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

• Published in: Journal of vascular surgery Vol. 54; no. 2; pp. 461 - 466
• Main Authors: Min, Sang-Il, MD, Yoon, Kyung-Chul, MD, Min, Seung-Kee, MD, PhD, Ahn, Sang Hyun, MD, Jae, Hwan Joon, MD, PhD, Chung, Jin Wook, MD, PhD, Ha, Jongwon, MD, PhD, Kim, Sang Joon, MD, PhD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.08.2011; Elsevier
• Subjects: Abdominal Pain - etiology; Aged; Algorithms; Aneurysm, Dissecting - complications; Aneurysm, Dissecting - diagnostic imaging; Aneurysm, Dissecting - surgery; Aneurysm, Dissecting - therapy; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Chi-Square Distribution; Decision Trees; Digestive System Surgical Procedures - adverse effects; Diseases of the aorta; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Female; Humans; Ischemia - complications; Ischemia - diagnostic imaging; Ischemia - surgery; Ischemia - therapy; Male; Medical sciences; Mesenteric Artery, Superior - diagnostic imaging; Mesenteric Ischemia; Middle Aged; Platelet Aggregation Inhibitors - administration & dosage; Republic of Korea; Retrospective Studies; Stents; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Vascular Diseases - complications; Vascular Diseases - diagnostic imaging; Vascular Diseases - surgery; Vascular Diseases - therapy; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Cardiovascular disease; Treatment; Superior mesenteric artery; Surgery
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2011.03.001

Objective 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. Methods 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. Results 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). Conclusions 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.