title: Failures and Lessons in the Endovascular Treatment of Symptomatic Isolated Dissection of the Superior Mesenteric Artery.
abstract: BACKGROUND
  To discuss failures and lessons in the endovascular treatment of symptomatic isolated dissection of the superior mesenteric artery (SIDSMA).
  
  
  METHODS
  Data from 33 patients with SIDSMA treated between July 2007 and September 2013 were retrospectively collected. The technical failures in and lessons from endovascular management were analyzed in terms of causes and prophylaxis.
  
  
  RESULTS
  Eighteen patients were successfully treated medically, 13 underwent stent placement, 1 underwent a hybrid procedure, and 1 had open fenestration. Full follow-ups (37 ± 21 months) were achieved in 28 patients. Failures to cannulate the true lumen occurred in 8 patients. Among these patients, femoral and brachial approaches were taken in 6 and 2 patients, respectively, and a 2-sided Fisher's exact test revealed no significant differences (P = 0.204). Among the 6 femoral failures, the true lumina were cannulated after conversion to the brachial approach in 3 cases. The perfusion of the distal SMA was not improved until the second stent was distally placed to cover the entire expanded false lumen in 1 case. Numerous branches originating from the false lumen were overlooked in 1 patient and were apparently compromised after stenting. Consequently, the patient died of intestinal necrosis. In a patient with a huge dissecting aneurysm, a stent was misplaced across the false lumen. Fortunately, a remarkable aneurysmal thrombosis formed at 3 months. In a patient who received a hybrid procedure, the stent was occluded at 2 weeks, most likely because the thrombus protruded into the stent.
  
  
  CONCLUSIONS
  Difficulty in cannulating the true lumen is not uncommon in the endovascular treatment of SIDSMA, and the selection of the arterial approach would benefit from being based on the morphology of the SMA arch. The lengths and branches of the involvement of the false lumen should be evaluated beforehand. Covered stents would be a reasonable option for lumina that contain thrombi.
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China. Electronic address: dzh926@126.com.
authors.forename: Zhihui
authors.initials: Z
authors.lastname: Dong
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Junjie
authors.initials: J
authors.lastname: Ning
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China. Electronic address: fu.weiguo@zs-hospital.sh.cn.
authors.forename: Weiguo
authors.initials: W
authors.lastname: Fu
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Daqiao
authors.initials: D
authors.lastname: Guo
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Xin
authors.initials: X
authors.lastname: Xu
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Chen
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Junhao
authors.initials: J
authors.lastname: Jiang
authors.affiliation: Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China.
authors.forename: Yuqi
authors.initials: Y
authors.lastname: Wang
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001027:Aortography / Q000379:methods; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D017538:Mesenteric Artery, Superior / Q000000981:diagnostic imaging / Q000503:physiopathology; D008875:Middle Aged; D011474:Prosthesis Design; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D013152:Splanchnic Circulation; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure