Spontaneous mesenteric arterial dissection
- Ramyar Gilani, MD
Ramyar Gilani, MD
- Assistant Professor of Surgery
- Baylor College of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Dissection of the mesenteric arteries can occur as a result of instrumentation or as a spontaneous event. It can occur in conjunction with aortic dissection or in isolation. The focus of this review is spontaneous, isolated dissection of the mesenteric arteries, particularly of the superior mesenteric artery but also of the celiac axis; isolated inferior mesenteric artery dissection is rarely reported.
Acute aortic dissection is discussed separately. (See "Overview of acute aortic syndromes" and "Clinical features and diagnosis of acute aortic dissection" and "Management of acute aortic dissection".)
MESENTERIC VASCULAR ANATOMY
Spontaneous mesenteric dissection has a predilection for the superior mesenteric artery (SMA) and also occurs in the celiac artery, though rarely in the inferior mesenteric artery. Combined SMA and celiac artery dissection can also occur.
Celiac axis — The celiac axis originates from the abdominal aorta at the level of the 12th thoracic vertebrae and provides blood flow to the structures arising from the primitive foregut. The 10th primitive ventral segmental artery gives rise to the celiac axis . The celiac axis is short, with its takeoff perpendicular to the aorta and perhaps slightly caudal. Most commonly, after a short course, the celiac axis branches to provide left gastric, hepatic, and splenic arteries; however, the pattern of branching can be highly variable.
Superior mesenteric artery — The superior mesenteric artery (SMA) originates from the abdominal aorta and provides arterial inflow to the structures of the midgut (figure 1). The SMA typically develops out of the 13th primitive ventral segmental artery; however, many aberrations can occur during development, resulting in a range of anomalies . The origin of the SMA is located just below the origin of the celiac axis at the level of the first lumbar vertebrae. From its origin, the SMA courses anteriorly with varying degrees of angulation from the aorta for a distance of approximately 2 cm, after which it turns inferiorly, coursing along a similar axis to the aorta. Within this portion, the SMA has an outer wall and an inner wall, which has a bearing on the pathophysiology of SMA dissection. (See 'Etiologic factors' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Schoenwolf GC, Larsen WJ. Larsen's Human Embryology, 4th ed, Churchill Livingstone/Elsevier, Philadelphia 2009.
- White RD, Weir-McCall JR, Sullivan CM, et al. The celiac axis revisited: anatomic variants, pathologic features, and implications for modern endovascular management. Radiographics 2015; 35:879.
- Lange JF, Komen N, Akkerman G, et al. Riolan's arch: confusing, misnomer, and obsolete. A literature survey of the connection(s) between the superior and inferior mesenteric arteries. Am J Surg 2007; 193:742.
- Cronenwett JL, Johnston KW. Rutherford's Vascular Surgery, 7th ed, Saunders/Elsevier, London 2010.
- Young B, Heath JW, Stevens A, et al.. Wheater's Functional Histology: A Text and Colour Atlas, 4th ed, Churchill Livingstone, Edinburgh 2000.
- Sakamoto I, Ogawa Y, Sueyoshi E, et al. Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery. Eur J Radiol 2007; 64:103.
- Park YJ, Park CW, Park KB, et al. Inference from clinical and fluid dynamic studies about underlying cause of spontaneous isolated superior mesenteric artery dissection. J Vasc Surg 2011; 53:80.
- Chang SH, Lien WC, Liu YP, et al. Isolated superior mesenteric artery dissection in a patient without risk factors or aortic dissection. Am J Emerg Med 2006; 24:385.
- Cho BS, Lee MS, Lee MK, et al. Treatment guidelines for isolated dissection of the superior mesenteric artery based on follow-up CT findings. Eur J Vasc Endovasc Surg 2011; 41:780.
- Yun WS, Kim YW, Park KB, et al. Clinical and angiographic follow-up of spontaneous isolated superior mesenteric artery dissection. Eur J Vasc Endovasc Surg 2009; 37:572.
- Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120:2519.
- Park YJ, Park KB, Kim DI, et al. Natural history of spontaneous isolated superior mesenteric artery dissection derived from follow-up after conservative treatment. J Vasc Surg 2011; 54:1727.
- Garrett HE Jr. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg 2014; 59:1433.
- Luan JY, Guan X, Li X, et al. Isolated superior mesenteric artery dissection in China. J Vasc Surg 2016; 63:530.
- Morris JT, Guerriero J, Sage JG, Mansour MA. Three isolated superior mesenteric artery dissections: update of previous case reports, diagnostics, and treatment options. J Vasc Surg 2008; 47:649.
- Suzuki S, Furui S, Kohtake H, et al. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging 2004; 29:153.
- Furukawa H, Moriyama N. Spontaneous dissection of the superior mesenteric artery diagnosed on multidetector helical CT. J Comput Assist Tomogr 2002; 26:143.
- Dushnitsky T, Peer A, Katzenelson L, Strauss S. Dissecting aneurysm of the superior mesenteric artery: flow dynamics by color Doppler sonography. J Ultrasound Med 1998; 17:781.
- Sparks SR, Vasquez JC, Bergan JJ, Owens EL. Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg 2000; 14:105.
- Cho YP, Ko GY, Kim HK, et al. Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery. Br J Surg 2009; 96:720.
- Takach TJ, Madjarov JM, Holleman JH, et al. Spontaneous splanchnic dissection: application and timing of therapeutic options. J Vasc Surg 2009; 50:557.
- Gobble RM, Brill ER, Rockman CB, et al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J Vasc Surg 2009; 50:1326.
- Ahn HY, Cho BS, Mun YS, et al. Treatment results for spontaneous isolated superior mesenteric artery dissection according to our previous guidelines and collective literature review. Ann Vasc Surg 2014; 28:1595.
- Carter R, O'Keeffe S, Minion DJ, et al. Spontaneous superior mesenteric artery dissection: report of 2 patients and review of management recommendations. Vasc Endovascular Surg 2011; 45:295.
- Baker RJ, Fischer JE. Mastery of Surgery, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2001.
- Luan JY, Li X, Li TR, et al. Vasodilator and endovascular therapy for isolated superior mesenteric artery dissection. J Vasc Surg 2013; 57:1612.
- Zerbib P, Perot C, Lambert M, et al. Management of isolated spontaneous dissection of superior mesenteric artery. Langenbecks Arch Surg 2010; 395:437.
- Cormier F, Ferry J, Artru B, et al. Dissecting aneurysms of the main trunk of the superior mesenteric artery. J Vasc Surg 1992; 15:424.
- Wu XM, Wang TD, Chen MF. Percutaneous endovascular treatment for isolated spontaneous superior mesenteric artery dissection: report of two cases and literature review. Catheter Cardiovasc Interv 2009; 73:145.
- Katsura M, Mototake H, Takara H, Matsushima K. Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review. World J Emerg Surg 2011; 6:16.
- Lv PH, Zhang XC, Wang LF, et al. Management of isolated superior mesenteric artery dissection. World J Gastroenterol 2014; 20:17179.
- Tsuji Y, Hino Y, Sugimoto K, et al. Surgical intervention for isolated dissecting aneurysm of the superior mesenteric artery--a case report. Vasc Endovascular Surg 2004; 38:469.
- MESENTERIC VASCULAR ANATOMY
- Celiac axis
- Superior mesenteric artery
- Collateral circulation
- DEFINITION AND PATHOPHYSIOLOGY
- Etiologic factors
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL FEATURES
- - Physical examination
- - Laboratories
- Vascular imaging
- DIFFERENTIAL DIAGNOSIS
- Abdominal exploration
- Initial medical therapy and monitoring
- - Antithrombotic therapy
- - Blood pressure lowering
- - Pain control
- - Open approach
- - Endovascular approach
- FOLLOW-UP AND SURVEILLANCE
- Aneurysm formation
- SUMMARY AND RECOMMENDATIONS