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Three Surgical Cases of Segmental Arterial Mediolysis
Nobutaka Mukai*1, Hidenori Karasaki1, Taku Maejima1, Toru Kono1, Yusuke Mizukami2
1Surgery, Sapporo Higashi Tokusyukai Hospital, Sapporo, Japan; 2Center for clinical and biomedical Research, Sapporo Higashi Tokusyukai Hospital, Sapporo, Japan
Background
Segmental Arterial Mediolysis (SAM) is a disease entity first described by Slavin in 1976. It causes segmental dissecting aneurysm typically affecting medium-sized abdominal artery, which sometimes results in catastrophic hemorrhages in the abdomen. It is characterized histologically by vacuolization and lysis of the outer arterial media leading to dissecting aneurysms and vessel rupture presenting clinically with self-limiting abdominal pain or catastrophic hemorrhages in the abdomen. The gold standard for the diagnosis of SAM is pathological examination of surgically resected lesions or postmortem findings.
We describe three resected cases of pathologically confirmed SAM
Case reports
Case.1
An 86-year-old man who presented with abdominal pain and loss of consciousness was admitted to our hospital. He had previous histories of atrial fibrillation and hemorrhagic gastric ulcer. Contrast enhancement computed tomography (CECT) revealed hemorrhage from the left gastric artery (LGA). An emergency total gastrectomy without interventional radiology was done because of hypovolemic shock during the examination. He died of hepatic failure postoperatively. Pathological examination revealed dissecting aneurysm at the LGA characteristic to SAM.
Case.2
A 59-year-old man with abdominal pain was taken to our hospital in the ambulance. He had a previous history of cerebral infarction. CECT showed dissection of the superior mesenteric artery (SMA) and the ruptured aneurysm of the middle colic artery (MCA). Angiogram indicated the beaded pattern of the MCA. The dissection of the SMA enable to approach the catheter to the MCA, resulted in the failure of interventional hemostasis. Then he underwent an emergency extended right hemicolectomy. Histology confirmed dissecting aneurysm at the MCA characteristic to SAM.
Case.3
An 80-year-old man of the rupture of the MCA aneurysm was transferred to our hospital. He had previous histories of atrial fibrillation and chronic heart failure. Although the beaded pattern of the MCA was evident by angiogram, the catheter could not reach there. He underwent an emergency extended right hemicolectomy. Pathology revealed dissecting aneurysm at the LGA characteristic to SAM.
Conclusion
We had three cases of pathologically confirmed SAM. We also had some cases successfully treated conservatively or non-surgically. Pathological confirmations of SAM were not evident in these cases. Some of such cases which were diagnosed as idiopathic rupture of aneurysm would have been SAM. An establishment of the appropriate strategy to SAM should be warrant by developing the imagiological diagnostic criteria instead of pathological one.
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