Download 15050-55107-1

Dear Editor-in-chief,
We reconsidered the manuscript and done the corrections to the valuable critics of the
rewievers .
1. You need to provide concrete information about symptom duration and intensity, usage of
pain medication, and which treatments were used in addition to LMWH. These details are
needed to support your choice, endovascular treatment. Most of the recent reports on isolated
SMA dissection have suggested conservative treatment as the first choice. Endovascular
treatment or surgery has been recommended when the patients were refractory to conservative
treatment or when there was evidence of intestinal ischemia.
The patient had 4 hours of acute abdominal pain which was exacerbated with food intake. No
abnromality was identified on his Ultrasound examination. He received 2x 500mg tablets of
paracetamol before admitted to emergency without any change on his symptoms. After CT
was taken LMWH was administered and there was no change in patients symptoms.
2. Etiology of isolated SMA dissection has not yet been clarified. However, you should
mention whether the patient had possible causes of SMA dissection, including previous upper
abdomen surgery or trauma.
The patient did not have any of the possible causes of isolated SMA dissection which can be
counted as fibromuscular dysplasia, atherosclerosis, cystic medial necrosis, and elastic tissue
abnormalities like Marfan and Ehlers-Danlos syndromes. There was no abdominal surgery or
trauma in his medical history.
3. You wrote b Medical treatment is initially used if bowel perfusion stil continues and there
seems to be no rupture of the SMA aneurysm.b This may be confusing to the readers. You
should differentiate between SMA dissection and an SMA aneurysm. If the SMA aneurysm
was a complication of SMA dissection, it was not acute. Most authors report SMA aneurysms
as a late complication of SMA dissection. For late complications, we do not recommend
emergency endovascular stent.
Endovascular Stenting is performed if the patient has the findings of bowel ischemia,
aneurysm of SMA larger than 2 cm or compression of the patent lumen more than 80% was
the phrase we used . In regard of your contribution we may rephrase it to ; Endovascular
Stenting is performed if the patient has the findings of bowel ischemia or compression of
the patent lumen more than 80% in order to stop confusion.
4. You wrote b Emergent surgery is indicated when ES is unsuccessful. In this situation, why
did you select LMWH rather than UFH?
Emergent surgery is indicated when thrombosis of SMA give rise to bowel necrosis or
hemorrhage was the sentence we used. As there was no bowel wall thickening and the only
clinical finding was pain with the CT results we did not change the treatment regime. 5000 IU
intravenous heparin is used additionally in case of stent placement to inhibit the instent
thrombosis.
5. Please check ref. #3 b J Vasc Surg 2007;51:97Sb . I could not find it.
We change the reference 2 and 3 in the revised manuscript. The references are after 2011.
6. There is diffuse stenosis in the initial DSA, but the flow to the distal arterial arcades is not
restricted. If you had selected the figure at a different time, these distal arterial arcades could
have been seen more clearly. There is no difference in diffuse SMA stenosis between Figure
2A and 2B. Therefore, the patientb s symptom might not be related to the stent even though
the symptom improved after stent placement. For a more accurate comparison, it would be
better to make both images of the same size and to take them at the same location at the same
time.
The figures resolutions are 300 dpi and the yare all in jpeg format. The arrows are placed in
the figures and explanations are written in figure legends. Also the Figure1 changed with
more clear one.
7. As you can also see in Figure 2, dissection started from near the SMA origin, extended to
the ileocolic artery and multiply involved several jejunal branches. It is difficult to recanalize this long segment dissection extended into multiple branches with a single short
segment stent insertion.
As the dissection originated from the SMA origin there was the risk of increase in the stenosis
of he orifice lumen and the aim of the stent placement to proximal segment was to reduce
probable inward movement of the dissection flap which would reduce the distal flow
8. Your statement b the aim of therapy in SMA dissection is recanalize the affected lumenb
is hardly correct because most of the recent reports on isolated SMA dissection have
suggested conservative treatment as the first choice.
In dissection cases there is an increasing tendency towards the use of conservative therapy. As
there is a limited number of publishings with small series and there was no change of the
patients complaints we preferred to stent the first larger segment which we thought was the
initiation of the dissection .