Loeffler Jacob W, Obara Hideaki, Fujimura Naoki, Bove Paul, Newton Daniel H, Zettervall Sara L, van Petersen Andre S, Geelkerken Robert H, Charlton-Ouw Kristofer M, Shalhub Sherene, Singh Niten, Roussel Arnaud, Glebova Natalia O, Harlander-Locke Michael P, Gasper Warren J, Humphries Misty D, Lawrence Peter F
Division of Vascular Surgery, Department of Surgery, University of California, Davis, Sacramento, Calif.
Division of Vascular Surgery, Keio University School of Medicine, Tokyo, Japan.
J Vasc Surg. 2017 Jul;66(1):202-208. doi: 10.1016/j.jvs.2017.01.059. Epub 2017 May 12.
Isolated dissection of the mesenteric vessels is rare but increasingly recognized. This study aimed to evaluate patient characteristics, primary treatment, and subsequent outcomes of mesenteric dissection using multi-institutional data.
All patients at participant hospitals between January 2003 and December 2015 with dissection of the celiac artery (or its branches) or dissection of the superior mesenteric artery (SMA) were included. Patients with an aortic dissection were excluded. Demographic, treatment, and follow-up data were collected. The primary outcomes included late vessel thrombosis (LVT) and aneurysmal degeneration (AD).
Twelve institutions identified 227 patients (220 with complete treatment records) with a mean age of 55 ± 12.5 years. Median time to last follow up was 15 months (interquartile range, 3.8-32). Most patients were men (82% vs 18% women) and symptomatic at presentation (162 vs 65 asymptomatic). Isolated SMA dissection was more common than celiac artery dissection (n = 158 and 81, respectively). Concomitant dissection of both arteries was rare (n = 12). The mean dissection length was significantly longer in symptomatic patients than in asymptomatic patients in both the celiac artery (27 vs 18 mm; P = .01) and the SMA (64 vs 40 mm; P < .001). Primary treatment was medical in 146 patients with oral anticoagulation or antiplatelet therapy (n = 76 and 70, respectively), whereas 56 patients were observed. LVT occurred in six patients, and 16 patients developed AD (3% and 8%, respectively). For symptomatic patients without evidence of ischemia (n = 134), there was no difference in occurrence of LVT with medical therapy compared with observation alone (9% vs 0%; P = .35). No asymptomatic patient (n = 64) had an episode of LVT at 5 years. AD rates did not differ among symptomatic patients without ischemia treated with medical therapy or observed (9% vs 5%; P = .95). Surgical or endovascular intervention was performed in 18 patients (3 ischemia, 13 pain, 1 AD, 1 asymptomatic). Excluding the patients treated for ischemia, there was no difference in LVT with surgical intervention vs medical management (one vs five; P = .57).
Asymptomatic patients with isolated mesenteric artery dissection may be observed and followed up with intermittent imaging. Symptomatic patients tend to have longer dissections than asymptomatic patients. Symptomatic isolated mesenteric artery dissection without evidence of ischemia does not require anticoagulation and may be treated with antiplatelet therapy or observation alone.
肠系膜血管孤立性夹层分离较为罕见，但越来越受到关注。本研究旨在利用多机构数据评估肠系膜夹层分离患者的特征、初始治疗及后续结局。
纳入2003年1月至2015年12月参与研究医院中所有患有腹腔干动脉（或其分支）夹层分离或肠系膜上动脉（SMA）夹层分离的患者。排除主动脉夹层患者。收集人口统计学、治疗及随访数据。主要结局包括晚期血管血栓形成（LVT）和动脉瘤样退变（AD）。
12家机构共识别出227例患者（220例有完整治疗记录），平均年龄55±12.5岁。末次随访的中位时间为15个月（四分位间距为3.8 - 32个月）。大多数患者为男性（82%对18%为女性），就诊时出现症状者（162例对65例无症状）。孤立性SMA夹层分离比腹腔干动脉夹层分离更常见（分别为158例和81例）。两条动脉同时发生夹层分离的情况罕见（12例）。腹腔干动脉有症状患者的平均夹层长度显著长于无症状患者（分别为27mm对18mm；P = 0.01），SMA也是如此（64mm对40mm；P < 0.001）。146例患者接受药物治疗，采用口服抗凝或抗血小板治疗（分别为76例和70例），56例患者进行观察。6例患者发生LVT，16例患者出现AD（分别为3%和8%）。对于无缺血证据的有症状患者（134例），药物治疗与单纯观察相比，LVT发生率无差异（9%对0%；P = 0.35）。5年时，无无症状患者（64例）发生LVT事件。接受药物治疗或观察的无缺血有症状患者中，AD发生率无差异（9%对5%；P = 0.95）。18例患者接受了手术或血管内介入治疗（3例因缺血、13例因疼痛、1例因AD、1例无症状）。排除因缺血接受治疗的患者，手术干预与药物治疗相比，LVT发生率无差异（1例对5例；P = 0.57）。
孤立性肠系膜动脉夹层分离的无症状患者可进行观察，并通过间歇性影像学检查进行随访。有症状患者的夹层往往比无症状患者更长。无缺血证据的有症状孤立性肠系膜动脉夹层分离不需要抗凝治疗，可采用抗血小板治疗或单纯观察。
