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We read with great interest the recent article by Wen et al. [1]. The authors reported 12 consecutive patients who received endovascular treatment with a covered stent and declared that endovascular treatment should be performed in patients with a spontaneous dissection of the superior mesenteric artery (SMA) patients who are symptomatic, without aneurysms rupture or bowel necrosis. We would like to elaborate on the management strategy of SMA dissection.
More and more evidence shows that conservative treatment should be considered as the first-line therapy in patients without any signs of bowel ischemia or rupture [2, 3]. The false lumen will gradually obliterate with remodelling of the true lumen which may lead to a restoration of the true lumen patency after conservative treatment. A systematic review reported that there was no significant difference in mortality of symptomatic SMA dissection patients without accompanying proof of bowel ischemia or aneurysm between interventional treatment and conservative treatment [4]. Besides, the side branches obstruction in the stented segment is inevitable for a long-term follow-up [5].
According to the modified Sakamoto’s classification, there were two cases of type II and 10 cases in type III, respectively, and all patients should be underwent conservative treatment [6]. Covered stent placement can be considered to patients who failed conservative treatment.
References
Wen D, Wang Z, Yu J, et al. Endovascular stent-graft repair of spontaneous isolated dissection of the superior mesenteric artery. Cardiovasc Intervent Radiol. 2018. https://doi.org/10.1007/s00270-018-1889-0.
Kim H, Park H, Park SJ, et al. Outcomes of spontaneous isolated superior mesenteric artery dissection without antithrombotic use. Eur J Vasc Endovasc Surg. 2018;55(1):132–7.
Tanaka Y, Yoshimuta T, Kimura K, et al. Clinical characteristics of spontaneous isolated visceral artery dissection. J Vasc Surg. 2017. https://doi.org/10.1016/j.jvs.2017.08.054.
Kimura Y, Kato T, Inoko M. Outcomes of treatment strategies for isolated spontaneous dissection of the superior mesenteric artery: a systematic review. Ann Vasc Surg. 2017. https://doi.org/10.1016/j.avsg.2017.07.027.
Chang CF, Lai HC, Yao HY, et al. True lumen stenting for a spontaneously dissected superior mesenteric artery may compromise major intestinal branches and aggravate bowel ischemia. Vasc Endovasc Surg. 2014;48:83–5.
Garrett HE Jr. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg. 2014;59(5):1433–9.
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Jia, Z. Regarding “Endovascular Stent-Graft Repair of Spontaneous Isolated Dissection of the Superior Mesenteric Artery”. Cardiovasc Intervent Radiol 41, 821 (2018). https://doi.org/10.1007/s00270-018-1905-4
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DOI: https://doi.org/10.1007/s00270-018-1905-4