CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 319 not shown. A stent (8 × 39 mm, Ominlink, Abbott, USA) was successfully implanted to seal off the dissection, revealing the proximal jejunal branches. Intra-operative angiography also showed severe stenosis of the coeliac axis, and another stent (9 × 29 mm, Ominlink, Abbott, USA) was successfully implanted to expand the stenosis. Soon afterwards, laparoscopy showed no bloody peritoneal effusion, no intestinal necrosis, poor jejuno-ileal blood supply and slow intestinal peristalsis. Epigastric pain was relieved postoperatively, and the patient was discharged smoothly. However, two months later, the patient was re-admitted to hospital due to severe flatulence after meals. He was characterised by left lower abdominal distension, which was obviously relieved after fasting, accompanied by nausea and vomiting but no abdominal pain or diarrhoea. CTA showed a swollen and dilated jejuno-ileal section due to thrombosis in the left branches of the SMA. After communication with the patient, a second-look laparoscopy was performed. Approximately 60 cm of the jejunoileal region starting 20 cm from the Treitz ligament was swollen. Peristalsis in this region was slow, it had a ruddy appearance, and part of the omentum supplied its blood supply. The swollen and dilated jejuno-ileal section was removed, and side-to-side anastomosis of the normal intestine was performed (Fig. 3). Meanwhile, a jejunal nutrient tube was placed through the nose to the distal end of the anastomosis. Postoperative pathology indicated ischaemic intestinal changes. After enteral nutrition was given, the patient recovered well and resumed a normal diet one week after the operation. Discussion The treatment strategy of SISMAD needs to be developed according to change in condition of the patient. Our patient was first admitted with sudden peritonitis, which was considered to be possibly related to the acute superior mesenteric arterial dissection and intestinal ischaemia. During pre-operative CTA, we also found that the patient had severe coeliac axis stenosis. Considering that the patient did not have chronic abdominal pain or weight loss, we did not make the diagnosis of median arcuate ligament syndrome (MALS). In order to improve his symptoms and increase the intestinal blood supply, we performed the first emergency operation, which was a minimally invasive endovascular repair to seal off the dissection, dilate the true lumen of the SMA and the stenosis of the coeliac axis. After that we performed laparoscopy, but no necrotic bowel was found. Abdominal pain was relieved postoperatively. On his second admission, the patient presented with severe flatulence after meals, which was considered to be possibly Fig. 3. Intra-operative photo shows the swollen and dilated jejuno-ileal section. Fig. 2. Pre-operative CT scan shows isolated dissection of the superior mesenteric artery and thrombosis of the branch (green arrow), and stenosis of the coeliac artery (white arrow). Fig. 1. Pre-operative cross-sectional imaging of CT scan shows isolated dissection of the superior mesenteric artery (white arrow).
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