Spontaneous isolated dissection of the superior mesenteric artery (SID-SMA) is a rare condition, and there is still no consensus on optimal management. Here, we present three cases of SID-SMA, that were treated by surgical revascularization with urgent iliomesenteric bypass surgery without intestine resection, endovascular therapy with stent placement, and conservative management. The purpose of this study is to review these three cases and propose an algorithm for optimal management of SID-SMA.Key words: spontaneous isolated dissection of the superior mesenteric artery, endovascular therapy, surgical treatment Case Report Case 1A 47-year-old man presented at an emergency department complaining of severe abdominal pain with a sudden onset. He had no medical history, cardiovascular risk factors or recent trauma. He was pale and sweaty with hypertension. An examination of his abdomen showed epigastric mild tenderness without any signs of peritonitis. Laboratory tests were unremarkable. Contrast-enhanced computed tomography (CT) revealed SID-SMA with a thrombosed false lumen that began at the origin of the SMA and extended for 5 cm with no evidence of bowel ischemia. Initially, we chose conservative treatment with anticoagulation therapy and blood pressure control. However, his abdominal pain persisted and follow-up CT revealed progression of SMA dissection and little flow through the SMA because of compression of the true lumen by the false lumen ( Fig. 1A and B). In addition, imaging indicated signs of bowel ischemia and partial necrosis; therefore, we decided to perform urgent surgery. Laparotomy revealed a pulseless small bowel without necrosis. We proceeded with a bypass operation between the jejunal branch of the SMA and the right common iliac artery using the left great saphenous vein as a free graft. His postoperative course was uneventful, and follow-up CT showed good general vascularization of the bowel and full patency of the graft, although the SMA was completely occluded (Fig. 1C). The patient was discharged on postoperative day 20 and was asymptomatic for 1 year after surgery with no disease progression. Case 2A 62-year-old man was admitted to an emergency department because of the sudden onset of severe abdominal pain. His medical history was remarkable for chronic atrial fibrillation and hypertension under treatment with olmesartan (20 mg/day), diltiazem (100 mg/day) and warfarin

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A 75-year-old man underwent emergent endovascular aortic repair for a ruptured abdominal aortic aneurysm. Two years later, computed tomography revealed aneurysm enlargement with endoleaks. Next, late open conversion was performed. Intraoperatively, we detected a spurting type II endoleak from an artery within the aneurysmal wall, which was unconnected to any branch vessels outside the aneurysm, and surgical ligation and sacotomy was performed uneventfully. To our knowledge, this is the first report to intraoperatively identify a type II endoleak from an artery within the aneurysm wall. Even for atypical type II endoleak, such as this case, open surgical repair should be effective.

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Background Total arch replacement (TAR) with a frozen elephant trunk (FET) is a common technique for acute aortic dissection, but there is no consensus on the optimal size of the FET. Methods Forty-four patients who underwent TAR with FET for acute aortic dissection at our hospital since 2014 were included. The aortic diameter obtained from FET was measured on postoperative computed tomography (CT) and the estimated oversizing ratio was calculated. We investigated the relationship between the estimated oversizing ratio and postoperative outcomes. We also measured the maximum true lumen diameter, circumference of the true lumen, and total aortic diameter at the same level as the FET end on preoperative CT and examined the correlation with the aortic diameter obtained from FET. Results The average estimated oversizing ratio was 109%. Early postoperative CT showed complete thrombosis of the false lumen in 41 (93.2%) patients. No distal stent graft-induced new entry occurred during follow-up. The correlation coefficients between the three measurements and aortic diameter obtained from FET were 0.64 (maximum true lumen diameter), 0.76 (true lumen diameter calculated from circumference), and 0.72 (total aortic diameter), respectively. Conclusions The aortic diameter obtained from FET on postoperative CT was strongly correlated with the true lumen diameter calculated from the circumference and total aortic diameter on preoperative CT. It is reasonable to select a size of approximately 130% of the true lumen diameter calculated from the circumference or 80% to 85% of the total aortic diameter.

We herein report a case of leg malperfusion caused by dynamic obstruction after aortic dissection diagnosed by the exercise ankle brachial pressure index test that could not be diagnosed solely by examining the symptoms and investigations at rest. This case suggests that exercise can be a key factor in the diagnosis of this complication. Furthermore, blood pressure elevation can be an exacerbating factor in dynamic obstruction. We recommend conducting an aggressive evaluation of the symptoms and medical examinations not only at rest but also under stress.

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Introduction The efficacy of endovascular treatment for complicated Stanford type B acute aortic dissection is being established. However, aortic events sometimes occur, and some cases require surgical intervention. Report A 52 year old man underwent ascending aorta replacement for Stanford type A acute aortic dissection in August 2016. Post-operative computed tomography (CT) showed residual dissection from the aortic arch to the right common iliac artery and a large re-entry in the right common iliac artery (RCIA). Two months after the operation, CT revealed enlargement of the false lumen of the thoracic aorta and the thoracic aortic diameter. Aiming to reduce the false lumen and remodel the aorta, a three stage operation was performed, as described below. Four months after the dissection, total aortic arch replacement and a frozen elephant trunk insertion were performed as the first stage. Subsequently, as a second stage operation, thoracic endovascular repair (TEVAR) was performed using a Zenith® Dissection Endovascular System (Cook Japan Co., Ltd, Tokyo, Japan), with the aim of expanding the true aortic lumen. The implanted devices were a stent graft for the proximal part and two bare stents for the middle and distal part. As a third stage operation, abdominal aortic endovascular treatment was performed with the purpose of closing the re-entry from the RCIA. However, two years after the three stage operation, CT showed that the thoracic aorta was over 60 mm in diameter. Graft replacement of the thoraco-abdominal aorta was performed. The bare stents were expected to be easily removable from the aorta, but unexpectedly, they were strongly attached to the intima, which made it extremely difficult to perform surgical and aortic operations. Discussion Surgical operations for the aorta can become more difficult after bare stent placement in the aorta.