Clinical features of isolated superior mesenteric artery dissection in the emergency department: a single center retrospective study

Isolated superior mesenteric artery dissection (ISMAD) is a relatively rare disease and often lacks specificity in its clinical presentation, diagnosing it in emergency departments quickly and accurately is a challenge. The study was conducted to understand the basic characteristics of ISMAD including age of onset, risk factors, gender difference and whether D-dimer can be used as a biomarker for its detection. We retrospectively analyzed patients with ISMAD admitted to the emergency department of Xiangya Hospital of Central South University from September 1, 2017 to September 30, 2020. The data included the patient’s basic information and the first laboratory test results after admission, including routine blood, liver function, renal function and coagulation function tests. Statistical analysis of results was done using GraphPad Prism 5. There were a total of 17 (15 male and 2 female) patients with a mean age of 52.53 ± 7.11 years diagnosed with ISMAD. Out of these, 7 (41%) patients had history of hypertension, 7 (41%) had history of smoking and/or alcohol intake, and almost all patients experienced significant abdominal pain and fullness. Four patients (24%) were initially misdiagnosed. The laboratory test results of renal, liver function tests and myocardial enzymology were in their normal ranges. In coagulation results, the positive rates of fibrinogen degradation products (FDP) and D-dimer were 29% and 35%, respectively. We compared these ISMAD results with our previous results for acute aortic dissection (AAD). D-dimer and FDP levels were lower in the ISMAD than in the AAD patients (P = 0.0004, P = 0.0325, respectively), and negative rates of D-dimer and FDP in ISMAD (65%, 71%) were higher than in AAD patients (14%, 24%) (P < 0.0001, P = 0.0003, respectively). In our study, ISMAD mostly occurred in middle-aged male patients with known hypertension or active smoking status. Misdiagnosis was common (24% of cases). Since D-dimer and FDP levels proved to be of limited diagnostic value, an abdominal Computed Tomography (CT) scan should be conducted in patients with unclear abdominal pain at an early stage of their diagnostic workup.

Abdominal pain; Isolated superior mesenteric artery dissection; D-dimer; Fibrinogen degradation product

[1] Luan JY, Guan X, Li X, Wang CM, Li TR, Zhang L, et al. Isolated superior mesenteric artery dissection in China. Journal of Vascular Surgery. 2016; 63: 530-536.

[2] Bauersfeld SR. Dissecting aneurysm of the aorta; a presentation of 15 cases and a review of the recent literature. Annals of Internal Medicine. 1974; 26: 873-889.

[3] Jia Z, Tu J, Jiang G. The classification and management strategy of spontaneous isolated superior mesenteric artery dissection. Korean Circulation Journal. 2017; 47: 425.

[4] Wu Z, Yi J, Xu H, Guo W, Wang L, Chen D, et al. The significance of the angle between superior mesenteric artery and aorta in spontaneous isolated superior mesenteric artery dissection. Annals of Vascular Surgery. 2017; 45: 117-126.

[5] Karaolanis G, Antonopoulos C, Tsilimigras DI, Moris D, Moulakakis K. Spontaneous isolated superior mesenteric artery dissection: systematic review and meta-analysis. Vascular. 2019; 27: 324-337.

[6] Park YJ, Park C, Park KB, Roh YN, Kim D, Kim Y. Inference from clinical and fluid dynamic studies about underlying cause of spontaneous isolated superior mesenteric artery dissection. Journal of Vascular Surgery. 2011; 53: 80-86.

[7] Park YJ, Park KB, Kim D, Do YS, Kim D, Kim Y. Natural history of spontaneous isolated superior mesenteric artery dissection derived from follow-up after conservative treatment. Journal of Vascular Surgery. 2011; 54: 1727-1733.

[8] Tanaka Y, Tada H, Takeda Y, Iino K, Hayashi K, Takemura H, et al. Spontaneous isolated superior mesenteric artery dissection requiring emergent surgery. Internal Medicine. 2018; 57: 2681-2684.

[9] Olson JD. D-dimer: an overview of hemostasis and fibrinolysis, assays, and clinical applications. Advances in Clinical Chemistry. 2015; 69: 1-46.

[10] Nazerian P, Mueller C, Soeiro ADM, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation. 2019; 137: 250-258.

[11] Zhang F, Li X, Zhang J, Wang A, Zhou L, Li X. Levels of D-dimer, fibrinogen, and fibrinogen degradation product in patients with acute chest pain. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2018; 44: 1209-13.

[12] Ullah W, Mukhtar M, Abdullah HM, Ur Rashid M, Ahmad A, Hurairah A, et al. Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circulation Journal. 2019; 49: 400-418.

[13] Zhang X, Xiang P, Yang Y, Chen J, Guan J, Liu M, et al. Correlation between computed tomography features and clinical presentation and management of isolated superior mesenteric artery dissection. European Journal of Vascular and Endovascular Surgery. 2018; 56: 911-917.

[14] Suzuki S, Furui S, Kohtake H, Sakamoto T, Yamasaki M, Furukawa A, et al. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdominal Imaging. 2004; 29: 153-157.

[15] Cho BS, Lee MS, Lee MK, Choi YJ, Kim CN, Kang YJ, et al. Treatment guidelines for isolated dissection of the superior mesenteric artery based on follow-up CT findings. European Journal of Vascular and Endovascular Surgery. 2011; 41: 780-785.

[16] Bima P, Pivetta E, Nazerian P, Toyofuku M, Gorla R, Bossone E, et al. Systematic review of aortic dissection detection risk score plus D-dimer for diagnostic rule-out of suspected acute aortic syndromes. Academic Emergency Medicine. 2020; 27: 1013-1027.

[17] Sato N, Takahashi H, Shibata A. Fibrinogen/fibrin degradation products and D-dimer in clinical practice: interpretation of discrepant results. American Journal of Hematology. 1995; 48: 168-174.

[18] Tanaka Y, Yoshimuta T, Kimura K, Iino K, Tamura Y, Sakata K, et al. Clinical characteristics of spontaneous isolated visceral artery dissection. Journal of Vascular Surgery. 2018; 67: 1127-1133.