Isolated Dissection of Superior Mesenteric Artery: Study on the Treatment Guidelines

Purpose: Isolated superior mesenteric artery (SMA) dissection is a rare, but increasing vascular disorder. However, optimal treatment guidelines are not well established. The purpose of this study is to review a single institutional experience in the management of isolated SMA dissections and establish optimal treatment guidelines. Methods: Between November 2004 and August 2009, 26 patients were diagnosed with isolated SMA. dissection at Eulji University Hospital. Diagnosis was confirmed with CT scans in all patients. We retrospectively reviewed the medical records, imaging studies, and the early outcomes of the patients. Results: There were 22 (84.5%) men and 4 women. The mean age was 55.4 (39 similar to 74) years. The mean follow-up was 39.1 (4.1 similar to 53.3) months. In 15 patients, CT scans were performed for abdominal pain, and in the other 11 patients, the isolated SMA dissections were detected incidentally during workup for other causes. The radiographic findings included an intimal flap with a patent false lumen in 16 and intramural hematoma in 10. The dissection started at a mean of 22.3 (5 similar to 46) mm from the origin of the SMA with a mean length was 47.7 (1.0 similar to 150) mm. Treatments included expectant management in 13, anticoagulation in 6, stenting in 6 patients, and surgery in one case of bowel infarction. None required additional intervention. All patients remained asymptomatic during follow-up. Conclusion: Most patients with isolated SMA dissection were successfully managed medically. Surgical or percutaneous intervention should be reserved for those with evidence of bowel necrosis or mesenteric ischemia and failed cases to initial medical treatment. 단독성 상장간막동맥 박리는 온라인 의학저널 데이터베이스인 퍼브메드(PubMed)에서 isolated superior mesenteric artery dissection을 중심 단어(keyword)로 검색하면 현재까지 영어 의학저널에서 106예밖에 검색이 안될 정도로 드문 질환이다.(1) 발병원인, 병태생리나 치료 등에 대한 것들이 확실하게 정립되어있지 않다. 지금까지 제시된 치료 지침들은 문헌에 보고된 여러 논문을 검색하여 검토하고 분석 한 결과 수술적응증 유무, 증상, 내막편(intimal flap) 혹은 혈관 협착 유무, 협착의 길이 등에 따라 치료 지침을 제시한 것이었으며 이외에 전산화 단층촬영에 나타난 상장간막동맥 박리의 모양에 따른 치료 지침을 제시하기도 하였다.(2-4) 지금까지 보고된 치료 방법은 특별한 치료가 없는 기대요법(expectant management), 항응고제 투여, 혈관 내 치료 및 수술 등이 있으나 의미 있고 체계적인 치료 지침이 확립되지 않아 동맥의 해부학적 적정성, 환자의 동반질환이나 증상의 정도, 의사의 선호도 등에 따라 제각기 시행되고 있는 실정이다. 저자들은 본원에서 경험한 예를 분석하여 이에 대한 적 절한 치료 지침을 제시하고자 본 연구를 시행하였다.Gobble RM, 2009, J VASC SURG, V50, P1326, DOI 10.1016/j.jvs.2009.07.019Subhas G, 2009, ANN VASC SURG, V23, P788, DOI 10.1016/j.avsg.2008.12.006Morris JT, 2008, J VASC SURG, V47, P649, DOI 10.1016/j.jvs.2007.08.052Casella IB, 2008, J VASC SURG, V47, P197, DOI 10.1016/j.jvs.2007.07.051Sakamoto I, 2007, EUR J RADIOL, V64, P103, DOI 10.1016/j.ejrad.2007.05.027KIM HK, 2007, J KOREAN SOC VASC SU, V23, P159Picquet J, 2005, J VASC SURG, V42, P788, DOI 10.1016/j.jvs.2005.05.048Froment P, 2004, CARDIOVASC INTER RAD, V27, P529, DOI 10.1007/s00270-003-0158-yNagai T, 2004, INTERNAL MED, V43, P473Okada M, 2004, INTERNAL MED, V43, P451Kim JH, 2004, KOREAN J RADIOL, V5, P134Suzuki S, 2004, ABDOM IMAGING, V29, P153, DOI 10.1007/s00261-003-0110-2Leung DA, 2000, EUR RADIOL, V10, P1916Yasuhara H, 1998, J VASC SURG, V27, P776Nakamura K, 1997, SURG TODAY, V27, P272AMBO T, 1994, SURG TODAY, V24, P933SISTERON A, 1975, CHIRURGIE ARTERIOPAT, P197