Spontaneous superior mesenteric artery dissection due to idiopathic large vessel vasculitis-report of a case and review of the literature

Abstract

Background

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is defined as superior mesenteric artery (SMA) dissection without the presence of aortic dissection. SISMAD can be asymptomatic or present with acute abdominal pain. Diagnosis is usually by computed tomography angiography (CTA). The exact etiology of SISMAD is not known. Atherosclerosis, hypertension, and high convexity of SMA have been implicated in the development of SISMAD. The majority can be managed by conservative measures. Endovascular stenting is advised when medical management fails. Open surgery has a limited role in this condition. Nonspecific large vessel vasculitis can cause inflammation around the visceral aorta, celiac artery, and SMA, leading to dissection in these vessels. Recognizing mesenteric artery vasculitis as a potential cause of abdominal pain can be challenging. Usually, they show only elevated nonspecific inflammatory markers and no features of systemic vasculitis. Addition of steroids can help to resolve the inflammation and avoid unnecessary intervention.

Methods

We are reporting here of a successful conservative management of a 55-year-old male patient with SISMAD due to isolated large vessel vasculitis involving the SMA. He had no systemic vasculitis, and the CTA showed typical features of SMA vasculitis and dissection. In addition to traditional medical management, he was given an infusion of methyl prednisolone followed by oral steroids.

Results

He had complete relief of symptoms and was discharged after 5 days. Follow-up CTA showed flow in the true lumen though the true lumen showed stenosis.

Conclusions

Isolated mesenteric artery vasculitis without systemic involvement is rarely reported in the literature, which can be the cause for dissection not being recognized. Patients diagnosed with SISMAD should undergo routine checks for inflammatory markers and vasculitis. If the markers are high, steroids may be added to the conservative measures to reduce the inflammation, which can help in remodeling of the SMA and thereby improving the outcome. The majority of patients with SISMAD could be initially managed by medical treatment. Persistent pain and fear of missing the diagnosis of bowel ischemia have been the most important causes for early conversion to intervention. The addition of a short course of steroids, especially for those with elevated inflammatory markers, can help in early resolution of the inflammation with relief of pain. This would help to avoid unnecessary intervention.