Optimal management strategy for spontaneous isolated dissection of a visceral artery

Objectives To describe our clinical experiences and recommend a management strategy for spontaneous isolated dissection of a visceral artery. Methods A retrospective study of patients from December 2005 to December 2015 was performed. Thirty-two patients had spontaneous isolated dissection of a visceral artery. Clinical features, computed tomography findings, the treatment method, and follow-up results were evaluated. Results There were 28 men and 4 women (mean age, 54 years). Dissection locations were the celiac artery in 10, superior mesenteric artery in 17, and celiac artery and superior mesenteric artery in 5 patients. Celiac artery stenosis existed with spontaneous isolated dissection of a visceral artery at a high rate. After diagnosis, the blood pressure of all patients was immediately controlled to a lower level. Three patients with arterial rupture and one patient with bowel infarction underwent operations for complications. Overall, the treatment of dissection involved drug therapy alone. The last follow-up computed tomography results of the true lumen residual ratio and the length of the dissected artery improved compared to the values on admission; the maximum diameter of the dissected artery did not enlarge. Eleven patients almost completely improved. No patients had any adverse event. Conclusions Most patients with spontaneous isolated dissection of a visceral artery can be first treated conservatively for dissection with strict blood pressure control and surveillance.

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

Vascular and Endovascular Surgery ◽

10.1177/1538574417729271 ◽

2017 ◽

Vol 51 (8) ◽

pp. 538-544 ◽

Cited By ~ 5

Author(s):

Toshihisa Ichiba ◽

Masahiko Hara ◽

Keiji Yunoki ◽

Masaki Urashima ◽

Hiroshi Naitou

Keyword(s):

Computed Tomography ◽

Medical Treatment ◽

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

False Lumen ◽

Maximum Diameter ◽

Artery Dissection ◽

Arterial Aneurysm ◽

Superior Mesenteric Artery Dissection

Objective: 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). Methods: 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. Results: 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. Conclusion: 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.

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Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

Scandinavian Journal of Surgery ◽

10.1177/14574969211000546 ◽

2021 ◽

pp. 145749692110005

Author(s):

S. Acosta ◽

F. B. Gonçalves

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Conservative Therapy ◽

Case Series ◽

Celiac Artery ◽

Artery Dissection ◽

Covered Stents ◽

Bowel Infarction

Background and Aims: There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited. Material and Methods: The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis. Results and Conclusions: Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

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Percutaneous mechanical thrombectomy of superior mesenteric artery embolism

Radiology and Oncology ◽

10.2478/raon-2013-0029 ◽

2013 ◽

Vol 47 (3) ◽

pp. 239-243 ◽

Cited By ~ 12

Author(s):

Dimitrij Kuhelj ◽

Pavel Kavcic ◽

Peter Popovic

Keyword(s):

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Mechanical Thrombectomy ◽

Long Term Results ◽

Successful Outcome ◽

Bowel Infarction ◽

Intestinal Infarction ◽

Percutaneous Mechanical Thrombectomy ◽

Artery Embolism

Abstract Background. The present series present three consecutive cases of successful percutaneous mechanical embolectomy in acute superior mesenteric artery ischemia. Superior mesenteric artery embolism is a rare abdominal emergency that commonly leads to bowel infarction and has a very high mortality rate. Prompt recognition and treatment are crucial for successful outcome. Endovascular therapeutic approach in patients with acute SMA embolism in median portion of its stem is proposed. Case reports. Three male patients had experienced a sudden abdominal pain and acute superior mesenteric artery embolism in median portion of its stem was revealed on computed tomography angiography. No signs of intestinal infarction were present. The decision for endovascular treatment was made in concordance with the surgeons. In one patient 6 French gauge Rotarex® device was used while in others 6 French gauge Aspirex® device were used. All patients experienced sudden relief of pain after the procedure with no signs of intestinal infarction. Minor procedural complication - rupture of a smaller branch of SMA during Aspirex® treatment was successfully managed by coiling while transient paralytic ileus presented in one patient resolved spontaneously. All three patients remained symptom-free with patent superior mesenteric artery during the follow-up period. Conclusions. Percutaneous mechanical thrombectomy seems to be a rapid and effective treatment of acute superior mesenteric artery embolism in median portion of its stem in absence of bowel necrosis. Follow-up of our patients showed excellent short- and long-term results.

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Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries

Vascular ◽

10.1177/1708538119893827 ◽

2019 ◽

Vol 28 (2) ◽

pp. 142-151

Author(s):

Shelley Maithel ◽

Areg Grigorian ◽

Roy M Fujitani ◽

Nii-Kabu Kabutey ◽

Brian M Sheehan ◽

...

Keyword(s):

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Inferior Mesenteric Artery ◽

Celiac Artery ◽

Visceral Artery ◽

Trauma Patients ◽

Mechanism Of Injury ◽

Artery Injury ◽

Risk Of Mortality ◽

Increased Risk

Objectives Celiac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients. Methods The Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed. Results From 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34). Conclusions Compared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.

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Multidetector computed tomography in the diagnosis of spontaneous isolated superior mesenteric artery dissection: changes in diameter on nonenhanced scan and stent treatment follow-up

Journal of International Medical Research ◽

10.1177/0300060519860328 ◽

2019 ◽

Vol 47 (12) ◽

pp. 6139-6148

Author(s):

Weiqiang Yan ◽

Rong Huang ◽

Qiao Shi ◽

Huiming Shan ◽

Yi Zhu ◽

...

Keyword(s):

Computed Tomography ◽

Superior Mesenteric Artery ◽

Multidetector Computed Tomography ◽

Mesenteric Artery ◽

Artery Dissection ◽

Control Group ◽

Clinical Value ◽

Stent Patency ◽

Significant Difference

Objective This study was performed to assess the changes in diameter of the superior mesenteric artery (SMA) in patients with spontaneous isolated SMA dissection (SISMAD) on nonenhanced multidetector computed tomography (MDCT) and determine the clinical value of follow-up MDCT after endovascular stent placement (ESP). Methods The diameters of the SMA and superior mesenteric vein (SMV) as measured on nonenhanced MDCT were compared between 20 patients with SISMAD and 20 control subjects. ESP was performed in 14 patients with SISMAD, and follow-up MDCT was performed after ESP. Results The mean diameter of the SMA in the SISMAD group and control group was 11.69 ± 1.26 and 7.10 ± 0.97 mm, respectively, with a statistically significant difference. The SMA diameters were even larger than the SMV diameters. Follow-up MDCT showed stent patency in 13 patients and occlusion in 1 patient. Conclusions An enlarged diameter of the SMA on nonenhanced MDCT is an important finding for diagnosis of SISMAD, and MDCT is a valuable follow-up method after ESP for SISMAD.

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Visceral Mycotic Aneurysm: Superior Mesenteric Artery Aneurysm Caused by K. pneumoniae

Dubai Medical Journal ◽

10.1159/000517222 ◽

2021 ◽

pp. 1-4

Author(s):

Reham Almasoud ◽

Alaaeddin Nwilati ◽

Saeb Bayazid ◽

Mamoun Shafaamri

Keyword(s):

Infectious Disease ◽

Antibiotic Therapy ◽

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Mycotic Aneurysm ◽

Artery Aneurysm ◽

Management Plan ◽

Resected Tissue ◽

Infectious Disease Specialists

We herein report a rare case of mycotic aneurysm of the superior mesenteric artery caused by <i>Klebsiella pneumoniae</i>. A 66-year-old man, a known case of hypertension and aorto-oesophageal fistula with stented aorta in 2010 and 2018, presented to the emergency department multiple times over 2 months with severe postprandial abdominal pain associated with vomiting and fever. On his last presentation, the obtained blood cultures grew ESBL positive <i>K. pneumoniae</i> and a repeated computed tomography (CT) showed a growing aneurysm at the origin of the ileocecal branch of the superior mesenteric artery measuring 17 × 10 mm (the aneurysm was 8 × 7.5 mm in the CT angiography on the previous admission). Extensive workup did not reveal the underlying cause of the mycotic aneurysm, thus we believe the cause to be the infected aortic stent, leading to bacteraemia and vegetations to the mesenteric artery causing the aneurysm. The management plan was placed by a multidisciplinary team consisting of vascular surgeons and infectious disease specialists along with review from a dietician to evaluate the patient’s nutritional status. The patient was started on total parenteral nutrition due to his postprandial pain and on antibiotic therapy according to the infectious disease team’s recommendation. He underwent surgical resection of the mycotic aneurysm, which showed a thrombosed aneurysm in the jejunoileal mesenteric area. The histopathology of the resected tissue demonstrated inflammatory aneurysm of the mesenteric artery. Following the surgery, the patient continued his antibiotic therapy and was discharged on the 13th post-operative day with follow-up appointments in the vascular surgery and infectious disease clinic.

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Anomalous arterial supply to the gallbladder from the superior mesenteric artery: angiography and computed tomography findings in two cases

Acta Radiologica ◽

10.1080/02841850802282829 ◽

2008 ◽

Vol 49 (9) ◽

pp. 987-990 ◽

Cited By ~ 1

Author(s):

Y. Katada ◽

M. Kishino ◽

K. Ishihara ◽

T. Takeguchi ◽

H. Shibuya

Keyword(s):

Computed Tomography ◽

Superior Mesenteric Artery ◽

Hepatic Artery ◽

Mesenteric Artery ◽

Cystic Artery ◽

Arterial Supply ◽

Hepatic Arteries ◽

Right Hepatic Artery ◽

Pancreatic Artery ◽

The Right

The arterial supply of the gallbladder usually arises from the right hepatic artery. Other origins include the left, proper, and common hepatic arteries. We report cases of the cystic artery arising from the superior mesenteric artery and arising from the dorsal pancreatic artery originating in turn from the superior mesenteric artery, as demonstrated by angiography and computed tomography.

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Computed tomography of the superior mesenteric artery syndrome

Clinical Imaging ◽

10.1016/s0899-7071(96)00027-7 ◽

1997 ◽

Vol 21 (3) ◽

pp. 210-212 ◽

Cited By ~ 7

Author(s):

G.C. Ooi ◽

K.L. Chan ◽

K.F. Ko ◽

W.C.G. Peh

Keyword(s):

Computed Tomography ◽

Superior Mesenteric Artery ◽

Mesenteric Artery ◽

Superior Mesenteric Artery Syndrome

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Hypotensive and Regional Haemodynamic Effects of Exercise, Fasted and after Food, in Human Sympathetic Denervation

Clinical Science ◽

10.1042/cs0940049 ◽

1998 ◽

Vol 94 (1) ◽

pp. 49-55 ◽

Cited By ~ 11

Author(s):

Sharmini Puvi-Rajasingham ◽

Gareth D. P. Smith ◽

Adeola Akinola ◽

Christopher J. Mathias

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Superior Mesenteric Artery ◽

Vascular Resistance ◽

Mesenteric Artery ◽

Autonomic Failure ◽

Sympathetic Denervation ◽

Stroke Distance

1. In human sympathetic denervation due to primary autonomic failure, food and exercise in combination may produce a cumulative blood pressure lowering effect due to simultaneous splanchnic and skeletal muscle dilatation unopposed by corrective cardiovascular reflexes. We studied 12 patients with autonomic failure during and after 9 min of supine exercise, when fasted and after a liquid meal. Standing blood pressure was also measured before and after exercise. 2. When fasted, blood pressure fell during exercise from 162 ± 7/92 ± 4 to 129 ± 9/70 ± 5 mmHg (mean arterial pressure by 22 ± 5%), P < 0.0005. After the meal, blood pressure fell from 159 ± 8/88 ± 6 to 129 ± 6/70 ± 4 mmHg (mean arterial pressure by 22 ± 3%), P < 0.0001, and further during exercise to 123 ± 6/61 ± 3 mmHg (mean arterial pressure by 9 ± 3%), P < 0.01. The stroke distance—heart rate product, an index of cardiac output, did not change after the meal. During exercise, changes in the stroke distance—heart rate product were greater when fasted. 3. Resting forearm and calf vascular resistance were higher when fasted. Calf vascular resistance fell further after exercise when fasted. Resting superior mesenteric artery vascular resistance was lower when fed; 0.19 ± 0.02 compared with 032 ± 0.06, P < 0.05. After exercise, superior mesenteric artery vascular resistance had risen by 82%, to 0.53 ± 0.12, P < 0.05 (fasted) and by 47%, to 0.29 ± 0.05, P < 0.05 (fed). 4. On standing, absolute levels of blood pressure were higher when fasted [83 ± 7/52 ± 7 compared with 71 ± 2/41 ± 3 (fed), each P < 0.05]. Subjects were more symptomatic on standing post-exercise when fed. 5. In human sympathetic denervation, exercise in the fed state lowered blood pressure further than when fasted and worsened symptoms of postural hypotension.

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