Endovascular treatment with flow-diverting stents of symptomatic superior mesenteric artery after dissection aneurysm

Abstract

Isolated and spontaneous superior mesenteric artery dissection is a rare cause of acute abdominal pain. Whereas there is widespread consensus on conservative treatment of asymptomatic forms, revascularization would seem indicated in symptomatic complicated cases. A 73-year-old man presented with worsening epigastric pain. A computed tomography scan revealed an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The postdissection aneurysm was treated by endovascular exclusion with flow-diverting stents. The abdominal pain was completely relieved, and the patient remained asymptomatic at follow-up.

Necessity of revascularization for acute mesenteric ischemia in symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery

“…[21][22][23][24] Further, many studies have reported the use of stents for patients with AMI caused by SIDSMA. 5,[25][26][27] This approach may be effective for preventing the progression of bowel necrosis. However, it remains controversial because of some reported failures.…”

Non-operative management of isolated spontaneous superior mesenteric artery dissection

“…Surgical management remains a mainstay of treatment for failed conservative management, vascular compromise or an acute abdomen. Endovascular treatments should be considered with use of a flow diverting stent in patients with suspected intestinal ischemia, angina abdominis, worsening abdominal pain despite conservative management, true lumen compression >80%, SMA aneurysm of >2 cm or dissection progression [ 1 , 2 , 4 , 8 ]. For patients presenting with evidence of advanced intestinal ischemia or aneurysmal rupture, emergent open surgical intervention is indicated such as SMA re-implantation, resection or repair of the affected segment with interposition bypass or graft [ 1 , 2 , 8 ].…”

“…Isolated spontaneous superior mesenteric artery (SMA) dissection is a rarely reported and potentially fatal cause of acute abdominal pain. In a MEDLINE literature search in 2011 only 168 cases were reported with an estimated incidence of 0.06% in post-mortem studies [ 1 , 2 ]. Clinical presentation of SMA spontaneous dissection has been found to most commonly occur in males in their mid-50s presenting with acute epigastric pain usually after overeating and drinking [ 1 , 3 ].…”

“…Clinical presentation of SMA spontaneous dissection has been found to most commonly occur in males in their mid-50s presenting with acute epigastric pain usually after overeating and drinking [ 1 , 3 ]. Of the cases reported, uncontrolled hypertension accounts for 30% of coexisting medical conditions followed by smoking, intra-abdominal cancer and hypercholesterolemia [ 1 , 2 ]. In contrast, there is a low correlation with atherosclerosis and atherosclerotic heart disease [ 1 , 3 ].…”

“…An accepted theory to support spontaneous dissection is based on the anatomy and the hemodynamic force created by the blood flowing through the SMA. It is believed that the convex curvature of the artery leads to dissection occurring in proximity to the ostium [ 2 , 5 ]. Interestingly, there has been a positive correlation found between pain severity and the length of dissection on imaging [ 6 ].…”