Conservative versus stent treatment for spontaneous isolated superior mesenteric artery dissection after the failure of initial 3 days’ conservative treatment: A 10-year follow-up study

Abstract

Objectives

To compare the safety and effectiveness of conservative and stent treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) patients after the failure of initial 3 days’ conservative treatment.

Methods

All newly diagnosed SISMAD patients between 2013 and 2017 were retrospectively reviewed. After the failure of 3 days’ conservative treatment, all patients were recommended for stent treatment, but some patients refused to choose it. Their demographic, radiologic, and clinical data were compared.

Results

57 patients were not improved after initial 3 days’ conservative treatment. Among them, 19 patients were chose to receive stent placement and 38 patients were continually treated with conservative treatment. The median follow-up time was 92.0 (range 62.7–120.4) months. There were no bowel ischemia and arterial rupture. No significant difference was observed in clinical complete recovery (Conservative 31/38 vs Stent 12/19, p =.19) and hospitalization time (Conservative 8.3 ± 1.7 days vs Stent 7.2 ± 1.5 days, p =.59) between conservative and stent treatment groups. Significant statistical differences were found in radiological complete remodeling (6/38 vs 16/19, p < .01) and hospitalization expense (8662 ± 2886 China Yuan vs 32,935 ± 11,767 China Yuan, p < .01) between these two groups.

Conclusions

Although undergoing the failure of initial 3 days’ conservative treatment, continue conservative treatment still is safe and effective for SISMAD patients. Stent placement could be chosen as an alternative treatment, especially for patients potentially with bowel ischemia or arterial rupture.

Keywords

Superior mesenteric artery dissection conservative treatment stent treatment effectiveness

Introduction

Spontaneous isolated superior mesenteric artery dissection (SISMAD) refers to the dissection that only involves superior mesenteric artery (SMA) without apparent causes. In recent years, for the more frequent use of emergency enhanced computed tomography (CT) and CT angiography (CTA), the literature reports of SISMAD are increasing, analyzing the cause of disease,^1,2 morphological classification,^3–7 treatment strategy,^8–22 and prognosis.^23,24

Among them, treatment strategies that were the most reported were mainly divided into conservative and stent treatment. Part of the articles compared the two treatments,^{8–13,16–18,21} but patients who failed after initial conservative treatment were rarely investigated with long-term follow-up. Moreover, the comparison content was only focusing on imaging results and short-term symptom recovery.

Using 10 year follow-up data from our department of vascular surgery, the aim of this study is to compare the safety and effectiveness of conservative and stent treatments from multiple aspects comparisons in patients failed from initial 3 days’ conservative treatment.

Materials and methods

Study population

We retrospectively reviewed a collected database of the symptomatic SISMAD patients from January 2013 to December 2017 in our department of vascular surgery. SISMAD was diagnosed using enhanced CT or CTA. Patients were included if they met the following criteria: newly diagnosed patients without previous treatment for SISMAD; no apparent causes; no other vascular diseases such as aortic dissection, celiac dissection, iliac dissection, fibromuscular dysplasia, cystic medical necrosis, Marfan syndrome, and Ehlers–Danlos syndrome. Patients were excluded if their abdominal pain was significantly relieved after 3 days initial conservative treatment (Figure 1).

Figure 1.

The detailed progress of patient selection.

Data collection

A series of demographic, radiologic, and clinical data were collected, including age, gender, body mass index (BMI), onset time, onset symptoms, hypertension, smoking, alcohol abuse, location of dissection, length of dissection, aorta-SMA angle, thrombosis, treatment, patient’s daily condition, hospitalization time, and expense. All patients were followed-up regularly after discharge (every 3 months in first year and then once a year), involving the follow-up treatment, CTA, and clinical symptoms. Complete remodeling was defined as no residual stenosis or occlusion, no false lumen, and no intramural thrombus at the SMA trunk (Figure 2). Complete recovery of clinical symptoms was defined as no abdominal pain or discomfort and no digestive symptoms. The duration of follow-up time was counted from March 2013 to December 2022.

Figure 2.

Imaging at the time of onset and follow-up. Patient 1: Complete remodeling in 10 months (conservative treatment); Patient 2: Incomplete remodeling in 5 years (conservative treatment); Patient 3: Complete remodeling in 3 months (stent treatment); Patient 4: Incomplete remodeling in 10 years (stent treatment).

Treatment of SISMAD

Conservative treatment was performed as the first-line treatment if no bowel ischemia or arterial rupture was occurred. After 3 days’ conservative treatment, patients who still have excruciating abdominal pain were defined as conservative treatment failure. All these failure patients were recommended for stent placement. Patients were informed regarding the benefits and risks of both conservative and stent treatments. The final treatment performed was according to the patient’s decision.

Stent placement procedures were performed using the transfemoral approach; a 6F sheath was introduced into the abdominal aorta. A 6F guiding catheter was then used as an access channel to the SMA root. A 0.035-inch guide-wire was used for the selective cannulation of distal SMA via the true lumen. Subsequently, the self-expanding stent (Precise, PRORXTM, Cordis, 6*40-80mm) was placed in the true lumen at the level of the dissection over the guide-wire.

Conservative treatment consists of fasting, nutritional support, pain relief, control of blood pressure, vasodilator therapy, and anticoagulation therapy (low-molecular-weight heparin). All of the patients whether underwent conservative treatment or stent placement were managed with antiplatelet therapy (aspirin monotherapy) for 12 months after discharge.

Statistical analysis

Categorical variables are reported as frequencies and continuous variables as medians and ranges. Categorical variables were compared using chi-square test or Fisher’s exact test, as appropriate. A p value of <0.05 was considered to be significant. Database were stored using Microsoft Excel (Microsoft Corp, Redmond, WA, USA) and statistical analyses using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA).

Results

Baseline characteristics

The detailed process of patient selection is shown in Figure 1. A total of 50 males and 7 females with a mean age of 54 years were included in this study. After 3 days conservative treatment without improvement, 19 patients were treated with stent placement and 38 patients were continually treated with conservative treatment. Baseline characteristics are summarized in Table 1.

Table 1.

Baseline characteristics of the study population.

	Conservative	Stent	p
Age (years)			0.77
<55	24	11
≥55	14	8
Gender			0.21
Male	35	15
Female	3	4
BMI (Kg/m²)			0.39
<24	18	12
≥24	20	7
Onset time (hours)			0.77
<24	26	12
≥24	12	7
Onset symptoms			1.00
Single	27	14
Multiple	11	5
Hypertension			1.00
Presence	13	7
Absence	25	12
Smoking			0.51
Presence	10	3
Absence	28	16
Alcohol abuse			1.00
Presence	6	3
Absence	32	16
Location of SMAD			0.26
Root	33	14
Distal	5	5
Length of SMAD (mm)			0.77
<50	15	6
≥50	23	13
Aorta-SMA angle			1.00
<75°	14	7
≥75°	24	12
Thrombosis			0.78
Presence	24	13
Absence	14	6

BMI: Body mass index; SMA: Superior mesenteric artery; SMAD: SMA dissection.

The prognosis of both conservative and stent treatments

In the conservative group, 17 patients improved and were discharged within 8 days, 13 within 10 days, and the longest was 13 days. The average length of hospital stay was 8.3 ± 1.7 days, and none of them developed peritonitis symptoms or dissection rupture. In the stent group, 8 improved within 6 days, 7 within 8 days, and 4 after 9 days, with a mean hospital stay of 7.2 ± 1.5 days. The average hospitalization expense of conservative and stent group were 8662 ± 2886 China Yuan (CNY) and 32,935 ± 11,767 CNY, respectively. 36 (95%) patients in the conservative group spent less than 10,000 CNY, and 17 (89%) patients in the stent group spent more than 20,000 CNY.

The median follow-up time was 92.0 (range 62.7–120.4) months. At the end of follow-up period, 31 (82%) patients’ clinical symptoms in the conservative group had completely recovered, 2 (5%) patients still had abdominal pain, 4 (10%) patients had abdominal discomfort, and 1 (3%) patient had tolerable abdominal distension. In the stent group, 12 (63%) patients had complete recovery of clinical symptoms, 3 (16%) patients still had abdominal pain, and 4 (21%) patients had abdominal discomfort. In the conservative treatment group, 6 (16%) patients had complete vascular remodeling, 15 (39%) patients still had dissection, 3 (8%) patients had small aneurysm, and 14 (37%) patients had stenosis. In the stent group, 16 (84%) patients had complete vascular remodeling and 3 (16%) patients still had dissection (Figure 2).

Comparison between conservative and stent treatments

No significant differences were observed in baseline characters between conservative and stent groups (Table 1). There was also no significant statistical difference in complete clinical recovery (conservative 31/38 (82%) versus stent 12/19 (63%), p =.19) and hospitalization time (conservative 8.3 ± 1.7 days vs stent 7.2 ± 1.5 days, p =.59) between these two groups. However, significant differences were found in radiological complete remodeling (conservative 6/38 (16%) versus stent 16/19 (84%), p < .01) and hospitalization expense (conservative 8662 ± 2886 CNY vs stent 32,935 ± 11,767 CNY, p<.01) between these two groups (Table 2).

Table 2.

Conservative versus stent treatment.

	Conservative	Stent	p
Recovery of symptoms			0.19
Complete	31	12
Incomplete	7	7
Remodeling of SMA			<0.01
Complete	6	16
Incomplete	32	3
Hospitalization time (days)			0.59
<8	17	10
≥8	21	9
Hospitalization expense (CNY)			<0.01
<20000	38	2
≥20,000	0	17

SMA: Superior mesenteric artery; CNY: China Yuan.

Discussion

Conservative treatment was performed as the first-line treatment if no bowel ischemia or arterial rupture was noted.^9–17 Most of the patients were improved by initial conservative treatment, but some did not. For these patients, the choice of treatment is controversial. Many reports choose stent treatment or open surgery for fear of disease progression, but the probability of intestinal necrosis and aneurysm rupture is low in the real world.^8–22 We found that continued conservative treatment is still feasible, the long-term recovery of clinical symptoms is not inferior to stent treatment, and furthermore, the hospitalization cost is much lower than stent treatment. Certainly, stent treatment is also safe and effective, especially for those who are potentially at risk of bowel ischemia or arterial rupture.

In some studies, stenting therapy was performed after 8–24h without pain relief,^19,20 while in some studies, stenting was not considered until 5–7 days after observation.^13,24 In the early stage, due to the lack of experience, no guidelines, and fear of disease progression, stent therapy was recommended after the failure of initial 3 days’ conservative treatment in our center. But some patients still refused to choose it, mainly for the following reasons: (1) Many patients benefit from conservative treatment (100/157 in this study). (2) The cost of stent treatment is high; they have to pay more at their own expense. (3) The long-term prognosis of stent treatment is unclear, and there are risks of stent occlusion, displacement, and fracture.

Through long-term follow-up, we found that conservative treatment could also achieve complete vascular remodeling in six patients (Figures 2), indicating that the SMA had a strong ability to self-repair. Three patients still had local dissection after stent treatment, which may be related to the failure of bare stent to completely isolate the dissection rupture (Figures 2). Clinical symptoms were completely recovered in 31 patients treated with conservative treatment without complete vascular remodeling. Most of the patients could improve the intestinal blood supply by expanding the true lumen or establishing collateral circulation. In addition, seven patients treated with stents still had residual clinical symptoms, which may be related to irreversible nerve damage at the onset and long-term stimulation of stents. There are abundant retroperitoneal plexus around the superior mesenteric artery, and the original vascular morphology is changed and these nerves are stimulated after stent implantation. Although stent treatment can significantly improve the vascular morphology, it cannot guarantee the complete recovery of clinical symptoms. Although conservative treatment has the risk of exacerbation, the actual occurrence probability is extremely low, and the long-term clinical symptoms recover well.

Complete recovery of clinical symptoms is not consistent with complete remodeling of SMA. It is not necessary to stent SMAD patients prematurely in order to pursue rapid treatment or better imaging results. As long as there is no bowel ischemia or artery rupture, treating conservatively and waiting patiently for SMA to self-repair can also achieve good results.

This study had several limitations. First, it is a retrospective study, not a randomized controlled trial; thus, the level of evidence could be improved further. Second, the study sample size was relatively small (most patients improved after 3 days’ conservative treatment) that will limit the overall relevance of our results. Third, some patients of lower socioeconomic status refused stent treatment, and this may impact follow-up and other findings that might track with socioeconomic status.

Conclusions

To the best of our knowledge, the present study was the first to compare conservative and stent treatment for SISMAD patients after the failure of initial conservative treatment. Both conservative and stent treatment are safe and effective in SISMAD patients after the failure of initial 3 days’ conservative treatment. Stent treatment could be an alternative treatment, especially for those who are potentially at risk of bowel ischemia or arterial rupture. A prospective randomized clinical trial with large sample size is required to verify our findings.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lei Wang

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