Outcomes of Spontaneous Mesenteric Arterial Dissections
Wande B. Pratt, MD, Harleen K. Sandhu, MD, MPH, Rana O. Afifi, MD, Hazim J. Safi, MD, Ali Azizzadeh, MD, Kristofer M. Charlton-Ouw, MD.
University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
Introduction
Spontaneous isolated mesenteric arterial dissection (SIMAD), encompassing the superior mesenteric and celiac artery branches in the absence of an aortic dissection, is an uncommon but potentially serious condition. Although improvements in imaging modalities such as computed tomography angiography (CTA) have enabled early diagnosis, optimal management of SIMAD is poorly understood. We reviewed our experience to elucidate the natural history, clinical and radiological features at presentation and during the course of SIMAD management.
Methods
Retrospective review of medical records for all patients presenting from 2009-2015 with mesenteric arterial dissections was performed. Patients without initial imaging were excluded.
Results
19 patients with adequate imaging were included with isolated visceral arterial dissections, of which 2 had traumatic etiology and 17 were spontaneous. Mean age was 60.3±10 years and 9 (53%) were males. There was nearly equal distribution between superior mesenteric (9, 53%) and celiac branch arteries (8, 47%). Two patients that were referred for genetic testing were found to have vascular Ehlers-Danlos Syndrome (vEDS). Most patients were conservatively managed with antiplatelet or anticoagulant therapy upon diagnosis (15, 88%) and continued for 6-12 months. Most patients were symptomatic (11, 65%) on diagnosis. Open surgical decompression was done for one patient with median arcuate ligament syndrome. One vEDS patient had endovascular coiling of the splenic artery with open repair of celiac artery dissecting aneurysm. Another vEDS patient with ruptured iliac artery aneurysm had early mortality (7%). Over median follow-up of 19 (IQR: 11-27) months, there were no recurrences, no new aneurysms, and no need for other invasive interventions. Follow-up CTA of majority (83%) showed favorable arterial wall remodeling in most. Four (24%) nonoperative patients had persistent but mild symptoms.
Conclusions
Nonoperative management is reasonable for most patients if symptoms subside after the initial event. Genetic testing should be considered, especially in patients under 50 years old. Surgical interventions
including endovascular stenting and open repair can be reserved for those with residual or persistent symptoms, progression, or aneurysm formation.
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