孤立性肠系膜上动脉夹层保守治疗缓解后再发患者的腔内治疗：附8例报告

目的:探讨症状性孤立性肠系膜上动脉夹层(ISMAD)经保守治疗缓解后再发患者的腔内治疗情况。方法:回顾性整理分析复旦大学附属中山医院2015年7月—2017年6月间8例行腔内治疗的症状性ISMAD一期接受保守治疗症状缓解后再发患者临床资料。结果:8例患者均为男性,平均年龄51.14岁,保守治疗后临床症状再发,临床影像学表现较前均明显加重。5例患者腔内治疗成功,共植入11枚支架;3例患者导丝无法选入远端真腔,腔内治疗失败,其中2例转为保守治疗,1例转为开腹手术。围手术期间5例患者成功接收腔内修复治疗患者临床症状消失。腔内治疗失败者2例出现腹膜刺激症状,其中1例因腹膜炎、多器官功能障碍死亡,另1例接收开放手术治疗恢复远端血供后临床症状消失;1例患者存在持续肠系膜上动脉(SMA)缺血症状,经药物治疗后改善。平均随访时间15个月,腔内修复5例中,2例SMA夹层重构差(假腔部分血栓化,远端真腔有狭窄,分支显影稀疏),1例部分重构,2例完全重构;开放手术治疗者恢复良好,慢性SMA缺血症状消失;保守治疗者仍残留慢性SMA缺血症状,但较入院时改善。结论:症状性ISMAD保守治疗后存在一定的复发概率,复发后病变较初发时明显加重,腔内手术难度和失败率增加,并可造成严重不良后果。

Endovascular treatment of recurrence of symptomatic isolated superior mesenteric artery dissection after initial successful conservative treatment: a report of 8 cases

Objective: To investigate the efficacy of endovascular treatment in patients with recurring symptoms after initial successful conservative treatment for symptomatic isolated superior mesenteric artery dissection (ISMAD).Methods: The clinical data of 8 patients who experienced recurring symptoms after initial successful conservative treatment for symptomatic ISMAD undergoing endovascular treatment between July 2015 to June 2017 in the Department of Vascular Surgery of the Affiliated Zhongshan Hospital of Fudan University were retrospectively analyzed. Results: All the 8 patients were male with an average age of 51.14 years. The clinical symptoms of the patients recurred after conservative treatment, and the CT scan findings were aggravated compared with the initial observation. Endovascular treatment was successfully performed in 5 patients with 11 stents implanted. Endovascular treatment was unsuccessful in 3 patients because the guide wire failed to enter the distal true lumen, of whom, 2 cases were continued with conservative treatment and 1 case was converted to open surgery. Clinical symptoms of the 5 patients with successful endovascular treatment were completely alleviated during the perioperative period. In the 3 failed patients, 2 cases presented with peritoneal stimulation, of whom, 1 case died due to severe peritonitis and multiple organ dysfunction and the clinical symptoms disappeared in another one who underwent open surgery after distal blood supply restoration; 1 case presented with persistent symptoms of superior mesenteric artery (SMA) ischemia and improved after medical treatment. The median follow-up time was 15 months. In the 5 patients with endovascular treatment, 2 cases had unsatisfactory remodeling of the SMA (partial thrombolization of the false lumen, stenosis in the distal true lumen and sparse display of the branches), 1 case had partial remodeling and 2 cases had complete remodeling. The patient undergoing open surgery recovered well and the symptoms of chronic SMA ischemia disappeared. The symptoms of chronic SMA ischemia were still observed in the patients undergoing conservative treatment bur were markedly relieved compared with those at admission. Conclusion: Symptomatic ISMAD has certain risk of recurrence after initial successful conservative treatment. After recurrence, the disease may markedly worsen compared to the first onset, and the difficulty and failure rate of endovascular intervention are increased, which may cause severe adverse consequences.