Management Of Dissection Of The Superior Mesenteric Artery

Objective: Discuss the diagnosis and management of patients with symptomatic dissection of the superior mesenteric artery (SMA).
Methods: Two patients presented with a 1-2 day history of severe abdominal pain and radiographic evidence of dissection of the SMA. The first patient was a 75 year old male who underwent MRA at an outside hospital documenting dissection of the SMA. He had previously experienced similar pain 15 years prior resulting in a nontherapeutic laparotomy. There was no significant history of trauma. The second patient was transferred from an outside hospital after undergoing a CT scan which was initially interpreted as “acute thrombus within the SMA.” Further evaluation of the CT scan as well as subsequent duplex ultrasound confirmed the diagnosis of dissection. He had no prior episodes of pain, but worked as a laborer with a pneumatic jackhammer-type device that caused repetitive motion trauma to his abdomen.
Results: After initial treatment with heparin and bowel rest, both patients were transitioned to coumadin, with gradual advancement of diet. Within 5-7 days of the onset of symptoms, both were discharged with minimal pain, tolerating a normal diet, with a target INR of 2-3. Clinical followup at one year (Patient #1), and one month (Patient #2) showed complete resolution of symptoms. Coumadin therapy was continued for 6 months. At 6 month (CT scan) and 12 month (duplex ultrasound) followup, Patient #1 had complete radiographic resolution of the dissection.
Conclusion: Dissection of the SMA can be difficult to diagnose, and can be managed nonoperatively. Treatment with anticoagulants with close clinical and radiographic followup can obviate the need for surgical intervention, and result in suitable long term outcomes.