Spontaneous Superior Mesenteric Artery Dissection Research Articles

Spontaneous Coronary Artery Dissection: Does Being Unemployed Matter? Insights from the GSCAD Registry.

BackgroundSpontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome (ACS) and sudden cardiac death. Physical or emotional stressors are the most commonly reported triggers for SCAD. Unemployment has been identified as a source of emotional stress and is linked to poor mental and physical health.ObjectiveTo examine the association between employment status and in-hospital and follow-up adverse cardiovascular events in patients with SCAD.MethodsWe conducted a retrospective, multi-center, observational study of patients undergoing coronary angiography for ACS between January 2011 and December 2017. The total number of patients enrolled was 198,000. Patients were diagnosed with SCAD based on angiographic and intravascular imaging modalities whenever available. There were 83 patients identified with SCAD from 30 medical centers in 4 Arab gulf countries. In-hospital (myocardial infarction, percutaneous intervention, ventricular tachycardia/ventricular fibrillation, cardiogenic shock, death, internal cardioverter/defibrillator placement, dissection extension) and follow-up (myocardial infarction, de novo SCAD, death, spontaneous superior mesenteric artery dissection) cardiac events were compared among those who were employed and those who were not.ResultsThe median age of patients in the study was 44 (37- 55) years. There were 42 (50.6%) female patients, and 41 (49.4) male patients. Of the cohort, 50 (60%) of the patients were employed and the remaining 33 (40%) were unemployed. 66% of all men were employed and 76% of all women were unemployed. After adjusting for gender unemployment was associated with worse in-hospital and follow-up cardiac events (adjusted OR 7.1, [1.3, 37.9]), p = 0.021.ConclusionAdverse cardiovascular events were significantly worse for patients with SCAD who were unemployed.

Abdominal pain at complicated spontaneous superior mesenteric artery dissection

La diseccion espontanea de la arteria mesenterica superior (AMS) es una entidad que se describe como un desgarro o rotura de la intima y de las capas internas de la media permitiendo el paso de sangre creando una luz falsa en la capa media. El diagnostico clinico se establece tras la aparicion de dolor abdominal subito en pacientes con factores de riesgo cardiovascular y su manejo puede ser endovascular o mediante cirugia a cielo abierto, dependiendo de diversos factores que mencionaremos. La clasificacion se describio en base a los hallazgos por TAC. Se presenta el caso de un paciente de 48 anos con diseccion espontanea de la AMS.

The impact of endovascular treatment on clinical outcomes of stable symptomatic patients with spontaneous superior mesenteric artery dissection

ObjectiveTo evaluate the efficacy and clinical outcomes of endovascular treatment for superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with medical management alone after successful initial medical management. MethodsIn this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs, a composite of dissection-related death, the recurrence of mesenteric ischemia symptoms, and a requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA. ResultsA total of 94 patients with SMAD who underwent successful initial medical management (91 males; mean age, 50.4 ± 6.3 years) were enrolled in the study. Fifty-seven (60.6%) received medical management alone, and 37 (39.4%) underwent endovascular repair after initial medical management. In the endovascular group, the technical success rate was 86.5% (32 of 37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain, and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1, 3, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log rank P = .046). ConclusionsEndovascular treatment and medical management alone result in similar MAE-free survival for patients with SMAD after successful initial medical management. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.

Spontaneous Coronary Artery Dissection in the Gulf: G-SCAD Registry

Data on spontaneous coronary artery dissection (SCAD) is based on European and North American registries. We assessed the prevalence, epidemiology, and outcomes of patients presenting with SCAD in Arab Gulf countries. Patients (n = 83) were diagnosed with SCAD based on angiographic and intravascular imaging whenever available. Thirty centers in 4 Arab Gulf countries (Kingdom of Saudi Arabia, United Arab Emirates, Kuwait, and Bahrain) were involved from January 2011 to December 2017. In-hospital (myocardial infarction [MI], percutaneous coronary intervention, ventricular tachycardia/fibrillation, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) cardiac events were recorded. Median age was 44 (37-55) years, 42 (51%) were females and 28.5% were pregnancy-associated (21.4% were multiparous). Of the patients, 47% presented with non-ST-elevation acute coronary syndrome, 49% with acute ST-elevation myocardial infarction, 12% had left main involvement, 43% left anterior descending, 21.7% right coronary, 9.6% left circumflex, and 9.6% multivessel; 52% of the SCAD were type 1, 42% type 2, 3.6% type 3, and 2.4% multitype; 40% managed medically, 53% underwent percutaneous coronary intervention, 7% underwent coronary artery bypass grafting. Females were more likely than males to experience overall (in-hospital and follow-up) adverse cardiovascular events (P = .029).

Clinical Presentation and Outcome of Patients With Spontaneous Coronary Artery Dissection Versus Atherosclerotic Coronary Plaque Dissection.

Atherosclerotic coronary plaque dissection (ACPD) is one cause of acute coronary syndrome (ACS) caused by underlying atherosclerosis. Spontaneous coronary artery dissection (SCAD) occurs outside the setting of atherosclerosis among young women and individuals with few or no conventional atherosclerotic risk factors, and has emerged as an important cause of ACS, and sudden death. A comparison between ACPD and SCAD has not been previously addressed in the literature. Our study will compare ACPD and SCAD. Patients with confirmed diagnosis of SCAD and ACPD were retrospectively identified from 30 centers in 4 Arab Gulf countries between January 2011 and December 2017. In-hospital (ventricular tachycardia/ventricular fibrillation, myocardial infarction (MI), percutaneous coronary intervention, dissection extension, cardiogenic shock, death, implantable cardioverter-defibrillator placement) and follow-up (MI, de novo SCAD, spontaneous superior mesenteric artery dissection, death) events were compared between them. Eighty-three cases of SCAD and 48 ACPD were compared. ACPD patients were more frequently male (91.67% vs. 49.40%, P < 0.001) and older (58.5 vs. 44, P < 0.001). Cardiovascular risk factors were more prevalent in patients with ACPD, including diabetes mellitus (60.4% vs. 25.3%), dyslipidemia (62.5% vs. 38.5%), and hypertension (62.5% vs. 31.3%), P < 0.001. Hospital presentation of ST-elevation MI was diagnosed in 48% of SCAD versus 27% of ACPD patients (P = 0.012). SCAD patients received medical-only treatment in 40% of cases and ACPD in 21% (P = 0.042). In-hospital and follow-up events were comparable in both groups (P = 0.25). Despite a completely different pathophysiology of ACS between SCAD and ACPD, in-hospital and follow-up events were comparable.

The Impact of Endovascular Treatment on Clinical Outcomes of Spontaneous Superior Mesenteric Artery Dissection After Successful Initial Conservative Therapy

The objective was to evaluate the efficacy and clinical outcomes of endovascular treatment of superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with conservative treatment alone after successful initial conservative treatment. In this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs; a composite of dissection-related death, recurrence of mesenteric ischemia symptoms, and requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA. A total of 94 SMAD patients who underwent successful initial conservative treatment (91 male; mean age, 50.4 ± 6.3 years) were enrolled in the study; 57 (60.6%) received conservative treatment alone, and 37 (39.4%) underwent endovascular repair after initial conservative treatment. In the endovascular group, the technical success rate was 86.5% (32/37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1 year, 3 years, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log-rank, P = .046). Endovascular treatment and conservative treatment alone result in similar MAE-free survival for SMAD patients after successful initial conservative therapy. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.Fig 2Kaplan-Meier curve of patients with spontaneous superior mesenteric artery (SMA) dissections (SMADs). A, Cumulative freedom from major adverse events (MAEs); B, freedom from MAEs stratified by group; C, freedom from SMA stenosis or occlusion stratified by group; D, freedom from SMAD rupture or aneurysm stratified by group. The blue line indicates the conservative group; the green line, endovascular group.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Isolated spontaneous superior mesenteric artery dissection: A rare cause of unexplained abdominal pain

AbstractIsolated spontaneous superior mesenteric artery dissection is a rare disease. The natural history of this rare vascular disease is not well established. Herein, we report the case of a 41‐year‐old male presented with intermittent epigastric pain. A computed tomography scan showed a proximal superior mesenteric artery dissection with jejunal branches involvement. The symptom was improved after prostaglandin E1 therapy. A follow‐up of abdominal computed tomography showed stationary lesion of superior mesenteric artery. Gastroenterologists should recognize and pay attention to this rare cause of unexplained abdominal pain. Management of isolated superior mesenteric artery dissection is varied on the clinical presentation. Conservative treatment may be the first choice for the patients without evidence of bowel ischemia.

Ventricular Arrhythmias in Patients with Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome in young women, with a wide clinical spectrum of severity. Ventricular arrhythmia (VA) can occur and worsen prognosis. The current study compared in-hospital and follow-up adverse cardiovascular events in patients with and without VA at presentation. Eighty-three cases of SCAD were collected retrospectively from 4 Gulf countries (KSA, UAE, Kuwait, and Bahrain) during the period from January 2011 to December 2017. We divided the patients into 2 groups: those with and without VA at presentation. VA was defined as ventricular tachycardia and/or ventricular fibrillation. In-hospital (recurrent VA, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared among the 2 groups. The median age of patients in the study was 44 (37-55) years. Forty-two (51%) were women. VA occurred in 10 (12%) patients in the first 24-hour of hospitalization, and 5 (50%) of those patients had recurrent in-hospital VA. Among those with recurrent VA, 1 died during hospitalization and 1 died within the first year following hospital discharge. In-hospital adverse cardiovascular events were significantly more frequent for patients with SCAD who presented with VA. However, follow-up events were not statistically significant between those with and without VA at presentation.

Staged Endovascular Intervention with Ultrasound-Assisted Thrombolysis and Stent Placement for Spontaneous Isolated Superior Mesenteric Artery Dissection with Total Thrombotic Occlusion.

Staged Endovascular Intervention with Ultrasound-Assisted Thrombolysis and Stent Placement for Spontaneous Isolated Superior Mesenteric Artery Dissection with Total Thrombotic Occlusion.

A Rare Cause of Acute Abdomen: Spontaneous Isolated Superior Mesenteric Artery Dissection

A Rare Cause of Acute Abdomen: Spontaneous Isolated Superior Mesenteric Artery Dissection

The value of CT findings for prognostic prediction of spontaneous superior mesenteric artery dissection.

Spontaneous superior mesenteric artery (SMA) dissection is rare cause of acute abdomen. Time-dependent change of SMA dissection has not been established. To determine Sakamoto classification (SC) type of acute and chronic SMA dissection (aSMAD and cSMAD) to predict the treatment methods and outcome. From April 2003 to March 2017, unenhanced and contrast-enhanced CT were used to diagnose acute symptomatic or chronic asymptomatic SMA dissection in 25 consecutive patients without aortic dissection. Correlations between SCs and treatment methods and outcomes were investigated. All 13 patients with aSMAD initially received conservative treatment. Initial SCs in aSMAD were type I = 1, type III = 9, and type IV = 3. Three of nine initial type III and two of three initial type IV changed to type I at follow-up. One of nine type III changed to type II at follow-up. Ohers did not change. One with initial type III required vascular repair, so the final SC was not available. Three patients required bowel resection. In cSMAD of 12 patients, the initial/final SC were type I and IV in ten and two patients, respectively, without change during follow-up. cSMAD was significantly older than aSMAD. The initial length of dissection of aSMAD was longer than in the cSMAD group. In aSMAD, the final length of dissection was significantly shorter than in the initial computed tomography scan. Initial SC differed significantly between aSMAD and cSMAD. Initial SC types in aSMAD were type III and IV mainly, and changed during the observation period. In cSMAD, SC types were I and IV without change.

Clinical Outcomes of Conservative Treatment in Patients with Symptomatic Isolated Spontaneous Renal Artery Dissection and Comparison with Superior Mesenteric Artery Dissection

The aims of this study were to report the clinical outcomes of conservative medical treatment in patients with symptomatic isolated spontaneous renal artery dissection (SRAD) and compare them with those of spontaneous superior mesenteric artery dissection (SSMAD). This was a single centre, observational comparative study between SRAD and SSMAD. Data from a prospective visceral artery dissection registry were analysed retrospectively. Between June 2010 and December 2016, 23 consecutive patients with symptomatic isolated SRAD who initially received conservative medical treatment were included. The primary outcomes were the aggravation of dissection requiring intervention and dissection related mortality. To evaluate the prognosis of symptomatic isolated SRAD, the clinical outcomes of isolated SRAD were compared with those of symptomatic isolated SSMAD (n=40) during the same study period. The primary outcome incidence was 39% (9/23) in patients with symptomatic isolated SRAD during the median follow up period of 20 months (range 0-63 months). The dissection related mortality rate was 17% (4/23), and the cause of death in all cases was an abrupt rupture of the dissecting aneurysm with significant true lumen stenosis. None of the patients without aneurysm or with true lumen occlusion had dissection related mortality. During the same study period, compared with the patients with symptomatic isolated SSMAD who initially received conservative medical treatment, the primary outcome incidence (39% vs. 10%, p=.009) and dissection related mortality rate (17% vs. 0%, p=.016) were statistically significantly higher in patients with symptomatic isolated SRAD. Although the present analysis involved only a small number of patients, it revealed that symptomatic isolated SRAD with dissection related aneurysm and true lumen stenosis is a potentially life threatening condition and that aggressive surgical or endovascular interventions should be considered in these patients, who are refractory to conservative medical treatment.

Clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection

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

Serial Follow-Up Evaluation With Computed Tomography After Conservative Medical Treatment in Patients With Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection.

There is no detailed information available about trend in the morphological change after conservative medical treatment in patients with symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD). We enrolled 27 consecutive patients with symptomatic SISMAD who underwent conservative medical treatment between 2006 and 2015. The long-term prognosis, natural history, and serial follow-up computed tomography (CT) findings of risk factors of rupture such as arterial diameter and false lumen enhancement were retrospectively assessed. Spontaneous isolated superior mesenteric artery dissection usually developed in middle-aged men around 50 years old who had a history of smoking. Follow-up CT was performed at 1 to 6 months, 7 to 12 months, and after 12 months. Superior mesenteric artery (SMA) maximum diameter was 10.3 mm (quartile 9.5-11.3) on initial CT and expanded in 47.1% patients during 1- to 6-month follow-up, which decreased over time ( P < .001 at 7- to 12-month follow-up, P = .001 after 12-month follow-up). On the other hand, false lumen enhancements were revealed in 9 (33.3%) patients on initial CT. The size of false lumen enhancement was expanded in the longest diameter in 35.3% patients and in shortest diameter in 29.4% during 1- to 6-month follow-up. However, the size of false lumen decreased in all patients after 12-month follow-up. All patients were alive without arterial aneurysm rupture and hospital readmission during the median of 523 days (170-799) study period. We demonstrated that both SMA maximum diameter and false lumen enhancement were transiently expanded in some patients during 6-month follow-up, but no longer expanded after 12-month follow-up. Patients with symptomatic SISMAD could be treated medically with scheduled careful follow-up CT evaluations.

Outcomes and Radiographic Findings of Isolated Spontaneous Superior Mesenteric Artery Dissection

Outcomes and Radiographic Findings of Isolated Spontaneous Superior Mesenteric Artery Dissection

Outcomes and Radiographic Findings of Isolated Spontaneous Superior Mesenteric Artery Dissection

This study aimed to investigate the features, treatments, and prognosis of patients with symptomatic and asymptomatic isolated SMA dissection. Data from 35 consecutive patients in whom isolated SMA dissection was diagnosed on computed tomography angiography (CTA) between 2004 and 2015 at two general hospitals in Japan, were collected retrospectively. Nineteen symptomatic patients were compared, and 16 asymptomatic patients with incidentally revealed SMA dissection were also compared. In addition, the vascular remodelling and outcomes during follow-up were evaluated. The patient characteristics in the symptomatic and incidental groups were comparable except for age; mean ages were 55.9±13.9 and 65.3±10.9 years, respectively. Most of the symptomatic patients were managed conservatively (including antiplatelet therapy, anticoagulants, blood pressure control, or bowel rest). In addition, one patient was initially treated by endovascular intervention because of intestinal ischaemia, and another was switched from conservative to surgical treatment. The in-hospital outcome was good with no mortality. In the incidental group, all 16 patients were observed as outpatients without additional treatment. Complete remodelling of the false lumen was observed in 31% of patients with follow-up CTA, and was associated with the presence of symptoms and the absence of false lumen with blood flow at diagnosis. Neither recurrent or new onset abdominal pain, intervention for SMA dissection, nor SMA related death was observed in either group during the follow-up period (750±779 and 1200±951 days). The characteristics of asymptomatic patients with incidentally revealed SMA dissection were comparable with those of symptomatic patients, except for age. During follow-up, factors favouring complete remodelling of false lumens were the presence of symptoms, and the absence of false lumen blood flow at diagnosis.

Isolated Spontaneous Dissection of the Superior Mesenteric Artery: Report of Two Cases

Isolated spontaneous superior mesenteric artery (SMA) dissection is rare, and difficult to diagnose due to nonspecific signs and symptoms. The clinic presentations include abdominal pain, nausea, and vomiting. The incidence appears to be increasing, possibly as a result of the widespread use of computed tomography angiography (CTA) imaging for abdominal pain. There is no consensus regarding the best treatment of spontaneous isolated dissection of the SMA. Herein, we present 2 cases in which isolated superior mesenteric dissection was diagnosed by CTA. The first case received conservative treatment, and the other case received endovascular therapy. Both patients had good long-term clinical results.

Isolated Dissection of the Superior Mesenteric Artery: Case Report

Introduction: The dissection of the superior mesenteric artery (SMA) may occur as a part of aortic dissection or may be rarely isolated. Patients present with vague abdominal pain, particularly beginning after meals. Case Report: In the present report, we want to present a case admitted to the emergency department with an incompatible persistent abdominal pain with physical examination diagnosed, isolated spontaneous SMA dissection and treated conservatively in the light of recent literature. Conclusion: Clinical course in SMA dissection may be different from each other; thus, it is difficult to predict the outcome. Because of this clinical diversity, there are different treatment approaches ranging between conservative treatment, endovascular therapy, and surgical revascularization.

Early Detection of a Rare Case: Idiopathic Spontaneous Superior Mesenteric Artery Dissection, by Duplex Ultrasonography

Spontaneous dissection of the superior mesenteric artery (SMA) without involvement of the aorta is an extremely rare condition. It could be a surgical emergency because ischaemic intestine due to artery occlusion is life-threatening and the prognosis is time-dependent. We present a 55-year-old man with a 5-day history of progressive abdominal pain. He had a negative laboratory work-up and pan-endoscopy showed multiple gastric ulcers. Despite treatment, he had persistent severe epigastric pain disproportionate to physical findings. Bedside duplex ultrasonography revealed the absence of color signal in the proximal SMA. Angiography confirmed the diagnosis of SMA dissection. Mesenteric vascular emergency including arterial dissection should be taken into consideration in patients who present with severe abdominal pain of unknown origin. Abdominal bruit may be the only vital clue but is usually difficult in the noisy emergency department. Duplex ultrasonography can be helpful to detect blood flow abnormality whenever in doubt. (Hong Kong j. emerg.med. 2015;22:189-193)

Diagnosis and treatment of spontaneous isolated superior mesenteric artery dissection: analysis of seven patients

Objective To analyze the CT manifestations of spontaneous isolated superior mesenteric artery dissection (SISMAD) and evaluate the feasibility and efficacy of endovascular stent placement therapy. Methods Seven male patients (mean age,48 years; range,36-62 years) who suffered from SISMAD received endovascular stent placement in our institution.All patients were diagnosed by computed tomographic angiography (CTA).Follow-up was performed with CTA at the first,third and sixth month after discharge.The CT manifestations,clinical results,complications,and follow-up outcomes were reviewed. Results An intimal flap separating the proximal portion of the SMA into stenotic true and dilated false lumina could be seen on all patients' CTA images.Patient No.1 had a concomitant celiac trunk dissection and patient No.2 had a celiac trunk saccular aneurysm.Endovascular stent placement was successfully performed for 7 patients with complete relief of clinical symptoms.Eleven self-expanding stents (6-8 mm in diameter and 30-40 mm in length) were deployed in the SMAs.One stent was used in 3 patients and two stents were used in 4 patients.The concomitant dissection and aneurysm in the celiac trunks were thought to be at risk of rupture,so a self-expanding stent and a covered stent were deployed in the celiac trunks during the same session respectively.During the follow-up period (median,28 months; range,16-42 months),false lumina were thrombosed and disappeared in 6 patients by the end of the third month.One patient who had mild recurrent abdominal pain during the first follow-up month became asymptomatic with continued antiplatelet and anticoagulation therapy for 3 months.CTA showed that the mural thrombosis resulted in stenosis in the proximal segment of the SMA.No thrombosis or stenosis was found in the lumina of the stents. Conclusion Endovascular stent placement is a safe and feasible treatment for SISMAD. Key words: Superior mesenteric artery; Dissection; Stent,endovascula