CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 318 AFRICA Case Reports A case of spontaneous isolated superior mesenteric arterial dissection with coeliac axis stenosis Kun Ye, Yong Wang, Shengyun Wan Abstract Spontaneous isolated superior mesenteric arterial dissection with coeliac axis stenosis is rare but serious. We report a case of a 54-year-old male with coeliac axis stenosis who presented with acute superior mesenteric arterial dissection, which caused thrombosis of the branches. This is the first report of the full course of treatment using endovascular repair and laparoscopic surgery to deal with spontaneous isolated superior mesenteric arterial dissection combined with coeliac axis stenosis. This approach has been shown to be safe and effective for yielding short-term results. Keywords: spontaneous isolated superior mesenteric arterial dissection, coeliac axis stenosis, isolated visceral arterial dissection Submitted 11/3/20, accepted 14/11/22 Published online 10/3/23 Cardiovasc J Afr 2023; 34: 318–320 www.cvja.co.za DOI: 10.5830/CVJA-2022-066 Spontaneous isolated superior mesenteric arterial dissection (SISMAD) that is not associated with aortic dissection represents 8% of all visceral arterial dissections and has an overall prevalence of 0.06% in cadaveric studies, described for the first time by Bauersfeld in 1947.1 In addition, there have been an increasing number of reports since the improvements in technology, and computed tomography (CT) imaging has been in widespread use for abdominal pain.2,3 Computerised tomography angiogram (CTA) is a valuable diagnostic modality for SISMAD. Many classification schemes have been developed based on CTA, such as the Yun, Sakamoto and Zerbib classifications. In recent years, Luan’s type4 and Qiu’s type5 have been developed. However, the condition of the distal branches involved were not included in previous classifications. Clinical manifestations vary widely depending on the location of the intimal tear, the range of the dissection, the degree of the compromise of the true lumen, and the number of collateral arteries.6 Better typing methods may be needed in the future. According to the previous literature, the therapeutic regimen for patients with SISMAD should be based on clinical symptoms, and conservative management is feasible in most cases. It is recommended that endovascular stenting combined with laparoscopic exploration and/or open surgery could be a reasonable option for symptomatic SISMAD in which peritonitis is present.7 The reported incidence of coeliac axis stenosis ranges from12.5 to 24% in Western populations.8 Reported causes of coeliac axis stenosis are arteriosclerosis, injury from catheter manipulation, surgical trauma, Takayasu arteritis, and compression of the coeliac axis by the median arcuate ligament (MAL).9 Among the general population, stenosis of the coeliac axis is usually asymptomatic. This is because of the different vascular systems that can provide collateral circulation. Severe stenosis of the coeliac axis is commonly associated with enlargement of the arteries of the pancreatic–duodenal arcade, which supply the coeliac axis via retrograde flow from the superior mesenteric artery (SMA). Only one SISMAD patient with coeliac axis stenosis has been reported in the literature thus far. This patient had an asymptomatic coeliac axis stenosis and was found to have acquired SISMAD accidentally. To date, this work is the first report of a hybrid approach for SISMAD combined with coeliac axis stenosis. Case report The patient was a 54-year-old male with a history of uncontrolled hypertensionwhowas admitted to hospital with sudden epigastric pain lasting for three days. The abdomen was bulging and there was pain in the whole abdomen and rebound pain in the periumbilical abdomen. Borborygmus was weak (about twice a minute) and no sounds could be heard in the blood vessels. CTA of the abdomen showed dissection of the proximal segment of the superior mesenteric artery (Fig. 1), thrombosis in the left branches of the SMA, and stenosis of the coeliac axis (Fig. 2). Hence, the patient was diagnosed with SISMAD (Yun type II) and coeliac axis stenosis. Informed consent was obtained from the patient, and emergency angiography was performed. Intra-operative angiography showed dissection of the SMA, the intimal tear was 2.5 cm from the ostium, and jejuno-ileal branches were Department of General Surgery, 2nd Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China Kun Ye, MD Yong Wang, MD, 1378606242@qq.com Shengyun Wan, MD
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