Silent Superior Mesenteric Artery Dissection Discovered During Hypertensive Emergency With Acute Pulmonary Edema in an End-Stage Renal Disease Patient.

Introduction

Isolated spontaneous dissection of the superior mesenteric artery (ISMAD) is an uncommon but increasingly recognized vascular pathology, largely due to advances in imaging modalities, such as computed tomography angiography (CTA) [ 1 , 2 ]. Clinical presentation is highly variable, ranging from acute abdominal pain to entirely asymptomatic cases detected incidentally [ 3 , 4 ]. Hypertension and atherosclerosis are among the most frequently associated risk factors, likely contributing to increased arterial wall stress and intimal injury [ 5 , 6 ]. Management remains controversial and may include conservative therapy, antithrombotic treatment, endovascular intervention, or surgical repair, depending on clinical presentation and the presence of complications, such as bowel ischemia [ 3 , 7 ]. We report a case of asymptomatic superior mesenteric artery (SMA) dissection identified during evaluation of hypertensive emergency and acute pulmonary edema in a patient with end-stage renal disease (ESRD).

Case presentation

A 62-year-old man with chronic kidney disease on thrice-weekly hemodialysis, hypertension, and hyperlipidemia presented following a hemodialysis session with progressively worsening shortness of breath and new-onset lower extremity edema. On arrival, his blood pressure was 206/138 mmHg. Physical examination revealed jugular venous distension and diffuse crackles on lung auscultation, while cardiac examination was unremarkable. The abdomen was soft and non-tender, without signs of peritonitis. The patient denied chest pain and had no acute gastrointestinal symptoms. Laboratory evaluation revealed elevated high-sensitivity troponin levels without ST elevation on electrocardiogram (Figure 1 ), consistent with demand ischemia, and a brain natriuretic peptide (BNP) level >2,000 pg/mL.

There was no evidence of lactic acidosis. Hemoglobin was approximately 10 g/dL, consistent with chronic normocytic anemia, and the platelet count was 90,000/µL, presumed to be reactive in the setting of acute illness. Labs on admission are categorized in Table 1 .

Chest X-ray revealed pulmonary edema and pleural effusions (Figure 2 ).

Urgent CTA of the abdomen and pelvis was performed to exclude aortic dissection or pulmonary embolism. No aortic dissection was identified. Incidentally, an isolated dissection of the SMA was noted (Figure 3 ). The imaging demonstrated an intimal flap in the proximal SMA, with a patent true lumen and a false lumen extending distally, without occlusion of any branches. Bowel loops enhanced normally, and there was no evidence of pneumatosis or mesenteric venous gas.

CTA of the chest showed moderate emphysema and pleural effusion (Figure 4 ).

The vascular surgery team evaluated the patient and recommended conservative management, given the absence of abdominal symptoms or signs of ischemia, as the true lumen remained patent and bowel imaging was stable. The patient was admitted to the intensive care unit for close monitoring and management. The patient was treated for a hypertensive emergency. Intravenous antihypertensive therapy with esmolol and nicardipine infusions was initiated to achieve rapid blood pressure control, targeting less than 140/90 mmHg. Volume overload was addressed with two urgent hemodialysis sessions, removing 2-3 L of fluid via ultrafiltration. With diuresis and blood pressure control, his pulmonary edema improved, and bilevel positive airway pressure was gradually weaned by hospital day three.

Therapeutic anticoagulation was initiated for the SMA dissection. The patient initially received a heparin infusion, followed by a transition to apixaban 5 mg twice daily for outpatient therapy. Although the benefit of anticoagulation in isolated spontaneous SMA dissection remains uncertain, it was chosen to reduce the risk of thrombosis in the false lumen.

During hospitalization, the patient's abdominal examinations remained benign, with no pain or tenderness. Serial lactate levels and hemoglobin remained stable, indicating no ischemic or bleeding complications. Cardiology supervised the management of hypertensive cardiac injury and added oral antihypertensive agents - including labetalol, nifedipine, and hydralazine - as intravenous infusions were tapered. Nephrology continued management of dialysis and anemia of chronic kidney disease, maintaining erythropoiesis-stimulating agents and intravenous iron. Hematology evaluated thrombocytopenia and ruled out heparin-induced thrombocytopenia; the platelet count recovered spontaneously with supportive care. Heparin-induced thrombocytopenia and serotonin-release assay were negative. A workup for multiple myeloma was planned on an outpatient basis.

By hospital day four, the patient was breathing comfortably on a nasal cannula, and blood pressure was well controlled on oral medications. He reported no abdominal complaints. The patient was discharged home on hospital day five with instructions to continue antihypertensive therapy and apixaban (renal adjusted dosing). Follow-up was arranged with vascular surgery and primary care, with outpatient CTA or duplex ultrasound planned in three months to assess remodeling of the SMA.

Discussion

This case illustrates several important aspects of ISMAD, particularly in the complex setting of ESRD and hypertensive emergency. Although ISMAD classically presents with acute abdominal pain, it can occasionally be clinically silent, as demonstrated in this case. Most published series report abdominal pain as the predominant symptom; however, a subset of patients may be asymptomatic or minimally symptomatic and are often diagnosed incidentally during imaging performed for unrelated indications [ 1 , 2 ]. Our patient's SMA dissection was identified during CTA performed for suspected vascular pathology, in the absence of any abdominal complaints, highlighting the importance of careful evaluation of imaging beyond the primary indication [ 1 , 3 ]. The patient's clinical profile aligns with the typical epidemiology of ISMAD, which predominantly affects middle-aged men with underlying vascular risk factors, such as hypertension and atherosclerosis [ 1 , 4 ]. Systemic hypertension is one of the most frequently reported comorbidities and contributes to increased arterial wall stress and intimal injury [ 1 , 5 ].

Additionally, the presence of hyperlipidemia and ESRD further contributes to vascular pathology through mechanisms such as accelerated atherosclerosis, vascular calcification, and chronic uremia [ 6 , 7 ]. While ESRD is not a well-established independent risk factor for ISMAD, it likely creates a vulnerable vascular environment that may predispose patients to arterial injury [ 2 , 3 ].

CTA remains the imaging modality of choice for diagnosing ISMAD due to its high sensitivity and ability to delineate the intimal flap, true and false lumens, and branch vessel perfusion [ 1 , 8 ]. Current literature and expert consensus recommend conservative therapy for hemodynamically stable patients without complications such as bowel ischemia, persistent pain, or progression of dissection [ 1 , 2 , 8 ].

In contrast, endovascular or surgical intervention is reserved for patients with complications, including true lumen compromise, aneurysmal dilation, or intestinal infarction [ 8 ]. A critical component of management in this case was prompt and controlled blood pressure reduction. Hypertensive emergency, particularly when associated with acute pulmonary edema, carries a high risk of morbidity and mortality and requires immediate intervention [ 1 , 7 , 8 ]. Current guidelines recommend rapid but controlled lowering of blood pressure using intravenous agents, followed by transition to oral antihypertensive therapy once stabilization is achieved [ 7 , 8 ]. Strict blood pressure control is also essential in ISMAD to prevent propagation or rupture of the dissection, with some literature emphasizing tighter targets in these patients [ 2 , 7 ]. Volume management was equally important, particularly given the patient's ESRD status. Volume overload is a major contributor to hypertension and acute heart failure in dialysis patients, and effective ultrafiltration plays a key role in achieving hemodynamic stability [ 5 ]. Close monitoring during hospitalization confirmed clinical stability, with no abdominal symptoms or bowel ischemia. Follow-up imaging is recommended for ISMAD, as conservative management often leads to stabilization or complete remodeling. Multidisciplinary care addressed comorbidities: cardiology managed demand-related myocardial injury, nephrology optimized dialysis, and transient thrombocytopenia resolved with supportive care and outpatient follow-up.

Conclusions

Isolated SMA dissection is a rare but increasingly recognized entity due to advanced imaging. This case underscores that ISMAD can be found incidentally even in the absence of abdominal pain, especially in patients undergoing evaluation for other vascular emergencies. In hypertensive patients, especially those on dialysis, vigilant attention to blood pressure and volume is key. Uncomplicated ISMAD without bowel compromise can be managed conservatively: blood pressure reduction, possible anticoagulation, and supportive care. Vascular surgery consultation and serial exams are prudent to detect any evolution. With this approach, outcomes are excellent, and surgery is rarely needed. We recommend that clinicians consider visceral artery dissections in hypertensive crises and emphasize multidisciplinary management and follow-up in complex patients.

Disclosures

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design: Tutul Chowdhury, Nisha K. Sapkota, Aditi Parulkar, Anusha Akella, Mehak G. Mastoi, Minhaz Murshad, Mujibur Majumder

Acquisition, analysis, or interpretation of data: Tutul Chowdhury, Nisha K. Sapkota, Aditi Parulkar, Anusha Akella, Mehak G. Mastoi, Minhaz Murshad, Mujibur Majumder

Drafting of the manuscript: Tutul Chowdhury, Nisha K. Sapkota, Aditi Parulkar, Anusha Akella, Mehak G. Mastoi, Minhaz Murshad, Mujibur Majumder

Critical review of the manuscript for important intellectual content: Tutul Chowdhury, Nisha K. Sapkota, Aditi Parulkar, Anusha Akella, Mehak G. Mastoi, Minhaz Murshad, Mujibur Majumder

Supervision: Tutul Chowdhury, Mujibur Majumder

References

1 A case report of an isolated superior mesenteric artery dissection caused by childbirth BMC Gastroenterol Feng Q Zhao J Zang L Chen Y Li S 428 21 2021 34774024 10.1186/s12876-021-01994-0 PMC8590309

2 Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis Korean Circ J Ullah W Mukhtar M Abdullah HM 400 418 49 2019 31074212 10.4070/kcj.2018.0429 PMC6511528

3 Current strategy for the treatment of symptomatic spontaneous isolated dissection of superior mesenteric artery J Vasc Surg Min SI Yoon KC Min SK 461 466 54 2011 21571493 10.1016/j.jvs.2011.03.001

4 Hypertensive emergency StatPearls Alley WD Schick MA Treasure Island, FL StatPearls Publishing 2023 https://www.ncbi.nlm.nih.gov/books/NBK470371/ 29261994

5 Management of spontaneous isolated mesenteric artery dissection: a systematic review Scand J Surg Acosta S Gonçalves FB 130 138 110 2021 33724090 10.1177/14574969211000546 PMC8258720

6 Spontaneous dissection of the celiac artery: a case report J Vasc Surg Woolard JD Ammar AD 1256 1258 45 2007 17543692 10.1016/j.jvs.2007.01.048

7 Nonoperative management of isolated celiac and superior mesenteric artery dissection: case report and review of the literature Vascular Mousa AY Coyle BW Affuso J Haser PB Vogel TR Graham AM 359 364 17 2009 19909685 10.2310/6670.2009.00053

8 Management of spontaneous isolated dissection of the superior mesenteric artery: case report and literature review World J Emerg Surg Katsura M Mototake H Takara H Matsushima K 16 6 2011 21549001 10.1186/1749-7922-6-16 PMC3108290