症状性孤立性肠系膜上动脉夹层的治疗误区

症状性孤立性肠系膜上动脉夹层(symptomatic isolated dissection of superior mesenteric artery,SIDSMA)可致肠缺血或破裂潜在风险,至今尚无基于大样本随机对照研究的治疗指南,在治疗流程的选择以及手术治疗细节方面尚存在不少误区。本文基于文献回顾和作者自身经验提出:①可行的治疗流程:对于无腹膜刺激征的SIDSMA首选保守治疗,若无缓解或加重,且仍无腹膜刺激征,可尝试腔内治疗,若失败可继续保守治疗,严密观察。对于伴有腹膜刺激征者,可尝试腔内支架置入,若成功则同期行腹腔镜探查,必要时予以肠切除。若腔内支架置入失败,则剖腹探查,根据探查结果决定肠切除、旁路、血栓内膜切除或开窗。②无法选择进入真腔是腔内治疗失败的常见因素,根据肠系膜上动脉起始段形态适当选择肱动脉入路会有所帮助。③术前注重评估发自假腔的分支数量和直径,及其支架置入可能带来的缺血风险。④支架导入和释放前,应该确认导丝的行径,避免其穿越假腔。

Pitfalls during Treatment of Symptomatic Isolated Dissection of Superior Mesenteric Artery

Symptomatic isolated dissection of superior mesenteric artery （ SIDSMA ） is a rare but potentially fatal en- tity. However, most of these reports were isolated case reports, and a consensus treatment protocol remains lacking so far. It would be meaningful to propose a reasonable treatment algorithm for it and discuss the causes and preventions of the technical failures and lessons throughout the treatment. On the basis of the literature review and our own experience, the reasonable treatment algorithm was postulated. Majority of SIDSMA cases without peritonitis could be successfully treated with the medical therapy. The endovascular stent placement could safely and effectively restore the SMA perfusion with a satisfactory patency rate in medically unsuccessful cases. For SIDSMA with peritonitis, the endovascular stenting combined with laparoscopic ex- ploration and/or open surgery could be a reasonable option. The difficulty in cannulating the true lumen appeared to be a com- mon technical failure during the endovascular treatment of SIDSMA, and the brachial approach might be helpful. It should be evaluated beforehand whether there are any important or many branches originating from the false lumen. It is supposed to be confirmed prior to deployment of the stent whether the movement route of the guide wire is completely along the true lumen.