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Objective:To investigate the influencing factors and clinical effect analysis of the choice of treatment method for spontaneous isolated superior mesenteric artery dissection (SISMAD).Methods:The clinical data of 35 patients with SISMAD admitted to Beijing Friendship Hospital, Capital Medical University from December 2015 to November 2021 were retrospectively analyzed. They were divided into conservative group ( n=24) and surgical group (endoluminal stent group + open surgery group, n=11). The conservative group was treated with conservative methods, the endoluminal stent group ( n=10) was treated with endoluminal stent placement, and the open surgery group ( n=1) was treated with superior mesenteric artery endarterectomy + angioplasty + ileal resection. The white blood cell (WBC) count on admission, the time of abdominal pain, YOO classification, aorta mesenteric angle(AMA), and the length of hospital stay between the two groups were analyzed. All patients were followed up for more than 24 months, at the end of which the vascular remodeling rate of superior mesenteric artery (SMA) between the two groups was studied. In addition, the primary patency rate and secondary patency rate of intracavitary stents were analyzed. Measurement data that conform to normal distribution were expressed as mean ± standard deviation ( ± s), and independent samples t-test was used for comparison between groups; measurement data that do not conform to normal distribution were expressed as median (interquartile range) [ M( Q1,Q3)], the nonparametric test was used for comparison between groups. Enumeration data were compared between groups using the Chi-square test. Results:Univariate analysis showed that compared with the conservative group, the IVS type in YOO classificationin of surgical group was significantly more than the conservative group. There was no significant difference in WBC, duration of abdominal pain, or AMA at admission ( P>0.05). In addition, the length of hospital stay in the conservative group was significantly shorter than that in the surgical group. No intestinal necrosis occurred in endoluminal stent group. After 24 months of follow-up, the remodeling rate of SMA in the surgical group was higher than that in the conservative group; the primary patency rate of the endoluminal stent group was 87.5%, and the secondary patency rate was 100%. One patient in the conservative group developed SMA dissection aneurysm during 12 months of follow-up and received endovascular treatment. Conclusions:For the treatment of SISMAD, most patients can be cured by conservative treatment. However, for patients with consistent abdominal pain and IVS type in YOO classification, if there is no severe manifestation of peritonitis, it is recommended to perform endovascular stent placement as soon as possible to open the blood supply. Meanwhile, the SMA stenting has an ideal long-term patency rate and vascular remodeling rate.
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@#BACKGROUND: Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare cause of abdominal pain. The aim of the study is to investigate the role of a new parameter, the ratio of the SMA diameter to the superior mesenteric vein (SMV) diameter (SMA/SMV) based on non-enhanced computed tomography (CT), in the early diagnosis of SISMAD. METHODS: In a registry study from December 2013 to June 2021, 97 abdominal pain SISMAD patients (SISMAD group) admitted to our hospital were enrolled. Meanwhile, the matched sex and age abdominal pain non-SISMAD patients at 1:2 were collected in reverse chronological order as the control group. Student's t-test, Wilcoxon rank-sum test, and Chi-square test were used to compare differences between the SISMAD and control groups. MedCalc was used to generate receiver operating characteristic (ROC) curve. RESULTS: A total of 291 abdominal pain patients, including 97 SISMAD patients and 194 non-SISMAD patients, were included in the current study. The maximum SMA diameter, perivascular exudation, and SMA/SMV based on non-enhanced CT were significant between the two groups (all P<0.05). ROC curves showed that for the maximum SMA diameter, the area under the curve (AUC), cut-off, sensitivity, and specificity were 0.926, 9.80, 93.8%, and 79.4%, respectively. For SMA/SMV, its AUC, cut-off, sensitivity, and specificity were 0.956, 0.83, 88.7%, and 92.3%, respectively. The diagnostic efficiency of SMA/SMV was better than that of the maximum SMA diameter (P<0.05). The combined parameters of SMA/SMV and maximum SMA diameter had the best diagnostic efficiency (AUC=0.970). CONCLUSION: SMA/SMV may be a potential marker for SISMAD.
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Objective To investigate the clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD).Methods The retrospective cross-sectional study was conducted.The clinical data of 80 patients with SISMAD who were admitted to the Wuhan Union Hospital Affiliated to Huazhong University of Science and Technology from February 2002 to March 2017 were collected.All the patients underwent computed tomographic angiography (CTA) and digital subtraction angiography (DSA) examinations,and then received conservative medical treatment,endovascular interventional treatment or exploratory laparotomy and revascularization.Observation indicators:(1) clinical features;(2) treatment;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed once at 1,6 and 12 months after discharge and once every year after 1 year up to March 2017.Follow-up included recurrence of abdominal pain,changes of superior mesenteric artery (SMA) dissection or changes of SMA and remodeling of dissection after stent implantation.Measurement data were represented as average (range).Results (1) Clinical features:①) Clinical manifestation:75 of 80 patients had symptoms,and 5 without symptoms were diagnosed during health examination.Of 75 patients with symptoms,abdominal pain was the first symptom,with the main of the peri-umbilicus and epigastric pains,without peritoneal irritation sign,including 14 with nausea and vomiting and 4 with bloody stool.②) Results of imaging examination:80 patients were confirmed by CTA examination.CTA showed that there was local thickening of SMA,true and false double-lumen formation,thinner true arterial lumen with visible intimal flap shadow and thrombosis in the false lumen.Results of CTA showed that the first break was located within 1-6 cm from opening of SMA in 77 patients and in the middle and distal segment of SMA in 3 patients,without aortic dissection (AD).(2) Treatment:of 75 patients with symptoms,53 received conservative medical treatment with an effective rate of 70.7％ (53/75),average time of symptomatic remission was 5 days (range,1-12 days);22 received stent imnplantation via right femoral artery approach using self-expanding bare stent or covered stent,with a success rate of implantation of 95.5％ (21/22),including 21 with successful implantations and 1 with false implantation.One patient with false implantation had symptomatic remission after 1-week conservative medical treatment,and there was no exploratory laparotomy and revascularization.Five patients without symptom were required to control blood pressure and get regular follow-up,without other intervention.(3) Follow-up:75 patients with symptoms were followed up for 36 month (range,1-60 months).During follow-up,of 53 patients with conservative medical treatment,2 patients had significant progressions of SMA dissection by CTA examination,1 had recurrence and exacerbation of abdominal pain accompanied with bloody stool at 2-month follow-up,showing an aneurism of SMA dissection by DSA examination,and 1 had recurrence of abdominal pain at 1-year follow-up,both patients were improved after stent implantation;other 51 had no recurrence.Of 22 patients with stent implantation,1 had repeated abdominal pain during follow-up and the symptom became aggravated at 1-year follow-up,showing a thrombosis fonnation and proximal stenosis by CTA examination,and then underwent stent implantation in the proximal stenosis after anticoagulant therapy;SMA dissection of 1 patient completely healed at 2-year follow-up by CTA examination;other 20 patients had stent patency.Five patients without symptom had regular follow-up,showing no disease progression.Conclusions The symptoms of SISMAD are different,and abdominal pain is the one of main symptoms.At present,treatment regimens include conservative medical treatment,endovascular interventional treatment and surgery,and individualized treatment is decided according to clinical symptoms and physical signs of patients and imaging examinations.
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With the development of imaging technology,the reports of spontaneous isolated superior mesenteric artery dissection become more frequently,but there is no consensus on the therapeutic plans which consist of conservative therapy,endovascular treatment and surgical treatment.Therefore,the related questions of the spontaneous isolated superior mesenteric artery dissection will be discussed in order to improve the diagnosis and treatment of vascular diseases of digestive tract with a review of literatures.