Detecting isolated superior mesenteric artery dissection with computed tomography

Abstract

Aim: Isolated superior mesenteric artery (SMA) dissection without associated aortic dissection is a rare entity. The aim of the study is to evaluate its incidence, and multidetector computed tomography (MDCT) and computed tomography angiography (CTA) findings, as well as show the clinical importance of this condition, which should be diagnosed and treated urgently. Methods: Images of all patients who underwent contrast enhanced CTA or MDCT scan from July 2017 to July 2020 at our radiology department were examined retrospectively. A total of 600 CTA and 14000 contrast enhanced MDCT scans (14600 CT) were evaluated. Only the cases with isolated SMA dissections without aortic involvement, who had arterial phases on contrast enhanced MDCT images, were included. Aortic dissection cases with SMA involvement, and non-contrast MDCT images were excluded. Age, gender, symptoms, presence of thrombosis or bowel ischemia were noted. Average extension of dissection and distance from origin were measured. Results: Ten patients (7 M, 3 F), aged between 48-66 years (mean: 57 years), had isolated SMA dissection. The mean distance of dissection from origin and mean extension were 1.9 cm and 3.4 cm, respectively. Patients were treated with conservative anticoagulation therapy. Follow-up CTA or MDCT showed normal SMA without evidence of dissection in 5 patients, decreased extension and length of dissection in 3 patients and no significant difference in 2 patients. Conclusion: Isolated SMA dissection is a rare but important cause of abdominal pain. Early diagnosis allows correct treatment. CT is a useful noninvasive method for diagnosis and anticoagulation therapy is successful.

Keywords

• Superior mesenteric artery
• dissection
• computed tomography
• mesenteric ischemia
• isolated

İzole süperior mezenterik arter diseksiyonunun bilgisayarlı tomografi ile tespit edilmesi

Abstract

Amaç: Aort diseksiyonu olmaksızın görülen izole süperior mezenterik arter (SMA) diseksiyonu nadir bir durumdur. Çalışmanın amacı, insidansı ve çok dedektörlü bilgisayarlı tomografi (ÇKBT) ve bilgisayarlı tomografi anjiyografi (BTA) bulgularını değerlendirmek ve acilen teşhis ve tedavi edilmesi gereken bu durumun klinik önemini ortaya koymaktır. Yöntemler: Temmuz 2017'den Temmuz 2020'ye kadar radyoloji bölümümüzde kontrastlı BTA veya ÇKBT taraması yapılan tüm hastaların görüntüleri geriye dönük olarak incelendi. 600 BTA ve 14000 kontrastlı ÇKBT taraması değerlendirildi. Sadece, aort tutulumu olmayan izole SMA diseksiyonları dahil edildi. SMA tutulumu olan aort diseksiyonları dahil edilmedi. Arteriyel faza sahip kontrastlı ÇKBT görüntüleri dahil edildi. Yaş, cinsiyet, semptomlar, tromboz veya bağırsak iskemisi varlığı kaydedildi. Ortalama diseksiyon uzunluğu ve orijinden uzaklık ölçüldü. Bulgular: 10 hastada (7 E, 3 K) izole SMA diseksiyonu vardı. Hastaların yaş aralığı 48 ile 66 (ortalama 57) arasındaydı. Diseksiyonun orijinden ortalama uzaklığı 1,9 cm ve ortalama uzunluğu 3,4 cm idi. Hastalar konservatif olarak antikoagülan ile tedavi edildi. Takip BTA veya ÇKBT’de 5 hastada diseksiyonda kaybolma, 3 hastada diseksiyon uzunluğunda azalma izlenirken 2 hastada anlamlı bir fark saptanmadı. Sonuç: İzole SMA diseksiyonu nadir görülen önemli karın ağrısı nedenlerindendir. Erken teşhis doğru ve zamanında tedaviye izin verir. BT tanı için yararlı noninvaziv bir yöntemdir ve antikoagülan tedavi başarılıdır.

Keywords

• Superior mezenterik arter
• Diseksiyon
• Bilgisayarlı tomografi
• Mezenterik iskemi,
• İzole

References

1. 1. Bauersfeld SR. Dissecting aneurysm of the aorta: a presentation of fifteen cases and a review of the recent literature. Ann Intern Med. 1947;26:873-89. doi: 10.7326/0003-4819-26-6-873.
2. 2. Ullah W, Mukhtar M, Abdullah HM, Ur Rashid M, Ahmad A, Hurairah, A et al. Diagnosis and management of isolated Superior Mesenteric Artery dissection: A systemic review and meta-analysis. Korean Circ J. 2019;49(5):400-18. doi: 10.4070/kcj.2018.0429
3. 3. Leung DA, Schneider E, Kubik-Huch R, Marincek B, Pfammatter T. Acute mesenteric ischemia caused by spontaneous isolated dissection of the superior mesenteric artery: treatment by percutaneous stent placement. Eur Radiol. 2000;10:1916-9. doi: 10.1007/s003300000520
4. 4. Lamprecht G, Trabold T, Gregor M, Lamberts R. Spontaneous, self-limited, non-atherosclerotic dissection of the superior mesenteric artery. Eur J Gastroenterol Hepatol. 2003;15:437-9. doi: 10.1097/00042737-200304000-00018
5. 5. Elshiekh A, Matharu NM. Type 3 intestinal failure after bypass grafting for isolated acute superior mesenteric artery dissection: A case report. Turkish Journal of Vascular Surgery. 2020;29(10):1-4.
6. 6. Garrett HE Jr. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg. 2014;59(5):1433-9.e92. doi: 10.1016/j.jvs.2014.01.040.
7. 7. Nagai T, Torishima R, Uchida A, Nakashima H, Takahashi K, Okawara H, et al. Spontaneous dissection of the superior mesenteric artery in four cases treated with anticoagulation therapy. Internal Medicine. 2004;43:437-78. doi: 10.2169/internalmedicine.43.473
8. 8. Suzuki S, Furui S, Kohtake H, Sakamoto T, Yamasaki M, Furukawa A, et al. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging. 2004;29:153-7. doi: 10.1007/s00261-003-0110-2

9. 9. Solis MM, Ranval TJ, McFarland DR, Eidt JF. Surgical treatment of superior mesenteric artery dissecting aneurysm and simultaneous celiac artery compression. Ann Vasc Surg. 1993; 7:457-62. doi: 10.1007/BF02002130
10. 10. 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;8:236-40.
11. 11. Sheldon PJ, Esther JB, Sheldon EL, Sparks SR, Brophy DP, Oglevie SB. Spontaneous dissection of the superior mesenteric artery. Cardiovasc Intervent Radiol. 2001;24:329-31. doi: 10.1007/s00270-001-2565-0.
12. 12. Miyomato N, Sakurai Y, Hirokami M, Takahashi K, Nishimori H, Tsuji K, et al. Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: report of a case. Radiat Med. 2005;23(7):520-4.
13. 13. Sagiuchi T, Asano Y, Yanaihara H, Aoki Y, Woodhams R, Hayakawa K. Three-dimensional CT in isolated dissecting aneurysm of the superior mesenteric artery: a case report. Radiat Med. 2001;19:271-3. PMID:11724259
14. 14. Gouëffic Y, Costargent A, Dupas B, Heymann MF, Chaillou P, et al. Superior mesenteric artery dissection: case report. J Vasc Surg. 2002;35:1003-5. doi: 10.1067/mva.2002.122152
15. 15. Sparks SR, Vasquez JC, Bergan JJ, Owens EL. Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg. 2000;14:105-9. doi: 10.1007/s100169910019
16. 16. Akuzawa N, Seki H, Oku Y, Totsuka M, Hatori T, Imai K. Three cases of spontaneous isolated dissection of the superior mesenteric artery. J Emerg Med. 2015;48:e111-6. doi: 10.1016/j.jemermed.2014.12.017
17. 17. 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.
18. 18. Takehara Y, Takahashi M, Fukaya T, Kaneko M, Koyano K, Sakaguchi S. Computed tomography of isolated dissecting aneurysm of the superior mesenteric artery. J Comput Assist Tomogr. 1988;12:678-80. doi: 10.1097/00004728-198807000-00036
19. 19. Corbetti F, Vigo M, Bulzacchi A, Angelini F, Burigo E, Thiene G. CT diagnosis of spontaneous dissection of the superior mesenteric artery. J Comput Assist Tomogr. 1989;13(6):965-7. doi: 10.1097/00004728-198911000-00006
20. 20. Krupski WC, Effenecy DJ, Ehrenfeld WK. Spontaneous dissection of the superior mesenteric artery. J Vasc Surg. 1985;22:731-4. doi: 10.1016/0741-5214(85)90046-1
21. 21. Vignati PV, Welch JP, Ellison L, Cohen JL. Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection. J Vasc Surg. 1992;16:109-12.
22. 22. 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;19:1-3. doi: 10.1007/s10016-005-0018-0
23. 23. 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 Endovascular Surg. 2004;38(5):469-72. doi: 10.1177/153857440403800513.
24. 24. Picquet J, Abilez O, Penard J, Jousset Y, Rousselet MC, Enon B. Superficial femoral artery transposition repair for isolated superior mesenteric artery dissection. J Vasc Surg. 2005;42(4):788-91. doi: 10.1016/j.jvs.2005.05.048.
25. 25. Asif S, Qureini A, Bennett J. A Rare Case of Spontaneous Isolated Dissection of the Superior Mesenteric Artery. Cureus 2019.11(5):e4725. doi: 10.7759/cureus.4725.