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Iatrogenic Superior Mesenteric Artery Dissection Repair With Open Septectomy
Sarah A. Loh, MD, David Kuwayama, MD, MPhil, Britt Tonnessen, MD.
Yale New Haven Hospital, New Haven, CT, USA.
DEMOGRAPHICS: Mesenteric ischemia is a disease process with both a high mortality risk and negative impact on patient quality of life. Rare superior mesenteric artery (SMA) dissections pose a particular challenge for endovascular or open therapy, as they often extend past the proximal artery into multiple branches. We present a case of an open SMA septectomy of a subacute iatrogenic dissection after SMA stenting.
HISTORY: A 53-year-old female presented with acute abdominal pain and elevated lactate in the setting of chronic intestinal angina. History was significant for smoking and cocaine use. CTA revealed celiac occlusion and high-grade proximal SMA stenosis without calcification. She underwent SMA stenting and balloon angioplasty and a subsequent exploratory laparotomy with viable bowel. With reintroduction of diet, she complained of continued post-prandial pain. CTA demonstrated a dissection flap distal to the SMA stents with a small true lumen, felt to be iatrogenic from the first procedure (Figure 1a). She received parenteral nutrition with a plan for reoperation at 6 weeks.
PLAN: Midline laparotomy was performed through the prior incision. The superior mesenteric vein (SMV) and SMA were approached anteriorly at the base of the mesentery. Multiple branches were controlled. The prior SMA stents were manually palpated. Using micropuncture access distal to the dissected area, retrograde control of the SMA was obtained using a 6mm balloon (Figure 1b). A dissection flap was identified within the mid and distal SMA and excised (Figure 1c). The SMA was reconstructed with a bovine patch. Follow-up CTA demonstrated a widely patent SMA with no residual dissection. The patient has no further intestinal angina.
DISCUSSION: SMA dissection is uncommon and does not always require revascularization. However, in this patient with persistent symptoms and narrow true lumen, reconstruction was warranted. Despite recent laparotomy, we selected an open approach in order to preserve multiple SMA branches and to avoid long-segment stenting. Retrograde endovascular control of the inflow provided excellent access to the true lumen of the SMA. This case demonstrates the feasibility of a hybrid approach involving open SMA septectomy and retrograde balloon control which resulted in a favorable outcome for the patient.
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