Fujiwara Sho, Sekine Yuki, Nishimura Ryuichi, Tadasa Kazuya, Miyazaki Shukichi
Department of Molecular Pathology, Tohoku University School of Medicine, Sendai, Miyagi, Japan.
Department of Surgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan.
Surg Case Rep. 2018 Jan 8;4(1):5. doi: 10.1186/s40792-017-0412-1.
Nonocclusive mesenteric ischemia (NOMI) is a mesenteric arterial spasm and intestinal ischemia. This disease is a highly lethal disease because diagnosis and decision of appropriate treatments are often difficult. Operations cannot resolve the spasms and may worsen the situation. However, the safety and effectiveness of catheterization for NOMI with aortic dissection (AD) have not yet been elucidated. Here, we report a successful case of early diagnosis and treatment of NOMI with type B AD involving the superior mesenteric artery (SMA) using the intra-arterial infusion of a vasodilator via the SMA.
An 83-year-old man was admitted to our hospital because of abdominal pain after a motor accident. We performed intestinal resection and splenectomy for intestinal perforation and splenic hemorrhage and treated conservatively for acute AD, liver injury, renal hematoma, and pneumothorax. On postoperative day (POD) 2, the patient had localized abdominal pain. Follow-up computed tomography suggested a smaller superior mesenteric vein sign and segmental lack of enhancement in the intestinal wall and ascites without SMA occlusion. Thus, the patient was diagnosed with NOMI. Although the patient had type B AD including the SMA, we performed selective mesenteric arteriography and transcatheter papaverine infusion via the SMA and prostaglandin via the peripheral vein. Seven days post treatment, mesenteric blood flow improved and intestinal wall enhancement was restored.
The intra-arterial infusion of a vasodilator is highly efficient and safety treatment option for NOMI with type B AD. Prompt and accurate management can prevent massive small bowel resection, and this procedure is essential in resolving a spasm independent of whether a necrotic bowel has been resected.
非闭塞性肠系膜缺血（NOMI）是一种肠系膜动脉痉挛和肠缺血疾病。该疾病致死率高，因为诊断和选择合适的治疗方案通常很困难。手术无法解除痉挛，反而可能使情况恶化。然而，主动脉夹层（AD）合并NOMI时导管介入治疗的安全性和有效性尚未阐明。在此，我们报告一例成功早期诊断和治疗B型AD累及肠系膜上动脉（SMA）的NOMI病例，通过经SMA动脉内输注血管扩张剂进行治疗。
一名83岁男性因车祸后腹痛入住我院。我们对肠穿孔和脾出血进行了肠切除和脾切除术，并对急性AD、肝损伤、肾血肿和气胸进行了保守治疗。术后第2天，患者出现局限性腹痛。后续计算机断层扫描显示肠系膜上静脉征较小，肠壁节段性强化缺失及腹水，无SMA闭塞。因此，患者被诊断为NOMI。尽管患者患有包括SMA在内的B型AD，但我们进行了选择性肠系膜动脉造影，并经SMA动脉内输注罂粟碱，经外周静脉输注前列腺素。治疗7天后，肠系膜血流改善，肠壁强化恢复。
动脉内输注血管扩张剂是治疗B型AD合并NOMI的高效且安全的治疗选择。及时准确的处理可避免大范围小肠切除，无论是否已切除坏死肠段，该操作对于解除痉挛至关重要。
