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Wang B, Pan J, Xu Y, Qiu X, Ding Z, Li D, Zhang H, Qiu C, Wu Z. Long-term Outcomes of Endovascular Versus Medical Treatment for Isolated Superior Mesenteric Artery Dissection: A 10-Year Retrospective Study. Cardiovasc Intervent Radiol 2025; 48:593-602. [PMID: 40011282 DOI: 10.1007/s00270-025-03985-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 02/03/2025] [Indexed: 02/28/2025]
Abstract
PURPOSE Isolated superior mesenteric artery dissection (IMAD) is increasing in prevalence. Both endovascular and medical treatments are frequently used, but based on studies with relatively small sample sizes and limited follow-up. This article aims to compare the long-term outcomes of medical treatment versus endovascular treatment for isolated superior mesenteric artery dissection. MATERIALS AND METHODS Patients who were treated for IMAD at our institution between June 2009 and March 2019 were retrospectively investigated. The primary outcomes were freedom from adverse events and the complete remodeling rate. Propensity score matching (PSM) was used to align baseline data, ensuring comparability between the two groups. RESULTS The study cohort comprises 226 patients with IMAD. The mean follow-up duration was 74.9 ± 28.3 months. One hundred and ninety-one patients (84.5%) received endovascular treatment, and 35 (15.5%) were treated medically. The freedom from adverse event rate was 91.8% in the endovascular group and 79.6% in the medical group at 60 months (p < 0.05) and 87.6% and 74.6%, at 120 months (p < 0.05). The complete remodeling rate was 69.3% in the endovascular group and 29.0% in the medical group (p < 0.01) at 60 months and 70.8% and 37.8%, respectively, at 120 months (p < 0.01). After propensity score matching, the freedom from adverse event rate was 91.9% versus 85.6% (p < 0.05) at 60 months and 87.8% versus 78.6% (p < 0.05) at 120 months. The complete remodeling rate was 69.8% versus 43.0% (p < 0.01) at 60 months and 71.2% in the endovascular group versus 43.0%. CONCLUSION The freedom from adverse event and complete remodeling rates were higher in patients with IMAD who received endovascular treatment than in those who were treated medically during long-term follow-up. LEVEL OF EVIDENCE Level 3, non-randomized controlled cohort/follow-up study.
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Affiliation(s)
- Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China
| | - Yiting Xu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China
| | - Xuxian Qiu
- Department of Vascular Nursing, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenwei Ding
- Department of Surgery, Affiliated Xiaoshan Hospital, Hangzhou Normal University, No.728 North Yucai Road, Hangzhou, China
| | - Donlin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China.
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Rd, Hangzhou, 310003, China.
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Jiang X, Chen D, Meng Q, Liu X, Liang L, He B, Ding W. The value evaluation of Nomogram prediction model based on CTA imaging features for selecting treatment methods for isolated superior mesenteric artery dissection. BMC Med Imaging 2024; 24:267. [PMID: 39375582 PMCID: PMC11460108 DOI: 10.1186/s12880-024-01438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 09/23/2024] [Indexed: 10/09/2024] Open
Abstract
OBJECTIVE To evaluate value of Nomogram prediction model based on CTA imaging features for selecting treatment methods for isolated superior mesenteric artery dissection (ISMAD). METHODS Symptomatic ISMAD patients were randomly divided into a training set and a validation set in a 7:3 ratio. In the training set, relevant risk factors for conservative treatment failure in ISMAD patients were analyzed, and a Nomogram prediction model for treatment outcome of ISMAD was constructed with risk factors. The predictive value of the model was evaluated. RESULTS Low true lumen residual ratio (TLRR), long dissection length, and large arterial angle (superior mesenteric artery [SMA]/abdominal aorta [AA]) were identified as independent high-risk factors for conservative treatment failure (P < 0.05). The receiver operating characteristic curve (ROC) results showed that the area under curve (AUC) of Nomogram prediction model was 0.826 (95% CI: 0.740-0.912), indicating good discrimination. The Hosmer-Lemeshow goodness-of-fit test showed good consistency between the predicted curve and the ideal curve of the Nomogram prediction model. The decision curve analysis (DCA) analysis results showed that when probability threshold for the occurrence of conservative treatment failure predicted was 0.05-0.98, patients could obtain more net benefits. Similar results were obtained for the predictive value in the validation set. CONCLUSION Low TLRR, long dissection length, and large arterial angle (SMA/AA) are independent high-risk factors for conservative treatment failure in ISMAD. The Nomogram model constructed with independent high-risk factors has good clinical effectiveness in predicting the failure.
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Affiliation(s)
- Xiaodong Jiang
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China
| | - Dongjian Chen
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China
| | - Qingbin Meng
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China
| | - Xiaokan Liu
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China
| | - Li Liang
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China
| | - Bosheng He
- Department of Department of Imaging Medicine, Second Affiliated Hospital of Nantong University, Nantong, 226014, Jiangsu, China.
| | - Wenbin Ding
- Department of Interventional Radiology, Second Affiliated Hospital of Nantong University, No.666 Shengli Road, Nantong, Jiangsu, 226014, Jiangsu, China.
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Vuong NM, Bui VDA, Nguyen DT, Nguyen D, Jain N, Vervoort D, Nguyen TH, Tran LMB. Spontaneous isolated superior mesenteric artery dissection: an investigative case report. Radiol Case Rep 2024; 19:4117-4121. [PMID: 39114864 PMCID: PMC11305183 DOI: 10.1016/j.radcr.2024.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 08/10/2024] Open
Abstract
Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare cause of acute abdominal pain, but could potentially be fatal to patients, and should be recognized soon in the emergency department after excluding other common causes. Computed tomography (CT) is the modality of choice for initial diagnosis and follow-up. Currently there is no evidence-based guidelines for managing SISMAD. A 58-year-old man being suspected of a mesenteric artery dissection was referred to our emergergy department. The patient was monitored, treated conservatively with anticoagulant and discharged after 3 days. Follow-up CT scans at 6 month, 1 year and 1 year and a half post discharge showed a partially occluded false lumen, the diameter of true lumen had increased in size and no signs of bowel ischemia. SISMAD should be considered as part of differential diagnoses when patients in their fifth to seventh decades of life present with acute abdominal pain. Treatment includes conservative management, percutaneous endovascular interventions, or surgery, but most patients can be managed conservatively.
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Affiliation(s)
- Ngoc-Minh Vuong
- Department of Adult Cardiac Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Vinh Duc An Bui
- Department of Thoracic and Cardiovascular Surgery, Hue Central Hospital, Hue City, Vietnam
| | - Duy Thanh Nguyen
- Department of Radiology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Dang Nguyen
- Massachusetts General Hospital, Corrigan Minehan Heart Center, Harvard Medical School, Boston, MA, USA
| | | | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Truong Hung Nguyen
- Department of Adult Cardiac Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Thoracic and Cardiovascular Surgery Department, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh city, Vietnam
| | - Luan Minh Bao Tran
- Thoracic and Cardiovascular Surgery Department, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh city, Vietnam
- Department of Thoracic and Vascular Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
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Ye M, Zhou Q, Wu J, Zhang Z, Li B, Zheng T, Shao G. Conservative Versus Endovascular Treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection: A Clinical and Imaging Follow-up Study. J Endovasc Ther 2024; 31:840-852. [PMID: 37026460 DOI: 10.1177/15266028231163733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
PURPOSE Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disease, the treatment strategies for which remain debated. This retrospective study aimed to compare the outcomes of conservative and endovascular treatments in patients with SISMAD. MATERIALS AND METHODS Fifty-eight patients with SISMAD confirmed by computed tomography angiography admitted to our hospital between November 2017 and May 2021 and received confirmed conservative (n=43) or endovascular (n=15) treatment. The patient demographics, imaging analysis, and follow-up results were analyzed and compared. RESULTS The cohort included 54 males and 4 females with a mean age of 52 years. Abdominal pain was the major complaint (49/58, 84.5%), followed by chest pain (2/58, 3.4%). The mean follow-up was 9.1±7.9 months. The 2 main Sakamoto types were type III (27/58, 46.6%) and type IV (16/58, 27.6%). Most patients in both groups had angle 1 (aortomesenteric angle) and angle 2 (superior mesenteric artery [SMA] course) of over 80°. About 67.3% of patients had long length of dissection (>60 mm). The median distance between the SMA root and the dissection entry site was 1.5 cm, mostly (84.5% of the patients) in the curved segment of the SMA. Telephone follow-ups found that most patients survived pain-free, and none underwent intestinal resection. Only 4 patients, 2 in each group, had recurrent abdominal pain during follow-up and received stenting treatment to achieve complete vascular remodeling. Importantly, we found that the conservative and endovascular therapies achieved similar high remodeling rates (94% and 100%, respectively; p=0.335). The conservative group achieved satisfying vascular remodeling (partial, 35%; complete, 59%), making it as safe and effective a treatment as endovascular therapy. CONCLUSIONS Initial conservative management is safe and effective in patients with SISMAD. A high technical success rate and favorable short-term outcomes were associated with endovascular procedures as secondary interventions. It would be helpful to conduct large-scale, prospective, randomized controlled trials with long-term follow-up for SISMAD. CLINICAL IMPACT 1. This research provided more detail clinical information, such as evaluation of abdominal pain and measurements of SMA angles, which is all relevant to treatment. 2. What's more, the most surprising results of follow-up part shown that conservative treatment could reached the remodeling rate as high as endovascular treatment, which was relatively low in other studies. It helps us share our treatment experience with clinicians. 3. In addition, we get limited knowledge about this rare disease, it's encouraging us to do more researches based on the results we had.
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Affiliation(s)
- Mengmeng Ye
- Ningbo University of Medical School, Ningbo, China
| | - Qingyun Zhou
- Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Jiacheng Wu
- Ningbo University of Medical School, Ningbo, China
| | - Zheng Zhang
- Ningbo University of Medical School, Ningbo, China
| | - Bo Li
- Ningbo University of Medical School, Ningbo, China
| | - Tao Zheng
- Ningbo University of Medical School, Ningbo, China
| | - Guofeng Shao
- Ningbo University of Medical School, Ningbo, China
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Wang J, Luan F, Bai Z, Liu Z. Systematic review and meta-analysis of current evidence in endograft therapy for spontaneous isolated superior mesenteric artery dissection. Updates Surg 2024; 76:1169-1181. [PMID: 38546969 DOI: 10.1007/s13304-024-01821-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/04/2024] [Indexed: 08/24/2024]
Abstract
The role of endovascular stent therapy (EST) in the treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD) has gained momentum in recent years but remains controversial. We gathered research examining the advantages and disadvantages of EST for SISMAD patients. Primary outcomes involved both immediate and long-term results. Random or fixed effect models were used for effect size (ES) calculation with 95% confidence interval (CI) based on 50% heterogeneity threshold. Our analysis incorporated data from 21 studies including 611 SISMAD cases treated by EST. Our findings show a complication rate of approximately 1% following EST (95%CI 0.01-0.02, I2 = 0%, P = 0.97), with a bare minimum mortality rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P > 0.05) and a reintervention rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P = 0.89). We also found technique success and symptom resolution approaching 94% and 99%, respectively, in the immediate postoperative phase. In the long run, we observed a recurrence of symptoms at 3% (95%CI 0.00-0.06, I2 = 58.6%, P < 0.01), creation of new dissections at 1% (95%CI 0.00-0.02, I2 = 0%, P = 0.73), aneurysm progression at 2% (95%CI 0.00-0.03, I2 = 42.7%, P = 0.12), reintervention due to complications at 3% (95%CI 0.00-0.05, I2 = 0%, P = 0.43) and stenotic stents at 12% (95%CI 0.04-0.23, I2 = 77.5%, P < 0.01). Nevertheless, high levels of stent patency 98% (95% CI 0.97-1.00, I2 = 0%, P = 0.51) and complete remodeling 88% (95% CI 0.82-0.94, I2 = 65.5%, P < 0.05) were observed postoperatively. Overall, EST presents minimal complications and promising long-term outcomes for SISMAD, although the prevalence of stent stenosis requires further attention.
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Affiliation(s)
- Jian Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, 310051, Zhejiang, China
| | - Fengming Luan
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, 310051, Zhejiang, China
| | - Zhixuan Bai
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, 310051, Zhejiang, China
| | - Zhengjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, 310051, Zhejiang, China.
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Zhang B, Shen Y, Jin L, Wang J. Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection. Langenbecks Arch Surg 2024; 409:215. [PMID: 39008150 DOI: 10.1007/s00423-024-03406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable. METHODS A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold. RESULTS 9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion. CONCLUSION EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.
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Affiliation(s)
- Baoyou Zhang
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Yuexin Shen
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Ling Jin
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Jian Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, Zhejiang, 310051, China.
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Knarr J, Augustin AM, Hartung V, Krajinovic K, Kickuth R. Management of isolated dissection of the superior mesenteric artery. ROFO-FORTSCHR RONTG 2024; 196:726-734. [PMID: 38176435 DOI: 10.1055/a-2221-3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Jonas Knarr
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Anne Marie Augustin
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Viktor Hartung
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | | | - Ralph Kickuth
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
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Qi X, Tang B, Zhang H, Fu J, Chen Y, Luo H. Midterm Results of the Conservative, Bare Stent, and Bare Stent-Assisted Coiling Treatments for Symptomatic Isolated Superior Mesenteric Artery Dissection. Ann Vasc Surg 2023; 96:232-240. [PMID: 37169250 DOI: 10.1016/j.avsg.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND We compared the early and midterm (31, 3-63 months) outcomes of conservative treatment, bare stent treatment (BST), and bare stent-assisted coiling treatment (BSACT) to determine the most effective treatment for patients with symptomatic isolated superior mesenteric artery dissection (SISMAD). METHODS Consecutive patients with SISMAD admitted to the study hospital between January 2016 and December 2021 were included in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed. RESULTS A total of 121 patients were included in the study (23 with conservative treatment, 42 with BST, and 56 with BSACT). Symptoms were relieved in 91.3% of conservative patients, whereas all patients (100%) with BST or BSACT had symptom relief (P = 0.035). There was no significant difference in the length of hospital stay between the 2 endovascular treatments (P = 0.9051), but hospital stay was significantly shorter compared to conservative treatment (P < 0.0001). The cumulative rate of complete remodeling was 100% for BSACT versus 46.3% for BST (P < 0.0001) versus 42.9% for conservative patients (P < 0.0001). There were no significant differences between the last 2 groups (P = 0.3925). The prevalence of adverse events for abdominal pain recurrence and aneurysm formation was also significantly lower in the BSACT group at follow-up. CONCLUSIONS BSACT for SISMAD has a preferable early outcome. The cumulative complete remodeling rate and the event-free survival rate are satisfactory at midterm follow-up. BSACT is an effective approach for SISMAD.
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Affiliation(s)
- Xiaotong Qi
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Fu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Wu H, Tang B, Zhang H, Ran K, Chen Y, Luo H. Endovascular treatment of systematic isolated mesenteric artery dissection with a patent false lumen: Bare stents alone versus stent-assisted coiling. Sci Prog 2023; 106:368504231214959. [PMID: 38116780 PMCID: PMC10664444 DOI: 10.1177/00368504231214959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Bare stent treatment and bare stent-assisted coiling treatment have not been directly compared in symptomatic isolated superior mesenteric artery dissection with a patent false lumen. Thus, we compared the early and mid-term outcomes of bare stent treatment and bare stent-assisted coiling treatment to determine the most effective remedy for patients with this condition. METHODS Consecutive patients diagnosed with systematic isolated superior mesenteric artery dissection with a patent false lumen admitted to the study hospital between January 2016 and December 2021 were enrolled in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed. RESULTS A total of 85 patients (83 men) were included. 34.1% (n = 29) adopted bare stent treatment and 65.9% (n = 56) underwent bare stent-assisted coiling treatment. The symptoms were relieved in all patients (100%) with bare stent treatment and bare stent-assisted coiling treatment. There was no significant difference in the length of hospital stay between the two endovascular treatments (p = 0.354). The cumulative complete remodeling rate was 100% in bare stent-assisted coiling treatment vs. 70.4% in bare stent treatment (p < 0.0001). The prevalence of adverse events for abdominal pain recurrence (none in BST or bare stent-assisted coiling treatment), and formation of the aneurysm (two in bare stent treatment, and none in bare stent-assisted coiling treatment) showed no significant difference at follow-up. CONCLUSION Both bare stent treatment and bare stent-assisted coiling treatment for symptomatic isolated superior mesenteric artery dissection with a patent false lumen have the same satisfying early outcome. In the midterm follow-up, bare stent-assisted coiling treatment has the higher cumulative complete remodeling rate which could be prioritized to treat this condition.
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Affiliation(s)
- Huan Wu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Ran
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Reis PEO, Ristow AV. When and how to treat isolated visceral artery dissections - protocol proposal. J Vasc Bras 2023; 22:e20230066. [PMID: 37576733 PMCID: PMC10421573 DOI: 10.1590/1677-5449.202300662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/19/2023] [Indexed: 08/15/2023] Open
Affiliation(s)
- Paulo Eduardo Ocke Reis
- Universidade Federal Fluminense – UFF, Rio de Janeiro, RJ, Brasil.
- Clínica Vascular Ocke Reis, Rio de Janeiro, RJ, Brasil.
| | - Arno Von Ristow
- Academia Nacional de Medicina, Rio de Janeiro, RJ, Brasil.
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-Rio, Rio de Janeiro, RJ, Brasil.
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Chen X, Xu L, Xu Z, Fan Z, Huang J, Li J, Zhang Z, Lin C. Analysis of safety and efficacy of conservative treatment and endovascular treatment in patients with spontaneous isolated mesenteric artery dissection. Front Surg 2023; 9:944079. [PMID: 36684275 PMCID: PMC9852537 DOI: 10.3389/fsurg.2022.944079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/04/2022] [Indexed: 01/09/2023] Open
Abstract
Background Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease with abdominal pain as the main clinical manifestation, but its optimal treatment strategy has not yet been determined. Based on this, this study explored a safe and effective treatment method by analyzing and comparing the safety and efficacy of conservative treatment and endovascular treatment in SISMAD patients. Methods The clinical and imaging data and treatment effects of 85 patients with SISMAD who were admitted to the General Surgery Department of the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from January 2008 to December 2020 were retrospectively analyzed. Two groups were treated, the data of patients in conservative treatment group and endovascular treatment group were analyzed, and a safe and effective treatment method for SISMAD was discussed. Results The mean follow-up time was 36.58 ± 25.03 months. The success rate of interventional operation was 86.11% (31/36), and the operation failed because the guide wire could not enter the true lumen in four cases. One case was terminated due to poor physical condition of the patient who could not tolerate surgery. There were no significant differences in gender, body mass index, clinical manifestations, and past history between conservative treatment and endovascular treatment (P > 0.05), but in age, superior mesenteric artery-distal aorta angle, distance from the superior mesenteric artery opening to dissection, dissection length, and true lumen stenosis. There was a statistical difference between the two groups in the rate and Yun classification (P < 0.05). Conclusions Conservative treatment is effective for most symptomatic SISMAD patients, and close monitoring is required; for patients with persistent symptoms and severe true lumen stenosis (especially Yun classification type III), endovascular treatment is preferred; endovascular treatment is mainly based on endovascular bare stent placement. Patients receiving stent implantation may suffer from stent stenosis or occlusion in the long term, and most of them have no obvious symptoms of intestinal ischemia; the prognosis is good.
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Affiliation(s)
- Xiaobin Chen
- Department of General Surgery, Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China,Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Lei Xu
- Department of General Surgery, Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China,Correspondence: Chen Lin ZaiZhong Zhang
| | - Zhaojun Xu
- Graduate School, Qinghai University, Xining, China
| | - Zuyou Fan
- Department of General Surgery, Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Jianqiang Huang
- Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Junjie Li
- Department of General Surgery, Dongfang Hospital of Xiamen University, School of Medicine, Xiamen University, Fuzhou, China
| | - ZaiZhong Zhang
- Department of General Surgery, Dongfang Hospital of Xiamen University, School of Medicine, Xiamen University, Fuzhou, China,Correspondence: Chen Lin ZaiZhong Zhang
| | - Chen Lin
- Department of General Surgery, Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China,Department of General Surgery, 900th Hospital of Joint Logistics Support Force, Fuzhou, China,Department of General Surgery, Dongfang Hospital of Xiamen University, School of Medicine, Xiamen University, Fuzhou, China,Correspondence: Chen Lin ZaiZhong Zhang
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Sun J, Wang L, Que Y, Li H, Wu K, Yuan D, Xiong J, Wang W. Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: a Multicentre Experience. Eur J Vasc Endovasc Surg 2022; 64:507-514. [PMID: 36038050 DOI: 10.1016/j.ejvs.2022.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 08/13/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Isolated mesenteric artery dissection (IMAD) is an increasingly diagnosed disease. However, multicentre studies to support clinical decision making are limited. This multicentre retrospective study aimed to investigate the characteristics, treatment options, and outcomes of IMAD. METHODS Data from consecutively enrolled patients with IMAD between October 2009 and May 2021 at three hospitals were collected retrospectively. One hundred and ninety uncomplicated symptomatic IMAD patients were divided into two groups: conservative (n = 141) and operative (n = 49). The costs, length of hospital stay, factors affecting outcomes, symptom relief, and complete remodelling of superior mesenteric artery (SMA) were analysed between the two groups. RESULTS Compared with patients who received operative treatment, patients receiving conservative treatment had shorter hospital stays (8.2 ± 4.6 vs. 11.9 ± 6.4 day, p < .020) and lower hospital costs (14 900 ± 1 048 vs. 60 400 ± 7 733 yuan, p < .001). In contrast, patients receiving operative treatment showed higher complete SMA remodelling (95.9% vs. 51.8%, p < .001). The cumulative rate of symptom relief was similar between the groups (p = .71). The rates were 78% vs. 79%, 87% vs. 87%, 89% vs. 87% at one, 12, and 60 months in the conservative and operative groups, respectively. Further subgroup analysis showed that endovascular treatment of IMAD had the advantage of shorter hospital stays than open surgery (10.7 ± 4.5 vs. 25.2 ± 9.4 days, p < .010). Univariable analysis showed that Sakamoto type II was associated with failed complete SMA remodelling (odds ratio 0.34; 95% confidence intervals 0.13 - 0.91; p = .031). CONCLUSION IMAD patients achieved good long term survival and symptom relief regardless of the treatment. Sakamoto type II IMAD is a risk factor for failed complete SMA remodelling. Although endovascular treatment provided a higher rate of complete SMA remodelling, the conservative group had statistically significantly shorter hospital stays, lower hospital costs, and similar cumulative rates of symptom relief. Therefore, this study supports conservative treatment as the main strategy for uncomplicated symptomatic IMAD patients.
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Affiliation(s)
- Jinjian Sun
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lei Wang
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yifu Que
- Department of Vascular and Endovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, Beijing, China
| | - Hou Li
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kemin Wu
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, the First Medical Centre of Chinese PLA General Hospital, Beijing, China; Department of Vascular and Endovascular Surgery, Hainan Hospital, Chinese PLA General Hospital, Sanya, Hainan, China.
| | - Wei Wang
- Department of General &Vascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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13
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Zhou F, Zheng Z, Pan Y. General features, management strategies, and outcomes of symptomatic spontaneous isolated celiac artery dissection. Front Surg 2022; 9:972276. [PMID: 36338634 PMCID: PMC9635887 DOI: 10.3389/fsurg.2022.972276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives Spontaneous isolated celiac artery dissection (SICAD) is a rare condition that has not been fully investigated and reported, and very little is known regarding its prognosis and management. Here, we aimed to provide more evidence on the management strategy and outcome for symptomatic SICAD based on the experience of a single center. Methods From January 2018 to December 2021, a total of consecutive 51 patients with symptomatic SICAD were retrospectively included in this study. These patients had been selectively treated with conservative treatment (n = 31) or endovascular treatment (n = 20). Baseline data, imaging findings, treatment strategy, outcomes, and follow-up data have been described and analyzed. Results The mean age of the patients was 53.2 ± 9.6 years, 44 (86.3%) were male, and 36 (70.6%) had hypertension. The median length of stay was 10.0 days. The complete remission rate was 92.2% on discharge. The median follow-up time was 21.0 months. A secondary intervention was required for two patients during follow-up in the conservative group, wherein one underwent a stent placement three months after discharge because of progression of symptoms and extension of dissection, and the other required intervention one month after discharge because of symptomatic progression. No secondary intervention was required in the endovascular group. Occasional and mild relapse of symptoms occurred in two patients in both the conservative and endovascular groups, with no secondary intervention. The length of dissection (25.5 ± 11.8 mm vs. 19.1 ± 7.4 mm, P = 0.022) and complete remodeling rate (85.7% vs. 15.4%, P < 0.001) in the endovascular group were greater than that in the conservative group. Conclusion Patients with symptomatic SICAD who were selectively treated with conservative treatment or endovascular treatment had satisfactory early and medium-term outcomes. Endovascular treatment showed significant advantages in the complete remodeling of the celiac artery and presented with a lower rate of secondary intervention. Moreover, it was found to be a safe and effective remedy for failed conservative treatment.
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Huang X, Li G, Zhang X, Chen Z, Xu M, Sun Y. Natural Course and Treatment of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection with Total True Lumen Occlusion. Vasc Endovascular Surg 2022; 57:41-47. [PMID: 36171181 DOI: 10.1177/15385744221130836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We retrospectively investigated the association between the imaging features of spontaneous isolated superior mesenteric artery dissection (SISMAD) accompanied by total true lumen occlusion and the clinical symptoms to identify the patients at high risk and establish personalized therapeutic options. METHODS Among 261 patients with SISMAD, we selected 37 with Yun's type III dissection; 35 patients underwent successful conservative management and 2 patients underwent exploratory laparotomy. After discharge, all patients were periodically followed up on an outpatient basis. We recorded patients' general condition, symptoms, time until symptom relief, imaging findings and follow-up results. RESULTS All patients experienced acute abdominal pain prior to admission, with an onset time of 29.95 ± 24.66 hours. The mean time until relief of abdominal pain in patients who received conservative treatment was 42.17 ± 38.09 hours. Correlation analysis revealed no correlation between the length of dissection or of the occluded segment and abdominal pain intensity. Pain scores were lower and time until pain relief was shorter in patients with a definite arc of Riolan (AOR) on admission than in those without an AOR. No collateral circulation was observed in the two patients who underwent exploratory laparotomy, and distal intestinal perfusion was poor in these cases. Complete and partial remodeling of the superior mesenteric artery (SMA) was observed in 6 and 16 patients, respectively at the 12-month follow-up. Although the SMA remained occluded in 12 patients, abundant collateral circulation was detected. Three patients were lost to follow-up. CONCLUSION This study highlights that conservative treatment should be attempted as first-line therapy in most patients with Yun's type III SISMAD. Complete AOR can contribute to remission of clinical symptoms during the acute stage. Poor distal blood flow of occluded vessels may serve as an important indicator for identification of patients at high risk of ischemic intestinal necrosis.
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Affiliation(s)
- Xianchen Huang
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Guanqiang Li
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Xicheng Zhang
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
| | - Zhaolei Chen
- Department of Vascular Surgery, 370089Yangzhou University Affiliated Northern Jiangsu People's Hospital, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Miao Xu
- Department of Vascular Surgery, 370089Yangzhou University Affiliated Northern Jiangsu People's Hospital, The Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuan Sun
- Department of Interventional Radiology and Vascular Surgery, 606537Dushu Lake Hospital Affiliated to Soochow University, Soochow, China
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15
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Zhang Y, Zhou JY, Liu J, Bai C. Diagnosis of spontaneous isolated superior mesenteric artery dissection with ultrasound: A case report. World J Clin Cases 2022; 10:5717-5722. [PMID: 35979106 PMCID: PMC9258376 DOI: 10.12998/wjcc.v10.i17.5717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/16/2022] [Accepted: 04/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease that originates from the superior mesenteric artery, without the presence of aortic and other arterial dissections. Most cases are diagnosed using contrast-enhanced computed tomography (CECT), whereas the application of ultrasound is less common.
CASE SUMMARY Here, we report a case of SISMAD with sudden epigastric pain that worsened as the main symptom after eating. The patient had a long history of hypertension with unknown blood pressure control but no history of smoking or alcohol consumption. This case was initially diagnosed using ultrasound and the results were later confirmed by CECT. After admission, the patient fasted, followed by parenteral nutrition support and fluid supplementation to maintain electrolyte and acid–base balance. Metoprolol succinate sustained-release tablets and aspirin were given as nonoperative treatments. After 1 wk, the symptoms improved, and the patient was discharged. During telephone follow-up, the patient did not develop similar symptoms.
CONCLUSION Whether ultrasound can be used as a routine and noninvasive imaging method for the diagnosis of SISMAD needs further exploration.
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Affiliation(s)
- Yi Zhang
- Department of Ultrasound, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610599, Sichuan Province, China
| | - Jiang-Ying Zhou
- Department of Ultrasound, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610599, Sichuan Province, China
| | - Jian Liu
- Department of Ultrasound, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610599, Sichuan Province, China
| | - Chen Bai
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610599, Sichuan Province, China
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Lei Y, Liu J, Lin Y, Li H, Song W, Li Z, Huang W, Chen S. Clinical characteristics and misdiagnosis of spontaneous isolated superior mesenteric artery dissection. BMC Cardiovasc Disord 2022; 22:239. [PMID: 35610570 PMCID: PMC9131659 DOI: 10.1186/s12872-022-02676-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare disease with a potentially fatal pathology. Due to the lack of specificity of clinical characteristics and laboratory tests, misdiagnosis and missed diagnosis are often reported. Therefore, the aim of this study was to investigate the clinical characteristics and misdiagnosis of SISMAD. Methods In a registry study from January 2013 to December 2020, 110 patients with SISMAD admitted to the First Affiliated Hospital of Wenzhou Medical University were enrolled. Descriptive methods were used to analyse clinical characteristics, laboratory data, diagnostic method or proof, misdiagnosed cases, plain computed tomography (CT) findings and dissection features. To study the relationship between dissection features and treatment modality, the selected patients were classified into the conservative group (n = 71) and the non-conservative group (n = 39). The Chi-square test and Student’s t-test were used to compare the conservative and non-conservative groups. Results One hundred ten patients with SISMAD, including 100 (90.9%) males and 10 (9.1%) females, with a mean age of 52.4 ± 7.6 years, were enrolled in the study. Relevant associated comorbidities included a history of hypertension in 43 cases (39.1%), smoking in 46 cases (41.8%), and alcohol consumption in 34 cases (30.9%). One hundred four patients (94.5%) presented with abdominal pain. Abnormalities in the C-reactive protein lever, white blood cells count and D-dimer lever were the 3 most common abnormal findings. There were 32 misdiagnosis or missed diagnosis. Fourteen cases were misdiagnosed because of insufficient awareness. Twelve cases were misdiagnosed because of disease features. Twenty cases were misdiagnosed as SMA embolism. Among them, There were 15 cases of Yun type IIb SISMAD. Sixty-six patients underwent plain CT. The maximum SMA diameter was 12.1 (11.3–13.1) mm, and the maximum SMA diameter was located on the left renal vein (LRV) plane in 68.2% of cases. Dissection features observed on contrast-enhanced CT (CECT), CT angiography (CTA), or digital subtraction angiography (DSA) showed that there were 70 cases (63.6%) of Yun type IIb SISMAD, the maximum SMA diameter was 13.0 ± 2.4 mm, the location of the maximum SMA diameter was on the LRV plane in 64.5% of cases, and 7.3% of cases were complicated with intestinal obstruction, including bowel necrosis in 3.6% of cases. There were differences between the conservative group and non-conservative groups in the residual true lumen diameter or degree of true lumen stenosis and the presence of intestinal obstruction or bowel necrosis (all P < 0.05). Conclusion For SISMAD, misdiagnosis and missed diagnosis were usually caused by insufficient awareness and disease features. SISMAD should be considered in the differential diagnosis of patients presenting with unexplained abdominal pain, especially males, patients in the 5th decade of life, patients with hypertension, and patients with an enlarged SMA diameter or a maximum SMA diameter located on the LRV plane on plain CT. Mesenteric CTA or CECT should be recommended for the investigation of these conditions.
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Affiliation(s)
- Yuanli Lei
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Jinying Liu
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Yi Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Huiping Li
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Wenxing Song
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Zhangping Li
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Weijia Huang
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Shouquan Chen
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China.
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Choke E, Tay JS. SISMAD: Leave Alone or Stent? Eur J Vasc Endovasc Surg 2020; 60:872. [PMID: 32962918 DOI: 10.1016/j.ejvs.2020.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore.
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore
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