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Isolated Dissection of the Superior Mesenteric Artery After Living Donor Liver Transplantation: A Case Report
Isolated Dissection of the Superior Mesenteric Artery After Living Donor Liver Transplantation: A Case Report H. Kokai, Y. Sato, S. Yamamoto, H. Oya, T. Kobayashi, T. Watanabe, K. Miura, and K. Hatakeyama
ABSTRACT Isolated dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, particularly after living donor liver transplantation (LDLT). We experienced a case of isolated dissection of the SMA after LDLT performed in a 56-year-old man diagnosed with hepatitis B virus–related cirrhosis and hepatocellular carcinoma within the Milan criteria. He had no past history of hypertension or diabetes mellitus. At 6 days after LDLT, the patient underwent an emergency portal vein thrombectomy with ligation of a huge left gastric vein shunt. Thereafter anticoagulant and antiplatelet therapy were initiated. At 12 days after LDLT, a contrast-enhanced computer assisted tomography (CT) scan revealed the presence of a thrombus in a false lumen and a thin flap enlarged in the SMA. Because he presented neither abdominal pain nor biochemical data suggesting mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The thrombus in the false lumen was reduced and the intimal flap in the SMA disappeared according to the results of a CT scan 4 months after LDLT. He has remained free of symptoms for 4 years. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia; conservative treatment is indicated for patients with minimal, resolving, or no pain, but requires close follow-up. SOLATED dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, often occurring with symptoms of an acute abdomen. Sometimes this condition resolves spontaneously, and can be managed with conventional medical therapy.1 This case report describes isolated dissection of the SMA after living donor liver transplantation (LDLT) without any clinical symptom, as demonstrated by a contrast-enhanced computer assisted tomography (CT) scan. The patient was treated successfully with anticoagulant, antiplatelet, and antihypertensive therapy.
I
CASE REPORT A 56-year-old man was diagnosed as having hepatitis B virus– related cirrhosis in 1996. On May 2005, he underwent radiofrequency ablation therapy (RFA) for hepatocellular carcinoma (HCC). Thereafter, he repeatedly experienced hepatic encephalopathy. On December 2006, a CT scan showed a simple 2 cm liver nodule, which was diagnosed as a new HCC lesion. He and his family sought LDLT in January 2007. He had no past history of hypertension or diabetes mellitus. 0041-1345/12/$–see front matter doi:10.1016/j.transproceed.2012.01.020 588
In February 2007, he underwent right lobe liver transplantation from an ABO-incompatible living donor. The graft volume recipient weight ratio (GRWR) was 0.8. Biliary reconstruction was performed using a duct-to duct anastomosis. Operative time was 508 minutes and blood loss was 3010 g. At 6 days after LDLT, he experienced a portal vein thrombus accompanied by vascular steal to the left gastric vein that had been preserved during the LDLT. We performed an emergency portal vein thrombectomy and ligation of the huge left gastric vein shunt; thereafter we initiated anticoagulant and antiplatelet therapies. At 12 days after LDLT, a follow-up CT scan for the portal thrombus revealed the presence of a thrombus in a false lumen and a thin flap in the SMA (Fig 1A, B, and C). The dissection began 1.5 cm from the origin of the SMA, extending for 7 cm From the Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan. Address reprint requests to Hidenaka Kokai, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan. E-mail: kokain@med. niigata-u.ac.jp © 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 44, 588 –590 (2012)
DISSECTION OF THE SMA
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Fig 1. (A, B, and C) Contrast-enhanced CT scan on 12 days after LDLT revealed presence of thrombus of the false lumen and an intimal flap in the SMA. (D) The dissection began 1.5 cm from the origin of the SMA and extended for 7 cm.
(Fig 1D). Because he presented neither abdominal pain nor biochemical data consistant with mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The regimen led to a reduction in the thrombus in the false lumen and a disappearance of the intimal flap in the SMA according to a contrast-enhanced CT scan performed 4 months after the LDLT (Fig 2). He has remained symptom-free for 4 years.
DISCUSSION
Isolated dissection of the SMA not associated with aortic dissection is rare. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia, because of the high risk of bowel
necrosis.2 However, patients with minimal, resolving, or no pain can be treated conservatively. The nonoperative approach to isolated SMA dissection requires close follow-up with a focus on the clinical signs of mesenteric ischemia and repeated contrast-enhanced CT examinations. Surgical indications to address an isolated dissection of the SMA are an increasing size of the aneurysmal dilatation, thrombosis of the true lumen of the SMA, or persistent symptoms despite anticoagulation.1 Recently, percutaneous stent placement to treat isolated SMA dissection has been reported to be useful under nonurgent condition. However, the clinical outcomes and complications after stent placement remain insufficiently evaluated because of the small number of patients.3 In our case, the isolated dissection of
590
KOKAI, SATO, YAMAMOTO ET AL
the SMA after LDLT was detected unexpectedly by contrast-enhanced CT, despite no clinical symptoms. Fortunately, he was successfully treated by conservative means without any invasive therapy. However, SMA dissection is able to redevelop4; thus, we need to perform follow-up CT scans at regular intervals. REFERENCES
Fig 2. Contrast-enhanced CT scan 4 months after LDLT revealed a reduction in the thrombosis of the false lumen and disappearance of the intimal flap in the SMA.
1. Takayama H, Takeda S, Saito SK, et al: Spontaneous isolated dissection of the superior mesenteric artery: case report. Intern Med 41:713, 2002 2. Hirai S, Hamanaka Y, Mitsui N, et al: Spontaneous and isolated dissection of the main trunk of the superior mesenteric artery: case report. Ann Thorac Cardiovasc Surg 8:236, 2002 3. Miyamoto N, Sakurai Y, Hirokami M, et al: Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: report of a case. Radia Med 23:520, 2005 4. Sparks SR, Vasquez JC, Berqan JJ, et al: Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg 14:105, 2000
ABSTRACT Isolated dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, particularly after living donor liver transplantation (LDLT). We experienced a case of isolated dissection of the SMA after LDLT performed in a 56-year-old man diagnosed with hepatitis B virus–related cirrhosis and hepatocellular carcinoma within the Milan criteria. He had no past history of hypertension or diabetes mellitus. At 6 days after LDLT, the patient underwent an emergency portal vein thrombectomy with ligation of a huge left gastric vein shunt. Thereafter anticoagulant and antiplatelet therapy were initiated. At 12 days after LDLT, a contrast-enhanced computer assisted tomography (CT) scan revealed the presence of a thrombus in a false lumen and a thin flap enlarged in the SMA. Because he presented neither abdominal pain nor biochemical data suggesting mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The thrombus in the false lumen was reduced and the intimal flap in the SMA disappeared according to the results of a CT scan 4 months after LDLT. He has remained free of symptoms for 4 years. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia; conservative treatment is indicated for patients with minimal, resolving, or no pain, but requires close follow-up. SOLATED dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, often occurring with symptoms of an acute abdomen. Sometimes this condition resolves spontaneously, and can be managed with conventional medical therapy.1 This case report describes isolated dissection of the SMA after living donor liver transplantation (LDLT) without any clinical symptom, as demonstrated by a contrast-enhanced computer assisted tomography (CT) scan. The patient was treated successfully with anticoagulant, antiplatelet, and antihypertensive therapy.
I
CASE REPORT A 56-year-old man was diagnosed as having hepatitis B virus– related cirrhosis in 1996. On May 2005, he underwent radiofrequency ablation therapy (RFA) for hepatocellular carcinoma (HCC). Thereafter, he repeatedly experienced hepatic encephalopathy. On December 2006, a CT scan showed a simple 2 cm liver nodule, which was diagnosed as a new HCC lesion. He and his family sought LDLT in January 2007. He had no past history of hypertension or diabetes mellitus. 0041-1345/12/$–see front matter doi:10.1016/j.transproceed.2012.01.020 588
In February 2007, he underwent right lobe liver transplantation from an ABO-incompatible living donor. The graft volume recipient weight ratio (GRWR) was 0.8. Biliary reconstruction was performed using a duct-to duct anastomosis. Operative time was 508 minutes and blood loss was 3010 g. At 6 days after LDLT, he experienced a portal vein thrombus accompanied by vascular steal to the left gastric vein that had been preserved during the LDLT. We performed an emergency portal vein thrombectomy and ligation of the huge left gastric vein shunt; thereafter we initiated anticoagulant and antiplatelet therapies. At 12 days after LDLT, a follow-up CT scan for the portal thrombus revealed the presence of a thrombus in a false lumen and a thin flap in the SMA (Fig 1A, B, and C). The dissection began 1.5 cm from the origin of the SMA, extending for 7 cm From the Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan. Address reprint requests to Hidenaka Kokai, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan. E-mail: kokain@med. niigata-u.ac.jp © 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 44, 588 –590 (2012)
DISSECTION OF THE SMA
589
Fig 1. (A, B, and C) Contrast-enhanced CT scan on 12 days after LDLT revealed presence of thrombus of the false lumen and an intimal flap in the SMA. (D) The dissection began 1.5 cm from the origin of the SMA and extended for 7 cm.
(Fig 1D). Because he presented neither abdominal pain nor biochemical data consistant with mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The regimen led to a reduction in the thrombus in the false lumen and a disappearance of the intimal flap in the SMA according to a contrast-enhanced CT scan performed 4 months after the LDLT (Fig 2). He has remained symptom-free for 4 years.
DISCUSSION
Isolated dissection of the SMA not associated with aortic dissection is rare. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia, because of the high risk of bowel
necrosis.2 However, patients with minimal, resolving, or no pain can be treated conservatively. The nonoperative approach to isolated SMA dissection requires close follow-up with a focus on the clinical signs of mesenteric ischemia and repeated contrast-enhanced CT examinations. Surgical indications to address an isolated dissection of the SMA are an increasing size of the aneurysmal dilatation, thrombosis of the true lumen of the SMA, or persistent symptoms despite anticoagulation.1 Recently, percutaneous stent placement to treat isolated SMA dissection has been reported to be useful under nonurgent condition. However, the clinical outcomes and complications after stent placement remain insufficiently evaluated because of the small number of patients.3 In our case, the isolated dissection of
590
KOKAI, SATO, YAMAMOTO ET AL
the SMA after LDLT was detected unexpectedly by contrast-enhanced CT, despite no clinical symptoms. Fortunately, he was successfully treated by conservative means without any invasive therapy. However, SMA dissection is able to redevelop4; thus, we need to perform follow-up CT scans at regular intervals. REFERENCES
Fig 2. Contrast-enhanced CT scan 4 months after LDLT revealed a reduction in the thrombosis of the false lumen and disappearance of the intimal flap in the SMA.
1. Takayama H, Takeda S, Saito SK, et al: Spontaneous isolated dissection of the superior mesenteric artery: case report. Intern Med 41:713, 2002 2. Hirai S, Hamanaka Y, Mitsui N, et al: Spontaneous and isolated dissection of the main trunk of the superior mesenteric artery: case report. Ann Thorac Cardiovasc Surg 8:236, 2002 3. Miyamoto N, Sakurai Y, Hirokami M, et al: Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: report of a case. Radia Med 23:520, 2005 4. Sparks SR, Vasquez JC, Berqan JJ, et al: Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg 14:105, 2000