- Open Access
Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review
© Katsura et al; licensee BioMed Central Ltd. 2011
- Received: 9 April 2010
- Accepted: 8 May 2011
- Published: 8 May 2011
Background and method
The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.
We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.
Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.
- Superior Mesenteric Artery
- Mesenteric Ischemia
- False Lumen
- Bowel Ischemia
- True Lumen
Spontaneous dissection of the superior mesenteric artery (SMA) is not associated with aortic dissection, and is a rare but potentially fatal disease. It is now being reported more often, which is a reflection of the increased use of imaging techniques, such as multidetector row computed tomography (MDCT), multiplanar (MPR) imaging, reconstruction imaging, and CT angiography (CTA) [1–4]. Three different therapeutic approaches are possible: conservative management [5–7], surgical revascularization [8–11], or endovascular therapy [12–18]. However, there is no consensus on the best treatment and its pathogenesis is unclear.
Spontaneous dissection of the SMA is a rare condition and is not associated with aortic dissection. It was first described by Bauerfield in 1947 . In previously reported cases before 1972, the prognosis was very poor [19, 20]. However, the prognosis has improved significantly since 1975 as a result of advancements in surgical techniques and imaging modalities [1–4].
The etiology of the disease has not yet been established, but atherosclerosis, cystic medial necrosis, and fibromuscular dysplasia have been implicated, often associated with untreated hypertension . Solis et al.  have hypothesized that dissection usually begins 1.5-3 cm from the orifice of the SMA, thus sparing the origin of the artery. This segment of the SMA corresponds with the exit of the artery from the pancreas and is exposed to shearing force because this area forms the border zone between the fixed retropancreatic portion and the more distal mobile mesenteric portion. In two of the three present cases, dissection began from just after the orifice of the SMA, and in the other, dissection began 6 cm from the orifice. Our findings were not consistent with the hypothesis of Solis et al., but we suppose that the dissection plane can extend not only distally but also proximally.
The natural history of the disease is also unclear and depends on each case. Most patients present with acute epigastric pain, which is considered to be caused by the dissection itself or intestinal ischemia. Other common symptoms are nausea, vomiting, melena, and abdominal distention. These patients present acutely with symptom duration of <4 weeks . Laboratory tests and abdominal radiography are usually unremarkable. Therefore, we often initially presume that the patient has enterocolitis and gastritis. Sometimes, laboratory tests show slightly elevated serum amylase, such as in our case 1, which might be caused by occlusion of the duodeno-pancreatic arcade .
Diagnosis in the acute stage has become possible as a result of advances and increased use of imaging techniques such as MDCT, leading to MPR and reconstruction imaging, and CTA [1–4]. Dynamic enhanced CT shows that the separated true lumen and false lumen can be identified by the presence of an intimal flap. Plain CT shows areas of high intensity if there is an acute clot in the false lumen. Sakamoto et al.  have categorized SMA dissection into four types based on contrast-enhanced CT scanning. Recently, Yun et al.  have added total thrombotic occlusion of the SMA trunk to Sakamoto's classification, and have devised a new classification of three types based on angiographic findings: type I: patent true and false lumina that show entry and re-entry sites; type II: patent true lumen but no re-entry flow from the false lumen; type IIa: visible false lumen but no visible re-entry site (blind pouch of false lumen); type IIb: no visible false luminal flow (thrombosed false lumen), which usually causes true luminal narrowing; and type III: SMA dissection with occlusion of SMA.
However, neither Sakamoto et al. nor Yun et al. have found a clear relationship between radiological appearance and clinical course. Abdominal color Doppler echo is also effective for following hemodynamic changes within the SMA, bowel movement, and signs of bowel ischemia, such as wall thickening and intestinal dilatation.
Some treatment algorithms for management of spontaneous SMA dissection have been reported [22, 25, 26]. At present, however, there is no established opinion on the indications for surgical revascularization, conservative medical management, or endovascular therapy. Some cases have been successfully treated by conservative therapy, such as anticoagulation [5, 6]. Karacagi et al have reported that immediate anticoagulation therapy achieved prevention of clot formation in the true lumen in patients with spontaneous dissection of the carotid artery. Nagai et al insisted that the disease pattern of SMA dissection seems similar with internal carotid artery and emphasized anticoagulation therapy is necessary for SMA dissection. On the other hand, Sparks et al.  have reported a case in which the patient developed recurrent symptoms and disease progression 1 year later, which was a failure of the non-operative approach. This case indicates that a non-operative approach with anticoagulation of the isolated SMA dissection requires close follow-up, but it does not prevent disease progression. At that time, there is no consensus on the best drugs to be administered and administration period, so we didn't give anticoagulant for our case No.3. But we now suppose that anticoagulation therapy is valid for this disease when we chose conservative treatment.
Sparks et al. have suggested that indications for surgery are increasing size of the aneurysmal dilatation of the SMA, luminal thrombosis, or persistent symptoms despite anticoagulation. Various procedures for surgical intervention have been reported [8–11], including aortomesenteric or iliomesenteric bypass, thrombectomy, intimectomy with or without patch angioplasty, ligation, and resection. These surgical procedures have been performed with good short-term results.
Recent minimally invasive techniques, such as percutaneous endovascular stent placement and intralesional thrombolytic therapy, could be useful in certain cases, especially in patients at high risk for surgery [12–18]. However, it is usually difficult to find the site at which tearing of the artery wall started during dissection of the SMA, and the dissection often extends to the distal portion of the SMA, as in our present cases. There are still many problems with stent placement itself, such as risk of re-occlusion of a stented SMA and possible obstruction of side branches of the stented segment. Although we think that endovascular stent placement is feasible in patients without peritonitis or mesenteric ischemia, the long-term results should continue to be evaluated. Intralesional thrombolytic therapy with urokinase have also been reported, but some cases later underwent stenting  and laparotomy [29, 30] because of clinical deterioration.
Clinical characteristics of patients with SMA dissection
Follow up CT
6 cm from the orifice
of the SMA
just after the orifice
of the SMA
just after the orifice
resolved false lumen
of the SMA
There is no consensus on the best treatment of spontaneous isolated dissection of the SMA. Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.
The authors would like to thank all the surgical attending physicians and radiologists and residents at Okinawa Prefectural Chubu Hospital for their dedication and hard work in managing this study.
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal
- Suzuki S, Furui S, Kohtake H, Sakamoto T, Yamasaki M, Furukawa A, Murata K, Takei R: Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging. 2004, 29: 153-157.View ArticlePubMedGoogle Scholar
- Hyodoh H, Hyodoh K, Takahashi K, Yamagata M, Kanazawa K: Three-dimensional CT imaging of an isolated dissecting aneurysm of the superior mesenteric artery. Abdom Imaging. 1996, 21: 515-516.View ArticlePubMedGoogle Scholar
- Sheldon PJ, Esther JB, Sheldon EL, Sparks SR, Brophy DP, Oglevie SB: Spontaneous dissection of the superior mesenteric artery. Cardiovasc Intervent Radiol. 2001, 24: 329-331.View ArticlePubMedGoogle Scholar
- Furukawa H, Moriyama N: Spontaneous dissection of the superior mesenteric artery diagnosed on multidetector helical CT. J Comput Tomogr. 2002, 26: 143-144.View ArticleGoogle Scholar
- Nagai T, Torishima R, Uchida A, Nakashima H, Takahashi K, Okawara H, Oga M, Suzuki K, Miyamoto S, Sato R, Murakami K, Fujioka T: Spontaneous dissection of the superior mesenteric artery in four cases treated with anticoagulation therapy. Intern Med. 2004, 43: 473-478.View ArticlePubMedGoogle Scholar
- Takayama H, Takeda S, Saitoh SK, Hayashi H, Takano T, Tanaka K: Spontaneous isolated dissection of the superior mesenteric artery. Intern Med. 2002, 41: 713-716.View ArticlePubMedGoogle Scholar
- Cho YP, Ko GY, Kim HK, Moon KM, Kwon TW: Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery. Br J Surg. 2009, 96: 720-723.View ArticlePubMedGoogle Scholar
- Kochi K, Orihashi K, Murakami Y, Sueda T: Revascularization using arterial conduits for abdominal angina due to isolated and spontaneous dissection of the superior mesenteric artery. Ann Vasc Surg. 2005, 19: 418-420.View ArticlePubMedGoogle Scholar
- Tsuji Y, Hino Y, Sugimoto K, Matsuda H, Okita Y: Surgical intervention for isolated dissecting aneurysm of the superior mesenteric artery: A case report. Vasc Endovasc Surg. 2004, 38: 469-472.View ArticleGoogle Scholar
- Picquet J, Abilez O, Pénard J, Jousset Y, Rousselet MC, Enon B: Superficial femoral artery transposition repaire for isolated superior mesenteric artery dissection. J Vasc Surg. 2005, 42: 788-791.View ArticlePubMedGoogle Scholar
- Cormier F, Ferry J, Artru B, Wechsler B, Cormier JM: Dissecting aneurysms of the main trunk of the superior mesenteric artery. J Vasc Surg. 1992, 15: 424-30.View ArticlePubMedGoogle Scholar
- Leung DA, Schneiber E, Kubik-Huch R, Marineck 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: 1916-1919.View ArticlePubMedGoogle Scholar
- Yoon YW, Choi D, Cho SY, Lee DY: Successful treatment of isolated spontaneous superior mesenteric artery dissection with stent placement. Cardiovasc Intervent Radiol. 2003, 26: 475-478.View ArticlePubMedGoogle Scholar
- Froment P, Alerci M, Vandoni RE, Bogen M, Gertsch P, Galeazzi G: Stenting of a spontaneous dissection of the superior mesenteric artery:a new therapeutic approach?. Cardiovasc Intervent Radiol. 2004, 27: 529-532.View ArticlePubMedGoogle Scholar
- Kim JH, Roh BS, Lee YH, Choi SS, So BJ: Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol. 2004, 5: 134-138.PubMed CentralView ArticlePubMedGoogle Scholar
- Miyamoto N, Sakurai Y, Hirokami M, Takahashi K, Nishimori H, Tsuji K, Kang JH, Maguchi H: Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: Report of a case. Radiat Med. 2005, 23: 520-524.PubMedGoogle Scholar
- Casella IB, Bosch MA, Sousa WO Jr: Isolated spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement: case report. J Vasc Surg. 2008, 47: 197-200.View ArticlePubMedGoogle Scholar
- Gobble RM, Brill ER, Rockman CB, Hecht EM, Lamparello PJ, Jacobowitz GR, Maldonado TS: Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J Vasc Surg. 2009, 50: 1326-1332.View ArticlePubMedGoogle Scholar
- Bauerfield SR: Dissecting aneurysm of the aorta:a presentation of fifteen cases and a review of the recent literature. Ann Intern Med. 1947, 26: 873-889.View ArticleGoogle Scholar
- Hirai S, Hamanaka Y, Mitsui N, Isaka M, Kobayashi T: Spontaneous dissection of the main trunk of the superior mesenteric artery. Ann Thorac Cardiovasc Surg. 2002, 8: 236-240.PubMedGoogle Scholar
- Solis MM, Ranval TJ, McFarland DR, Eidt JF: Surgical Treatment of superior mesenteric artery dissection aneurysm and simultaneous celiac artery compression. Ann Vasc Surg. 1993, 7: 457-462.View ArticlePubMedGoogle Scholar
- Subhas G, Gupta A, Nawalany M, Oppat WF: Spontaneous isolated superior mesenteric artery dissection: a case report and literature review with management algorithm. Ann Vasc Surg. 2009, 23: 788-798.View ArticlePubMedGoogle Scholar
- Sakamoto I, Ogawa Y, Sueyoshi E, Fukui K, Murakami T, Uetani M: Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery. Eur J Radiol. 2007, 64: 103-110.View ArticlePubMedGoogle Scholar
- Yun WS, Kim YW, Park KB, Cho SK, Do YS, Lee KB, Kim DI, Kim DK: Clinical and angiographic follow-up of spontaneous isolated superior mesenteric artery dissection. Eur J Vasc Endovasc Surg. 2009, 37: 572-577.View ArticlePubMedGoogle Scholar
- Morris JT, Guerriero J, Sage JG, Mansour MA: Three isolated superior mesenteric artery dissections: update of previous case reports, diagnostics, and treatment options. J Vasc Surg. 2008, 47: 649-653.View ArticlePubMedGoogle Scholar
- Zerbib P, Perot C, Lambert M, Seblini M, Pruvot FR, Chambon JP: Management of isolated spontaneous dissection of superior mesenteric artery. Langenbecks Arch Surg. 2010, 395: 437-443.View ArticlePubMedGoogle Scholar
- Karacagil S, Hardemark HG, Bergqvist D: Spontaneous internal carotid artery dissection. Int Angiol. 1996, 15: 291-294.PubMedGoogle Scholar
- Sparks SR, Vasquez JC, Bergan JJ, Owens EL: Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg. 2000, 14: 105-109.View ArticlePubMedGoogle Scholar
- Javerliat I, Becquemin JP, d'Audiffret A: Spontaneous isolated dissection of the superior mesenteric artery. Eur J Vasc Endovasc Surg. 2003, 25: 180-184.View ArticlePubMedGoogle Scholar
- Hwang CK, Wang JY, Chaikof EL: Spontaneous dissection of the superior mesenteric artery. Ann Vasc Surg. 2010, 24: 254.e1-5.View ArticleGoogle Scholar
- Matsushima K: Spontaneous isolated dissection of the superior mesenteric artery. Am Coll Surg. 2006, 203: 970-971.View ArticleGoogle Scholar
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