Yuki Seto

Management Strategy of Isolated Spontaneous Dissection of the Superior Mesenteric Artery

OBJECTIVE Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. METHODS A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years). RESULTS We categorized SMA dissection into the six types according to the Sakamotos and Zerbibs classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months. CONCLUSION Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

A Case Report of Aneuysmectomy after Thrombo-Intimectomy for Spontaneous Isolated Superior Mesenteric Artery Dissection

A 53 year-old man was admitted with acute onset of severe abdominal pain, and we performed emergent thrombectomy and intimectomy for acute, complete occlusion of superior mesenteric artery (SMA) due to its spontaneous dissection. However, 4 months later the operated part of the SMA enlarged due to aneurysm and the patient was treated by aneuysmectomy and iliac-mesenteric bypass using a saphenous vein. Aggressive treatment such as surgical or endovascular procedure is necessary for severe ischemia due to SMA dissection.

Short-term and long-term outcomes of octogenarians after off-pump coronary artery bypass surgery

PurposeOff-pump coronary artery bypass has been reported to be associated with reduced morbidity and mortality after surgical coronary revascularization, especially in high-risk patients. The aim of this study was to clarify the efficacy of off-pump coronary artery bypass for the very elderly patients.MethodsWe compared the outcomes of octogenarians (n = 28, 82 ± 2 years) undergoing off-pump coronary artery bypass and those of the patients <80 years of age (n = 315, 67 ± 9 years) during short- and long-term periods.ResultsThere was no difference in hospital mortality between octogenarians and the younger cohort (3.8% vs. 0.6%; P = 0.11). A high rate of postoperative complications (e.g., pneumonia, transient renal dysfunction, ventricular arrhythmia) were observed in the octogenarians. The long-term survival (81% at 5 years) and the rate of freedom from cardiac death (92% at 5 years) and from cardiac events (85% at 5 years) were excellent in the octogenarians; they appeared less favorable, however, when compared with the younger group (95%, 98%, and 94% at 5 years, respectively). Most of the cardiac adverse events, including unexplained sudden death, occurred 6 months after the surgery in octogenarians.ConclusionOff-pump coronary artery bypass can be performed safely in octogenarians, with excellent early and late outcomes. Careful postoperative follow-up is required to reduce postoperative long-term adverse events. Off-pump coronary artery bypass is a feasible modality of coronary revascularization for octogenarians.