自发性孤立性肠系膜上动脉夹层的临床特征和治疗

Clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection

目的探讨自发性孤立性肠系膜上动脉夹层（SISMAD）的临床特征和治疗策略。方法采用回顾性横断面研究方法。收集2012年2月至2017年3月华中科技大学同济医学院附属协和医院收治的80例SISMAD患者的临床资料。患者行cT血管造影（CTA）检查和（或）DSA检查。患者明确诊断后行药物保守、腔内介入或剖腹探查及血运重建术治疗。观察指标：（1）临床特征。（2）治疗情况。（3）随访情况。采用门诊或电话方式进行随访。出院后1、6、12个月各随访1次，以后每年随访1次。随访内容为腹痛症状复发情况，CTA检查肠系膜上动脉（SMA）夹层变化或支架置入术后SMA变化及夹层重塑情况。随访时间截至2017年3月。正态分布的计量资料以平均数（范围）表示。结果（1）临床特征：①临床表现：80例患者中，75例有症状，5例无症状为健康体检时发现。75例有症状患者均以腹痛为首发症状，均无腹膜刺激征，腹痛以脐周及腹上区为主，14例伴恶心、呕吐，4例伴血便。②影像学检查结果：80例患者均经CTA检查明确诊断为SISMAD。CTA检查表现为SMA局部增粗、真假双腔形成、动脉真腔变细并可见内膜瓣影、假腔形成血栓，其中77例第一破口位于距肠系膜开口1～6cm以内，3例位于主干中远段。80例患者均未发现主动脉夹层。（2）治疗情况：75例有症状患者中，53例药物保守治疗有效，有效率为70．7％（53／75），症状缓解平均时间为5d（1。12d）；22例行支架置入术，均取右侧股动脉入路，置入自膨式裸支架或覆膜支架，其中21例成功，1例失败，手术成功率为95．5％（21／22），支架置入术失败患者予药物保守治疗1周后症状缓解。无行剖腹探查及血运重建术患者。5例无症状患者嘱其院外有效控制血压，定期随访，未作其他干预。（3）随访情况：75例有症状患者均获得随访，平均随访时间为36个月（1—60个月）。随访期间，53例药物保守治疗患者中，2例行CTA检查示SMA夹层进展明显，其中1例随访2个月时腹痛复发并加重伴血便，DSA检查示SMA夹层动脉瘤形成，1例随访1年时腹痛复发。2例均行支架置入术后好转。其余51例患者随访期间均未复发。22例行支架置入术患者中，1例随访期间腹痛症状反复，随访1年时症状加重，CTA检查示支架内血栓形成并近端狭窄，抗凝治疗后于近端狭窄处行支架置入术；1例随访2年CTA检查示SMA夹层完全愈合；其余20例支架均通畅。5例无症状患者定期随访，未出现病情进展。结论SISMAD症状不一，多以腹痛为首发症状。治疗方案包括药物保守、腔内介入及外科手术治疗，需结合患者临床特征及影像学检查制订个体化治疗方案。

Objective To investigate the clinical characteristics and treatment of spontaneous isolated superior mesenteric artery dissection （SISMAD）. Methods The retrospective cross-sectional study was conducted. The clinical data of 80 patients with SISMAD who were admitted to the Wuhan Union Hospital Affiliated to Huazhong University of Science and Technology from February 2002 to March 2017 were collected. All the patients underwent computed tomographic angiography （CTA） and digital subtraction angiography （DSA） examinations, and then received conservative medical treatment, endovascular interventional treatment or exploratory laparotomy and revascularization. Observation indicators ： （ 1 ） clinical features ; （2） treatment ; （3） follow-up. Follow-up using outpatient examination and telephone interview was performed once at 1, 6 and 12 months after discharge and once every year after 1 year up to March 2017. Follow-up included recurrence of abdominal pain, changes of superior mesenteric artery （SMA） dissection or changes of SMA and remodeling of dissection after stent implantation. Measurement data were represented as average （range）. Results （ 1 ） Clinical features： （!） Clinical manifestation： 75 of 80 patients had symptoms, and 5 without symptoms were diagnosed during health examination. Of 75 patients with symptoms, abdominal pain was the first symptom, with the main of the peri-umbilicus and epigastrie pains, without peritoneal irritation sign, including 14 with nausea and vomiting and 4 with bloody stool. （1） Results of imaging examination ： 80 patients were confirmed by CTA examination. CTA showed that there was local thickening of SMA, true and false double-lumen formation, thinner true arterial lumen with visible intimal flap shadow and thrombosis in the false lumen. Results of CTA showed that the first break was located within 1-6 cm from opening of SMA in 77 patients and in the middle and distal segment of SMA in 3 patients, without aortic dissection （AD）. （2） Treatment： of 75 patients with symptoms, 53 received conservative medical treatment with an effective rate of 70.7% （ 53/75 ）, average time of symptomatic remission was 5 days （range, 1-12 days）; 22 received stent implantation via fight femoral artery approach using self-expanding bare stent or covered stent, with a success rate of implantation of 95.5% （21/22） , including 21 with successful implantations and 1 with false implantation. One patient with false implantation had symptomatic remission after 1-week conservative medical treatment, and there was no exploratory laparotomy and revaseularization. Five patients without symptom were required to control blood pressure and get regular follow-up, without other intervention. （3） Follow-up： 75 patients with symptoms were followed up for 36 month （range, 1- 60 months）. During follow-up, of 53 patients with conservative medical treatment, 2 patients had significant progressions of SMA dissection by CTA examination, 1 had recurrence and exacerbation of abdominal pain accompanied with bloody stool at 2-month follow-up, showing an aneurism of SMA dissection by DSA examination, and 1 had recurrence of abdominal pain at 1-year follow-up, both patients were improved after stent implantation; other 51 had no recurrence. Of 22 patients with stent implantation, 1 had repeated abdominal pain during follow-up and the symptom became aggravated at 1-year follow-up, showing a thrombosis formation and proximal stenosis by CTA examination, and then underwent stent implantation in the proximal stenosis after anticoagulant therapy; SMA dissection of 1 patient completely healed at 2-year follow-up by CTA examination; other 20 patients had stent pateney. Five patients without symptom had regular follow-up, showing no disease progression. Conclusions The symptoms of SISMAD are different, and abdominal pain is the one of main symptoms. At present, treatment regimens include conservative medical treatment, endovascular interventional treatment and surgery, and individualized treatment is decided according to clinical symptoms and physical signs of patients and imaging examinations.