Single Center Experience of Operative Management in Isolated Mesenteric Artery Dissections

Abstract

Isolated mesenteric dissection of vessels is a rare occurrence with management strategies dependent on patient presentation. The study aimed to evaluate a single institution's experience on patient characteristics, treatment modalities, and outcomes on operative vs nonoperative management of mesenteric dissection. Patients from a single institution between January 2017 and November 2022 with diagnosis of superior mesenteric artery (SMA) or celiac artery dissection and its branches were included. Patients with concomitant descending aortic dissection were excluded. Patient demographics, imaging, treatments, and follow-up data was collected and underwent descriptive statistical analysis. All SMA dissections were categorized using the modified Sakamoto classification (types I-VI), with type VI indicating total occlusion of vessel due to dissection. There were 30 patients with diagnosis of isolated mesenteric dissection. Mean age was 61 years, and the majority were male (86%), Asian (60%), and symptomatic (70%). Majority had isolated SMA dissection (n = 19; 63.3%) with the remainder having isolated celiac (n = 9; 30%) or concomitant SMA and celiac dissection (n = 2; 6.7%). Twenty-one patients had involvement of SMA and categorized using the modified Sakamoto Classification (n = 5 type I, n = 0 type II, n = 2 type III, n = 4 type IV, n = 1 type V, n =7 type VI). Nonoperative treatment occurred in 63.3% (n = 19). Operative intervention rate was 33% (n = 10). All patients who underwent an operation were symptomatic with abdominal pain on presentation (P < .01) (Table I). Two patients presented with rupture and five presented with signs of acute mesenteric ischemia necessitating emergent exploration. Two patients required bowel resection for necrosis. Sakamoto classification was also significantly associated with operative intervention (P < .01). Patients presenting with abdominal pain were three times as likely to undergo operative treatment (odds ratio, 3.13; P < .01) (Table II), while patients with a modified Sakamoto classification type V and above were 10 times more likely to undergo an operative intervention (odds ratio, 10.5; P < .02) (Table II). A large majority of operative cases (n = 9; 90%) were diagnosed with involvement of SMA dissection. Unplanned secondary intervention rate was 30% (n = 3). There was 9.5% mortality rate amongst those with SMA vessel involvement (10% overall mortality). Among those patients that followed-up, all were asymptomatic at the time of follow-up (n = 16). Patients with nonoperative interventions had 57% favorable remodeling (n = 4). Symptomatic patient presentation and higher modified Sakamoto classification type (types V and VI) tend to require operative intervention. Although a majority of spontaneous isolated mesenteric dissections may be treated nonoperatively with either medical therapy or observation alone, identifying patient characteristics amongst those that require operative intervention are important considerations for management of this rare disease process.Table IClinical characteristics by operative interventionOverall, n = 30Operative repair, n = 10Nonoperative, n = 20P valueaAge61.00 ± 12.0854.30 ± 13.4164.35 ± 10.11.031Gender.6 Female4 (13)2 (20)2 (10) Male26 (87)8 (80)18 (90)Ethnicity/Race.032 Asian18 (60)5 (50)13 (65) Hispanic5 (17)2 (20)3 (15) Other3 (10)3 (30)0 (0) White4 (13)0 (0)4 (20)Smoking history.7 Yes10 (33)4 (40)6 (30) No20 (67)6 (60)14 (70)Atrial fibrillation.7 Yes7 (23)3 (30)4 (20) No23 (77)7 (70)16 (80)Hypertension.4 Yes10 (33)2 (20)8 (40) No20 (67)8 (80)12 (60)White blood cells.4 >1211 (37)5 (50)6 (30) 4-1219 (63)5 (50)14 (70)Systolic blood pressure groups>.9 High (>140)17 (57)6 (60)11 (55) Normal (100-140)11 (37)3 (30)8 (40) Low (<100)2 (6.7)1 (10)1 (5.0)Modified Sakamoto class (types I-VI).008 Type I5 (24)1 (11)4 (33) Type II0 (0)0 (0)0 (0) Type III2 (9.5)1 (11)1 (8.3) Type IV4 (19)0 (0)4 (33) Type V2 (9.5)0 (0)2 (17) Type VI8 (38)7 (78)1 (8.3)Symptomatic at presentation.011 Yes20 (67)10 (100)10 (50) No10 (33)0 (0)10 (50)Length of stay7.67 ± 8.5614.00 ± 10.424.50 ± 5.35.004Intensive care unit length of stay2.57 ± 4.766.50 ± 6.430.60 ± 1.67<.001Deceased.3 Yes3 (10)2 (20)1 (5) No27 (90)8 (80)19 (95)Values are mean ± SD or number (%).aWilcoxon rank-sum test; Fisher's exact test. Open table in a new tab Table IIOdds ratio analysis of symptomatic presentation and Sakamoto classification with operative interventionOR95% CIP valueSymptomatic at presentation3.131.08-406.55.011Sakamoto class type V-VI10.51.57-105.00.024CI, Confidence interval; OR, odds ratio. Open table in a new tab