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Retrograde Stent Placement for Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery
Retrograde Stent Placement for Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery Hiroshi Mitsuoka, Masanao Nakai, Yasuhiko Terai, Shinnosuke Gotou, Yuuta Miyano, Kouich Tsuchiya, and Fumio Yamazaki, Shizuoka-city, Japan
Various treatment options are currently available for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) including conservative management, anticoagulation therapy, endovascular stenting, and surgical repair. We report an experience with retrograde open mesenteric stenting for SIDSMA. A 45-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. Computed tomography angiography revealed a long occlusion of the SMA trunk. Initially, an endovascular solution was attempted, but this was unsuccessful as the guidewire failed to cross the lesion. Four hours after the onset of symptoms, because of aggravation of abdominal pain, the patient underwent an exploratory laparotomy under general anesthesia. The small intestine looked pale, and the arterial pulsation was not recognized in the mesentery. A 5-cm mesenteric portion of the SMA trunk was exposed. The SIDSMA diagnosis was confirmed after arteriotomy because a freshly formed thrombus and a severely stenosed true lumen (TL) were detected beneath the adventitia. From the proximal stump of the TL, a 6-French sheath introducer was inserted in a retrograde fashion. The occlusion was traversed with a 0.035-in guidewire. After predilatation, self-expandable stents were placed inside the occluded SMA. The patient was discharged from the hospital 3 weeks after the operation. Stent patency has been confirmed for 6 months. Retrograde stenting performed under laparotomy could be a rescue procedure after the failure of percutaneous stenting for SIDSMA.
Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare vascular disease1 associated with a broad spectrum of clinical pictures. Many cases can be managed conservatively, but some require emergent treatments for severe intestinal ischemia with a long occlusion of the SMA.2 Although these lesions have been handled
We have no financial or other interest in the manufacture or distribution of the device. Department of Cardiovascular Surgery, Shizuoka Municipal Hospital, Shizuoka-city, Japan. Correspondence to: Hiroshi Mitsuoka, MD, PhD, Department of Cardiovascular Surgery, 10-93 Ote-machi, Aoi-ward, Shizuoka-city 4208630, Japan; E-mail: [email protected] Ann Vasc Surg 2016; 35: 203.e17–203.e21 http://dx.doi.org/10.1016/j.avsg.2016.01.029 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: March 10, 2015; manuscript accepted: January 16, 2016; published online: 26 May 2016
classically with open surgical procedures, endovascular therapies have been applied recently. However, endovascular stenting (ES) cannot be used for all SIDSMA cases for several reasons. ES for such a complicated lesion might take substantial time. A long procedure may aggravate the ischemic bowel injury. Furthermore, evaluation of the intestinal viability is extremely difficult in the endovascular setting. We present the case of a patient with SIDSMA who was treated with retrograde open mesenteric stenting (ROMS) after percutaneous ES failure. Endovascular recanalization could be achieved directly observing mesenteric blood flow recovery.
CASE REPORT A 45-year-old male patient was admitted to the hospital owing to sudden-onset severe abdominal and back pain. 203.e17
203.e18 Case reports
Annals of Vascular Surgery
Fig. 1. Preoperative contrast-enhanced computed tomography. Left, coronal view. Right, axial images at the levels of A (the orifice of SMA), B and C (15 and 30 mm below the orifice).
He was previously healthy and had no remarkable medical history or trauma except for a smoking habit. Computed tomography (CT) detected a 10-cm occlusion at the origin of the SMA (Fig. 1). No other arterial disorders were found. Although the precise diagnosis for the cause of SMA obstruction had not been made, the CT did not detect any signs of peritonitis. Atherosclerotic degeneration was not significant in his arterial system. No atrial fibrillation or other arrhythmia pattern was found on electrocardiogram. The patient was first referred to the gastrointestinal (GI) interventional department for a less invasive treatment. The GI interventionalists started the ES approximately 1 hr after the arrival of the patient. The procedure was started with right femoral access. The SMA could be cannulated selectively, but a guidewire could not be inserted further than a few centimeters from the SMA ostium. The ES continued for approximately 1.5 hr, but wire traversing of the lesion could not be achieved. Although the blood lactate level measured 0.9 mmol/L at the end of the procedure, the abdominal pain had been aggravated. At this time, the patient was referred to our department. Small intestinal viability was our major concern; therefore, the patient was transferred to the hybrid operating room, and an exploratory laparotomy with a midline incision was performed under general anesthesia. The small intestine was not necrotic but looked pale. Arterial pulsation was not observed in the mesentery. Using a lateral approach, we exposed approximately 5 cm of the SMA below the duodenum. SIDSMA was suspected, at this
time, because a freshly formed thrombus under the thin adventitia could be recognized. The exposed length of SMA was clamped proximally and distally. A transverse arteriotomy onto the exposed artery revealed that the true lumen (TL) was severely compressed by the thrombosed false lumen (FL; Fig. 2). Clots inside the exposed length of the FL were removed, and the TL was transected. A 6-French sheath introducer was inserted into the TL in a retrograde fashion. The occluded TL was traversed easily using a 0.035-in guidewire (Radifocus, Terumo, Tokyo, Japan). After predilatation using a 6-mm balloon (Mustang; Boston Scientific, Marlborough, MA), different sizes of self-expandable stents (8 and 10 mm in diameter and 3 cm in length; S.M.A.R.T, Cordis, Fremont, CA) were placed inside the occluded SMA. Although we preferred to include the entry of the dissection inside the stenting zone, the entry could not be visualized with angiography. The 10-mm stent was deployed proximally considering the need for sufficient coverage of the proximal portion. However, a stenosis remained between the distal end of the 10-mm stent and the first branch of the SMA. The outer vessel diameter at the level of the first branch was approximately 7 mm. Therefore, the 8-mm stent was deployed to treat the distal lesion, with a short proximal portion deployed inside the 10-mm stent. The stented lesion was postdilated using the 8- and 10-mm balloons. The transected part was anastomosed in an end-to-end fashion after placing tacking sutures at the proximal and distal stumps. A completion angiography showed arterial flow recovery in the SMA trunk and
Volume 35, August 2016
Case reports 203.e19
Fig. 2. Intraoperative findings. Left, the stenotic true lumen (TL: arrow) was found inside the thrombosed false lumen (FL). Right, the thrombus withdrawn from the FL.
branches (Fig. 3). After the procedure, the mesenteric arterial pulsation became visibly perceptible. An arterial Doppler signal could be detected not only from the mesentery but also at the surface of the jejunum and ileum, which had recovered the normally oxygenated color. The postoperative course was uneventful, except the patient had a postoperative fever of approximately 38 C. There were no symptoms indicating peritonitis. Because the first postoperative CT on the third postoperative day did not detect any signs of intestinal necrosis or peritonitis, oral food intake was started on the fourth postoperative day. To prevent intimal hyperplasia and stent occlusion, we prescribed cilostazol (200 mg/day) in addition to aspirin (100 mg/day). Two weeks later, the fever subsided. He was discharged on the 20th postoperative day. Stent patency has been confirmed for 6 months, and the patient made a full recovery to the preoperative status (Fig. 4).
DISCUSSION SIDSMA has been detected more frequently with the increased sensitivity of CT. Some asymptomatic cases can be detected, but most cases present with acute pain at the initial stage. The exact cause of the pain has not been elucidated. Yun et al.3 speculated that the pain was caused by the arterial dissection itself or inflammatory responses and that severity would correlate to the dissection length.
Fig. 3. Completion digital subtraction angiography.
203.e20 Case reports
Annals of Vascular Surgery
Fig. 4. Postoperative contrast-enhanced computed tomography. Patency of the stent was confirmed at the sixth postoperative month. Left, curved linear multiplanar view. Right, volume rendering image.
On the other hand, Cho et al.4 suggested that abdominal pain in SIDSMA would be related to visceral ischemia. The present patient complained of severe and worsening pain, and we confirmed a long length of dissection and severe degree of intestinal ischemia after laparotomy. Although no consensus guidelines on the proper management of SIDSMA exist, a case without such severe symptoms could be managed conservatively. If the expectant plan works successfully, the initial pain seems to be mitigated in a few days.2,5,6 On the other hand, Gobble et al. are in favor of ES in the early stage for symptomatic SIDSMA because of the low success rate with conservative management (31 of 56 cases in the reviewed expectant therapy) and high mortality rate (13 deaths in 25 operative cases in the review) with surgical procedures at the later stage.7 Anticoagulation therapy may not increase the success rate of conservative therapy (14 of 22 cases in the review).7 In any case, predicting the results of conservative therapy seems currently impossible at the initial stage.6 Therefore, if a conservative plan has been chosen for symptomatic SIDSMA, the case should be observed under the circumstance wherein assistance from vascular and endovascular expertise is readily available.
The entry tear of SIDSMA usually occurs at the greater curve of the SMA, along which the FL frequently goes.6 In the present case, however, the femoral approach had been selected initially. With this access, it is highly likely that the guidewire went along the greater curve of the SMA. Furthermore, owing to the difficulty in coaxial alignment of the catheter, this approach could provide insufficient backup support for the wire crossing. Therefore, a brachial approach should have been selected. In the current case, the change of approach may have helped in selecting the TL, but no study has compared the technical success rate in SMA intervention between the femoral and brachial approaches. Even if the SIDSMA diagnosis had been confirmed beforehand, the endovascular approach would not have been continued with brachial access because of the need to evaluate intestinal viability. It should be noted that the final diagnosis of SIDSMA was suspected after the patient was referred to us. The diagnosis was confirmed after we transected the artery and found a thrombus only in the FL. In the present case, the CT had shown the segmental occlusion of the SMA. No dissection flap was noticed, even in the postoperative work-up. However, there should have been a high index for SIDSMA,
Volume 35, August 2016
especially when the occlusion was detected in such a case without any atherosclerotic or thromboembolic risk factors. Otherwise, endovascular procedures performed under the wrong diagnosis may cause iatrogenic vascular injury. Other treatment options, such as surgical fenestration and bypass surgery, were available. However, the procedure may be time consuming, especially in such a complicated case with the dissection starting at the origin of the SMA. ROMS is a hybrid approach that combines open surgical and endovascular approaches. Milner et al.8 first introduced ROMS. This approach allows observation of the small intestine under direct vision, while providing endovascular access to the SMA at the base of the transverse mesocolon. The superior pushability and torquability achieved by direct access to the vessel would increase the technical success rate for the atherosclerotic occlusion.9 Long-term patency of ES for SIDSMA has not been reported. Different authors have used antegrade ES under various circumstances. Gobble et al.7 reported their experience with 4 successfully stented cases (1 emergency and 3 in the chronic stage), and the stents were patent from 5 to 19 months postoperatively. According to Dong et al.,6 despite 5 of 9 technical failures of ES to alleviate abdominal pain after conservative therapy failure, the patency of 4 stented cases was evident from 12 to 48 months. Min et al. reported the results of 6 procedures, 4 of which had been performed as the primary emergent procedure and 2 after the failure of initial conservative therapy. All had been patent from 2 to 64 months.2 Park et al.5 reported the asymptomatic occlusion at 18 months of an SMA stent, which was used for persistent abdominal pain concomitant with right colon cancer. Thus, the short-term results after successful ES seemed acceptable, but our literature search revealed no reports of ROMS for SIDSMA. Nonetheless, it seemed highly likely that the patency rate after ROMS would be comparable to that after the antegrade approach. For SIDSMA, there appears to be no need for a balloonexpandable stent. Min et al.2 recommended the use of self-expandable stents, in terms of flexibility and radial force. Dong et al.6 recommended that the stent be placed proximally beyond the initial tear. Unlike with atherosclerotic lesions, predilatation might not have been necessary. However, the slow predilatation of the balloon helped us evaluate the expandability of the lesion by ES. To prevent
Case reports 203.e21
intimal hyperplasia and stent occlusion, we prescribed cilostazol in addition to aspirin. Although there is no consensus about the use of antiplatelet drugs for SMA stenting for SIDSMA, this combination of antiplatelet drugs prevented restenosis after superficial femoral artery stenting.9 These drugs have been used previously after SMA stenting performed for SMA dissection after acute aortic dissection.10 In summary, ROMS seemed feasible for patients with severe acute mesenteric ischemia due to SIDSMA, especially after initial ES failure. As Wyers et al.11 proposed, this hybrid approach provided an efficient mesenteric approach while not compromising important surgical principles. Careful follow-up and accumulation of experiences are needed. REFERENCES 1. Takayama T, Miyata T, Shirakawa M, et al. Isolated spontaneous dissection of the splanchnic arteries. J Vasc Surg 2008;48:329e33. 2. Min SI, Yoon KC, Min SK, et al. Current strategy for the treatment of symptomatic spontaneous isolated dissection of superior mesenteric artery. J Vasc Surg 2011;54:461e6. 3. 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;37:572e7. 4. 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: 780e5. 5. 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;54:1727e33. 6. Dong Z, Fu W, Chen B, et al. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69Se76S. 7. Gobble RM, Brill ER, Rockman CB, et al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J Vasc Surg 2009;50:1326e32. 8. Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemiaea case report. Vasc Endovascular Surg 2004;38:89e91. 9. Ikushima I, Yonenaga K, Iwakiri H, et al. A better effect of cilostazol for reducing in-stent restenosis after femoropopliteal artery stent placement in comparison with ticlopidine. Med Devices 2011;4:83e9. 10. Suzuki K, Shimohira M, Hashizume T, et al. Stent placement for acute mesenteric artery occlusion associated with type B aortic dissection. Case Rep in Vasc Med 2015;2015:485141. 11. Wyers MW, Powell RJ, Nolan BW, et al. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. J Vasc Surg 2007;45:269e75.
Various treatment options are currently available for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) including conservative management, anticoagulation therapy, endovascular stenting, and surgical repair. We report an experience with retrograde open mesenteric stenting for SIDSMA. A 45-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. Computed tomography angiography revealed a long occlusion of the SMA trunk. Initially, an endovascular solution was attempted, but this was unsuccessful as the guidewire failed to cross the lesion. Four hours after the onset of symptoms, because of aggravation of abdominal pain, the patient underwent an exploratory laparotomy under general anesthesia. The small intestine looked pale, and the arterial pulsation was not recognized in the mesentery. A 5-cm mesenteric portion of the SMA trunk was exposed. The SIDSMA diagnosis was confirmed after arteriotomy because a freshly formed thrombus and a severely stenosed true lumen (TL) were detected beneath the adventitia. From the proximal stump of the TL, a 6-French sheath introducer was inserted in a retrograde fashion. The occlusion was traversed with a 0.035-in guidewire. After predilatation, self-expandable stents were placed inside the occluded SMA. The patient was discharged from the hospital 3 weeks after the operation. Stent patency has been confirmed for 6 months. Retrograde stenting performed under laparotomy could be a rescue procedure after the failure of percutaneous stenting for SIDSMA.
Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare vascular disease1 associated with a broad spectrum of clinical pictures. Many cases can be managed conservatively, but some require emergent treatments for severe intestinal ischemia with a long occlusion of the SMA.2 Although these lesions have been handled
We have no financial or other interest in the manufacture or distribution of the device. Department of Cardiovascular Surgery, Shizuoka Municipal Hospital, Shizuoka-city, Japan. Correspondence to: Hiroshi Mitsuoka, MD, PhD, Department of Cardiovascular Surgery, 10-93 Ote-machi, Aoi-ward, Shizuoka-city 4208630, Japan; E-mail: [email protected] Ann Vasc Surg 2016; 35: 203.e17–203.e21 http://dx.doi.org/10.1016/j.avsg.2016.01.029 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: March 10, 2015; manuscript accepted: January 16, 2016; published online: 26 May 2016
classically with open surgical procedures, endovascular therapies have been applied recently. However, endovascular stenting (ES) cannot be used for all SIDSMA cases for several reasons. ES for such a complicated lesion might take substantial time. A long procedure may aggravate the ischemic bowel injury. Furthermore, evaluation of the intestinal viability is extremely difficult in the endovascular setting. We present the case of a patient with SIDSMA who was treated with retrograde open mesenteric stenting (ROMS) after percutaneous ES failure. Endovascular recanalization could be achieved directly observing mesenteric blood flow recovery.
CASE REPORT A 45-year-old male patient was admitted to the hospital owing to sudden-onset severe abdominal and back pain. 203.e17
203.e18 Case reports
Annals of Vascular Surgery
Fig. 1. Preoperative contrast-enhanced computed tomography. Left, coronal view. Right, axial images at the levels of A (the orifice of SMA), B and C (15 and 30 mm below the orifice).
He was previously healthy and had no remarkable medical history or trauma except for a smoking habit. Computed tomography (CT) detected a 10-cm occlusion at the origin of the SMA (Fig. 1). No other arterial disorders were found. Although the precise diagnosis for the cause of SMA obstruction had not been made, the CT did not detect any signs of peritonitis. Atherosclerotic degeneration was not significant in his arterial system. No atrial fibrillation or other arrhythmia pattern was found on electrocardiogram. The patient was first referred to the gastrointestinal (GI) interventional department for a less invasive treatment. The GI interventionalists started the ES approximately 1 hr after the arrival of the patient. The procedure was started with right femoral access. The SMA could be cannulated selectively, but a guidewire could not be inserted further than a few centimeters from the SMA ostium. The ES continued for approximately 1.5 hr, but wire traversing of the lesion could not be achieved. Although the blood lactate level measured 0.9 mmol/L at the end of the procedure, the abdominal pain had been aggravated. At this time, the patient was referred to our department. Small intestinal viability was our major concern; therefore, the patient was transferred to the hybrid operating room, and an exploratory laparotomy with a midline incision was performed under general anesthesia. The small intestine was not necrotic but looked pale. Arterial pulsation was not observed in the mesentery. Using a lateral approach, we exposed approximately 5 cm of the SMA below the duodenum. SIDSMA was suspected, at this
time, because a freshly formed thrombus under the thin adventitia could be recognized. The exposed length of SMA was clamped proximally and distally. A transverse arteriotomy onto the exposed artery revealed that the true lumen (TL) was severely compressed by the thrombosed false lumen (FL; Fig. 2). Clots inside the exposed length of the FL were removed, and the TL was transected. A 6-French sheath introducer was inserted into the TL in a retrograde fashion. The occluded TL was traversed easily using a 0.035-in guidewire (Radifocus, Terumo, Tokyo, Japan). After predilatation using a 6-mm balloon (Mustang; Boston Scientific, Marlborough, MA), different sizes of self-expandable stents (8 and 10 mm in diameter and 3 cm in length; S.M.A.R.T, Cordis, Fremont, CA) were placed inside the occluded SMA. Although we preferred to include the entry of the dissection inside the stenting zone, the entry could not be visualized with angiography. The 10-mm stent was deployed proximally considering the need for sufficient coverage of the proximal portion. However, a stenosis remained between the distal end of the 10-mm stent and the first branch of the SMA. The outer vessel diameter at the level of the first branch was approximately 7 mm. Therefore, the 8-mm stent was deployed to treat the distal lesion, with a short proximal portion deployed inside the 10-mm stent. The stented lesion was postdilated using the 8- and 10-mm balloons. The transected part was anastomosed in an end-to-end fashion after placing tacking sutures at the proximal and distal stumps. A completion angiography showed arterial flow recovery in the SMA trunk and
Volume 35, August 2016
Case reports 203.e19
Fig. 2. Intraoperative findings. Left, the stenotic true lumen (TL: arrow) was found inside the thrombosed false lumen (FL). Right, the thrombus withdrawn from the FL.
branches (Fig. 3). After the procedure, the mesenteric arterial pulsation became visibly perceptible. An arterial Doppler signal could be detected not only from the mesentery but also at the surface of the jejunum and ileum, which had recovered the normally oxygenated color. The postoperative course was uneventful, except the patient had a postoperative fever of approximately 38 C. There were no symptoms indicating peritonitis. Because the first postoperative CT on the third postoperative day did not detect any signs of intestinal necrosis or peritonitis, oral food intake was started on the fourth postoperative day. To prevent intimal hyperplasia and stent occlusion, we prescribed cilostazol (200 mg/day) in addition to aspirin (100 mg/day). Two weeks later, the fever subsided. He was discharged on the 20th postoperative day. Stent patency has been confirmed for 6 months, and the patient made a full recovery to the preoperative status (Fig. 4).
DISCUSSION SIDSMA has been detected more frequently with the increased sensitivity of CT. Some asymptomatic cases can be detected, but most cases present with acute pain at the initial stage. The exact cause of the pain has not been elucidated. Yun et al.3 speculated that the pain was caused by the arterial dissection itself or inflammatory responses and that severity would correlate to the dissection length.
Fig. 3. Completion digital subtraction angiography.
203.e20 Case reports
Annals of Vascular Surgery
Fig. 4. Postoperative contrast-enhanced computed tomography. Patency of the stent was confirmed at the sixth postoperative month. Left, curved linear multiplanar view. Right, volume rendering image.
On the other hand, Cho et al.4 suggested that abdominal pain in SIDSMA would be related to visceral ischemia. The present patient complained of severe and worsening pain, and we confirmed a long length of dissection and severe degree of intestinal ischemia after laparotomy. Although no consensus guidelines on the proper management of SIDSMA exist, a case without such severe symptoms could be managed conservatively. If the expectant plan works successfully, the initial pain seems to be mitigated in a few days.2,5,6 On the other hand, Gobble et al. are in favor of ES in the early stage for symptomatic SIDSMA because of the low success rate with conservative management (31 of 56 cases in the reviewed expectant therapy) and high mortality rate (13 deaths in 25 operative cases in the review) with surgical procedures at the later stage.7 Anticoagulation therapy may not increase the success rate of conservative therapy (14 of 22 cases in the review).7 In any case, predicting the results of conservative therapy seems currently impossible at the initial stage.6 Therefore, if a conservative plan has been chosen for symptomatic SIDSMA, the case should be observed under the circumstance wherein assistance from vascular and endovascular expertise is readily available.
The entry tear of SIDSMA usually occurs at the greater curve of the SMA, along which the FL frequently goes.6 In the present case, however, the femoral approach had been selected initially. With this access, it is highly likely that the guidewire went along the greater curve of the SMA. Furthermore, owing to the difficulty in coaxial alignment of the catheter, this approach could provide insufficient backup support for the wire crossing. Therefore, a brachial approach should have been selected. In the current case, the change of approach may have helped in selecting the TL, but no study has compared the technical success rate in SMA intervention between the femoral and brachial approaches. Even if the SIDSMA diagnosis had been confirmed beforehand, the endovascular approach would not have been continued with brachial access because of the need to evaluate intestinal viability. It should be noted that the final diagnosis of SIDSMA was suspected after the patient was referred to us. The diagnosis was confirmed after we transected the artery and found a thrombus only in the FL. In the present case, the CT had shown the segmental occlusion of the SMA. No dissection flap was noticed, even in the postoperative work-up. However, there should have been a high index for SIDSMA,
Volume 35, August 2016
especially when the occlusion was detected in such a case without any atherosclerotic or thromboembolic risk factors. Otherwise, endovascular procedures performed under the wrong diagnosis may cause iatrogenic vascular injury. Other treatment options, such as surgical fenestration and bypass surgery, were available. However, the procedure may be time consuming, especially in such a complicated case with the dissection starting at the origin of the SMA. ROMS is a hybrid approach that combines open surgical and endovascular approaches. Milner et al.8 first introduced ROMS. This approach allows observation of the small intestine under direct vision, while providing endovascular access to the SMA at the base of the transverse mesocolon. The superior pushability and torquability achieved by direct access to the vessel would increase the technical success rate for the atherosclerotic occlusion.9 Long-term patency of ES for SIDSMA has not been reported. Different authors have used antegrade ES under various circumstances. Gobble et al.7 reported their experience with 4 successfully stented cases (1 emergency and 3 in the chronic stage), and the stents were patent from 5 to 19 months postoperatively. According to Dong et al.,6 despite 5 of 9 technical failures of ES to alleviate abdominal pain after conservative therapy failure, the patency of 4 stented cases was evident from 12 to 48 months. Min et al. reported the results of 6 procedures, 4 of which had been performed as the primary emergent procedure and 2 after the failure of initial conservative therapy. All had been patent from 2 to 64 months.2 Park et al.5 reported the asymptomatic occlusion at 18 months of an SMA stent, which was used for persistent abdominal pain concomitant with right colon cancer. Thus, the short-term results after successful ES seemed acceptable, but our literature search revealed no reports of ROMS for SIDSMA. Nonetheless, it seemed highly likely that the patency rate after ROMS would be comparable to that after the antegrade approach. For SIDSMA, there appears to be no need for a balloonexpandable stent. Min et al.2 recommended the use of self-expandable stents, in terms of flexibility and radial force. Dong et al.6 recommended that the stent be placed proximally beyond the initial tear. Unlike with atherosclerotic lesions, predilatation might not have been necessary. However, the slow predilatation of the balloon helped us evaluate the expandability of the lesion by ES. To prevent
Case reports 203.e21
intimal hyperplasia and stent occlusion, we prescribed cilostazol in addition to aspirin. Although there is no consensus about the use of antiplatelet drugs for SMA stenting for SIDSMA, this combination of antiplatelet drugs prevented restenosis after superficial femoral artery stenting.9 These drugs have been used previously after SMA stenting performed for SMA dissection after acute aortic dissection.10 In summary, ROMS seemed feasible for patients with severe acute mesenteric ischemia due to SIDSMA, especially after initial ES failure. As Wyers et al.11 proposed, this hybrid approach provided an efficient mesenteric approach while not compromising important surgical principles. Careful follow-up and accumulation of experiences are needed. REFERENCES 1. Takayama T, Miyata T, Shirakawa M, et al. Isolated spontaneous dissection of the splanchnic arteries. J Vasc Surg 2008;48:329e33. 2. Min SI, Yoon KC, Min SK, et al. Current strategy for the treatment of symptomatic spontaneous isolated dissection of superior mesenteric artery. J Vasc Surg 2011;54:461e6. 3. 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;37:572e7. 4. 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: 780e5. 5. 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;54:1727e33. 6. Dong Z, Fu W, Chen B, et al. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69Se76S. 7. Gobble RM, Brill ER, Rockman CB, et al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J Vasc Surg 2009;50:1326e32. 8. Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemiaea case report. Vasc Endovascular Surg 2004;38:89e91. 9. Ikushima I, Yonenaga K, Iwakiri H, et al. A better effect of cilostazol for reducing in-stent restenosis after femoropopliteal artery stent placement in comparison with ticlopidine. Med Devices 2011;4:83e9. 10. Suzuki K, Shimohira M, Hashizume T, et al. Stent placement for acute mesenteric artery occlusion associated with type B aortic dissection. Case Rep in Vasc Med 2015;2015:485141. 11. Wyers MW, Powell RJ, Nolan BW, et al. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. J Vasc Surg 2007;45:269e75.