Safety and efficacy of conservative, endovascular bare stent and endovascular coil assisting bare stent treatments for patients diagnosed with spontaneous isolated superior mesenteric artery dissection

Abstract

Introduction: Isolated dissection of visceral artery organs is very infrequently reported and when it occurs it mostly affects the superior mesenteric artery (SMA) with abdominal pain as the commonest presenting symptom. However, the best therapeutic strategy in symptomatic patients has not yet been established.

Aim: To evaluate the safety and efficacy of conservative, endovascular bare stent and endovascular coil assisting bare stent treatments for patients diagnosed with spontaneous isolated superior mesenteric artery dissection (SISMAD).

Material and methods: We reviewed patients who had SISMAD and received conservative, bare stent and coil assisting bare stent as a primary treatment between 2014 and 2018. Patient demographics, symptoms, angiographic findings and treatment outcomes were analyzed.

Results: A total of 62 patients was found to have SISMAD among whom 83.9% (n = 52) were male and 16% (n = 10) were female with the mean age of 52.55 ±7.22 years, range 33-77. 22.6% (n = 14) received conservative, 62.9% (n = 39) endovascular bare stent and 14. Four percent (n = 9) endovascular coil assisting bare stent treatment. The success rate in primary treatment was conservative 78.5% (n = 11), bare stent 97.4% (n = 38), coil assisting bare stent 100% (n = 9). The mean follow-up duration (months) was 28.76 ±12.87.

Conclusions: Endovascular bare stent placement is a safe, effective, and successful treatment in the management of symptomatic SISMAD. The diagnostic imaging result is a key point for planning appropriate treatment especially in patients with tapered vessels, longer dissection lesion, and dissection aneurysm where coil assisting bare stent shows good results. Conservative treatment should be given priority for the asymptomatic patient, but close monitoring is highly recommended.

Keywords: abdominal pain; bare stent; coil embolization; dissection aneurysm; endovascular treatment; superior mesenteric artery dissection.

Photo 1

Diagnostic abdominal CTA: A – cross-section plane shows spontaneous isolated SMA dissection with true lumen (black arrow) separated by intimal flapping (the pathognomonic finding of SISMAD) from false lumens (white arrow), B – CT reconstruction, longitudinal view revealing the entry site, dissection length and presence of pseudo-aneurysm, C – VR image lateral views revealing SMA vascular branches

Photo 2

Endovascular coil assisting bare stent: A – angiography revealing the entry point of the true lumen and dissection aneurysm, B – angiography taken after bare stent deployment shows persistent dissection aneurysm, C – successful false lumen coil embolization, D – control angiography revealed good blood flow of the SMA from the proximal to the distal as well as side branches with successfully sealing of false lumen by the coil

Photo 3

Management of bare stent stenosis by secondary stenting: A – angiography shows filling defect in the lumen of a bare stent at the proximal part indicating stenosis of the stent lumen, B – deployment of a secondary stent, C – secondary stent successfully deployed at the lesion site, D – control angiography revealing disappearance of filling defects after secondary stenting