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Hybrid management of ruptured isolated superior mesenteric artery dissecting aneurysm
Hybrid management of ruptured isolated superior mesenteric artery dissecting aneurysm Yoshikatsu Nomura, MD,a Masato Yamaguchi, MD,b,c Atsushi Kitagawa, MD,a,b Takuya Okada, MD,b,c Yutaka Okita, MD,a and Koji Sugimoto, MD,b,c Kobe, Japan A 70-year-old woman, with history of asymptomatic isolated superior mesenteric artery (SMA) dissection was admitted for acute abdominal pain. Computed tomography showed ruptured isolated SMA dissection. Endovascular treatment was chosen over surgical repair because of prior abdominal surgeries. Because an angulated SMA trunk and compressed true lumen by the dilated false lumen prevented the insertion of a guidewire into the SMA via the transfemoral artery, transmesenteric approach under laparotomy was selected. After creating a pull-through condition from the SMA to the left brachial artery, a successful stent graft placement with adequate hemostasis was achieved. The aneurysm shrunk remarkably, with no complication at follow-up. ( J Vasc Surg 2011;54:1808-11.)
Dissection of the superior mesenteric artery (SMA) in most cases extends from an aortic dissection. Isolated dissection of the SMA is an uncommon event, and a ruptured dissecting aneurysm is exceedingly rare. We present our technique of successful endovascular stent graft placement in a case of ruptured isolated SMA dissecting aneurysm using hybrid approach. CASE REPORT A 70-year-old woman with a previous history of Rendu– Osler–Weber disease presented with acute abdominal pain. She had been diagnosed with asymptomatic isolated SMA dissection 3 years before (Fig 1, A). She was treated for Stanford type B acute aortic dissection medically 16 months earlier and had undergone total arch replacement for acute Stanford type A dissection 12 months earlier. None of these dissections were associated with the SMA dissection and all of them were treated at different hospitals. She had also undergone four open laparotomies as follows: appendicitis, ectopic pregnancy, infra-renal abdominal aortic aneurysm with reconstruction of bifurcated grafting, and right hemicolectomy for transverse colon cancer. At admission, contrast-enhanced computed tomography (CT) showed the ruptured isolated SMA dissecting aneurysm (Fig 1, B). Laboratory tests showed anemia (Hb, 7.4 g/dL) and elevation of serum amylase (632 IU/L), but no elevation of WBC (5000/L) and lactate (10 mg/dL). On physical examination, she only complained of epigastric pain without peritoneal signs. The endovascular therapy was chosen over surgical revascularization because, with the history prior abdominal surgeries, there were From the Division of Cardiovascular Surgery, Department of Surgery,a Center for Endovascular Therapy,b and Department of Radiology,c Kobe University Graduate School of Medicine. Competition of interest: none. Reprint requests: Yoshikatsu Nomura, MD, Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650 – 0017, Japan (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.05.006
1808
thought to be difficulties for abdominal open surgery due to adhesions. Transfemoral SMA angiography showed rupture of the isolated SMA dissecting aneurysm. The SMA trunk was angulated and the true lumen was compressed by dilated false lumen which had no re-entry and formed a blind sac (Fig 2, A). This prevented the insertion of a guidewire into the true lumen first through the transfemoral and second through the brachial approach. Therefore, an alternative transmesenteric artery approach under laparotomy was selected. Through a midline abdominal incision, the ileal artery was exposed after dissecting severe adhesions under general anesthesia. The bowel surface appeared normal and not ischemic. After the 4F sheath (Medikit Co, Ltd, Tokyo, Japan) was inserted into the ileal artery through purse-string sutures, a 0.035inch guidewire (Terumo Co, Ltd, Tokyo, Japan) was advanced into the SMA and the descending thoracic aorta. The guidewire was captured with a snare catheter (diameter, 25 mm; Amplatz GooseNeck; ev3, Inc, Plymouth, Minn), which was inserted from the left brachial artery. The diameter of ileal artery did not allow insertion of sheath sized over 6F, and more proximal branches, which had a diameter suitable for insertion of a 6F sheath or bigger, could not be used due to the aneurysm and adhesions. Therefore, the 10F 80-cm long sheath (Super Arrow Flex Sheath; Arrow International Inc, Reading, Pa) was advanced from the left brachial artery, which was converted to an open access. The SMA was 8.5 mm in diameter at the aneurysm neck, while the length of the aneurysm neck was 33 mm. A 60-mm long self-expandable nitinol stent covered by expanded polytetrafluoroethylene (diameter, 10 mm; Niti-S Comvi; Taewoong Medical Co, Ltd, Gyeonggi-do, Korea) was deployed into the true lumen of the SMA, and postdilation was performed with a 4-cm long Powerflex angioplasty balloon (diameter, 10 mm; Cordis, Miami Lakes, Fla) to prevent endoleak. The dissection was in a chronic stage, so it was considered that there is low risk of further arterial rupture/tear extension. Subsequent angiography demonstrated a complete exclusion of the ruptured aneurysm (Fig 2, B). After the procedure, the access site to ileal artery was closed by purse string suture. The patient was discharged 17 days after surgery with oral aspirin. No complication occurred during postoperative and follow-up periods. A CT scan performed 1.5 years after surgery
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Fig 1. A, Contrast-enhanced computed tomography (CT) scan demonstrates isolated superior mesenteric artery (SMA) dissection and dilated false lumen (arrow). An arrowhead shows the compressed true lumen. B, Rupture of SMA dissecting aneurysm toward the right (arrow).
Fig 2. A, Selective angiography of the superior mesenteric artery (SMA) shows a rupture of the dissected SMA and compressed true lumen behind the false lumen (right anterior oblique 55° view). B, Angiography shows successful placement of stent graft using a hybrid approach.
showed the patent stent graft with remarkable shrinkage of the aneurysm (Fig 3).
DISCUSSION Abdominal visceral artery aneurysms represent as an uncommon vascular disease with an incidence of 0.01% to 2%,1 a rupture rate of 30% to 40%, and a mortality rate of
25% to 70%.2 SMA aneurysms are the third most common type of abdominal visceral artery aneurysms, with a frequency of 8%.1 The natural history of SMA aneurysms is not well documented. In the largest case series comprising 21 patients with SMA aneurysms, eight (38%) patients presented with rupture, and the operative mortality for repair was 37.5%.3 Isolated SMA dissection is a rare condi-
JOURNAL OF VASCULAR SURGERY December 2011
1810 Nomura et al
Fig 3. Contrast-enhanced computed tomography (CT) after 1.5 years shows the patency of the stent graft and remarkable shrinkage of the superior mesenteric artery (SMA) dissecting aneurysm.
tion, and the pathology of SMA dissections includes cystic medial necrosis, fibromuscular dysplasia, arteriosclerosis, and trauma.4 Our patient had a history of Rendu–Osler–Weber disease; however, the relationship between this disease and isolated SMA dissection is yet to be clarified. Rendu–Osler– Weber disease has previously been reported to be complicated with hepatic artery aneurysm5; however, to our knowledge, there are no reports regarding its association with SMA dissection and aneurysm. Most patients with SMA dissection generally complain of acute onset of abdominal pain, due to intestinal ischemia, the dissection itself, or both.4,6-14 Accompanying symptoms such as nausea, vomiting, diarrhea, and chills may be present.1-4 In rare cases, complications such as rupture6,7 and pancreatitis8 have been reported. In our patient, the rupture was located in front of the pancreas, with the rupture site pressing upon the pancreas. This may have influenced the slight elevation in the serum amylase level. Various procedures have been reported for the treatment of SMA dissection with intestinal ischemia or rupture. Surgical treatments include ligation and bypass with autologous arterial graft8 or vein graft,9 thrombectomy,10 and fixation of intimal flap.11 The absolute indications of surgical treatment are aneurysmal rupture and intestinal infarction. Regarding endovascular treatment for SMA aneurysms, most reports have focused on the embolization of SMA aneurysms with coils, cyanoacrylate, and thrombin.15-17 Recently, several authors have shown the results of stent placement into the true lumen12 as well as stent graft placement.13,14,18,19 Endovascular treatment is less invasive than surgical procedure. In particular, repairing the ruptured site with stent graft placement is attractive because it allows hemostasis to be achieved without interrupting the luminal flow. However, to our knowledge, there are no reports for stent graft placement for rupture of isolated
SMA dissecting aneurysm. For an infectious aneurysm, considerable deliberation would be required before using a stent graft; however, in our patient, there were no clinical signs of infection. Therefore, we considered stent graft placement to be applicable in this case. We recognize that the long-term patency of stent grafts for SMA remains unknown, and stent thrombosis leading to acute mesenteric ischemia is an important concern. It may sometimes be difficult to advance the bulky delivery system of the stent graft into the SMA via the percutaneous method. Here, inserting the guidewire into the SMA via a transfemoral approach was impossible due to the angulated SMA trunk and compression of the true lumen. We, therefore, attempted a transmesenteric retrograde approach for advancing the delivery system into the SMA, possibly via a transfemoral or brachial approach, by establishing a pull-through condition. When using this approach, small-diameter introducer can be useful (no greater than 6F), because the small puncture facilitates the repair of the SMA.20 Therefore, since the insertion of the delivery system of the stent graft is difficult via the transmesenteric approach alone, we consider that this method can be useful in hostile abdominal conditions due to its minimal requirements of synechotomy, while being definitely less invasive than surgical repair. In conclusion, ruptured isolated SMA dissecting aneurysm is exceedingly rare and life-threatening. To manage this hazardous condition, endovascular repair offers an attractive and less-invasive option. The approach via mesenteric artery as a hybrid method is effective and worth attempting when ordinary percutaneous approach is not available. REFERENCES 1. Carmeci C, James MC. Visceral artery aneurysm as seen in a community hospital. Am J Surg 2000;179:486-9.
JOURNAL OF VASCULAR SURGERY Volume 54, Number 6
2. Wanger WH, Allins AD, Treiman RL, Cohen JL, Foran RF, Levin PM. Ruptured visceral artery aneurysms. Ann Vasc Surg 1997;11:342-7. 3. Stone WM, Abbas M, Cherry KJ, Fowl RJ, Gloviczki P. Superior mesenteric artery aneurysms: is presence an indication for intervention? J Vasc Surg 2002;36:234-7. 4. Vignati PV, Welch JP, Ellison L, Cohen JL. Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection. J Vasc Surg 1992;16:109-12. 5. Miyabe K, Akita S, Kitajima Y, Hirai M, Naitoh I, Hayashi K, et al. Rupture of hepatic aneurysm complicating hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease) for which hepatic arterial coil embolization was effective. J Gastroenterol Hepatol 2007;22: 2352-7. 6. Suzuki S, Furui S, Kohtake H, Sakamoto T, Yamasaki M, Furukawa A. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging 2004;29:153-7. 7. Gouëffic Y, Costargent A, Dupas B, Heymann MF, Chaillou P, Patra P, et al. Superior mesenteric artery dissection: case report. J Vasc Surg 2002;35:1003-5. 8. Picquet J, Abilez O, Pénard J, Jousset Y, Rousselet MC, Enon B. Superficial femoral artery transposition repair for isolated superior mesenteric artery dissection. J Vasc Surg 2005;42:788-91. 9. Iha K, Nakasone H, Nakachi H, Horikawa Y, Gushiken M, Matsuda H. Surgical treatment of spontaneous dissection of the superior mesenteric artery: a case report. Ann Thorac Cardiovasc Surg 2000;6:65-9. 10. Barmeir E, Halachmi S, Croitoru S, Torem S. CT angiography diagnosis of spontaneous dissection of the superior mesenteric artery. Am J Roentgen 1998;171:1429-30. 11. Cormier F, Ferry J, Artru B, Wechsler B, Cormier JM. Dissecting aneurysms of the main trunk of the superior mesenteric artery. J Vasc Surg 1992;16:109-12. 12. Miyamoto N, Sakurai Y, Hirokami M, Takahashi K, Nishimori H, Tsuji K, et al. Endovascular stent placement for isolated spontaneous dissec-
Nomura et al 1811
13.
14.
15.
16.
17.
18.
19.
20.
tion of the superior mesenteric artery: report of a case. Radiat Med 2005;23:520-4. Baldi S, Zander T, Rabellino M, Maynar M. Endovascular management of a spontaneous dissecting aneurysm of the superior mesenteric artery: case report and discussion of treatment options. Ann Vasc Surg 2009; 23:e1-4. Ishida M, Kato N, Hirano T, Suzuki T, Shomura Y, Yada I. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent graft placement. Cardiovasc Intervent Radiol 2003; 26:403-6. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83; discussion 83. Carroccio A, Jacobs TS, Faries P, Ellozy SH, Teodorescu VJ, Ting W. Endovascular treatment of visceral artery aneurysms. Vasc Endovasc Surg 2007;41:373-82. Miller MT, Comerota AJ, Disalle R, Kaufman A, Pigott JP. Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review. J Vasc Surg 2007;45:381-6. Cowan S, Kahn MB, Bonn J, Becker GJ, Dimuzio P, Leichter R. Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent. J Vasc Surg 2002;35:805-7. Wallace MJ, Choi E, McRae S, Madoff DC, Ahrar K, Pisters P. Superior mesenteric artery pseudoaneurysm following pancreaticoduodenectomy: management by endovascular stent graft placement and transluminal thrombin injection. Cardiovasc Intervent Radiol 2007;30:518-22. Sonesson B, Hinchliffe RJ, Dias NV, Resch TA, Malina M, Ivancev K, et al. Hybrid recanalization of superior mesenteric artery occlusion in acute mesenteric ischemia. J Endovasc Ther 2008;15:129-32.
Submitted Jan 20, 2011; accepted May 1, 2011.
Dissection of the superior mesenteric artery (SMA) in most cases extends from an aortic dissection. Isolated dissection of the SMA is an uncommon event, and a ruptured dissecting aneurysm is exceedingly rare. We present our technique of successful endovascular stent graft placement in a case of ruptured isolated SMA dissecting aneurysm using hybrid approach. CASE REPORT A 70-year-old woman with a previous history of Rendu– Osler–Weber disease presented with acute abdominal pain. She had been diagnosed with asymptomatic isolated SMA dissection 3 years before (Fig 1, A). She was treated for Stanford type B acute aortic dissection medically 16 months earlier and had undergone total arch replacement for acute Stanford type A dissection 12 months earlier. None of these dissections were associated with the SMA dissection and all of them were treated at different hospitals. She had also undergone four open laparotomies as follows: appendicitis, ectopic pregnancy, infra-renal abdominal aortic aneurysm with reconstruction of bifurcated grafting, and right hemicolectomy for transverse colon cancer. At admission, contrast-enhanced computed tomography (CT) showed the ruptured isolated SMA dissecting aneurysm (Fig 1, B). Laboratory tests showed anemia (Hb, 7.4 g/dL) and elevation of serum amylase (632 IU/L), but no elevation of WBC (5000/L) and lactate (10 mg/dL). On physical examination, she only complained of epigastric pain without peritoneal signs. The endovascular therapy was chosen over surgical revascularization because, with the history prior abdominal surgeries, there were From the Division of Cardiovascular Surgery, Department of Surgery,a Center for Endovascular Therapy,b and Department of Radiology,c Kobe University Graduate School of Medicine. Competition of interest: none. Reprint requests: Yoshikatsu Nomura, MD, Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650 – 0017, Japan (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.05.006
1808
thought to be difficulties for abdominal open surgery due to adhesions. Transfemoral SMA angiography showed rupture of the isolated SMA dissecting aneurysm. The SMA trunk was angulated and the true lumen was compressed by dilated false lumen which had no re-entry and formed a blind sac (Fig 2, A). This prevented the insertion of a guidewire into the true lumen first through the transfemoral and second through the brachial approach. Therefore, an alternative transmesenteric artery approach under laparotomy was selected. Through a midline abdominal incision, the ileal artery was exposed after dissecting severe adhesions under general anesthesia. The bowel surface appeared normal and not ischemic. After the 4F sheath (Medikit Co, Ltd, Tokyo, Japan) was inserted into the ileal artery through purse-string sutures, a 0.035inch guidewire (Terumo Co, Ltd, Tokyo, Japan) was advanced into the SMA and the descending thoracic aorta. The guidewire was captured with a snare catheter (diameter, 25 mm; Amplatz GooseNeck; ev3, Inc, Plymouth, Minn), which was inserted from the left brachial artery. The diameter of ileal artery did not allow insertion of sheath sized over 6F, and more proximal branches, which had a diameter suitable for insertion of a 6F sheath or bigger, could not be used due to the aneurysm and adhesions. Therefore, the 10F 80-cm long sheath (Super Arrow Flex Sheath; Arrow International Inc, Reading, Pa) was advanced from the left brachial artery, which was converted to an open access. The SMA was 8.5 mm in diameter at the aneurysm neck, while the length of the aneurysm neck was 33 mm. A 60-mm long self-expandable nitinol stent covered by expanded polytetrafluoroethylene (diameter, 10 mm; Niti-S Comvi; Taewoong Medical Co, Ltd, Gyeonggi-do, Korea) was deployed into the true lumen of the SMA, and postdilation was performed with a 4-cm long Powerflex angioplasty balloon (diameter, 10 mm; Cordis, Miami Lakes, Fla) to prevent endoleak. The dissection was in a chronic stage, so it was considered that there is low risk of further arterial rupture/tear extension. Subsequent angiography demonstrated a complete exclusion of the ruptured aneurysm (Fig 2, B). After the procedure, the access site to ileal artery was closed by purse string suture. The patient was discharged 17 days after surgery with oral aspirin. No complication occurred during postoperative and follow-up periods. A CT scan performed 1.5 years after surgery
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Nomura et al 1809
Fig 1. A, Contrast-enhanced computed tomography (CT) scan demonstrates isolated superior mesenteric artery (SMA) dissection and dilated false lumen (arrow). An arrowhead shows the compressed true lumen. B, Rupture of SMA dissecting aneurysm toward the right (arrow).
Fig 2. A, Selective angiography of the superior mesenteric artery (SMA) shows a rupture of the dissected SMA and compressed true lumen behind the false lumen (right anterior oblique 55° view). B, Angiography shows successful placement of stent graft using a hybrid approach.
showed the patent stent graft with remarkable shrinkage of the aneurysm (Fig 3).
DISCUSSION Abdominal visceral artery aneurysms represent as an uncommon vascular disease with an incidence of 0.01% to 2%,1 a rupture rate of 30% to 40%, and a mortality rate of
25% to 70%.2 SMA aneurysms are the third most common type of abdominal visceral artery aneurysms, with a frequency of 8%.1 The natural history of SMA aneurysms is not well documented. In the largest case series comprising 21 patients with SMA aneurysms, eight (38%) patients presented with rupture, and the operative mortality for repair was 37.5%.3 Isolated SMA dissection is a rare condi-
JOURNAL OF VASCULAR SURGERY December 2011
1810 Nomura et al
Fig 3. Contrast-enhanced computed tomography (CT) after 1.5 years shows the patency of the stent graft and remarkable shrinkage of the superior mesenteric artery (SMA) dissecting aneurysm.
tion, and the pathology of SMA dissections includes cystic medial necrosis, fibromuscular dysplasia, arteriosclerosis, and trauma.4 Our patient had a history of Rendu–Osler–Weber disease; however, the relationship between this disease and isolated SMA dissection is yet to be clarified. Rendu–Osler– Weber disease has previously been reported to be complicated with hepatic artery aneurysm5; however, to our knowledge, there are no reports regarding its association with SMA dissection and aneurysm. Most patients with SMA dissection generally complain of acute onset of abdominal pain, due to intestinal ischemia, the dissection itself, or both.4,6-14 Accompanying symptoms such as nausea, vomiting, diarrhea, and chills may be present.1-4 In rare cases, complications such as rupture6,7 and pancreatitis8 have been reported. In our patient, the rupture was located in front of the pancreas, with the rupture site pressing upon the pancreas. This may have influenced the slight elevation in the serum amylase level. Various procedures have been reported for the treatment of SMA dissection with intestinal ischemia or rupture. Surgical treatments include ligation and bypass with autologous arterial graft8 or vein graft,9 thrombectomy,10 and fixation of intimal flap.11 The absolute indications of surgical treatment are aneurysmal rupture and intestinal infarction. Regarding endovascular treatment for SMA aneurysms, most reports have focused on the embolization of SMA aneurysms with coils, cyanoacrylate, and thrombin.15-17 Recently, several authors have shown the results of stent placement into the true lumen12 as well as stent graft placement.13,14,18,19 Endovascular treatment is less invasive than surgical procedure. In particular, repairing the ruptured site with stent graft placement is attractive because it allows hemostasis to be achieved without interrupting the luminal flow. However, to our knowledge, there are no reports for stent graft placement for rupture of isolated
SMA dissecting aneurysm. For an infectious aneurysm, considerable deliberation would be required before using a stent graft; however, in our patient, there were no clinical signs of infection. Therefore, we considered stent graft placement to be applicable in this case. We recognize that the long-term patency of stent grafts for SMA remains unknown, and stent thrombosis leading to acute mesenteric ischemia is an important concern. It may sometimes be difficult to advance the bulky delivery system of the stent graft into the SMA via the percutaneous method. Here, inserting the guidewire into the SMA via a transfemoral approach was impossible due to the angulated SMA trunk and compression of the true lumen. We, therefore, attempted a transmesenteric retrograde approach for advancing the delivery system into the SMA, possibly via a transfemoral or brachial approach, by establishing a pull-through condition. When using this approach, small-diameter introducer can be useful (no greater than 6F), because the small puncture facilitates the repair of the SMA.20 Therefore, since the insertion of the delivery system of the stent graft is difficult via the transmesenteric approach alone, we consider that this method can be useful in hostile abdominal conditions due to its minimal requirements of synechotomy, while being definitely less invasive than surgical repair. In conclusion, ruptured isolated SMA dissecting aneurysm is exceedingly rare and life-threatening. To manage this hazardous condition, endovascular repair offers an attractive and less-invasive option. The approach via mesenteric artery as a hybrid method is effective and worth attempting when ordinary percutaneous approach is not available. REFERENCES 1. Carmeci C, James MC. Visceral artery aneurysm as seen in a community hospital. Am J Surg 2000;179:486-9.
JOURNAL OF VASCULAR SURGERY Volume 54, Number 6
2. Wanger WH, Allins AD, Treiman RL, Cohen JL, Foran RF, Levin PM. Ruptured visceral artery aneurysms. Ann Vasc Surg 1997;11:342-7. 3. Stone WM, Abbas M, Cherry KJ, Fowl RJ, Gloviczki P. Superior mesenteric artery aneurysms: is presence an indication for intervention? J Vasc Surg 2002;36:234-7. 4. Vignati PV, Welch JP, Ellison L, Cohen JL. Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection. J Vasc Surg 1992;16:109-12. 5. Miyabe K, Akita S, Kitajima Y, Hirai M, Naitoh I, Hayashi K, et al. Rupture of hepatic aneurysm complicating hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease) for which hepatic arterial coil embolization was effective. J Gastroenterol Hepatol 2007;22: 2352-7. 6. Suzuki S, Furui S, Kohtake H, Sakamoto T, Yamasaki M, Furukawa A. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging 2004;29:153-7. 7. Gouëffic Y, Costargent A, Dupas B, Heymann MF, Chaillou P, Patra P, et al. Superior mesenteric artery dissection: case report. J Vasc Surg 2002;35:1003-5. 8. Picquet J, Abilez O, Pénard J, Jousset Y, Rousselet MC, Enon B. Superficial femoral artery transposition repair for isolated superior mesenteric artery dissection. J Vasc Surg 2005;42:788-91. 9. Iha K, Nakasone H, Nakachi H, Horikawa Y, Gushiken M, Matsuda H. Surgical treatment of spontaneous dissection of the superior mesenteric artery: a case report. Ann Thorac Cardiovasc Surg 2000;6:65-9. 10. Barmeir E, Halachmi S, Croitoru S, Torem S. CT angiography diagnosis of spontaneous dissection of the superior mesenteric artery. Am J Roentgen 1998;171:1429-30. 11. Cormier F, Ferry J, Artru B, Wechsler B, Cormier JM. Dissecting aneurysms of the main trunk of the superior mesenteric artery. J Vasc Surg 1992;16:109-12. 12. Miyamoto N, Sakurai Y, Hirokami M, Takahashi K, Nishimori H, Tsuji K, et al. Endovascular stent placement for isolated spontaneous dissec-
Nomura et al 1811
13.
14.
15.
16.
17.
18.
19.
20.
tion of the superior mesenteric artery: report of a case. Radiat Med 2005;23:520-4. Baldi S, Zander T, Rabellino M, Maynar M. Endovascular management of a spontaneous dissecting aneurysm of the superior mesenteric artery: case report and discussion of treatment options. Ann Vasc Surg 2009; 23:e1-4. Ishida M, Kato N, Hirano T, Suzuki T, Shomura Y, Yada I. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent graft placement. Cardiovasc Intervent Radiol 2003; 26:403-6. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83; discussion 83. Carroccio A, Jacobs TS, Faries P, Ellozy SH, Teodorescu VJ, Ting W. Endovascular treatment of visceral artery aneurysms. Vasc Endovasc Surg 2007;41:373-82. Miller MT, Comerota AJ, Disalle R, Kaufman A, Pigott JP. Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review. J Vasc Surg 2007;45:381-6. Cowan S, Kahn MB, Bonn J, Becker GJ, Dimuzio P, Leichter R. Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent. J Vasc Surg 2002;35:805-7. Wallace MJ, Choi E, McRae S, Madoff DC, Ahrar K, Pisters P. Superior mesenteric artery pseudoaneurysm following pancreaticoduodenectomy: management by endovascular stent graft placement and transluminal thrombin injection. Cardiovasc Intervent Radiol 2007;30:518-22. Sonesson B, Hinchliffe RJ, Dias NV, Resch TA, Malina M, Ivancev K, et al. Hybrid recanalization of superior mesenteric artery occlusion in acute mesenteric ischemia. J Endovasc Ther 2008;15:129-32.
Submitted Jan 20, 2011; accepted May 1, 2011.