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Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

Katsura M, Mototake H, Takara H, Matsushima K - World J Emerg Surg (2011)

Bottom Line: 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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Okinawa Prefectural Hokubu Hospital, 2-12-3 Onaka, Nago, Okinawa 905-8512, Japan. morihiro@bj8.so-net.ne.jp.

ABSTRACT

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.

Case presentation: 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.

Conclusion: 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.

No MeSH data available.


Related in: MedlinePlus

Sakamoto's type III dissection of the SMA. (a) preoperative MPR image of an abdominal enhanced CT scan show isolated dissection of the SMA began just after the orifice of the SMA and extended to the distal portion, with ULP and the narrow true lumen being compressed by the thrombosed false lumen. (b) postoperative 3 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP.
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Figure 2: Sakamoto's type III dissection of the SMA. (a) preoperative MPR image of an abdominal enhanced CT scan show isolated dissection of the SMA began just after the orifice of the SMA and extended to the distal portion, with ULP and the narrow true lumen being compressed by the thrombosed false lumen. (b) postoperative 3 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP.

Mentions: A 46-year-old woman presented to the emergency department with acute abdominal pain, back pain and vomiting. She had a history of hyperthyroidism but did not have any cardiovascular risk factors or recent trauma. On physical examination, mild periumbilical tenderness without signs of peritonitis was observed. Laboratory tests and abdominal radiography were unremarkable. Contrast-enhanced CT of the SMA showed abnormal wall thickness and irregular diameter, with a double lumen. Isolated dissection of the SMA began from just after the orifice of the SMA and separated the SMA into two distinct lumina for 3 cm from the origin of the artery; the distal portion of the SMA showed signs of thrombosis and stenosis, with the true lumen being compressed by the false lumen (figure 2a). There were no signs of bowel ischemia, such as bowel thickening, abnormal contrast enhancement, or ascites. We proceeded with emergency laparotomy because of continuous severe abdominal pain, but no evidence of ischemia was found throughout the entire bowel with intraoperative duplex scanning. We performed a bypass operation between the distal portion of the SMA and the right common iliac artery, using the saphenous vein as a free graft, to prevent progression of SMA dissection. The postoperative course was uneventful without anticoagulation therapy, but follow-up CT showed thrombotic graft occlusion. We suppose that graft was occluded because of strong native flow from the SMA, that is, flow competition. The patient was discharge on postoperative day 8 and was symptom free 5 years after surgery, with no recurrent symptoms and disease progression. 3 year after surgery, a thrombosed false lumen completely resolved with ulcer like projection (ULP) on follow up CT(figure 2b).


Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

Katsura M, Mototake H, Takara H, Matsushima K - World J Emerg Surg (2011)

Sakamoto's type III dissection of the SMA. (a) preoperative MPR image of an abdominal enhanced CT scan show isolated dissection of the SMA began just after the orifice of the SMA and extended to the distal portion, with ULP and the narrow true lumen being compressed by the thrombosed false lumen. (b) postoperative 3 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3108290&req=5

Figure 2: Sakamoto's type III dissection of the SMA. (a) preoperative MPR image of an abdominal enhanced CT scan show isolated dissection of the SMA began just after the orifice of the SMA and extended to the distal portion, with ULP and the narrow true lumen being compressed by the thrombosed false lumen. (b) postoperative 3 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP.
Mentions: A 46-year-old woman presented to the emergency department with acute abdominal pain, back pain and vomiting. She had a history of hyperthyroidism but did not have any cardiovascular risk factors or recent trauma. On physical examination, mild periumbilical tenderness without signs of peritonitis was observed. Laboratory tests and abdominal radiography were unremarkable. Contrast-enhanced CT of the SMA showed abnormal wall thickness and irregular diameter, with a double lumen. Isolated dissection of the SMA began from just after the orifice of the SMA and separated the SMA into two distinct lumina for 3 cm from the origin of the artery; the distal portion of the SMA showed signs of thrombosis and stenosis, with the true lumen being compressed by the false lumen (figure 2a). There were no signs of bowel ischemia, such as bowel thickening, abnormal contrast enhancement, or ascites. We proceeded with emergency laparotomy because of continuous severe abdominal pain, but no evidence of ischemia was found throughout the entire bowel with intraoperative duplex scanning. We performed a bypass operation between the distal portion of the SMA and the right common iliac artery, using the saphenous vein as a free graft, to prevent progression of SMA dissection. The postoperative course was uneventful without anticoagulation therapy, but follow-up CT showed thrombotic graft occlusion. We suppose that graft was occluded because of strong native flow from the SMA, that is, flow competition. The patient was discharge on postoperative day 8 and was symptom free 5 years after surgery, with no recurrent symptoms and disease progression. 3 year after surgery, a thrombosed false lumen completely resolved with ulcer like projection (ULP) on follow up CT(figure 2b).

Bottom Line: 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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, Okinawa Prefectural Hokubu Hospital, 2-12-3 Onaka, Nago, Okinawa 905-8512, Japan. morihiro@bj8.so-net.ne.jp.

ABSTRACT

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.

Case presentation: 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.

Conclusion: 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.

No MeSH data available.


Related in: MedlinePlus