Guomin Jiang

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

OBJECTIVE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.

Early Endovascular Treatment of Superior Mesenteric Occlusion Secondary to Thromboemboli

OBJECTIVE To evaluate our early experience with endovascular revascularization in patients with acute thromboembolic occlusion of the superior mesenteric artery (SMA). METHODS A retrospective review was conducted of all patients who underwent endovascular revascularization for acute thromboembolic SMA occlusion from May 2005 to May 2012. Endovascular revascularization was performed using aspiration, intra-arterial thrombolysis, and adjunctive stent-placement techniques. Laparotomy was performed if the patient developed clinical signs of advanced bowel ischemia after endovascular procedure. RESULTS Twenty-one patients underwent endovascular revascularization for acute thromboembolic SMA occlusion. All presented with acute-onset abdominal pain. Three patients had rebound tenderness before the procedure. Computed tomography angiography revealed complete occlusion in seven cases and incomplete occlusion in 14 cases, with no evidence of free gas or bowel necrosis. The median duration from onset of symptoms to revascularization was 8.7 ± 4.1 hours (range, 2-18 hours). Completely successful endovascular revascularization occurred in six cases (aspiration alone, 3 cases; combined aspiration and urokinase, 3 cases); partial success was achieved in 15 cases (aspiration alone, 4 cases; combined aspiration and urokinase, 10 cases; and combined aspiration, urokinase, and stent placement, 1 case). Laparotomy was required in five patients, all of whom had SMA main trunk complete occlusion and required small bowel resection. The 30-day mortality for all patients was 9.5%. During a median follow-up of 26 months, 15 patients remained asymptomatic, three patients reported occasional abdominal pain, and one patient had temporary short-bowel syndrome. CONCLUSIONS Percutaneous revascularization is a promising alternative to surgery for acute SMA occlusion in selected patients who have no signs of advanced bowel ischemia. Early diagnosis followed by prompt endovascular intervention with close postprocedural monitoring is key. Laparotomy is indicated in patients who develop new or worsening signs of peritonism after endovascular procedure, particularly in those who had complete occlusion of the main trunk of the SMA.

Ruptured Hepatic Carcinoma After Transcatheter Arterial Chemoembolization

Background Transcatheter arterial chemoembolization (TACE) is recommended as the first-line therapy for unresectable hepatic carcinoma (HCC). Serious complications such as hepatic abscess and hepatic decompensation are well known, but rupture of HCC after TACE is a rare complication. Objective The aim of this study was to identify the associated risk factors and the outcomes resulting from ruptured HCC after TACE. Methods A retrospective analysis was performed in 6 patients who experienced ruptured HCC after TACE. Results All patients underwent chemoembolization after superselective catheterization of the appropriate hepatic artery. The interval between the treatment of TACE and ruptured HCC was 6 to 17 days (mean [SD] 10.33 [4.08] days). Common features in ruptured HCC were large tumor size, location of the tumor adjacent to liver capsular membrane, and complete occlusion of the tumor feeding artery, especially in those with a large amount of iodized oil plus polyvinyl alcohol particles. Two patients underwent emergency embolization, and 4 patients received conservative treatment. Except for 2 patients treated conservatively who died 45 and 68 days after ruptured HCC with hepatic decompensation, the other 4 patients survived to the 6-month follow-up. Conclusions Ruptured HCC after TACE is a rare but serious complication. Large tumor size, location of the tumor adjacent to the liver capsule, and complete occlusion of the feeding artery may be predisposing factors. More research is needed to examine which patients presenting with ruptured HCC after TACE would benefit from conservative or emergency arterial embolization procedures.

Spontaneous Isolated Superior Mesenteric Artery Dissection: Genetic Heterogeneity of Chromosome Locus 5q13-14 in 2 Male Familial Cases

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease that occurs sporadically. In this report, we describe 2 cases of SISMAD involving an uncle and his nephew. Genetic studies revealed the presence of heterogeneity of a chromosome locus at 5q13-14 in 3 family members (the 2 patients and the nephews mother), an area previously found to be linked to familial ascending aortic aneurysms and dissections.

Cerebral lipiodol embolism after transarterial chemoembolization for hepatic carcinoma: A case report

We report a case of cerebral lipiodol embolism (CLE) after transarterial chemoembolization (TACE) for unresectable hepatic carcinoma (HCC). A 54-year-old man with unresectable HCC underwent TACE via the right hepatic artery and right inferior phrenic artery using a mixture of 40 mg pirarubicin and 30 mL lipiodol. His level of consciousness deteriorated after TACE, and non-contrast computed tomography revealed a CLE. The cerebral conditions improved after supportive therapy. The complication might have been due to hepatic arterio-pulmonary vein shunt caused by direct invasion of the tumor. Even though CLE is an uncommon complication of TACE, we should be aware of these rare complications in patients with high risk factors.

A systematic review on the safety and effectiveness of yttrium-90 radioembolization for hepatocellular carcinoma with portal vein tumor thrombosis.

Background/Aim: Over the past two decades, several advances have been made in the management of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT). Yttrium-90 (90Y) radioembolization has recently been made a treatment option for patients with HCC and PVTT. However, there is still a need to systematicly evaluate the outcomes of 90Y radioembolization for HCC and PVTT. We aimed to assess the safety and effectiveness of 90Y radioembolization for HCC and PVTT. We performed a systematic review of clinical trials, clinical studies, and abstracts from conferences that qualified for analysis. Materials and Methods: PubMed, EMBASE, Cochrane Database of Systematic Review, CINAHL, and the “gray” literature (Google Scholar) were searched for all reports (1991-2016) related to 90Y radioembolization for HCC and PVTT. Results: A total of 14 clinical studies and three abstracts from conferences including 722 patients qualified for the analysis. The median length of follow-up was 7.2 months; the median time to progression was 5.6 months, and median disease control rate was 74.3%. Radiological response data were reported in five studies, and the median reported value of patients with complete response, partial response, stable disease, and progressive disease were 3.2%, 16.5%, 31.3%, and 28%, respectively. The median survival was 9.7 months for all patients, including the median overall survival (OS) were 12.1, 6.1 months of Child-Pugh class A and B patients, and the median OS were 6.1, 13.4 months of main and branch PVTT patients, respectively. The common toxicities were fatigue, nausea/vomiting, abdominal pain, mostly not requiring medical intervention needed no medication intervention. Conclusions: 90Y radioembolization is a safe and effective treatment for HCC and PVTT.

The Classification and Management Strategy of Spontaneous Isolated Superior Mesenteric Artery Dissection

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is an uncommon but potentially catastrophic pathology. Multiple classification schemes have been proposed for this occurrence. Although no consensus has emerged regarding which classification should be used, Lis classification scheme is more precise and complete compared to other classification systems and can be used to guide the treatment of SISMAD. Initial conservative treatment is promising, with favorable early and long-term outcomes for most patients; endovascular treatment is recommended for patients with persistent/recurrent symptoms after conservative treatment; surgical treatment should be performed without delay for patients with arterial rupture, intestinal necrosis, or failed endovascular treatment.

Supplemental conventional transarterial embolization/chemoembolization therapy via extrahepatic arteries for hepatocellular carcinoma

PURPOSE To assess the value of conventional transarterial embolization/chemoembolization (cTAE/TACE) therapy via extrahepatic arteries for patients with unresectable hepatocellular carcinoma (HCC). METHODS Patients with unresectable HCC who underwent cTAE/TACE therapy via extrahepatic arteries between May 2008 and July 2016 across 4 medical centers were identified. The technical success, serum alpha-fetoprotein (AFP) levels changes, tumor response, disease control rate, survival rate, and major complication were analyzed. RESULTS A total of 185 patients (167 male and 18 female) were included in this study. A total of 401 procedures were performed of the 185 patients, with 2.2 ± 0.4 procedures for each patient. A total of 197 extrahepatic arteries were identified, including inferior phrenic artery (n = 80), omental artery (n = 39), gastric artery (n = 22), right renal capsular artery (n = 21), adrenal artery (n = 13), cystic artery (n = 11), and right internal mammary artery (n = 11). The technical success rate was 96.8% (179/185). The serum AFP levels were significantly reduced at 1 month after treatment in 71 patients whose AFP ≥400 ng/mL preprocedure (P < 0.01). The disease control rate was 93% (172/185) at 3 months after cTAE/TACE, with partial response, stable disease, or progressive disease of 115, 57, and 13 patients, respectively. The cumulative survival rate from the time of cTAE/TACE via extrahepatic arteries was 100% at 6 months. There were no embolization-related major complications. CONCLUSION cTAE/TACE therapy via the extrahepatic arteries can reduce the incidence of presence of residual HCC, and improve the therapeutic efficacy of cTAE/TACE.

Regarding “Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience”

We read with great interest the recent article by Raupach et al. [1]. The authors raised an important issue on the endovascular management of acute embolic occlusion of the superior mesenteric artery (SMA). The authors reported that two patients with the flow limiting stenosis of the main stem of the SMA after aspiration received stent placement; also, they made an algorithm for the treatment of acute embolic SMA occlusion (Table 3). We would like to elaborate on the stent placement in the stem of the SMA and the algorithm. Acosta et al. [2] reported a group of patients who received endovascular management of acute SMA occlusion, and the results of adjunctive local thrombolysis (rtPA at a rate of 0.5–1 mg/h) for incomplete aspiration embolectomy with residual clot were great. Also, the results of adjunctive local thrombolysis were proved in our report [3]. According to the authors report, two patients with the flow limiting stenosis of the main stem of the SMA after aspiration received stent placement [2]. Although stenting achieves good results initially, restenosis of the side branches or even obstruction in the stented segment is inevitable in the long-term follow-up [4]. We believe the two cases should receive adjunctive local thrombolysis after aspiration, and then stenting if aspiration and local thrombolysis fail. In the algorithm, the (aspiration ? stenting ? thrombolysis) is confusing; the authors should declare aspiration as an initial treatment, and adjunctive local thrombolysis should be performed if aspiration fails, and stenting is a treatment choice if both aspiration and adjunctive local thrombolysis fail.

Commentary Regarding “Computed Tomography Imaging Features and Classification of Isolated Dissection of the Superior Mesenteric Artery”

Isolated superior mesenteric artery dissection (SMAD) is a pleiomorphic disease. A systematic approach requires adequate classification. The purpose of classification is to organize patients into groups, which should be clinically informative in order to assist medical decision making. Four classification systems, which were all devised based on the imaging appearance of the SMAD, have been proposed over recent years; however, no consensus has emerged regarding which classification system should be used. Sakamoto et al. categorized SMAD into four types. However, they did not consider the type of total thrombotic occlusion of the SMA. Yun et al. categorized SMAD into three types, but they did not consider thrombosed false lumen with ulcer-like projection. Zerbib et al. categorized SMAD into six types. However, SMAD with retrograde propagation of the false lumen to the SMA ostium wasn’t addressed. Luan and Li categorized SMAD into four types, but they did not consider the true and the false lumen itself, such as the shape, the thrombosed false lumen, and stenosis of the true lumen. The main anatomic and physio-pathologic features of SMADs are the location, extent of the false lumen, and the distinction between thrombosed or not false and true lumen. All four classification systems take into account some of these anatomic features. However, they are all incomplete. What we need is a simple system that allows exhaustive description of all anatomic types of SMADs and meets both the capabilities of modern imaging techniques and the demands of an ever-growing treatment armamentarium.