自发性孤立性肠系膜上动脉夹层16例诊治分析

目的:探讨自发性孤立性肠系膜上动脉夹层(SISMAD)的临床特点及诊治路径。方法:回顾性分析2012年9月—2017年10月中南大学湘雅医院收治的16例SISMAD患者的临床资料。其中男12例,女4例;年龄47~70岁,中位数年龄56.5岁;其中14例表现为急性上腹痛或脐周痛,另外2例分别因肾结石及胸腺癌复查CT时发现SISMAD。所有患者均经过CTA扫描检查明确诊断。治疗方法包括保守治疗、腔内血管重建术及开放手术治疗。结果:保守治疗成功10例,腔内血管重建术治疗成功5例,1例保守治疗中出现血压下降,怀疑夹层破裂出血急诊行开放动脉修补术,成功重建肠系膜上动脉血运。16例患者全部获得随访,随访时间4~60个月,平均(28±13)个月,在随访期内无腹痛复发及肠道缺血症状。随访CT显示,保守治疗的患者无夹层瘤样扩张,腔内治疗成功的患者支架均通畅。结论:对于SISMAD,当诊断明确、肠系膜血运没有受到夹层严重影响、无腹膜炎征象时,应先给予保守治疗;没有缺血性肠坏死或腹膜炎征象、经保守治疗腹痛症状没有明显缓解时,应考虑采取腔内修复术;若出现夹层破裂出血、肠坏死或腹膜炎征象则应积极采取开放手术治疗。

Diagnosis and treatment of spontaneous isolated superior mesenteric artery dissection: an analysis of 16 patients

Objective: To investigate the clinical characteristics and therapeutic strategies of spontaneous isolated superior mesenteric artery dissection (SISMAD). Methods: The clinical data of 16 patients with SISMAD treated in Xiangya Hospital during September 2012 to October 2017 were retrospectively analyzed. Of the patients, 12 cases were male and 4 cases were female; the median ages ranged from 47 to 70 years, with a median age of 56.5 years; 14 cases presented with acute-onset abdominal pain or periumbilical pain, and 2 patients were accidently diagnosed by review CT scan for kidney stones and thymus cancer, respectively. The diagnosis in all patients was confirmed by CT scan. The treatment methods included conservative treatment, endovascular revascularization and open surgery. Results: Ten patients were successfully treated by conservative treatment, 5 patients were successfully treated with endovascular revascularization, and one patient received successful revascularization of the superior mesenteric artery by open arteriorrhaphy for suspicious dissection rupture/hemorrhage due to blood pressure decrease during conservative treatment. Follow-up was conducted in all of the 16 patients for 4 to 60 months, with an average period of (28±13) months. No recurrent abdominal pain or symptoms of intestinal ischemia was noted during follow-up. The review CT showed that there was no aneurysmal expansion of the dissection in patients who received conservative treatment, and the stents were patent in patients undergoing successful endovascular therapy. Conclusion: For SISMAD, conservative treatment should be the first treatment option in patients with definite diagnosis and no severe influence of dissection on the blood supply of the superior mesenteric artery and no signs of peritonitis; endovascular revascularization should be considered when there are no signs of ischemic intestinal necrosis or peritonitis, but no obvious relief of the abdominal pain after conservative treatment; open surgery should be immediately performed in those with signs of dissection rupture/hemorrhage, intestinal necrosis, or peritonitis.