Han Jt

Vasodilator and endovascular therapy for isolated superior mesenteric artery dissection

OBJECTIVE We report our experience in the treatment of isolated superior mesenteric artery dissection and review the clinical and imaging features reported in the literature. METHODS A retrospective study was conducted of 18 consecutive patients with isolated superior mesenteric artery dissection who presented at the Peking University Third Hospital between September 2008 and May 2012. Their clinical characteristics, including age, sex, medical history, risk factors, symptoms, diagnostic imaging modality, and treatment, were analyzed. Also reviewed were 278 patients with isolated superior mesenteric artery dissection reported in the English language literature. The epidemiology, mechanism, clinical presentation, imaging features, and treatment were discussed. RESULTS There were 14 men and four women with a mean age of 55.6 years (range, 41-84 years). Four patients were asymptomatic, and 14 presented with acute-onset abdominal pain. The diagnosis was established by contrast-enhanced computed tomography in 17 patients and ultrasound imaging in one patient. All dissections were located at the anterior wall and around the convex curvature of the superior mesenteric artery. The decision to intervene was based on symptoms. Three asymptomatic patients underwent successful conservative management, and one asymptomatic patient with an aneurysmal dilated false lumen underwent endovascular stent placement. For the 14 symptomatic patients, definitive treatment included catheter-directed infusion of a vasodilator in four and stent placement combined with catheter-directed infusion of a vasodilator in 10, of whom one patient underwent hybrid stent placement. No complications or deaths occurred. During the mean 14.9-month (range, 1-40 month) follow-up period, all patients were asymptomatic, and patency of the superior mesenteric artery was demonstrated by contrast-enhanced computed tomography scan. CONCLUSIONS Conservative management can be applied to asymptomatic patients with isolated superior mesenteric artery dissection. For symptomatic patients, stent placement is the definitive treatment if there is no arterial rupture or intestinal necrosis. Self-expanding bare stents that completely cover the curvature of the superior mesenteric artery are recommended. Catheter-directed infusion of a vasodilator can be an effective accessional process after stent placement.

Hybrid treatment of isolated dissection of the superior mesenteric artery.

Editor: The current treatment for isolated dissection of the superior mesenteric artery (SMA) includes conservative, surgical, and endovascular procedures. We describe a case of isolated dissection of the SMA treated by hybrid stent placement. A 48-year-old man presented at another hospital with acute periumbilicus pain. After treatment with fasting and vasodilation, the pain decreased but continued. After 27 days, the pain was suddenly exacerbated. The patient was transferred to our hospital. He had no past medical history. On physical examination, temperature, blood pressure, and heart rate were within normal ranges. The patient had epigastrium tenderness without tension and rebound pain. The bowel sounds were decreased. Laboratory tests were unremarkable except that fecal occult blood was positive. An abdominal plain film showed mild dilation and mild air-fluid levels in the small intestine. Contrast-enhanced computed tomography (CT) scan demonstrated isolated dissection of the SMA. The distance from the SMA orifice to the beginning of the dissection was 1.0 mm. The proximal part of the false lumen was dilated similar to a saccular aneurysm, measuring 8 mm 17 mm. The distal part was filled with thrombus. The true lumen was totally obstructed. The dissection extended to the terminal of the SMA trunk, with a length of 100.0 mm. The distal ileal and ileocolic branches were developed by collateral circulation (Fig, a, b). However, no signs of arteriosclerosis or intestinal necrosis were found. Emergent angiography was performed, using a right femoral artery approach under local anesthesia. The true lumen of the SMA was absent, and the false lumen showed saccular dilation. The distal branches of the SMA were retrograde developed by the arc of Riolan and the marginal artery of the mesentery. After administering a heparin bolus (6,000 IU), a 7-F guiding catheter (length 55 cm; Cordis, Miami Lakes, Florida) was introduced into the abdominal aorta and