Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 190-193

Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery


Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. S Roshan Rodney
Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_91_18

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  Abstract 


Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition often presenting with vague signs and symptoms. Although the disease entity is rare, the potential for morbidity and mortality is high. Computed tomographic angiography is the preferred imaging modality for identification of SID-SMA. It may be managed by conservative, surgical, or endovascular treatment based on clinical presentation, but there is no general consensus regarding the treatment strategy. Here, we describe a case of SID of SMA treated successfully with percutaneous endovascular stent placement.

Keywords: Computed tomography angiography, endovascular, spontaneous isolated dissection of superior mesenteric artery, stenting


How to cite this article:
Rodney S R, Vivekanand, Vishnu M, Raj S, Chaudhari H, S Sravan C P, Lende V, Vishal H, Krishna K S, Nishan B. Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery. Indian J Vasc Endovasc Surg 2019;6:190-3

How to cite this URL:
Rodney S R, Vivekanand, Vishnu M, Raj S, Chaudhari H, S Sravan C P, Lende V, Vishal H, Krishna K S, Nishan B. Endovascular stenting of spontaneous isolated dissection of superior mesenteric artery. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Nov 18];6:190-3. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/190/265785




  Introduction Top


Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA), without associated aortic dissection, is regarded as a clinically rare disease. This condition often manifests as acute abdomen.[1] The incidence is relatively increasing as a result of advances in computed tomography (CT) resolution and development of new imaging technologies. Treatment options range from observation to anticoagulation to open surgery or endovascular repair.[2],[3] We present a case of SID-SMA managed by endovascular intervention.


  Case Report Top


A 57-year-old male patient, nonsmoker, hypertensive for 5 years, presented with complaints of upper abdominal pain for 12 days. He had a past history of left renal calculus for which he had undergone lithotripsy in 2015. On admission, he was hemodynamically stable with mild epigastric tenderness. Contrast-enhanced CT abdomen of abdominal aorta revealed dissection in the SMA starting approximately 2 cm from its origin [Figure 1]. He was initially treated in an outside hospital with analgesics and antiplatelets, but in view of persistent pain, he referred to us for further management. Selective SMA angiogram confirmed the presence of a focal dissection of the SMA 2 cm from the ostia, with minimal compression of the true lumen by the partially thrombosed false lumen [Figure 2]. SMA stenting was done with 5 mm × 60 mm self-expanding stent [Figure 3] and [Figure 4]. His perioperative period was uneventful, and he improved symptomatically. He was discharged home with dual antiplatelets and was symptom free during follow-up.
Figure 1: Preoperative (computed tomography) angiogram with three-dimensional reconstruction showing isolated superior mesenteric artery dissection

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Figure 2: Intraoperative angiogram – superior mesenteric artery dissection with partial false-lumen thrombosis

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Figure 3: Poststent angio showing complete obliteration of the false lumen

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Figure 4: Angiogram showing good flow through the stent in the superior mesenteric artery

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  Discussion Top


SID-SMA is a rare condition with an incidence of 0.06% based on a series of autopsy cases.[4] The first case of SID-SMA was reported by Bauersfeld in 1947.[5] With the increasing use of contrast-enhanced CT, a growing number of cases with SID-SMA have been reported in recent years. Usually, the entry point of an SMA dissection starts at 1.5–3 cm from the ostia because this is the zone where the relatively fixed retropancreatic SMA becomes mobile at the mesenteric root. Local shear stress induced by the pancreas at this zone has been postulated as one of the accepted hypotheses for SMA dissection.[6] High blood pressure, smoking, and atherosclerosis have been considered the main risk factors for SID-SMA. Hence, blood pressure control is very important in reducing the distal progression of the SMA dissection and to prevent rupture.[7],[8] Sakamoto et al.[9] and subsequently Yun et al.[10] classified SID-SMA based on angiographic appearance as Type I – patent true and false lumens with visible entry and re-entry sites; Type IIa – patent true and false lumens with visible entry but no visible re-entry (blind pouch of false lumen); Type IIb – patent true lumen but thrombosed false lumen without visible re-entry which usually causes true luminal narrowing; and Type III – confirmed SMA dissection with occluded true and false lumens [Figure 5].
Figure 5: Angiographic classification of spontaneous isolated dissection of the superior mesenteric artery. Reproduced from Yun et al.

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SMA dissection may be completely asymptomatic or present as acute abdomen. In cases of chronic dissection with a compromised true lumen, patients may present with symptoms of postprandial pain and weight loss.[11] Rupture of the dissected SMA leads to hemorrhagic shock and even death. Due to the disease rarity, a high index of clinical suspicion is needed for diagnosis and treatment.[12],[13] CT angiography (CTA) is the investigation of choice to confirm the clinical suspicion, locate the entry point, and delineate the extension of the dissection. CTA may serve as a guide to decide on the treatment modality, conservative or operative.[14] Most patients with SID-SMA may experience a self-limited course, but it is also potentially fatal because of major complications such as the rupture of the dissection or secondary intestinal ischemia and infarction.[15] Treatment options include blood pressure control, antiplatelet therapy, anticoagulation, endovascular stenting, and surgical repair.[16],[17] Treatment objectives in SID-SMA are to limit the extension of dissection, to preserve the blood flow distally through the true lumen, and to prevent the rupture of the SMA, which can be achieved by the thrombosis and obliteration of the false lumen.[18] To date, there are no consensus guidelines regarding the best management of SID-SMA due to rarity of cases.[19],[20],[21]

Endovascular stent placement in the management of SID-SMA was first described by Leung et al.[22] Many clinical reports claim endovascular stent placement as efficacious providing immediate symptomatic improvement by obliterating the false lumen and increasing blood flow into the small intestine and preventing further progression of the SMA dissection.[23],[24],[25],[26],[27],[28],[29] Limitations to endovascular treatment of SID-SMA are occasional difficulty to find the entry site of SMA dissection. Moreover, the long-term results, such as the risk of restenosis and reocclusion of the stented segments, have yet to be determined.

In our patient, endovascular stent placement was performed as the initial treatment of choice attributing to its benefit of rapid relief of symptoms.


  Conclusion Top


Endovascular stent placement is a safe alternative to surgery or uncertain observation in the treatment armamentarium of SID-SMA. Endovascular stenting may be preferred in patients with SID-SMA without peritoneal signs for whom initial conservative treatment has failed. Long-term follow-up is necessary for evaluating the effectiveness of endovascular intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yu Z, Kondo N, Chiyoya M, Suzuki Y, Fukuda I. Selection and determination of treatment for the spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Dis 2018;11:101-5.  Back to cited text no. 1
    
2.
Kim H, Park H, Park SJ, Park BW, Hwang JC, Seo YW, et al. Outcomes of spontaneous isolated superior mesenteric artery dissection without antithrombotic use. Eur J Vasc Endovasc Surg 2018;55:132-7.  Back to cited text no. 2
    
3.
Barnes S, Kushner B. Isolated dissection of the superior mesenteric artery. Clin Pract Cases Emerg Med 2018;2:43-6.  Back to cited text no. 3
    
4.
Georgios Th. Galanopoulos, Konstantopoulos TP, Christakis IA, Antonopoulos PA, Papavassiliou VG. Arare cause of acute abdominal pain: Spontaneous isolated superior mesenteric artery dissection. Int Surg J 2018;5:2623-6.  Back to cited text no. 4
    
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Bauersfeld SR. Dissecting aneurysm of the aorta; a presentation of 15 cases and a review of the recent literature. Ann Intern Med 1947;26:873-89.  Back to cited text no. 5
    
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Akuzawa N, Kurabayashi M, Suzuki T, Yoshinari D, Kobayashi M, Tanahashi Y, et al. Spontaneous isolated dissection of the superior mesenteric artery and aneurysm formation resulting from segmental arterial mediolysis: A case report. Diagn Pathol 2017;12:74.  Back to cited text no. 6
    
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DeCarlo C, Ganguli S, Borges JC, Schainfeld RM, Mintz AJ, Mintz J, et al. Presentation, treatment, and outcomes in patients with spontaneous isolated celiac and superior mesenteric artery dissection. Vasc Med 2017;22:505-11.  Back to cited text no. 7
    
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Heo SH, Kim YW, Woo SY, Park YJ, Park KB, Kim DK, et al. Treatment strategy based on the natural course for patients with spontaneous isolated superior mesenteric artery dissection. J Vasc Surg 2017;65:1142-51.  Back to cited text no. 8
    
9.
Sakamoto I, Ogawa Y, Sueyoshi E, Fukui K, Murakami T, Uetani M, et al. Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery. Eur J Radiol 2007;64:103-10.  Back to cited text no. 9
    
10.
Yun WS, Kim YW, Park KB, Cho SK, Do YS, Lee KB, et al. Clinical and angiographic follow-up of spontaneous isolated superior mesenteric artery dissection. Eur J Vasc Endovasc Surg 2009;37:572-7.  Back to cited text no. 10
    
11.
Kimura Y, Kato T, Nagao K, Izumi T, Haruna T, Ueyama K, et al. Outcomes and radiographic findings of isolated spontaneous superior mesenteric artery dissection. Eur J Vasc Endovasc Surg 2017;53:276-81.  Back to cited text no. 11
    
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Kim YW. Current understandings of spontaneous isolated superior mesenteric artery dissection. Vasc Specialist Int 2016;32:37-43.  Back to cited text no. 12
    
13.
Ogino H. Current treatment strategy for spontaneous isolated dissection of the superior mesenteric artery. Circ J 2016;80:1323-5.  Back to cited text no. 13
    
14.
Tomita K, Obara H, Sekimoto Y, Matsubara K, Watada S, Fujimura N, et al. Evolution of computed tomographic characteristics of spontaneous isolated superior mesenteric artery dissection during conservative management. Circ J 2016;80:1452-9.  Back to cited text no. 14
    
15.
Han Y, Cho YP, Ko GY, Seo DW, Kim MJ, Kwon H, et al. Clinical outcomes of anticoagulation therapy in patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery. Medicine (Baltimore) 2016;95:e3480.  Back to cited text no. 15
    
16.
Nath A, Yewale S, Kousha M. Spontaneous isolated superior mesenteric artery dissection. Case Rep Gastroenterol 2016;10:775-80.  Back to cited text no. 16
    
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Mitsuoka H, Nakai M, Terai Y, Gotou S, Miyano Y, Tsuchiya K, et al. Retrograde stent placement for symptomatic spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg 2016;35:203.e17-21.  Back to cited text no. 17
    
18.
Funahashi H, Shinagawa N, Saitoh T, Takeda Y, Iwai A. Conservative treatment for isolated dissection of the superior mesenteric artery: Report of two cases. Int J Surg Case Rep 2016;26:17-20.  Back to cited text no. 18
    
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Jia Z, Zhao J, Jiang G. Comment on treatment results for spontaneous isolated superior mesenteric artery dissection according to our previous guidelines and collective literature review. Ann Vasc Surg 2015;29:160.  Back to cited text no. 19
    
20.
Lü PH, Zhang XC, Wang LF, Shi HB. Percutaneous endovascular reconstruction with bare stent implantation for isolated superior mesenteric artery dissection. Vasc Endovascular Surg 2014;48:406-11.  Back to cited text no. 20
    
21.
Li N, Lu QS, Zhou J, Bao JM, Zhao ZQ, Jing ZP, et al. Endovascular stent placement for treatment of spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg 2014;28:445-51.  Back to cited text no. 21
    
22.
Leung DA, Schneider E, Kubik-Huch R, Marincek B, Pfammatter T. Acute mesenteric ischemia caused by spontaneous isolated dissection of the superior mesenteric artery: Treatment by percutaneous stent placement. Eur Radiol 2000;10:1916-9.  Back to cited text no. 22
    
23.
Kim HK, Jung HK, Cho J, Lee JM, Huh S. Clinical and radiologic course of symptomatic spontaneous isolated dissection of the superior mesenteric artery treated with conservative management. J Vasc Surg 2014;59:465-72.  Back to cited text no. 23
    
24.
Dong Z, Fu W, Chen B, Guo D, Xu X, Wang Y, et al. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69S-76S.  Back to cited text no. 24
    
25.
Pang P, Jiang Z, Huang M, Zhou B, Zhu K, Shan H, et al. Value of endovascular stent placement for symptomatic spontaneous isolated superior mesenteric artery dissection. Eur J Radiol 2013;82:490-6.  Back to cited text no. 25
    
26.
Park YJ, Park CW, Park KB, Roh YN, Kim DI, Kim YW, et al. Inference from clinical and fluid dynamic studies about underlying cause of spontaneous isolated superior mesenteric artery dissection. J Vasc Surg 2011;53:80-6.  Back to cited text no. 26
    
27.
Lim EH, Jung SW, Lee SH, Kwon BS, Park JY, Koo JS, et al. Endovascular management for isolated spontaneous dissection of the superior mesenteric artery: Report of two cases and literature review. J Vasc Interv Radiol 2011;22:1206-11.  Back to cited text no. 27
    
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Jia ZZ, Zhao JW, Tian F, Li SQ, Wang K, Wang Y, et al. Initial and middle-term results of treatment for symptomatic spontaneous isolated dissection of superior mesenteric artery. Eur J Vasc Endovasc Surg 2013;45:502-8.  Back to cited text no. 28
    
29.
Park YJ, Park KB, Kim DI, Do YS, Kim DK, Kim YW, et al. Natural history of spontaneous isolated superior mesenteric artery dissection derived from follow-up after conservative treatment. J Vasc Surg 2011;54:1727-33.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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