Chapter 134 - Mesenteric artery dissection

Question 1

Spontaneous isolated SMA dissection first described

Answer 1

Bauersfeld 1947

Question 2

Current number of spontaneous isolated SMA (SISMAD) and celiac (SICAD) dissections

Answer 2

SISMAD 622 cases SICAD 100 cases concomitant 13 cases

Question 3

Epidemiology of SISMAD/SICAD

Answer 3

67-88% in men 50’s to 60’s age HTN in 30-40% of patients only Majority of cases in Korea, China, Japan

Question 4

Etiology of SIVAD

Answer 4

1) connective tissue disease (Marfan’s, Ehlers-Danlos, Loeys-Diez) 2) cystic medial necrosis 3) segmental arteriole mediolysis 4) Bechet 5) FMD 6) smoking 7) atherosclerosis 8) ETOH 9) obesity 10) heavy lifting 11) pregnancy majority of SIVAD do not have any of these

Question 5

Anatomy of the SISMAD

Answer 5

1-3 cm from SMA ostium SMA transition from fixed retropancreatic position with acute turn into mobile mesenteric root

Question 6

SISMAD genetic chromosomal link

Answer 6

locus 5q13-14 linked to familial ascending aortic aneurysm and dissection

Question 7

Symptoms of SIVAD

Answer 7

1) abdominal pain 90% (mid-epigastric radiation to back) 2) nausea vomiting 3) melena, diarrhea

Question 8

Sakamoto classification of SISMAD 2007 Zerbib added TYPE 5

Answer 8

Classify based on CT appearance TYPE 1: patent false lumen with entry + reentry TYPE 2: cul-de-sac false lumen without reentry TYPE 3: thrombosed false lumen with ulcer TYPE 4: thrombosed false lumen without ulcer TYPE 5: aneurysmal dissection with stenosis distally TYPE 6a: total thrombosis of SMA TYPE 6b: partial thrombosis of SMA

Question 9

Yun classification of SISMAD

Answer 9

TYPE 1: patent true and false lumen with entry and re-entry sites TYPE 2a: patent true lumen with no reentry site but patent FL TYPE 2b: patent true lumen with no reentry site but thrombosed FL TYPE 3: occluded SMA

Question 10

Luan classification

Answer 10

TYPE A: dissection at curve of SMA to SMA ostium TYPE B: dissected limited to curve of SMA TYPE C: extending from curve down distally but not to the ileocolic or distal ileal TYPE D: towards ileocolic/ileal artery

Question 11

Goal of stenting in SIVAD

Answer 11

1) eliminate stenosis of false lumen encroachment 2) stabilization of vessel integrity to avoid late degeneration

Question 12

Indication for SMA stenting in SISMAD

Answer 12

1) stenosis > 80% 2) dilation > 2cm

Question 13

Medical treatment of SISMAD with anticoagulation or antiplatelet

Answer 13

no good evidence for either

Question 14

SISMAD treatment algorithm

Answer 14

FIGURE 134.7

Question 15

Surveillance of SIVAD

Answer 15

Imaging 1 month then 6 months x 1 year then annually

Question 16

Percentage of patients with SISMAD that improve on medication only and have complete remodelling

Answer 16

41% improve on med therapy 15% complete remodelling

Question 17

Which class has best chance of complete remodelling in SISMAD

Answer 17

Yun class 2a/b