Elsevier

Annals of Vascular Surgery

Volume 64, April 2020, Pages 276-284
Annals of Vascular Surgery

Clinical Research
Management Strategy Based on Disease Stages for Patients with Symptomatic Isolated Mesenteric Artery Dissection

https://doi.org/10.1016/j.avsg.2019.09.037Get rights and content

Background

An optimal treatment regimen is sought for symptomatic isolated mesenteric artery dissection (IMAD) on the basis of its clinical staging.

Methods

From January 2011 to December 2018, 120 patients with symptomatic IMAD from two institutions were collected retrospectively. We reviewed the clinical features, risk factors, computed tomography (CT) images, treatment modalities, and follow-up results to propose a new management strategy based on the clinical stages of the disease.

Results

A total of 120 patients were collected in this study; 77 patients (69 men, 8 women; median age, 52.53 years; range, 39–73 years) who had undergone successful conservative management with antithrombotic agents were included in group A. The remaining 43 patients (34 men, 9 women; median age, 52.63 years; range, 26–66 years) who underwent invasive therapy were included in group B. Significant differences were observed between the two groups with respect to dissection length (50.72 ± 27.72 mm vs. 62 ± 24.3 mm; P = 0.02), true lumen residual diameter (3.31 ± 1.05 mm vs. 2.83 ± 2.05 mm; P = 0.01), and branch involvement (8 and 19, respectively; P < 0.001). Success was achieved in 76.24% (77/101) of patients treated by conservative management with antithrombotic agents in the acute stage; 43 patients underwent invasive interventional therapy in different stages of symptomatic IMAD. In group A, 6 patients had recurrent abdominal pain, three of whom underwent invasive intervention, and the remaining patients improved after conservative treatment. Positive remodeling was observed in 80.33% (49/61) of patients treated with conservative management alone versus 19.67% (12/61) of patients who experienced negative remodeling. Endovascular intervention in group B, CT angiography, or mesenteric angiography yielded complete remodeling in 23 (76.67%, 23/30) patients and evidence of stent restenosis in 7 (23.33%, 7/30) patients. Among the surgical patients, 7 patients showed improvement in the luminal diameter. However, 3 patients with short bowel syndrome require long-term parenteral nutrition.

Conclusions

Conservative management with antithrombotic agents should be a first-line regimen for symptomatic IMAD in the acute stage. If symptoms persist, endovascular intervention is a safe and feasible treatment in the subacute or chronic stage. When peritonitis is present, surgical treatment should be promptly performed, regardless of the disease stage.

Introduction

Symptomatic isolated mesenteric artery dissection (IMAD) is an uncommon type of acute abdomen caused by vascular lesions.1 Recently, its identification has been increasing annually with the advancement of imaging technology.2

In clinical settings, the initial manifestation of symptomatic IMAD is usually acute abdominal pain, which can endanger lives when intestinal necrosis occurs. In addition, a few asymptomatic cases can be detected as incidental findings during examinations for other complaints. Currently, various treatment strategies have been reported,3 including conservative management and invasive therapy4 (endovascular interventions and surgical procedures). However, no recommendation can be given with regard to the optimal treatment.5

This study retrospectively analyzed the clinical data of symptomatic IMAD patients to propose a new management strategy based on IMAD clinical stages.

Section snippets

Study Population

This retrospective study was approved by all participating institutional review boards with a waiver of informed consent. From January 2011 to December 2018, 120 consecutive patients diagnosed with symptomatic IMAD from two institutions were included in the study. The clinical information pertaining to each patient was collected from their medical records, predominantly consisting of general epidemiological data, clinical manifestations, comorbidities, symptoms, imaging findings, and the

Patients

Overall, one hundred twenty patients diagnosed with symptomatic IMAD were collected from January 2011 to December 2018 in this study. These patients were categorized into a conservative management group (group A) and an invasive therapy group (group B). Of these 120 patients with symptomatic IMAD, 77 patients (69 men, 8 women; median age, 52.53 years; range, 39–73 years) were included in group A; these patients had undergone successful conservative management. The remaining 43 patients (34 men,

Discussions

Acute and chronic arterial ischemia of symptomatic IMAD has been mentioned in the European Society for Vascular Surgery (ESVS) guidelines.18 However, the clinical stages of symptomatic IMAD have not been clearly defined. In our study cohort, it was found that abdominal pain disappeared in most patients with conservative management after 7.57 days of admission, and the imaging morphology gradually became stable after discharge. During this period, if persistent symptoms did not improve,

Conclusions

Conservative treatment with antithrombotic agents should be a first-line regimen for symptomatic IMAD in the acute stage. Close clinical observation is necessary, and when there is a suspicion of bowel ischemia, endovascular intervention is a safe and feasible treatment in the subacute or chronic stage. When peritonitis is present, surgical treatment should be promptly performed regardless of the stage.

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Y.J.X. and J.W.W. contributed equally to this work.

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

The authors have no conflict of interest to declare.

Ethics approval was provided by the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology ethics committee.

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