自发孤立性肠系膜上动脉夹层七例诊疗分析

Diagnosis and treatment of spontaneous isolated superior mesenteric artery dissection： analysis of seven patients

目的评估血管内支架置入术治疗自发孤立性肠系膜上动脉夹层的可行性及疗效。方法回顾性分析7例男性自发孤立性肠系膜上动脉夹层患者资料，经CTA确诊为自发孤立性肠系膜上动脉夹层，接受血管内支架置人术治疗。患者出院后1、3、6个月接受CTA随访。分析CT影像表现、手术效果、并发症情况及随访结果。结果7例患者CTA可见低密度的动脉内膜片将肠系膜上动脉近端分为扩张的假腔和受压狭窄的真腔，合并腹腔干动脉夹层1例、腹腔干动脉瘤1例；7例均支架置入治疗成功，临床症状缓解。术中于肠系膜上动脉置人自膨式金属裸支架共11枚。支架直径6—8mm，长度30～40inm；4例患者置入支架2枚、3例置入1枚。合并腹腔干动脉夹层的患者于腹腔干动脉内置入自膨式金属裸支架1枚，合并腹腔干动脉瘤的患者于腹腔干动脉内置人覆膜支架1枚。术后3个月时随访CTA显示，6例患者夹层假腔血栓形成并吸收消失，合并存在的腹腔干动脉夹层和腹腔干动脉瘤均消失；1例患者于术后第1个月随访时再发轻度腹痛，CTA检查证实肠系膜上动脉近端形成附壁血栓并导致管腔狭窄，经持续抗血小板、抗凝治疗3个月后腹痛逐渐消失。患者随访时间16～42个月，中位随访时间28个月。随访期间支架内未出现血栓形成或狭窄。结论血管内支架置入术是自发孤立性肠系膜上动脉夹层安全、有效的治疗方案。

Objective To analyze the CT manifestations of spontaneous isolated superior mesenteric artery dissection （SISMAD） and evaluate the feasibility and efficacy of endovascular stent placement therapy. Methods Seven male patients （mean age, 48 years; range, 36 -62 years） who suffered from SISMAD received endovascular stent placement in our institution. All patients were diagnosed by computed tomographic angiography （CTA）. Follow-up was performed with CTA at the first, third and sixth month after discharge. The CT manifestations, clinical results, complications, and follow-up outcomes were reviewed. Results An intimal flap separating the proximal portion of the SMA into stenotic true and dilated false lumina could be seen on all patients＇ CTA images. Patient No. 1 had a concomitant celiac trunk dissection and patient No. 2 had a celiac trunk saccular aneurysm. Endovascular stent placement was successfully performed for 7 patients with complete relief of clinical symptoms. Eleven self-expanding stents （6 - 8 mm in diameter and 30 - 40 mm in length） were deployed in the SMAs. One stent was used in 3 patients and two stents were used in 4 patients. The concomitant dissection and aneurysm in the celiac trunks were thought to be at risk of rupture, so a self-expanding stent and a covered stent were deployed in the celiac trunks during the same session respectively. During the follow-up period （median, 28 months; range, 16 -42 months） , false lumina were thrombosed and disappeared in 6 patients by the end of the third month. One patient who had mild recurrent abdominal pain during the first follow-up month became asymptomatic with continued antiplatelet and antieoagulation therapy for 3 months. CTA showed that the mural thrombosis resulted in stenosis in the proximal segment of the SMA. No thrombosis or stenosis was found in the lumina of the stents. Conclusion Endovascular stent placement is a safe and feasible treatment for SISMAD.