73

Original communication

Endovascular stent placement for

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isolated superior mesenteric artery

dissection with intestinal ischaemia
Baochen Liua, Chengnan Chua, Xinxin Fan, Weiwei Ding, and Xingjiang Wu
1
Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
a
These authors contributed equally to this paper

Summary: Background: Isolated superior mesenteric artery dissection (ISMAD) is rare, especially when associated with
intestinal ischaemia. We report our clinical experience managing this condition. Patients and methods: Medical records
from 22 patients with ISMAD and intestinal ischaemia were retrospectively analysed. Conservative treatment was given to
all patients as first line therapy. Subsequently, 15 patients received endovascular stent placement and three patients re-
ceived endovascular stent placement plus intestinal resection and anastomosis. Results: After conservative treatment,
the symptoms of three patients were remarkably relieved; however, a repeat contrast CT showed that stenosis was aggra-
vated. Hence, endovascular stent placement was performed in all 15 patients. Enteral nutrition was successfully restored
in 12 patients. Three patients showed signs of chronic intestinal ischaemia, including peritonitis and ileus. These patients
underwent intestinal resection and anastomosis. Enteral nutrition was restored at postoperative week two. No signs of
intestinal ischaemia recurred during two-years of follow-up. Conclusions: We recommend endovascular stent placement
as a feasible, effective, and minimally invasive procedure in patients with ISMAD and symptoms of intestinal ischaemia.

Keywords: Isolated superior mesenteric artery dissection, intestinal ischaemia, endovascular, stent placement

Introduction Patients and methods

Isolated superior mesenteric artery dissection (ISMAD) is
a rare disease. Although its reported incidence is merely
0.06 % [1], it can cause severe intestinal ischaemia, intes-
tinal infarction, and even death [2]. Early diagnosis and
treatment of ISMAD is ideal. Identification of ISMAD has
been facilitated by the development of imaging technol-
ogy, such as computer tomography angiography (CTA).
Management is aimed at symptom relief and prevention
of intestinal necrosis. Treatment involves a variety of op-
tions, including conservative, surgical revascularization
or endovascular approaches.
To date, the natural history of ISMAD is not well under-
stood because of the rarity and complexity of the condition
[3]. Furthermore, there is no consensus on management
guidelines [4–12]. The objective of this retrospective study
was to describe our single-centre experiences with ISMAD
and intestinal ischaemia.
Patients
This retrospective study was conducted at our national in-
testinal stroke centre, which was set up in October 2010.
So far, 207 intestinal shock patients have been recorded in
our centre. The medical records of consecutive patients
with superior mesenteric artery (SMA) dissection who re-
ceived treatment during July 2010 to July 2016 were as-
sessed. Patients with ISMAD and intestinal ischaemia
were included. Patients with SMA dissection associated
with aortic or other visceral arteries were excluded.
Patients’ demographic and clinical characteristics,
including age, sex, medical history, risk factors, symp-
toms, Sakamoto’s classification, and follow-up period
were recorded.
Diagnostic work-up and categorization

A contrast-enhanced CTA was performed on patients with

acute-onset abdominal pain when common causes were
excluded. An initial diagnosis of ISMAD was made accord-

© 2018 Hogrefe Vasa (2019), 48 (1), 73–78

https://doi.org/10.1024/0301-1526/a000738
 74
ing to clinical manifestations and the presence of an iso-
lated SMA wall dissection on abdominal CTA.
The entry and re-entry sites of the dissection, dissection
length, patency, and degree of luminal stenosis at the dis-
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sected segment of the SMA were assessed on CTA images.
ISMAD was categorized into four types based on Sakamo-
to’s classification [13]. Type I: Patent true and false lumen
that shows entry and re-entry sites. Type II: Patent true lu-
men but no re-entry flow from the false lumen. Type III:
No visible false luminal flow (thrombosis false lumen),
causing true luminal narrowing. Type IV: SMA dissection
with occlusion of the SMA.
Therapeutic regimens and follow-up
All patients received conservative treatment for three
to five days, including blood pressure control (under
130/80 mmHg for patients with hypertension), anticoag-
ulants (subcutaneous injection of low-molecular-weight
heparin calcium (4000 IU) q12h during hospitalization),
complete bowel rest, and parenteral nutrition. For asymp-
tomatic and symptom relief patients, follow-up CTA was
usually performed at one week, two weeks, one month,
and six months after admission, and annually thereafter
according to protocol. For patients with aggravated ab-
dominal pain, CTA was immediately performed for re-
view. If abdominal pain was relieved, and the CTA showed
no progress in the dissection, the conservative treatment
was continued. If there was no abdominal pain relief or
there was pain relief but disease progression on CTA, pa-
tients underwent endovascular stent placement (ESP).
Patients who underwent ESP were instructed to gradually
restore enteral nutrition. At this time, exploratory laparot-
omy was performed if there were signs of peritonitis or
intestinal obstruction.
Follow-ups were conducted in the outpatient clinic at
one and six months and every 12 months thereafter. CTA
findings and clinical manifestations were obtained to as-
sess treatment outcomes.
Table I. Clinical characteristics of asymptomatic patients.
Patients Age (years)/ Symptoms Risk factors Sakamoto’s
gender classification
1 44/M – Smoking
2 51/M – Hypertension
3 47/F – –
4 49/F – Hypertension
5 42/M – Hypertension Smoking
6 62/M – Hypertension Smoking
7 57/M – Diabetes
Vasa (2019), 48 (1), 73–78
B. Liu & C. Chu et al., Treatment for ISMAD
Results
Patient characteristics
Twenty-six consecutive patients with SMA dissection were
eligible for this study. After exclusion of patients with SMA
dissection associated with aortic or other visceral arteries
(n  =  2) and patients who rejected treatment (n  =  2), the
medical histories of 22 patients (19 male and three female)
with ISMAD were retrospectively reviewed.
The mean age of the included patients was 51 ± 7 years
(range, 38–67 years). All patients were admitted because
of ISMAD. Among them, seven patients were asympto-
matic dissections (31.8 %) (Table I), while the other 15 pa-
tients were symptomatic dissections (68.2 %) (Table II).
The accompanying symptoms included nausea (n  =  8),
vomiting (n = 5), fever (n = 1), bloody stool (n = 1), and radi-
ating pain to the back (n  =  1). Risk factors in the eligible
patients included hypertension (n  =  11; 50 %), smoking
(n = 10; 45.5 %), arteriosclerosis (n = 2; 0.1 %), and diabe-
tes (n = 3; 13.6 %). Results of laboratory tests were within
normal reference ranges, except for low albumin levels in
six patients (27.3 %) and a high C-reactive protein level in
four patients (18.2 %). All patients attended follow-up vis-
its in the outpatient clinics; mean follow-up period was
16 ± 10 months (range, 3–40 months) (Table I, II).
All patients were diagnosed with ISMAD by CTA, the
primary entry site was around the curvature of the SMA.
The median distance from the primary entry tear to the
ostium of the SMA was 21 ± 6 mm (range, 8–32 mm). Ac-
cording to Sakamoto’s classification[13], four patients were
type I (18.2 %), 10 patients were type II (45.5 %), six pa-
tients were type III (27.3 %), and two patients were type IV
(0.1 %).
After conservative treatment, none of the asympto-
matic patients (100 %) showed progress in dissection af-
ter repeated CTA. Three of the symptomatic patients
(20 %) were remarkably relieved of their symptoms. Ac-
cording to Sakamoto’s classification, they are type I
(33.3 %), type II (33.3 %), and type III (33.3 %), respec-
Treatment Conservative Follow-up
Treatment result months
II Conservative treatment Success 6
II Conservative treatment Success 8
II Conservative treatment Success 12
III Conservative treatment Success 18
IV Conservative treatment Success 40
IV Conservative treatment Success 16
I Conservative treatment Success 5
© 2018 Hogrefe
 B. Liu & C. Chu et al., Treatment for ISMAD 75

Table II. Clinical characteristics of symptomatic patients.

Patients Age (years/ Symptoms Risk factors Sakamoto’s Treatment Outcome Follow-up
gender) classification months
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1 38/M Abdominal pain, Hypertension II ESP Pain resolution 6

nausea, vomiting

2 41/M Abdominal pain Hypertension smoking II ESP Pain resolution 8

3 59/M Abdominal pain Smoking II ESP Pain resolution 12

4 53/M Abdominal pain Hypertension Smoking III ESP Pain resolution 18

5 48/M Abdominal pain Diabetes IV ESP Pain resolution 40

6 53/M Abdominal pain, – IV ESP + surgery Pain resolution 16

fever, nausea, vomiting,

7 54/M Abdominal pain, Hypertension I ESP Pain resolution 5

nausea, vomiting

8 55/M Abdominal pain, Hypertension III ESP Pain resolution 7

nausea, vomiting Smoking

9 45/M Abdominal pain Hypertension III ESP Pain resolution 38

10 49/M Abdominal pain Hypertension Smoking III ESP Pain resolution 10

radiating to the back

11 61/M Abdominal pain, nausea, – III ESP + surgery Pain resolution 12

vomiting, bloody stools

12 51/F Abdominal pain, nausea – III ESP + surgery Pain resolution 14

13 67/M Abdominal pain, nausea Smoking II ESP Pain resolution 8

14 48/M Abdominal pain, nausea Diabetes II ESP Pain resolution 3

15 44/M Abdominal pain, Traumatic Smoking II ESP Pain resolution 18

ESP: Endovascular stent placement.

tively. However, a CTA performed on the 14th day after Discussion

admission showed that stenosis was aggravated (Figure
1). Conservative treatment failed to relieve abdominal
pain in the other 12 symptomatic patients.
ESP was performed successfully in all 15 patients
(8 × 60  mm bare mental stent, BARD, in six patients;
6 × 60  mm bare mental stent, BARD, in seven patients;
6 × 40 mm bare mental stent, BARD, in two patients). Be-
cause of the too narrow angle between aorta and SMA
(< 45°), three of the patients were changed to the brachial
approach, while the other remained in the femoral ap-
proach group. There were no treatment-related complica-
tions. Abdominal pain was alleviated after the procedure
and disappeared gradually within three to five days.
Enteral nutrition was gradually restored in all 15 pa-
tients. During this time, three (20 %) patients showed signs
of chronic intestinal ischaemia, including peritonitis, ileus,
and a rapid decrease in albumin levels. Infusion of human
serum albumin failed to increase albumin levels. CT scan
indicated partial intestinal ischaemia and intestinal wall
oedema. Surgery was performed and nonviable bowel was
resected. Abdominal pain and signs of peritoneal irritation
disappeared on postoperative day one to two. Enteral nutri-
tion was successfully restored within two weeks.
At the last follow-up, all patients were alive and had ex-
perienced no recurrence of symptoms.
The rare disease, ISMAD, was first reported in 1947 by Bau-
ersfeld [1]. With increasing use of contrast-enhanced CT
scans for abdominal patients, ISMAD has been reported
more frequently in recent years [14]. While potential aetio-
logical factors of ISMAD are identified in the literature and
include arteriosclerosis, medial degeneration of the arterial
wall, trauma, and inflammation [15, 16], the exact cause re-
mains unclear. Therefore, a treatment guideline for patients
with ISMAD has not yet been established. This study pre-
sents a case series of patients with ISMAD to provide more
information on the management of this condition.
The pathogenesis of ISMAD may include shearing stress
of the SMA [17]. In our case series, the primary entry site of
the dissection was located at the proximal segment of the
SMA. This segment is the transition portion, connecting
the fixed segment under the pancreas to the unfixed seg-
ment at the mesenteric root. Due to this anatomical struc-
ture, the anterior wall may be subject to abnormal shearing
stress, resulting in ISMAD.
Sakamoto et al. categorized ISMAD into four types de-
pending on CT imaging [13]. According to our study, each of
these types was associated with persistent abdominal pain,
which could not be relieved by conservative treatment, as
well as symptoms related to intestinal ischaemia. These

© 2018 Hogrefe Vasa (2019), 48 (1), 73–78

 76
findings indicate that the selection of a therapeutic regimen
should not be based on imaging findings alone [18, 19].
Conservative treatment is recommended as first-line
therapy for ISMAD [4, 20, 21]. In the current study, all pa-
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tients received conservative treatment, including hypo-
tensive and antiplatelet medication, bowel rest, intrave-
nous fluids, and nutritional support. Abdominal pain was
markedly relieved in 20 % of patients, but CTA revealed
that the compression of true lumen became more serious.
These findings are in accordance with a previous study
[22]. In contrast, Park et al. [20] reported on 53 ISMAD
patients who received conservative treatment as first-line
therapy. Over a 23-month period of follow-up, the extent
of the false lumen was diminished in 41.3 % of patients,
the length of the dissection was diminished in 23.9 % of
patients, and the dissection was completely remodelled in
15.2 % of patients. Cho et al. [4] found similar results in 15
ISMAD patients who received conservative treatment.
These data suggest that most patients with ISMAD can be
successfully managed with conservative treatment. This
approach likely failed in our symptomatic patients because
they were suffering from intestinal ischaemia, which re-
sulted in persistent abdominal pain, and/or signs of perito-
neal irritation. However, taking both symptomatic and
asymptomatic dissection into consideration, we received
similar results as in Park’s and Cho’s studies. In the studies
of Park et al. [20] and Cho et al. [4], 17.4 and 43.3 % of the
patients, respectively, were asymptomatic. In our study,
the percentage was 31.8 %. Therefore, ISMAD, especially
asymptomatic dissection, can be successfully managed in
first-line therapy.
Endovascular treatment of an isolated SMA dissection
has been first reported by Leung [23], and since then, nu-
merous studies of stent placement for spontaneous iso-
lated dissection of SMA have been reported [24]. Unlike
conservative treatment, endovascular therapy can imme-
diately relieve mesenteric ischaemia and prevent further
progression. We performed stent placement as our pa-
tients were symptomatic and because dissection of the
SMA can rapidly progress into chronic intestinal ischae-
Figure 1. Patient 2, Computer tomography angiography (CTA).
A: Isolated superior mesenteric dissection; B: after two weeks of conservative treatment, the true lumen was more compressed; C: three months
after endovascular stent placement, the true lumen was patent and there was revascularization.
Vasa (2019), 48 (1), 73–78
B. Liu & C. Chu et al., Treatment for ISMAD
mia or intestinal necrosis. The stented cases in our series
showed no procedure-related complications, pain was re-
solved in three to five days, and all stents were patent on
CTA during the follow-up period. The covered stent was
reported to be used to repair the dissection [25]. In our
opinion, bare stents are more suitable. Covered stents can
more easily cover the SMA branches, affecting the blood
supply of the intestine.
Three patients in our case series are particularly nota-
ble. After stent placement, during the reperfusion period,
these patients experienced bloating, diarrhoea and hypo-
proteinaemia, and enteral nutrition could not be restored.
CT scan showed lesions confined to a short length of the
intestine, which developed into an intestinal stenosis (Fig-
ure 2). The patients suffered protein losing enteropathy
[26,  27]. As intestinal stenosis was limited, intestinal re-
section and anastomosis were performed; 30–60  cm of
the intestine were resected. In these cases, ESP was par-
ticularly important. ESP can result in immediate revascu-
larization, therefore, a suspicious ischaemic intestine can
be rescued. Performing laparotomy or fenestration lapa-
rotomy without ESP makes it difficult to ensure the intes-
tine will remain viable. These three patients returned to
their normal diet within 15–20 days. During follow-up, no
intestinal necrosis, morbidity or mortality developed in
these patients and CTA revealed the stents to be patent.
Limitations
Three major limitations exist in our study. First, it was a
retrospective review. Second, the absence of other treat-
ment groups, which do not allow for direct comparison
with other strategies. Finally, the number of patients was
relatively small and the duration of the follow-up was re-
latively short. Prospectively randomized clinical studies
with a large number of patients and long follow-ups are
needed to explore whether the endovascular treatment is
appropriate in terms of patients’ long-term outcome.
© 2018 Hogrefe
 B. Liu & C. Chu et al., Treatment for ISMAD
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Conclusions
ISMAD with symptoms of intestinal ischaemia is chal-
lenging to manage. Our case series indicates that ESP can
provide immediate relief of mesenteric ischaemia and
prevent further progression. For those patients who un-
derwent intestinal resection, ESP shortens the length of
resection and ensures the intestine remains viable. We
recommend ESP as a feasible, effective, and minimally
invasive procedure in patients with ISMAD and symp-
toms of intestinal ischaemia.
Acknowledgments
Supported by the National Natural Science Foundation of
China (Grant No. 81770532, Dr. Weiwei Ding) and Jiangsu
Province Medical Foundation for Youth Talents (Grant
No. QNRC2016901, Dr. Weiwei Ding).
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Submitted: 19.03.2018
Accepted after revision: 31.05.2018
Published online: 19.09.2018
There are no conflicts of interest existing.
Correspondence address
Weiwei Ding, PhD
Research Institute of General Surgery, Jinling Hospital
305 East Zhongshan Road
210002 Nanjing
China
dingweiweinj@icloud.com
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