Treatment of Spontaneous Isolated Superior Mesenteric Artery Dissection　– Reply –

We thank Dr Jia and his colleagues for their interest in our study.¹ Their opinion is that the treatment decision for spontaneous isolated superior mesenteric artery (SMA) dissection should be based on symptom severity and that endovascular treatment should be considered first for patients with severe intestinal ischemia or aneurysm. We read Dr Jia’s comment with interest.

However, we would like to point out that the individual differences regarding pain from intestinal ischemic symptoms are vast and the correlation between the degree of pain and extent of ischemia is unknown. The severity of symptoms may not always match the severity of intestinal ischemia in spontaneous isolated SMA dissection. Furthermore, conservative treatment is possible even in the presence of abdominal pain if serious mesenteric ischemia (intestinal necrosis) is not detected in various tests.^2–7 Application of revascularization based only on symptoms could be overtreatment. In addition, no single modality has been established to diagnose intestinal ischemia, which should be evaluated comprehensively based on vital signs, and the results of physical examinations, blood tests, blood gas analysis, and dynamic-enhanced computed tomographic examinations.

Endovascular treatment of spontaneous isolated SMA dissection is not contraindicated. However, in case of suspected intestinal necrosis, direct evaluation of the intestinal condition is paramount. If laparotomy is performed, bypass surgery can be performed at the same time. Endovascular treatment that includes stent placement is less invasive, but reocclusion or blockage of normal branches can also occur.⁸ Moreover, the long-term results of endovascular treatment are unknown. Thus, it is not appropriate as a first-choice treatment of spontaneous isolated SMA dissection.

Conflict of Interest

None.

• Koichi Tomita, MD
• Hideaki Obara, MD, PhD
• Kentaro Matsubara, MD, PhD
• Naoki Fujimura, MD, PhD
• Yuko Kitagawa, MD, PhD
• Department of Surgery, Keio University School of Medicine, Tokyo, Japan

(Released online July 8, 2016)

References

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