BACKGROUND

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular condition where the superior mesenteric artery is affected by dissection without involving other arteries. Its incidence is estimated at 0.06% to 0.08% globally. The possible causes include polyarteritis nodosa (PAN), an autoimmune disease affecting medium-sized arteries. SISMAD can manifest with various clinical presentations, from asymptomatic to acute bowel ischemia, warranting consideration when common causes of acute abdomen are ruled out.

CASE SUMMARY

This is the case of a 44-year-old female Filipino, hypertensive, who complained of abdominal pain, initially managed as intestinal amoebiasis. Abdominal examination showed a soft, non-tender abdomen with no guarding, making the symptoms disproportionate to physical examination. Due to persistence of symptoms despite a full antibiotic course, further workup was done. Computed tomography (CT) scan of the whole abdomen with contrast revealed an isolated dissection of the proximal superior mesenteric artery (SMA) with thrombosis which was confirmed on CT angiography. The diagnosis of PAN was established based on the correlation of clinical presentation, laboratory findings and imaging results. Conservative management was done and to address the thrombosis, anticoagulation with heparin was initiated. The patient was also given methylprednisolone pulse therapy and cyclophosphamide with good response. Resolution of symptoms noted and she was eventually discharged improved.

CONCLUSION

SISMAD and PAN are independently rare conditions. This unique case involved both diseases in a 44-year-old Filipino female, and to date, there have been no reported similar cases worldwide. Early diagnosis of the disease requires a high degree of suspicion and pattern recognition. This is crucial for timely treatment and improved prognosis. Furthermore, close surveillance is important to identify potential relapses even after symptom resolution.

Human ; Female ; Adult: 25-44 Yrs Old ; Polyarteritis Nodosa ; Mesenteric Artery, Superior

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular condition where the superior mesenteric artery is affected by dissection without involving other arteries. Its incidence is estimated at 0.06% to 0.08% globally. Possible causes include trauma, congenital connective tissue disorders, arteriosclerosis, and vasculitis such as polyarteritis nodosa (PAN). SISMAD can manifest with various clinical presentations, from asymptomatic to acute bowel ischemia, warranting consideration when common causes of acute abdomen are ruled out.

This is a case of a 44-year-old female Filipino, who complained of abdominal pain, initially managed as intestinal amoebiasis. Abdominal examination showed a soft, non-tender abdomen with no guarding, making the symptoms disproportionate to physical examination. Due to persistence of symptoms despite full antibiotic course, further work up was done. Computed tomography (CT) scan of the whole abdomen with contrast revealed an isolated dissection of the proximal superior mesenteric artery (SMA) with thrombosis which was confirmed on CT angiography. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), cytoplasmic antineutrophilic cytoplasmic antibodies (ANCA) and perinuclear ANCA were both negative; antinuclear antibody (ANA), C3 and C4 levels were also unremarkable. The diagnosis of PAN was established based on the correlation of clinical presentation, laboratory findings, and imaging results. She was given methylprednisolone pulse therapy and cyclophosphamide with good response. Anticoagulation with heparin was initiated to address the thrombosis. The patient had complete bowel rest, pain management, intravenous hydration, and parenteral nutrition. Resolution of symptoms noted and was eventually discharged improved.

SISMAD and PAN are independently rare conditions. This unique case involved both diseases in a 44-year-old Filipino female. Early diagnosis of the disease requires a high degree of suspicion and pattern recognition. This is crucial for timely treatment and improved prognosis. Furthermore, close surveillance is important to identify potential relapses even after symptom resolution.

Human ; Female ; Adult: 25-44 Yrs Old ; Polyarteritis Nodosa ; Pan

BACKGROUND

A patent and functional vascular access (VA) is the lifeline of hemodialysis patients. Prevention of VA failure and maintaining patency are crucial to ensure efficient dialysis, reduce morbidity, lessen healthcare costs and improve patient outcomes. This study aims to determine the risk factors of VA failure among hemodialysis dependent end-stage renal disease (ESRD) patients.

METHODOLOGY

This is a retrospective, case-control study conducted between July 2022 and December 2022. One hundred forty six ESRD patients consisting of 73 with VA failure and 73 without VA failure, undergoing hemodialysis in Manila Doctors Hospital (MDH) - Hemodialysis Unit were included in the study. At least one age (up to 5 years or younger) and sex-matched control was recruited per case (1:1 case-control sampling). The relation of patient demographic profile, smoking, comorbidities (ie, hypertension, diabetes, dyslipidemia, coronary artery disease [CAD], peripheral artery disease [PAD] and heart failure [HF]), duration of dialysis, location of VA, preoperative vessel diameter and arterial peak systolic velocity (PSV) and history of central vein catheterization to VA failure were analyzed. Odds ratio and their 95% confidence interval (CI) for the association of risk factors to VA failure were calculated.

RESULTS

Based on univariate analysis, the following are significant risk factors for VA failure: diabetes (OR 2.35, CI 1.20-4.62), CAD (OR 3.58, CI 1.58-8.13) and PAD (OR 3.04, CI 1.11-8.29). On multivariate analysis, two variables are significant risk factors associated with VA failure, namely: heart failure (OR 7.3, CI 2.15-21.4) and history of ipsilateral central venous catheter (OR 5.51, CI 1.99-15.3) (p = 0.05). Distal radiocephalic VAs have higher failure rates (53.42%) than proximal brachiocephalic (23.36%) and brachiobasilic (8.22%).

CONCLUSION

Diabetes, CAD, PAD, HF and history of ipsilateral central vein catheterization are significant risk factors for VA failure. Distal VA has higher failure rates compared to proximal access in these high-risk patients. This information may guide clinicians in making the appropriate recommendation regarding location of VA in this subset of patients. Aside from patient comorbidities, inherent characteristics, patency and functionality of VA vessels may be influenced by other extrinsic factors leading to VA failure.

Human ; Esrd ; Kidney Failure, Chronic