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection

Abstract

Objective To investigate the clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD). Methods The retrospective cross-sectional study was conducted. The clinical data of 80 patients with SISMAD who were admitted to the Wuhan Union Hospital Affiliated to Huazhong University of Science and Technology from February 2002 to March 2017 were collected. All the patients underwent computed tomographic angiography (CTA) and digital subtraction angiography (DSA) examinations, and then received conservative medical treatment, endovascular interventional treatment or exploratory laparotomy and revascularization. Observation indicators: (1) clinical features; (2) treatment; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed once at 1, 6 and 12 months after discharge and once every year after 1 year up to March 2017. Follow-up included recurrence of abdominal pain, changes of superior mesenteric artery (SMA) dissection or changes of SMA and remodeling of dissection after stent implantation. Measurement data were represented as average (range). Results (1) Clinical features: ① Clinical manifestation: 75 of 80 patients had symptoms, and 5 without symptoms were diagnosed during health examination. Of 75 patients with symptoms, abdominal pain was the first symptom, with the main of the peri-umbilicus and epigastric pains, without peritoneal irritation sign, including 14 with nausea and vomiting and 4 with bloody stool. ② Results of imaging examination: 80 patients were confirmed by CTA examination. CTA showed that there was local thickening of SMA, true and false double-lumen formation, thinner true arterial lumen with visible intimal flap shadow and thrombosis in the false lumen. Results of CTA showed that the first break was located within 1-6 cm from opening of SMA in 77 patients and in the middle and distal segment of SMA in 3 patients, without aortic dissection (AD). (2) Treatment: of 75 patients with symptoms, 53 received conservative medical treatment with an effective rate of 70.7%(53/75), average time of symptomatic remission was 5 days (range, 1-12 days); 22 received stent implantation via right femoral artery approach using self-expanding bare stent or covered stent, with a success rate of implantation of 95.5%(21/22), including 21 with successful implantations and 1 with false implantation. One patient with false implantation had symptomatic remission after 1-week conservative medical treatment, and there was no exploratory laparotomy and revascularization. Five patients without symptom were required to control blood pressure and get regular follow-up, without other intervention. (3) Follow-up: 75 patients with symptoms were followed up for 36 month (range, 1-60 months). During follow-up, of 53 patients with conservative medical treatment, 2 patients had significant progressions of SMA dissection by CTA examination, 1 had recurrence and exacerbation of abdominal pain accompanied with bloody stool at 2-month follow-up, showing an aneurism of SMA dissection by DSA examination, and 1 had recurrence of abdominal pain at 1-year follow-up, both patients were improved after stent implantation; other 51 had no recurrence. Of 22 patients with stent implantation, 1 had repeated abdominal pain during follow-up and the symptom became aggravated at 1-year follow-up, showing a thrombosis formation and proximal stenosis by CTA examination, and then underwent stent implantation in the proximal stenosis after anticoagulant therapy; SMA dissection of 1 patient completely healed at 2-year follow-up by CTA examination; other 20 patients had stent patency. Five patients without symptom had regular follow-up, showing no disease progression. Conclusions The symptoms of SISMAD are different, and abdominal pain is the one of main symptoms. At present, treatment regimens include conservative medical treatment, endovascular interventional treatment and surgery, and individua-lized treatment is decided according to clinical symptoms and physical signs of patients and imaging examinations. Key words: Spontaneous isolated superior mesenteric artery dissection; Radiology; Drug therapy; Surgical procedures, operative; Stent implantation