Successful revascularization of isolated SMA dissection

Successful revascularization of

isolated SMA dissection

Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University

Junichi Tazaki, Takeshi Kimura

Case Fifty-five y.o male was admitted to our hospital due to acute abdominal pain nausea and vomit with acute onset. CT revealed dissection at ostium of superior mesenteric artery (SMA), and true lumen was compressed by false lumen.

Risk factor: Hypertension, Current smoker ECG: Sinus rhythm ABG: pH7.414 pO2 71 pCO2 38 K 3.5 BE -0.8

SMA

SMA

Entry point

Hematoma at False lumen

CT at onset

SMA

Entry was closed with thrombus.

Blood flow of true lumen was improved.

Day 1 CT

Entry point

False lumen

True lumen

Abdominal pain relapsed many times . Therefore we performed endovascular therapy.

Day 4, Severe abdominal pain relapsed. The patient could not tolerate complete bed rest

because he is medical doctor.

EVT to SMA Lt brachial approach Guiding sheath : 6.5Fr sheathless PV angle 90cm

SMA

EVT to SMA

Entry point

Lt brachial approach Guiding sheath : 6.5Fr sheathless PV angle 90cm

Non-touch technique

0.014 Agosal (Rinato) wire

0.035 wire

Lt brachial approach Guiding sheath : 6.5Fr sheathless PV angle 90cm

Entry point

False lumen

True lumen

EVT to SMA

Entry point

False lumen

True lumen

After first wire pass

IVUS after first wire cross

False lumen was blind end

After 1st stent

Misago 8-40mm

Final Angiogram

Misago 6-80mm

5 Month after EVT

Discussion

Spontaneous isolated dissection of the superior mesentric artery(SIDSMA) mainly occurs in fifth decade male.

Sakamoto I,etal. Imaging appearances and management of isolated spontaneous dissection of the superior

mesenteric artery. Eur J Radiol. 2007;64:103–110

I. Sakamoto et al. / European Journal of Radiology 64 (2007) 103–110 105

Fig. 1. Drawings illustrate imaging classification of spontaneous dissection of the superior mesenteric artery. Type I: patent false lumen with both entry and re-entry;

type II: ‘cul-de-sac’ shaped false lumen without re-entry; type III: thrombosed false lumen with ulcer like projection (ULP), which is defined as a localized blood-filled

pouch protruding from the true lumen into the thrombosed false lumen; type IV: completely thrombosed false lumen without ULP.

In all of them, the false lumen of the SMA remained unchanged

in size during the follow-up period of 12–48 months (Fig. 2).

One patient with type II dissection underwent urgent surgery

because of occlusion of the true lumen, attributing to small

bowel ischemia (Fig. 3). In this case, catheter angiography

demonstrated not only occlusion of the SMA, but also severe

stenosis of the celiac trunk due to compression by the median

arcuate ligament. His postoperative course was uneventful dur-

Fig. 2. 49-year man with type I dissection of the superior mesenteric artery (SMA). (A) Coronal MPR images at the onset clearly depict an intimal flap in the SMA

and compression of the true lumen by the dilated false lumen, together with the entry (arrow) and re-entry sites (open arrow). (B) SMA arteriograms demonstrate the

dilated false lumen and the entry (arrow) located a few centimeters from the vessel origin. The re-entry site (open arrow) is also revealed. The patient was followed

up conservatively, and the false lumen remained unchanged during the follow-up period of 36 months. F: false lumen.

Initial and middle-term results of treatment for symptomatic spontaneous isolated dissection of superior

mesenteric artery Eur J Vasc Endovasc Surg 2013. 45. 502-508

Sakamoto classification

Discussion

patients with severe symptoms should be considered EVT with self expanding stent

Min, et. Al Current strategy for the treatment of symptomatic spontaneous isolated dissection of superior mesenteric artery JVascSurg2011; 54:461-6.

Summary

We report the successful revascularization of intestinal ischemia due to isolated SMA dissection supported by CT and IVUS.

Thank you for your attention!