Management Strategy and Radiologic Outcomes of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection Based on Angiographic Classification: The Follow-Up Experience in a Single Center

Abstract

Purpose:

To investigate the demographics, clinical features, radiologic measurement, treatment, and outcomes of symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD) according to computed tomography (CT) classification.

Methods:

This retrospective study included 201 patients diagnosed with symptomatic SISMAD from November 2014 to December 2020. Symptomatic spontaneous isolated superior mesenteric artery dissection was categorized into four types based on CT images by Yun’s angiographic classification. Their clinical characteristics, images features, treatment methods, and radiological outcomes were comparatively analyzed by CT angiographic types.

Results:

SISMADs were categorized into type I (13.9%) patent false lumen (FL) with both entry and re-entry; type IIa (37.3%), blind pouch of FL; type IIb (43.3%), thrombosed FL; and type III (5.5%), and the occlusion of superior mesenteric artery (SMA). Type IIb, the most common SISMAD, showed the largest true lumen (TL) residual diameter and the lowest percentage of TL stenosis. Type III positioned most proximally to SMA origin and had the maximum dissection length. Symptomatic spontaneous isolated superior mesenteric artery dissections underwent conservative (75.1%), endovascular (22.4%), and surgical (2.5%) treatment. Conservative treatment was more frequent in type I (85.7%) and type IIb (83.9%) than in type IIa (65.3%) and type III (45.5%). Endovascular intervention was more commonly utilized in type IIa (32.0%) and type III (36.4%) than in type I (14.3%) and type IIb (14.9%). Conservative patients achieved FL vanishment/shrinkage (57.8%), stabilization (26.6%), and enlargement (15.6%). After conservative treatment, type I showed angiographic FL stabilization; type IIa achieved FL shrinkage (48.1%), stabilization (22.2%), and enlargement (29.6%); type IIb exhibited FL vanishment/shrinkage (92.0%) and enlargement (8.0%). Cumulative rate of stent patency was 92.3% during 6-year follow-up.

Conclusions:

Conservative management with close follow-up is initially provided especially for types I and IIb. Morphological stabilization is more frequent in type I of patent FL with entry and re-entry. False lumen vanishment or shrinkage was more likely to occur in type IIb due to the thrombus absorption. Endovascular intervention has excellent long-term in-stent patency and is predominantly utilized in types IIa and III. Blood flow sustained into a blind-ending FL causes the TL compression and stenosis in type IIa. Type III with the occlusion of SMA has the high risk of bowel ischemia.

Clinical Impact

According to Yun’s angiographic classification of spontaneous isolated superior mesenteric artery dissection (SISMAD), type I (13.9%) has patent true and false lumen and the morphological pattern is maintained stable; type IIa (37.3%) possesses a patent blind-ending false lumen which might shrink, remain unchanged, or enlarge; and endovascular intervention is suggested when conservative treatment failed; type IIb (43.3%) recovers spontaneously due to the absorption of false lumen thrombus and conservative treatment is preferentially considered; type III (5.5%) with the occlusion of main trunk carries a high risk of bowel necrosis, early endovascular intervention is proposed, and open surgery might be necessary.