Spontaneous Isolated Dissection Of The Superior Mesenteric Artery Research Articles

Isolated Intramural Hematoma of Superior Mesenteric Artery: Case Reports and a Review of Literature

(1) Background: Spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA) is a rare entity often considered as a subset of spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). It is characterized by a completely thrombosed false lumen with or without an ulcer-like projection with computed tomography (CT) imaging. The recent literature describes few reports with a relatively short-term follow-up. The natural course, prognosis, and treatment options for SIHSMA still lack consensus. We present two cases of acute abdominal pain in a young man due to IMH of the superior mesenteric artery with an extensive literature review. (2) Case report: A 46-year-old male patient was submitted to an urgent CTA for acute abdominal pain, showing the presence of an isolated dissection of the superior mesenteric artery, determining significant stenosis of the vessel with collateral vessel patency. The patient referred to a recent COVID-19 infection, whose course was paucisymptomatic. He was conservatively treated with antiplatelet therapy and corticosteroid treatments, and, after a few days, the symptomatology completely regressed; also, the 2-month-control CTA showed complete IMH regression and the absence of any signs of residual stenosis. The second patient was a 61-year-old male patient who was submitted to an urgent CTA for acute abdominal pain, showing the presence of an isolated dissection of the superior mesenteric artery, not determining significant vessel stenosis. He was conservatively treated with antiplatelet therapy and corticosteroid treatment, and after a few days, the symptomatology completely regressed and the radiological control showed complete dissection regression. (3) Conclusion: SISHSMA is a rare entity of vascular pathology, and conservative management represents the best medical strategy. We propose corticosteroid treatment as one of the most appropriate tools in the conservative treatment of SISHSMA.

The efficacy of thin struct bare stents for the treatment of spontaneous isolated dissection of the superior mesenteric artery

Objective: To examine the safety and effectiveness of thin struct bare stents for the treatment of spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Methods: The data of 32 patients admitted to First Hospital of Jiaxing (20 cases) and Jinling Hospital (12 cases) with SIDSMA from January 2016 to January 2021 were retrospectively analyzed. There were 27 males and 5 females, aging (54.8±9.4) years (range: 36 to 75 years). All patients were treated with thin struct bare stents. Controllable spring coils were used to fulfill the false lumen in 2 cases. Symptoms, vascular remodeling pattern at the SIDSMA lesion, and patency of the stents were observed during follow-up. Results: The surgical success rate was 100%. According to the length of the lesions and stents, the number of stents implanted was 1 in 17 cases, 2 in 11 cases and 3 in 4 cases. The angiography showed that blood flow in the stent was smooth and that the false lumen disappeared or weakened. The numerical rating scale for abdominal pain decreased from 6.1±1.5 (range: 4 to 10) preoperatively to 1.0 (1.0) (range: 0 to 3) 1 hour postoperatively (W=528, P<0.01). The compression rate of the true lumen of the superior mesenteric artery decreased from (92.3±6.7)% (range: 25% to 94%) preoperatively to 0.8 (1.2)% (range: 0 to 3.2%) 1 month postoperatively (W=528, P<0.01). The primary patency rate of CT angiography at 1 month postoperatively was 100%. The vascular remodeling rate was (92.3±6.7)% (range: 80% to 100%). All patients were followed for (46.3±17.0) months (range: 24 to 76 months). The cumulative patency rates in 1, 2 and 5 years were all 100%. Conclusion: The use of thin struct bare stents for SIDSMA is safety and efficacy.

Endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery.

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) occurs when a tear in the inner layer of the superior mesenteric artery (SMA) allows blood to flow between the layers of the SMA, forcing the layers apart, and creating two lumens. Abdominal pain is the most prevalent clinical manifestation. Other people may have no symptoms or experience nausea, vomiting, diarrhea, or blood in their stools. For people with SIDSMA who are not suspected of intestinal necrosis or intra-abdominal bleeding, medical treatment and endovascular therapy are the main treatment options. There is no consensus on the optimum first-line management strategy. To evaluate the benefits and harms of endovascular therapy versus medical treatment for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). We used standard, extensive Cochrane search methods. The latest search date was 3 August 2021. We planned to include all randomized controlled trials (RCTs) which compared endovascular therapy and medical treatments for SIDSMA. We planned to exclude studies where participants were treated with open surgery. We used standard Cochrane methods. Our primary outcomes were endovascular intervention rate and recurrent abdominal pain. Our secondary outcomes were open surgery rate, remodeling rate of SMA, new aneurysm formation of SMA, SMA occlusion, new dissection of SMA, death, symptom relief rate and complications of endovascular therapy. We planned to use GRADE to assess certainty of evidence for each outcome. We did not identify any RCTs to include in any analysis. We were not able to include any RCTs that compared endovascular therapy versus medical treatment in people with SIDSMA. High-quality RCTs that evaluate the benefits and harms of these interventions are needed to help determine the optimal strategy for managing SIDSMA.

Comparison of Superior Mesenteric Artery Remodeling and Clinical Outcomes between Conservative or Endovascular Treatment in Spontaneous Isolated Superior Mesenteric Artery Dissection.

The aim of this study was to analyze the superior mesenteric artery (SMA) remodeling after initial conservative or endovascular treatment with a standardized definition and midterm outcomes in patients with spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). This retrospective study enrolled patients with SIDSMA from January 2007 to August 2019. All patients were treated initially with conservative treatment. If they failed the medical treatment, they were converted to interventional treatment. The morphological endpoint was determined by the standardized SMA remodeling, and the clinical endpoints were determined by the in-hospital mortality, hospital stay, and the bowel-related mid-term mortality. A total of 34 consecutive patients with SIDSMA were identified. Twenty-three (67.6%) and eleven (33.4%) patients underwent conservative and interventional treatments, respectively. Clinical features and morphologic changes on CTA were available in 25 (73.5%) patients during the median follow-up of 23.3 months. Standardized SMA remodeling was significantly (p < 0.05) better in patients undergoing endovascular stenting, especially in patients with Yun’s IIb classification. There was no mesenteric ischemia or SMA aneurysm during follow-up period. Patients with SIDSMA can be treated safely with initial conservative treatment. However, significant portions of patients will require endovascular intervention due to the persistent symptoms. Clinically endovascular stenting could be performed successfully, and SMA remodeling was satisfactory during the mid-term follow-up.

Preliminary result of stents implantation for spontaneous isolated dissection of the superior mesenteric artery: a prospective single-arm study

ObjectiveTo access the efficacy of stents for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). MethodThe study is a prospective single-arm study which has been registered on Clinical Trials (NCT03916965). Clinical data and follow-up information of the SIDSMA patients who received stent implantation in the First Affiliated Hospital of Zhejiang University during April 1, 2019 and September 30, 2019 were collected. The patients were recommended to be followed up at 1, 3, 6 and 12 months. ResultsA total of 34 patients were enrolled. Their mean age was (54±8) years. Abdominal pain was the most common symptom. Patients received (2.1±0.6) stents on the average. Post-operation hospital stay was (2.7±1.6) days, and the patients were followed up for (2.3±1.9) months (CT angiography) and (5.5±1.7) months (clinical visit/phone call). There was no recurrence of abdominal pain. The CT angiography showed complete remodeling and incomplete remodeling took place in 23 and 9 patients (69.7% and 27.3%), respectively. Two patients (6.1%) had mild in-stent stenosis. No stent rupture or migration was reported. ConclusionThis study demonstrated a satisfactory short-term result of stents implantation for SIDSMA, which indicated the endovascular treatment could be the first-line therapy for SIDSMA.

Mid-Term Results of Endovascular Treatment for Spontaneous Isolated Dissection of the Superior Mesenteric Artery

Endovascular treatment (EVT) is an alternative method to treat spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Although its short-term results are promising, few mid-term results have been reported. This study reports the five year follow up of EVT for SIDSMA. A total of 128 consecutive patients with SIDSMA admitted to the study hospital between 2011 and 2016 were enrolled in this retrospective study. Their demographic information, clinical findings, EVT outcomes, and follow up results were analysed. Conservative treatment and pre-operative preparation were given immediately after admission, then digital subtraction angiography was performed. Stents were deployed in 112 out of 128 patients. The 16 patients who did not receive stents then continued conservative treatment. Peri-procedural complications occurred in three patients, including one death and two pseudoaneurysms at puncture sites. Mean follow up was 29.7 months (range 6-60 months) in patients with stents and 31.4 months (range 14-45 months) in patients without stents. During follow up, the overall complete remodelling rate in the stent group was 88.3%. Most took place within three months of stenting. The cumulative primary stent patency rate was 99.1%, and the cumulative event free survival rate was 99.0%, 95.8%, and 95.8% at one, three, and five years in patients with stents, compared with 62.5% at both one and three years in patents without stents (p<.001). EVT for SIDSMA is clinically successful. The event free survival rate, primary patency, and complete remodelling are satisfactory during mid-term follow up. Endovascular treatment is an effective approach for SIDSMA.

Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery

Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition often presenting with vague signs and symptoms. Although the disease entity is rare, the potential for morbidity and mortality is high. Computed tomographic angiography is the preferred imaging modality for identification of SID-SMA. It may be managed by conservative, surgical, or endovascular treatment based on clinical presentation, but there is no general consensus regarding the treatment strategy. Here, we describe a case of SID of SMA treated successfully with percutaneous endovascular stent placement.

Follow-up with computed tomography after spontaneous isolated dissection of the splanchnic artery

The aim of this study was to evaluate radiological changes after spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and spontaneous isolated dissection of the celiac artery (SIDCA) using computed tomography (CT). This single-center retrospective study was approved by the hospital institutional review board. We reviewed the medical records and morphological CT findings of 33 consecutive patients with SIDSMA or SIDCA who were diagnosed between January 2001 and February 2016. We analyzed changes on follow-up CT images including length of the dissection, presence of a thrombus in the false lumen, maximal outer diameter, degree of luminal stenosis, patency of distal flow, and end-organ injury. We classified short-term (within the first week) and long-term (between the first week and sixth month) follow-up groups and analyzed differences in radiological changes over time using Wilcoxon signed-rank tests (continuous variables) and Fisher exact probability tests (categorical variables). Additionally, we examined patients who completed follow-up CT within 3 days after symptomatic changes. Comparing initial and final CT findings, a majority of patients with SIDSMA and SIDCA showed no significant changes in most CT parameters, including dissection length, thrombus presence, dissection diameter, stenosis degree, and extended distal branch. Between the short-term and long-term CT follow-up groups, there were no significant differences in radiological changes except for in the degree of luminal stenosis at the dissected segment in SIDSMA (P = 0.043). Only 10 patients completed follow-up CT within 3 days after symptomatic changes (progression or regression); of these, 1 patient had radiological findings that matched symptom progression, showing an increase in the degree of luminal stenosis and end-organ injury. There was no splanchnic artery dissection-related mortality, symptom progression, or event recurrence. In conclusion, CT follow-up of SIDSMA and SIDCA was mainly useful in the acute phase of dissection, with no significant radiological changes occurring in the long term. Accordingly, we question the utility of long-term follow-up CT after spontaneous isolated arterial dissection, especially in the absence of symptom progression.

Conservative Management of Spontaneous Isolated Dissection of the Superior Mesenteric Artery.

Purpose We report the clinical outcomes of patients with spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) who were treated conservatively. Materials and Methods A retrospective review was performed in 14 patients from 2006 to 2016 with SIDSMA. Their clinical features and computed tomographic angiography (CTA) characteristics, treatment methods, and clinical outcomes were analyzed. The mean age was 53.6 (range, 41–73) years, and the mean follow-up duration was 20.6 (range, 1–54) months. Conservative management was the primary treatment if no bowel ischemia or arterial rupture was noted. Results The mean initial abdominal visual analog pain score was 7 (range, 5–9) in seven patients. The mean total duration of abdominal pain was 10.2 days (range, 2–42 days) in 10 patients. The mean percentage stenosis of the dissected SMA at the initial presentation was 78.8% in 14 patients. Complete obstruction of the SMA at the initial presentation was evident in 4 of the 14 patients (28.6%). Conservative management was successful in all 14 patients. None of the 14 patients developed bowel ischemia or an infarction. Abdominal pain did not recur in any patient during follow-up (mean, 20.6 months; range, 1–54 months). Conclusion Conservative management was successful for all SIDSMA patients, even those with severe compression of the true lumen or complete obstruction of the dissected SMA.

Immediate and middle term outcome of symptomatic spontaneous isolated dissection of the superior mesenteric artery.

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare but fatal condition. Herein, we report the therapeutic outcome of a contemporary series of 12 patients with SIDSMA who were treated with conservative, anticoagulation, or endovascular therapy. Revascularization was measured according to recanalization of the primary arterial occlusive lesion and reperfusion was measured by flow through the occluded vessel. Pain was evaluated by using the visual analog scale (VAS) at admission and at each follow-up visit. Type I SIDSMA was seen in 3 (25%) patients, type IIa in 4 (33.3%) patients, and type IIb in 5 (41.7%) patients. No patient had type III SIDSMA. The false lumens were patent in 6 (50%) patients. Partial thrombosis in the false lumen was demonstrated in CT scans in 5 (41.7%) patients and total thrombosis in 1 (8.3%) patient. Four (33.3%) patients received conservative therapy, and 2 (16.7%) patients received anticoagulation therapy. All six patients resumed normal blood flow in the SMA. The remaining six patients received endovascular stenting. After stent placement, excellent distal blood flow was restored. Abdominal pain was completely resolved in all patients except in one patient. No complications associated with SMA dissection occurred. If bowel perfusion is not compromised and the SMA aneurysm is not likely to rupture in patients with a symptomatic SIDSMA, conservative, or anticoagulation therapy can be considered. If patient has sustained intestinal ischemic symptoms, and severe compression of the true lumen, or dissecting aneurysm likely to rupture, endovascular therapy, or surgery should be adopted.

Endovascular Stent Placement for Treatment of Spontaneous Isolated Dissection of the Superior Mesenteric Artery

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare condition often associated with a poor prognosis. The goal of this study is to assess the efficacy of endovascular treatment of SIDSMA with stenting and investigate the possible therapeutic mechanisms involved. This is a retrospective review of all patients undergoing endovascular treatment of SIDSMA from January 2009 to December 2011. Patient demographics, history, clinical presentation, laboratory tests, image characteristics, endovascular treatments, and follow-up outcome were analyzed. Twenty-four patients with symptoms were treated. All except 1 patient (23 of 24, 96%) underwent successful stent placement (16 with single stent and 7 with overlapping stents). A total of 30 stents (4 balloon-expanded and 26 self-expanding) were placed during the procedures. In the perioperative period and during follow-up, symptom relief was achieved in 20 (83%) patients, and abdominal pain remained unchanged in 4 (17%). No death or serious complications occurred. The median length of hospital stay and follow-up was 3.25 ± 2.23 days (range 2-7 days) and 13.15 ± 8.27 months (range 6-23 months), respectively. Computed tomography angiography (CTA) performed 6 months postoperatively revealed stent patency in 23 cases (100%), false lumen patency in 5 cases (22%), and new development of dissection in the SMA distal to the stent in 1 case (4%). No significant differences were observed in the incidence of false lumen patency between patients treated with a single stent and those treated with overlapping stents, and between patients with and without symptom relief (P > 0.05 for both). For symptomatic SIDSMA patients without intra-abdominal hemorrhage and intestinal infarction, endovascular stent placement is a feasible treatment choice with a high success rate and good clinical outcome. Overlapping stenting may be proposed for patients with aneurysmal dilation. False lumen patency may occur in some cases during follow-up, but it does not affect improvement of SIDSMA symptoms.

Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification

To explore a therapy strategy for the spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) based on morphologic classification. Forty-two symptomatic patients with SIDSMA presenting with abdominal pain between January 2007 and December 2012 were enrolled in this retrospective study. We proposed a new morphologic classification with subtypes depending on the patency of the true lumen and reviewed the patients' clinical features, risk factors, computed tomography images (morphologic classification, location of entry site, dissection length, and true lumen residual diameter), treatment modalities, and follow-up results. Twenty-four patients received only observation treatment, seven received open surgery, and 11 received endovascular therapy. True lumen residual diameter in the observation group (46.6%) was statistically better than that in the surgery group (0%) and the endovascular group (18.3%) (P < .05). There was clinical progression in three and imaging progression in seven of the observation group, of which two patients received endovascular treatment and one patient died of bowel infarction. There were two clinical progressions and one imaging progression in the surgery group, of which two patients received additional surgery and one patient died of bowel infarction. The endovascular group obtained encouraging results with no progressions or complications. Symptomatic patients with SIDSMA are at risk of progression. We suggested a morphologic classification to guide the treatment. We recommend observation treatment with close follow-up for patients with patent true lumen flow and endovascular intervention for high-risk patients with true lumen stenosis or occlusion. Surgery is indicated for patients with suspected bowel infarction or arterial rupture.

Initial and Middle-term Results of Treatment for Symptomatic Spontaneous Isolated Dissection of Superior Mesenteric Artery

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is extremely rare. Various treatment options are currently available, including conservative treatment, endovascular stenting (ES) and surgical repair. Herein, we present our experience in the treatment of symptomatic SIDSMA. A retrospective study was conducted on 17 consecutive patients with symptomatic SIDSMA from May 2002 to May 2012. Conservative treatment consisted of strict blood-pressure control, bowel rest, nasogastric suction, intravenous fluid therapy and nutritional support as required; fasting was released on resolution of abdominal pain, and fluid food was given first; then, diet was resumed after complete resolution of abdominal pain. The decision to intervene was based on patient symptoms and signs, as well as the morphological characteristics of SMA dissection on computed tomography (CT) angiography. Self-expandable stents were placed via the common femoral artery approach. ES was indicated in patients with severe compression of the true lumen or dissecting aneurysm likely to rupture. All patients had acute-onset abdominal pain. Treatment included conservative treatment with the use of anticoagulation in five and without in nine patients, respectively. Three patients with severe compression of the true lumen or large dissecting aneurysm underwent ES as a primary treatment. ES was performed in two patients in whom initial conservative treatment failed. Patients who underwent ES were maintained on anti-platelet therapy for 3 months postoperatively. The median follow-up time was 24 months (range, 2-72 months). No complications were associated with the SIDSMA or ES. The patency of stents was demonstrated on follow-up CT scans up to 8.5 months (range, 4-38 months). Conservative treatment without anticoagulation can be applied successfully to the patients with symptomatic SIDSMA. Our strategy of restricting ES for these patients who have compression of the true lumen or dissecting aneurysm likely to rupture (and for those with failed conservative treatment) was successful.

Current strategy for the treatment of symptomatic spontaneous isolated dissection of superior mesenteric artery

Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is extremely rare. Various treatment options are currently available, including conservative management, anticoagulation, endovascular stenting, and surgical repair. Herein, we present our experience in the treatment of symptomatic SIDSMA. A retrospective study was conducted on 14 consecutive patients with symptomatic SIDSMA between January 2000 and January 2010. All patients had acute onset abdominal pain. The decision to intervene was based on patient symptoms and signs, as well as the morphologic characteristics of superior mesenteric artery (SMA) dissection on computed tomography (CT) angiography. Endovascular stenting (ES) was indicated in patients with severe compression of the true lumen or dissecting aneurysm likely to rupture. Self-expandable stents were placed via a right common femoral approach. None of the patients underwent anticoagulation, and patients who underwent ES were maintained on antiplatelet therapy for 3 months postoperatively. The median age of the study subjects was 59 years (range, 50-75 years). The median follow-up time was 27.5 months (range, 2-64 months). Treatment included conservative management without the use of anticoagulation in seven patients, ES in six, and necrotic bowel resection in one. Four patients with severe compression of the true lumen or large dissecting aneurysm underwent ES as a primary treatment. ES was additionally performed in two patients in whom initial conservative treatment failed (increasing dissecting aneurysm at 7-day follow-up CT scan in one and a reappearance of abdominal pain after resuming diet in the other). The median fasting time was significantly shorter in patients with primary ES (2.5 days) than in those managed conservatively (8.0 days). No complications associated with the SIDSMA or ES were developed. The patency of stents was demonstrated on follow-up CT scans up to 60 months (range, 1-60 months). Conservative management without anticoagulation can be applied successfully to the patients with symptomatic SIDSMA. Primary endovascular stenting is indicated if patients have suspected bowel ischemia, compression of the true lumen of the SMA >80%, or SMA aneurysm of >2.0 cm in diameter on initial CT scan. Endovascular stenting can also be provided to the patients in whom initial conservative treatment failed, as a rescue therapy.