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.)
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- 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