Isolated Mesenteric Artery Dissection Research Articles

Case-Control Study of 3D Morphology in Isolated Mesenteric Artery Dissection.

Isolated mesenteric artery dissection (IMAD) is uncommon and has not been investigated in detail. This study aimed to accurately identify the morphological differences of IMAD patients with control individuals using a detailed 3D volumetric analysis. In this retrospective case-control study, cases were patients with acute symptomatic IMAD treated in a French intestinal stroke center between January 2016 and November 2019. Case-control matching was (1:3) by age, gender, and body mass index (BMI). The semi-automatic morphological analysis of the mesenteric artery included volumetric measurements of the true and false lumen size, the centerline curvature and the 3D aortomesenteric angles. Seventeen IMAD cases (mean age 56 ± 4years, 94% men) were matched with 51 controls. The mean overall lumen (OL) volume was higher in IMAD patients as compared to controls (+ 64%, p < 0.001). In the same way, the mean OL cross-sectional area and diameters were higher in IMAD patients: + 77% for OL area (< 0.001) and + 34% for OL diameters (< 0.001). Meanwhile, no significant difference was found in terms of true lumen (TL) volume (p = 0.16) or cross-sectional area (p = 0.30) between IMAD patients and controls, whereas the mean TL diameter was lower in the IMAD group (p < 0.05). Patients with acute mesenteric ischemia had a lower [TL/OL volume] ratio (45% vs. 59%, p < 0.05) and longer dissections (63mm vs. 48mm, p < 0.01). The 3D aortomesenteric angle was significantly higher in IMAD patients at both 2cm (p < 0.01) and 4cm (p < 0.05) from the ostium. Using an original 3D semi-automated analysis, this study shows that IMAD induces significant morphological changes compared to control individuals: a larger aortomesenteric 3D angle, an increased overall volume and area. IMAD patients with acute mesenteric ischemia presented with a more severe morphological profile.

Volumetric Analysis of Progressive Remodeling of Isolated Mesenteric Artery Dissection Treated by Conservative Therapy

PurposeTo characterize remodeling of conservatively treated isolated mesenteric artery dissection (IMAD) using 3-dimensional (3D) volumetric analysis. Material and MethodsPatients with Type I/II (classification of Yun) treated by conservative therapy between January 2018 and January 2020 were prospectively included. Semiautomatic morphological analysis of the superior mesenteric artery (SMA) included volumetric measurements of the true lumen (TL), false lumen (FL), and overall lumen (OL) and 3D aortomesenteric angles from computed tomography angiography data at admission (T0), 1 month (T1), and 12 months (T12). The SMA morphology of patients with IMAD (n = 15, mean age 53 years ± 7; 87% men) was also compared with that of control individuals (n = 51, mean age 56 years ± 4; 94% men). ResultsA significant reduction in OL volume was observed (P <.001), whereas TL volume remained stable (P =.23). The TL/OL volume ratio significantly increased over time (P =.001) from 53% at T1 to 78% at T12. Aortomesenteric 3D angles at 2, 4, and 6 cm from the ostium showed a progressive decrease toward values observed in the control group (P =.013, P =.002, and P =.027, respectively). At T12, 5 patients (33%) had complete remodeling, and aneurysmal change was observed in 2 patients (<20 mm). Smoking and SMA angle at a distance of 6 cm from the ostium (T0) were the only factors affecting remodeling negatively at T12. ConclusionsOne-year remodeling in IMAD followed an overall decrease in OL volume related to a decrease in FL volume. Smokers and patients with larger SMA angles at baseline showed poorer remodeling. Spontaneous arterial remodeling in IMAD might favor conservative therapy.

Symptomatic Isolated Mesenteric Artery Dissection: Insights from a Conservative Approach

Symptomatic isolated mesenteric artery dissection (IMAD) is a rare vascular disease. Therefore, data on its natural history are scarce. Treatment strategies on whether to stent symptomatic IMAD remain controversial, with recent observational reports advocating an aggressive approach, with a low threshold for stenting. In this issue, Abdallah et al.1 provide alternative insights from a French intestinal stroke centre that adopts a conservative treatment algorithm for symptomatic IMAD.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC). 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). 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 etal., 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. 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.

Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: a Multicentre Experience

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. 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. 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). 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.

Commentary on “Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: A Multicentre Experience”: Too Itchy Fingers

Isolated mesenteric artery dissection involves dissection of the coeliac trunk and/or superior mesenteric artery (SMA) and/or inferior mesenteric artery. The present study deals with acute isolated symptomatic SMA dissection,1 which is the type of dissection associated with the most severe clinical consequences.2 A prerequisite for diagnosis of these patients with acute abdominal pain is high resolution computed tomography (CT) with intravenous contrast enhancement and imaging in the arterial phase; otherwise, a large proportion of patients will go undiagnosed.

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.

Primary Conservative Therapy for Symptomatic Isolated Mesenteric Artery Dissection with Severely Compressed True Lumen or Large Dissecting Aneurysm

PurposeTo investigate the safety and effectiveness of primary conservative therapy for patients with symptomatic isolated mesenteric artery dissection (IMAD) with a severely compressed true lumen and/or a large dissecting aneurysm. Materials and MethodsA total of 35 consecutive patients (all men; median age, 53 y) with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture who were treated with primary conservative therapy between November 2018 and February 2020 were assessed. A severely compressed true lumen was defined as luminal stenosis > 70%. A large dissecting aneurysm was defined as dissecting aneurysm diameter ≥ 1.5 times larger than the normal mesenteric artery diameter. ResultsThere was a strong positive relationship among abdominal pain, degree of luminal stenosis, and length of dissection (R = 0.811; P < .001). Conservative treatment was successful in all patients. Abdominal pain was eliminated within 4.7 d ± 4.8 (range, 2–31 d) in all patients, within 3.6 d ± 1.2 (range, 2–6) in the 31 patients with minor or moderate abdominal pain, and within 13.3 d ± 11.9 (range, 6–31 d) in the 4 patients with severe abdominal pain. Complete or partial remodeling of the mesenteric artery was achieved in 6 (17.1%) and 29 (82.9%) patients, respectively, during 8.6 mo ± 4.3 of follow-up. ConclusionsPrimary conservative therapy can be used safely and effectively in patients with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture.

Outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection with conservative management.

The aim of this study was to evaluate the computed tomography follow-up outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection (IMAD) after conservative management. In this retrospective study, 130 consecutive patients with symptomatic IMAD from three institutions were enrolled from January 2011 to December 2019. The general epidemiological data, clinical manifestations, first-episode symptoms, imaging findings, and treatment strategy selection were analyzed from the medical records. Among 130 patients diagnosed with symptomatic IMAD, positive remodeling of the SMA was achieved in 75.38% (98/130), and negative remodeling of the SMA was achieved in 24.62% (32/130). In the positive remodeling group, complete remodeling was achieved 39.23% (51/130) (type I 6 patients, type IIa 10 patients, type IIb 35 patients), in which type IIb was the most (p = 0.004). Moreover, of the 32 patients in whom negative remodeling of the SMA was achieved, significant differences were observed between the type IIa with respect to dissecting aneurysm formation (p = 0.04).Of the seven factors analyzed with a logistic regression model identified three factors significantly associated with negative remodeling: length of dissection (Waldχ2 13.331; OR 6.945; 95% CI 2.762-10.498; p = 0.014), true lumen residual diameter (TLRD) (Waldχ2 9.626; OR 7.85; 95% CI 1.892-19.063; p = 0.022), and branch involvement (Waldχ2 11.812; OR 7.247; 95% CI 1.245-14.830; p = 0.011). The prognosis of most symptomatic IMAD has a tendency to positive remodeling after conservative management, in which the initial type IIb classification is common. In contrast, risk factors for negative remodeling were type IIa, length of dissection, TLRD, and branch involvement. Patients with these morphological characteristics may not benefit from conservative management.

Management Strategy Based on Disease Stages for Patients with Symptomatic Isolated Mesenteric Artery Dissection

An optimal treatment regimen is sought for symptomatic isolated mesenteric artery dissection (IMAD) on the basis of its clinical staging. From January 2011 to December 2018, 120 patients with symptomatic IMAD from two institutions were collected retrospectively. We reviewed the clinical features, risk factors, computed tomography (CT) images, treatment modalities, and follow-up results to propose a new management strategy based on the clinical stages of the disease. A total of 120 patients were collected in this study; 77 patients (69 men, 8 women; median age, 52.53years; range, 39-73years) who had undergone successful conservative management with antithrombotic agents were included in group A. The remaining 43 patients (34 men, 9 women; median age, 52.63years; range, 26-66years) who underwent invasive therapy were included in group B. Significant differences were observed between the two groups with respect to dissection length (50.72±27.72mm vs. 62±24.3mm; P=0.02), true lumen residual diameter (3.31±1.05mm vs. 2.83±2.05mm; P=0.01), and branch involvement (8 and 19, respectively; P < 0.001). Success was achieved in 76.24% (77/101) of patients treated by conservative management with antithrombotic agents in the acute stage; 43 patients underwent invasive interventional therapy in different stages of symptomatic IMAD. In group A, 6 patients had recurrent abdominal pain, three of whom underwent invasive intervention, and the remaining patients improved after conservative treatment. Positive remodeling was observed in 80.33% (49/61) of patients treated with conservative management alone versus 19.67% (12/61) of patients who experienced negative remodeling. Endovascular intervention in group B, CT angiography, or mesenteric angiography yielded complete remodeling in 23 (76.67%, 23/30) patients and evidence of stent restenosis in 7 (23.33%, 7/30) patients. Among the surgical patients, 7 patients showed improvement in the luminal diameter. However, 3 patients with short bowel syndrome require long-term parenteral nutrition. Conservative management with antithrombotic agents should be a first-line regimen for symptomatic IMAD in the acute stage. If symptoms persist, endovascular intervention is a safe and feasible treatment in the subacute or chronic stage. When peritonitis is present, surgical treatment should be promptly performed, regardless of the disease stage.

Combination of Colour Duplex and Contrast Enhanced Ultrasound as an Alternative to Computed Tomography Angiography in Isolated Mesenteric Artery Dissection Surveillance

The aim was to investigate the effectiveness of colour duplex ultrasound (CDU) plus contrast enhanced ultrasound (CEUS) vs. computed tomography angiography (CTA) for surveillance in patients with isolated mesenteric artery dissection (IMAD). Patients who underwent CDU, CEUS, and CTA for surveillance of IMAD between January 2012 and May 2019 were included in the study. The accuracy of CDU, CEUS, and CTA for determining the morphological characteristics of IMAD was analysed. A total of 42 patients undergoing 76 total imaging examinations during follow up were included. Both CTA and CDU plus CEUS demonstrated the thrombosed false lumen for 28 (36.8%) examinations and the dissecting aneurysm for 20 (26.3%) examinations (both κ=1.0). The diameter of the dissecting aneurysm was 5.03±1.25mm using CDU and CEUS vs. 5.27±1.23mm on CTA (coefficient of consistency, 0.997; p<.001). The entry points were visualised by CDU and CEUS for 20 (26.3%) examinations and by CTA for 14 (18.4%) examinations (κ=0.769); no re-entry points were visualised by CDU and CEUS for any examinations but re-entry points were visualised by CTA for two (2.6%) examinations. The minimum inner diameter was 2.80±1.30mm on CDU and CEUS vs. 2.52±1.29mm on CTA (coefficient of consistency, 0.999; p<.001). The peak systolic velocities were 128.2±13.0cm/s at diagnosis and 98.7±4.9cm/s after one month (p<.001). The combination of CDU and CEUS can be used in place of CTA for the surveillance of IMAD.

Mesenteric Artery Remodeling after Conservative Management in Patients with Isolated Mesenteric Artery Dissection.

To retrospectively investigate factors associated with mesenteric artery remodeling after conservative management of isolated mesenteric artery dissection (IMAD) (dissection of the mesenteric arteries in the absence of aortic dissection or other known causes). A total of 107 patients diagnosed with IMAD between February 2010 and October 2018 were identified. Eighteen patients were excluded because they underwent stent placement (n= 11) or were lost to follow-up (n= 7). A total of 89 patients who underwent conservative management were therefore included in the study. Cox regression analysis was performed to identify factors associated with mesenteric artery remodeling. During 15.9 ± 10.9 months of follow-up, complete remodeling of the mesenteric artery was achieved in 66 patients (74.2%), and partial remodeling was achieved in 23 patients (25.8%). Of the 66 patients with complete remodeling, 6 (9.1%) had type IIa IMAD (visible false lumen, no visible re-entry site), and 60 (90.9%) had type IIb IMAD (thrombosed false lumen). The mean interval between IMAD diagnosis and complete remodeling was 14.4 ± 5.4 months for all patients. The mean intervals for patients with type IIa IMAD were 20.0 ± 6.2 months and 13.9 ± 5.1 months for patients with type IIb IMAD (P= .015). Mesenteric artery remodeling was significantly associated with the presence of symptoms (odds ratio, 10.800; 95% confidence interval, 1.961-59.470; P= .006). Complete remodeling of the mesenteric artery in patients with IMAD treated with conservative management is common, and the presence of symptoms is associated with complete remodeling.

Factors Associated with Failed Conservative Management in Symptomatic Isolated Mesenteric Artery Dissection

The aim of this study was to assess factors associated with conservative management failure in patients with symptomatic isolated mesenteric artery dissection. 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. 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). 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%.

More Light on Isolated Mesenteric Artery Dissection from the Countries of the Rising Sun

More Light on Isolated Mesenteric Artery Dissection from the Countries of the Rising Sun

Pentobarbital-induced sleep upregulates the survival p-FADD/FADD ratio in mouse brain cortex

The aim was to evaluate the outcomes of endovascular treatment with bare stents alone versus stent assisted coiling in isolated mesenteric artery dissection (IMAD) aneurysms.Patients with an IMAD aneurysm who underwent endovascular stenting between February 2010 and February 2017 at one of three institutions were included in this study. Data regarding technical success, procedure time, symptom resolution, complications, changes in IMAD aneurysm, and stent patency were recorded.A total of 38 patients (35 men) were included, 27 treated with bare stents alone and 11 treated with stent assisted coiling. Technical success was achieved in 100% of patients treated with bare stents and in 81.8% of those treated with stent assisted coiling (p = 0.078). The mean procedure times were 62.6 ± 5.3 min for treatment with bare stents and 116.4 ± 8.4 min for stent assisted coiling (p < 0.001). A total of 23 patients had persistent symptoms before stenting; all symptoms were resolved within 3.0 ± 0.7 days. No procedure related major complications occurred. Over 30.2 ± 18.1 months of follow up, complete resolution of the IMAD aneurysm was achieved in all patients; good stent patency and in stent re-stenosis were achieved in 65.8% and 34.2% patients, respectively. There were no occlusions of the stented arteries.Bare stents alone and stent assisted coiling have high technical success rates and demonstrate good intermediate patency in patients with an IMAD aneurysm. Bare stents alone may serve as an alternative to stent assisted coiling for the management of IMAD aneurysm

Endovascular Treatment of Patients with Isolated Mesenteric Artery Dissection Aneurysm: Bare Stents Alone Versus Stent Assisted Coiling

The aim was to evaluate the outcomes of endovascular treatment with bare stents alone versus stent assisted coiling in isolated mesenteric artery dissection (IMAD) aneurysms. Patients with an IMAD aneurysm who underwent endovascular stenting between February 2010 and February 2017at one of three institutions were included in this study. Data regarding technical success, procedure time, symptom resolution, complications, changes in IMAD aneurysm, and stent patency were recorded. A total of 38 patients (35 men) were included, 27 treated with bare stents alone and 11 treated with stent assisted coiling. Technical success was achieved in 100% of patients treated with bare stents and in 81.8% of those treated with stent assisted coiling (p=0.078). The mean procedure times were 62.6±5.3min for treatment with bare stents and 116.4±8.4min for stent assisted coiling (p<0.001). A total of 23 patients had persistent symptoms before stenting; all symptoms were resolved within 3.0±0.7 days. No procedure related major complications occurred. Over 30.2±18.1 months of follow up, complete resolution of the IMAD aneurysm was achieved in all patients; good stent patency and in stent re-stenosis were achieved in 65.8% and 34.2% patients, respectively. There were no occlusions of the stented arteries. Bare stents alone and stent assisted coiling have high technical success rates and demonstrate good intermediate patency in patients with an IMAD aneurysm. Bare stents alone may serve as an alternative to stent assisted coiling for the management of IMAD aneurysm.

Medical Therapy and Intervention Do Not Improve Uncomplicated Isolated Mesenteric Artery Dissection Outcomes Over Observation Alone

Medical Therapy and Intervention Do Not Improve Uncomplicated Isolated Mesenteric Artery Dissection Outcomes Over Observation Alone