Current strategy for the treatment of symptomatic
spontaneous isolated dissection of superior
mesenteric artery
Sang-Il Min, MD,a Kyung-Chul Yoon, MD,a Seung-Kee Min, MD, PhD,a Sang Hyun Ahn, MD,a Hwan
Joon Jae, MD, PhD,b Jin Wook Chung, MD, PhD,b Jongwon Ha, MD, PhD,a and Sang Joon Kim, MD,
PhD,a Seoul, Korea
Objective: Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is extremely rare. Various
treatment options are currently available, including conservative management, anticoagulation, endovascular stenting,
and surgical repair. Herein, we present our experience in the treatment of symptomatic SIDSMA.
Methods: A retrospective study was conducted on 14 consecutive patients with symptomatic SIDSMA between January
2000 and January 2010. All patients had acute onset abdominal pain. The decision to intervene was based on patient
symptoms and signs, as well as the morphologic characteristics of superior mesenteric artery (SMA) dissection on
computed tomography (CT) angiography. Endovascular stenting (ES) was indicated in patients with severe compression
of the true lumen or dissecting aneurysm likely to rupture. Self-expandable stents were placed via a right common femoral
approach. None of the patients underwent anticoagulation, and patients who underwent ES were maintained on
antiplatelet therapy for 3 months postoperatively.
Results: The median age of the study subjects was 59 years (range, 50-75 years). The median follow-up time was 27.5
months (range, 2-64 months). Treatment included conservative management without the use of anticoagulation in seven
patients, ES in six, and necrotic bowel resection in one. Four patients with severe compression of the true lumen or large
dissecting aneurysm underwent ES as a primary treatment. ES was additionally performed in two patients in whom initial
conservative treatment failed (increasing dissecting aneurysm at 7-day follow-up CT scan in one and a reappearance of
abdominal pain after resuming diet in the other). The median fasting time was significantly shorter in patients with
primary ES (2.5 days) than in those managed conservatively (8.0 days). No complications associated with the SIDSMA
or ES were developed. The patency of stents was demonstrated on follow-up CT scans up to 60 months (range, 1-60
months).
Conclusions: Conservative management without anticoagulation can be applied successfully to the patients with symptomatic SIDSMA. Primary endovascular stenting is indicated if patients have suspected bowel ischemia, compression of
the true lumen of the SMA >80%, or SMA aneurysm of >2.0 cm in diameter on initial CT scan. Endovascular stenting
can also be provided to the patients in whom initial conservative treatment failed, as a rescue therapy. ( J Vasc Surg 2011;
54:461-6.)
Spontaneous isolated dissection of superior mesenteric
artery (SIDSMA) is a clinically rare disease; less than 150
cases without associated aortic dissection have been reported in the literature.1-23 With technical advances in
multidetector computed tomography (CT), improved CT
resolution and the increasing popularity of CT for investigating abdominal pain, however, SIDSMA has been reported more frequently in recent years.11 SIDSMA is associated with a broad spectrum of clinical pictures, from
asymptomatic incidental findings to acute catastrophic
bowel ischemia/infarction or aneurismal superior mesenFrom the Departments of Surgerya and Radiology,b Seoul National University College of Medicine.
Competition of interest: none.
Reprint requests: Seung-Kee Min, MD, PhD, Department of Surgery, Seoul
National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110744, Korea (e-mail: [email protected]).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
0741-5214/$36.00
Copyright © 2011 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2011.03.001
teric artery (SMA) rupture. A variety of treatment options
have also been described for SIDSMA, including conservative management, anticoagulation, endovascular stenting
(ES), and open surgical repair. Although some patients
with no or mild symptoms can be successfully managed
with conservative management regimens,19 whether or not
anticoagulation should be used in cases of asymptomatic
SIDSMA remains a matter of some controversy. In cases of
symptomatic SIDSMA, moreover, there is currently no
consensus as to an appropriate treatment protocol.
Herein, we report a contemporary series of 14 cases
presenting with acute abdominal pain and describe the
management strategy we adopted in cases of symptomatic
SIDSMA, based on our experience and the current literature.
METHODS
A retrospective study was performed on 14 consecutive
patients (12 male, 2 female) with symptomatic SIDSMA
between January 2000 and January 2010 after obtaining
approval from the Institutional Review Board. All patients
presented with acute-onset abdominal pain. The diagnosis
461
JOURNAL OF VASCULAR SURGERY
August 2011
462 Min et al
Fig 1. Repeated computed tomography (CT) scans in long-term
follow-up patients. A, Conservative management without anticoagulation resulted in successful thrombosis and obliteration of the
false lumen. B, Endovascular stenting resulted in complete obliteration of the false lumen. Patency of the superior mesenteric
artery (SMA) stent is demonstrated up to 60 months postoperatively without in-stent restenosis. m, Month.
of SIDSMA was made by the characteristic CT findings24
including thrombosis of the false lumen, intramural hematoma, and/or intimal flap (Fig 1).
Conservative management for a patient with symptomatic SIDSMA consisted of strict blood pressure control,
bowel rest, and close observation, without the use of anticoagulation or antiplatelet agents. Endovascular management included self-expandable stent placement via a right
common femoral artery approach and antiplatelet therapy
for 3 months postoperatively. Self-expandable stents were
sized to the diameter of the normal proximal SMA and
stents 10% greater in diameter were chosen. The SMA was
selectively catheterized with a 6 Fr renal double curve
(RDC) catheter (Cordis Corporation, Bridgewater, NJ).
Because the SMA dissection usually begins 1.0 to 3.0 cm
from the orifice of the SMA, a self-expandable stent was
placed in the true lumen over the SV5 guidewire (Cordis
Endovascular, Bridgewater, NJ) so that the proximal end of
the stent was at the orifice of the SMA. SIDSMA complicated with bowel infarction or arterial rupture was surgically treated.
The decision to manage conservatively, to place a stent,
or to undergo surgery was based on patient symptoms and
signs, as well as the morphologic characteristics of SMA
dissection on CT angiography. The factors indicating ES
included severe compression of the true lumen (more than
80% compared with adjacent normal SMA diameter), and
aneurysmal dilation of the SMA likely to rupture on initial
CT, which was larger than 2 cm in diameter25,26 (Fig 2).
Aggravation of pain or increasing size of aneurysmal dilation of the SMA at follow-up CT were also considered
indicative of ES in patients undergoing conservative management.
Fig 2. Reconstructed computed tomography (CT) angiography
findings indicated for primary endovascular stenting. A, Severe
compression of the true lumen and (B) a patent superior mesenteric
artery stent and complete obliteration of the false lumen at 60-month
follow-up CT in patient no. 12. C, Large dissecting aneurysm (20.0
mm in diameter) and (D) near complete disappearance of the aneurysm at 36-month follow-up CT in patient no. 13.
Aneurysmal dilatation of SMA was defined as an increase in diameter of more than 50% relative to the normal
caliber of the SMA for each patient, as measured by a CT
scan. The percentage of true lumen compression by the
false lumen was also calculated from the CT scan. The
follow-up consisted of a physical examination and adjunctive CT at 1 month, 6 months, and yearly thereafter. In
patients with conservative management, CT was additionally checked at any time with aggravation of symptoms
during the early period of the hospital course or 7 days after
the initial diagnosis. Diet was resumed after complete resolution of abdominal pain and confirmation of normal
physical examination and laboratory data for more than 2
consecutive days in patients with conservative treatment.
CT findings at the 7-day follow-up CT scans are also a
useful indicator for resumption of diet.
Statistical analysis was conducted via Fisher’s exact test
and ␹2 test using SPSS software (version 15.0; SPSS Inc,
Chicago, Ill). P values of ⬍.05 were considered statistically
significant.
RESULTS
The median age of the patients was 59 years (range,
50-74 years), and the median follow-up time was 27.5
months (range, 2-64 months). Relevant comorbidities included hypertension (21.4%), diabetes mellitus (7.1%),
atrial fibrillation (7.1%), and dilated cardiomyopathy
(7.1%). No patients had identifiable risk factors such as
Ehler’s syndrome, Marfan’s syndrome, segmental arterial
mediolysis, trauma, fibromuscular dysplasia, or vasculitis.
All patients had acute onset abdominal pain at presentation.
Seven patients underwent conservative management with-
JOURNAL OF VASCULAR SURGERY
Volume 54, Number 2
Min et al 463
Table. Summary of symptomatic spontaneous isolated dissection of the superior mesenteric artery treated with
conservative management or ES
Distance
Max
Patient Age
from
True lumen
diameter
No
(years) SMA Os compression (%) of SMA
1
2
3
4
5
6
7
8
65
57
63
50
55
58
56
52
17.4 mm
16.4 mm
11.9 mm
10.0 mm
13.5 mm
9.7 mm
21.4 mm
9.2 mm
67.9
60.3
77.3
27.3
44.6
24.7
53.5
81.1
9
62 24.2 mm
77.5
10
52 25.2 mm
91.9
11
72 29.0 mm
80.2
12
58 13.3 mm
89.7
13
56 29.6 mm
61.7
Initial treatment
11.9 mm
12.1 mm
13.0 mm
11.9 mm
13.8 mm
14.8 mm
9.9 mm
13.6 mm
Conservative
Conservative
Conservative
Conservative
Conservative
Conservative
Conservative
8 ⫻ 40 mm
Zilver stent
12.9 mm Conservative
12.2 mm 8 ⫻ 40 mm
Zilver stent
12.5 mm 8 ⫻ 60 mm
Zilver stent
12.4 mm Conservative
20.0 mm 8 ⫻ 38 mm
Wallstent
Outcome
SMA at last
Fasting time F/U computed F/U
(days)
tomography months
Pain resolution
Pain resolution
Pain resolution
Pain resolution
Pain resolution
Pain resolution
Pain resolution
Pain resolution
8
8
18
5
8
2
4
2
O
O
O
O
O
O
O
O, P
26
32
2
9
61
15
14
32
Failed
7 ⫻ 40 mm
Zilver stent
Pain resolution
9 ⫹ 2 (After
ES)
O, P
29
3
O, P
2
3
O, P
51
O, P
64
O, P
36
Pain resolution
Failed
10 ⫻ 20 mm
Wallstent
Pain resolution
7 ⫹ 2 (After
ES)
1
ES, Endovascular stent; F/U, follow-up; O, obliterated false lumen; P, patent stent; SMA, superior mesenteric artery.
out anticoagulation. Six patients were treated by ES, as an
initial treatment in four patients and after the failure of
initial conservative management in two patients. No patient
received an open repair. One patient with bowel infarction
suspected from an initial CT scan underwent emergent
surgery. ES or surgical bypass was not attempted and 200
cm of the necrotic bowel segment was resected. Only 70 cm
of terminal ileum was saved. This patient was discharged 1
month after surgery.
The median distance from the SMA ostium to the
beginning of SMA dissection is 16.4 mm (range, 9.2-29.6
mm). The median length of SMA dissection was 80.0 mm
(range, 33.0-130.0 mm), and there was no difference in the
length of SMA dissection between the conservative treatment and ES groups (P ⫽ .54). The median diameter of
dissected SMA was 12.5 mm (range, 9.9-20.0 mm). Eight
patients evidenced aneurysmal dilatation, which is defined
as a diameter ⬎50% larger than that of normal SMA. A
patient with a large SMA aneurysm of 20.0 mm in diameter
(patient no. 13) underwent emergency ES, but aneurysmal
dilatation of the SMA in other patients did not affect the
decision regarding the treatment method. Patients treated
with ES evidenced significantly reduced true lumen diameters relative to the patients who were conservatively managed (80.3 ⫾ 4.4% vs 50.8 ⫾ 7.5%, respectively; P ⫽ .014).
The morphologic characteristics of SMA dissection for each
patient are summarized in the Table.
Conservative management was initially tried in nine
patients. No patients were treated with anticoagulation or
antiplatelet therapy. Among them, seven patients were
successfully treated with a median follow-up period of 15.0
months (range, 2-61 months), and serial CT scans demonstrated thrombosis and obliteration of the false lumen with
time as depicted in Fig 1, A (patient no. 5). The median
fasting time was 8.0 days (range, 2-18 days), the abdominal
pain was resolved, and the patients were discharged without
any significant complications. No complications associated
with SMA dissection occurred during follow-up. Two patients, who were treated initially with conservative management, underwent additional ES. Patient no. 9 evidenced an
increasing diameter of SMA aneurysm from 12.5 mm to
12.9 mm at the 7-day follow-up CT scan. Patient no. 12
suffered from the reappearance of abdominal pain with
resumption of diet after 7 days of conservative management. These two patients were treated successfully with
additional ES.
Four patients underwent primary ES. Self-expandable
stents (Wallstent; Boston Scientific Co, Natick, Mass; Zilver stent; Cook Medical, Bloomington, Ind) with diameters of up to 10 mm and overall lengths of up to 60 mm
were used. The median fasting time was 2.5 days (range,
1-4 days), which was significantly shorter than in the conservative management group (P ⫽ .008). Two patients who
underwent ES after failure of conservative management
required an additional 2 days of fasting time after ES, and
the total fasting time in these patients was longer: 11 days
and 9 days, respectively. Stent placement resulted in complete obliteration of the false lumen and the restoration of
excellent distal blood flow, and abdominal pain was completely resolved postoperatively in all patients. The median
follow-up was 32.5 months (range, 2-64 months), and
repeated CT scans demonstrated the patency of the SMA
464 Min et al
stents for up to 60 months without any in-stent restenosis
(Patient no. 12, Fig 1, B). No ES-related complications
were developed. The treatments and outcomes of each
patient are summarized in detail in the Table.
DISCUSSION
SIDSMA without aortic dissection is a very rare condition. The postmortem study revealed an incidence of 0.06%
in a series of 6666 autopsies.27 Recently, however,
SIDSMA has been reported more frequently.1-3,5-12,15-22
SIDSMA can be detected as an incidental finding, but may
also cause drastic complications such as bowel infarction and
severe hemorrhage. Although four approaches – conservative
management, anticoagulation, endovascular stenting, and
open surgery – have been previously reported, given the
paucity of the SMA dissections, the optimal treatment for
SIDSMA remains a matter of some controversy.
The natural course of SMA dissection would be as
follows4,9: (1) limited progression with thrombosis of the
false lumen; (2) progressive dissection to distal branches of
the SMA; (3) rupture through the adventitia; or (4) rapidly
expanding false lumen resulting in the narrowing or obliteration of the true lumen. Thus, the primary objective of
treatment in SIDSMA is to limit the extension of dissection, to preserve the blood flow distally through the true
lumen, and to prevent the rupture of the SMA. It should be
emphasized that the aforementioned treatment objectives
can be achieved by the thrombosis and obliteration of the
false lumen. Some authors insist that anticoagulation therapy is valid and should be a mainstay for the conservative
management of SIDSMA after the first successful treatment
with intravenous heparin (Ambo et al).14,21,23 This opinion
has been strengthened by the experience with treatment of
spontaneous dissection of the carotid artery, where anticoagulation is effective in preventing the formation of the
thrombus.28 Considering the aforementioned treatment
objectives of the SIDSMA and the previous reports3,10 that
have described the progression of disease and aneurysmal
dilatation in some cases despite the administration of
chronic anticoagulation therapy, anticoagulation or antiplatelet therapy could not be the optimal treatment for
SIDSMA. Additionally, Gobble et al19 recently reviewed
106 isolated dissections of the SMA and reported that 12
(30.0%) among 43 patients (excluding cases diagnosed on
autopsy) with expectant therapy failed and 8 (34.8%) out of
23 patients with anticoagulation failed. Moreover, anticoagulation required a prolonged fasting period of up to 33
days (27.2 days on average).14 In our series, seven patients
(77.8%) with symptomatic SIDSMA were treated successfully by conservative management without anticoagulation,
and the median fasting time (8.0 days) was significantly
reduced.
In the modern endovascular era, the use of percutaneous endovascular techniques for the SMA lesion has become feasible in a variety of conditions.29-31 A stent used
for SMA needs to have minimal shortening and good
flexibility, and it must not change location as a result of the
continuous movement of the mesentery.18 ES to the entry
JOURNAL OF VASCULAR SURGERY
August 2011
tear site of SMA dissection can cover the intimal flap and
occlude blood inflow to the false lumen. The false lumen
then is obliterated by thrombosis. Radial force of the selfexpandable stent can easily overcome the pressure of the
false lumen, which is usually caused by fresh thrombus and
stent also provide sufficient diameter of the true lumen.
Some authors18 favored stent graft in the treatment of the
SIDSMA. As the stent graft can cause the obliteration of
multiple side branches of the SMA, however, it is not
usually recommended. Stent graft can be successfully used
to cover the dissecting broad-base pseudoaneurysm of the
SMA of which intimal flap cannot be covered by open
stent.7
ES for the treatment of SIDSMA was initially reported
by Leung et al.16 Since that time, 16 patients with SIDSMA
have been treated with ES.3,5-7,12,15-20,22 ES was offered as
an initial treatment for aneurysmal dilation or bowel ischemia in nine patients and secondary to failed conservative
treatment with or without anticoagulation in seven patients. ES provided immediate symptomatic improvement
and prevented further progression of the SMA dissection
with a shorter fasting time. In our series, four patients
underwent primary ES for severe compression of the true
lumen (patients no. 8, 10, and 11) or large aneurysmal
dilation (patient no. 13). Secondary ES after failed conservative management was required in two patients; patient
no. 9 evidenced increasing SMA aneurysm on a short-term
follow-up CT scan, and patient no. 12 who had a near
occlusion of the true lumen on initial CT scan suffered from
the reappearance of abdominal pain after the resumption of
diet. Patients with ES evidenced immediate pain relief and
short fasting time. With a median follow-up of 32.5
months, the patency of the stents was demonstrated by
repeated CT scans of up to 60 months, which was the
longest follow-up case. Therefore, ES can be administered
as an initial treatment to patients with large aneurysmal
dilation of the SMA likely to rupture and in patients with
severe compression of true lumen resulting in bowel ischemia (Fig 2). ES can also be provided as a rescue therapy in
patients with failed conservative treatment. Because the
recurrence of an aneurysm 4 months after treatment with
ES was reported,18 which was treated with another stent,
patients treated with either conservative management or ES
should be followed up regularly.
Based on our experience and the current literature, we
propose the following algorithm for the treatment of a
symptomatic SIDSMA (Fig 3). Patients with a symptomatic SIDSMA should initially undergo conservative management without anticoagulation and antiplatelet therapy if
bowel perfusion is not compromised and if the SMA aneurysm is not likely to rupture. ES is indicated if patients have
suspected bowel ischemia, compression of the true lumen
of the SMA ⬎80%, or SMA aneurysm ⬎2.0 cm in diameter
on initial CT scan. Emergent open repair of dissection and
thrombectomy is indicated in patients with SMA thrombosis and questionable bowel viability. In cases of bowel
necrosis or severe hemorrhage, emergent surgery such as
bowel resection or open repair is indicated. Patients initially
JOURNAL OF VASCULAR SURGERY
Volume 54, Number 2
Fig 3. Suggested treatment algorithm for symptomatic spontaneous isolated dissection of superior mesenteric artery (SIDSMA).
CT, Computed tomography; ES, endovascular stenting.
treated with conservative management should be monitored closely and should undergo a follow-up CT scan at 7
days. In cases involving aggravating symptoms, no major
relief of pain within 7 days, or progression of SMA dissection on follow-up CT scan at 7 days, ES should be considered without delay. Imaging surveillance in successfully
treated patients, either by conservative treatment or ES,
should include CT scans at 1 month, 6 months, and yearly
thereafter. Open surgery is indicated in cases of failed ES.
The authors would like to thank Professor Jae Hyung
Park for his critical advice in the preparation of this article.
AUTHOR CONTRIBUTIONS
Conception and design: SKM, HJ, JH, SK
Analysis and interpretation: SIM, KY, SKM, SA, HJ, JC, SK
Data collection: SIM, KY, SKM, SA
Writing the article: SIM, KY, SKM, JC, JH
Critical revision of the article: SIM, KY, SKM, SA, HJ, JC, JH, SK
Final approval of the article: SIM, KY, SKM, SA, HJ, JC, JH, SK
Statistical analysis: SIM, KY, SKM, JH
Obtained funding: Not applicable
Overall responsibility: SKM
SIM and KY contributed equally to this article.
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Submitted Jan 10, 2011; accepted Mar 1, 2011.