PHÌNH TÁCH VÁCH ĐỘNG MẠCH MẠC TREO TRÀNG TRÊN

BS Lê Văn TàiBS Trần Châu Nhân

Trung Tâm Y Khoa MEDIC

Case report

Bệnh án• Bệnh nhân nam 50 tuổi, quê

Trà Vinh. • Bệnh sử: cao huyết áp, cao

nhất 15 cm Hg, đau thượng vị kéo dài, Hp test (+), bệnh nhân cũ của MEDIC, đã điều trị hết Hp. Cách đây 1 tháng đau bụng nhiều, không tiêu chảy, không sốt, nhập BV tĩnh điều trị 10 ngày với chẩn đoán viêm dạ dày, viêm ruột, xuất viện được 20 ngày, còn đau TV nên tái khám MEDIC.

Hình ảnh SA

Hình MSCT

BÀN LUẬN

• It was first reported in 1947, Bauersfeld et.al. • Superior mesentertic arterial (SMA) dissection

is an uncommon type of arterial dissection. It can either on its own (rarer) or occur as part of an extension of an aortic dissection.

• In isolated SMA dissections it usually begins a few centimeters from the SMA origin.

• The etiology of the disease has not yet been established, but atherosclerosis, cystic medial necrosis, fibromuscular dysplasia, congenital connective tissue disorders, mycotic infection and trauma have been implicated, often associated with untreated hypertension.

• Patients often present in middle age (50-60 of age). There is a recognised increased male predilection.

• Patients can present asymptomatic, vague abdominal pain, the pain being especially worse after a meal.

• Most patients present with acute epigastric pain, which is considered to be caused by the dissection itself or intestinal ischemia or intraperitoneal hemorrhage.

• Other common symptoms are nausea, vomiting, melena, and abdominal distention. These patients present acutely with symptom duration of <4 weeks.

• Gray-scale: revealed an aneurysmal dilatation of the SMA a few centimeters from the SMA's origin, with an echogenic linear membrane (an intimal flap) within the aneurysm.

• Color Doppler: Flow reversal, bi-directional flow and forward flow may occur in the false lumen during the cardiac cycle or absence of a signal in a total occlusion.

• On non-contrast CT, the SMA is often enlarged. Post contrast images often show a flap within the vessel in acute situations.

• Different therapeutic approaches are possible ranging from conservative management to surgical revascularisation to endovascular therapy.

• The prognosis is variable and it can sometimes be fatal.

Longitudinal (A) and transverse (B) sonograms of the SMA aneurysm show the intimal flap (arrow).

A B

A. Color Doppler image of the SMA dissecting aneurysm with checkered flow pattern. Flow is antegrade in the anterior (true lumen) compartment and retrograde in the posterior (false lumen) compartment.B. Contrast-enhanced CT shows the intimal flap in the SMA as a thin band of low density (arrow).

A B

Lateral view on selective angiography, with thecatheter (arrow) in the SMA, demonstrates the dissection andintimal flap (arrowheads).

(A) Abdominal CT with contrast in cross-section view revealed SMA dissection (white arrow). (B) Selective angiogram of SMA via lefthigh radial approach with 7F Kimney guiding catheter showed aneurismal dilatation from the SMA ostium followed by narrow lumen. (C) IVUSdisclosed that an intimal flap (white arrow) brought about true lumen and false lumen which was corresponding to a narrow portion on theangiogram.

A B C

(A) After express SD stent deployment, the stent balloon was used for Wallstent dilatation. (B) IVUS disclosed apposite stent position.(C) Angiography after deployment of two stents for the dissection revealed widened true lumen and complete recanalization of the SMA.

A

B c

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