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Emekli E, Bayav FD, Gündoğdu E. Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study. Surg Radiol Anat 2024:10.1007/s00276-024-03352-7. [PMID: 38622333 DOI: 10.1007/s00276-024-03352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/18/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.
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Affiliation(s)
- Emre Emekli
- Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey.
| | - Fatma Didem Bayav
- Department of Radiology, Karadeniz Ereğli State Hospital, Zonguldak, Turkey
| | - Elif Gündoğdu
- Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
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Yu Z, Dong X, Li R, Xiao C, Zhou S, Yuan Z, Gao Y, Li P. Irreversible Transmural Intestinal Necrosis in Acute Mesenteric Ischemia: Retrospective Cohort Study from a High-Volume Hospital. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38531051 DOI: 10.1089/lap.2024.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
Background: Owing to the low incidence rate and nonspecific symptoms of acute mesenteric ischemia (AMI), the identification and prediction of irreversible transmural intestinal necrosis (ITIN) and extensive bowel resection (≥100 cm) (EBR) are difficult and critical. This study aimed to investigate the risk factors for ITIN and EBR in patients with AMI. Methods: The clinical data of 254 AMI patients were retrospectively analyzed. Furthermore, the incidence of ITIN and EBR were set as dependent variables, and relevant risk factors were screened using univariate and multivariate logistic regression analyses. The comparisons of surgical characteristics and postoperative recovery outcomes between the EBR and control group were also conducted. Results: The presence of hemorrhagic (odds ratio [OR] = 28.356, P < .001) or other types ascites (OR = 13.051, P = .003), peritonitis (OR = 8.463, P = .005), intestinal diameter >2.35 cm (OR = 5.493, P = .020), and serum creatinine (CREA) >95 μmol/L (OR = 4.866, P = .048) were identified as independent risk factors for ITIN in patients with AMI. In addition, serum C-reactive protein (CRP) >15 mg/L (OR = 38.023, P = .006), and CREA >100 μmol/L (OR = 6.248, P = .035) were proved to be independently associated with EBR for ITIN cases. Compared to the control group, EBR significantly increased the likelihood of requiring enterostomy (P = .001), blood transfusion (P = .002), and transfer to intensive care unit (P = .016), while also prolonging the recovery time for intestinal function (P = .014). Conclusions: The presence of ascites, peritonitis, intestinal diameter >2.35 cm, and serum CREA >95 μmol/L were independently correlated with ITIN for AMI cases, while serum CRP >15 mg/L and CREA >100 μmol/L independently increased the risk of EBR.
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Affiliation(s)
- Zhiyuan Yu
- School of Medicine, Nankai University, Tianjin, China
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiaoyu Dong
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rui Li
- School of Medicine, Nankai University, Tianjin, China
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chun Xiao
- Department of General Surgery, PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Sixin Zhou
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhen Yuan
- School of Medicine, Nankai University, Tianjin, China
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yunhe Gao
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Peiyu Li
- School of Medicine, Nankai University, Tianjin, China
- Medical School of Chinese PLA, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Stonko DP, Edwards J, Abdou H, Treffalls R, Walker P, Morrison JJ. Raising Systemic Blood Pressure to Delay Irreversible Intestinal Ischemia in a Swine Model of Proximal Superior Mesenteric ArteryOcclusion. J Surg Res 2024; 295:70-80. [PMID: 37992455 DOI: 10.1016/j.jss.2023.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Acute proximal superior mesenteric artery (SMA) occlusion is highly lethal, and adjuncts are needed to mitigate ischemic injury until definitive therapy. We hypothesized that raising mean arterial pressure (MAP) >90 mmHg with norepinephrine may delay irreversible bowel ischemia by increasing gastroduodenal artery (GDA) flow despite possible pressor-induced vasospasm. METHODS 12 anesthetized swine underwent laparotomy, GDA flow probe placement, and proximal SMA exposure and clamping. Animals were randomized between conventional therapy (CT) versus targeted MAP >90 mmHg (MAP push; MP) where norepinephrine was titrated after 45 min of SMA occlusion. Animals were followed until bowel death or 4 h. Kaplan-Meier bowel survival, mean normalized GDA flow, and histology were compared. RESULTS 12 swine (mean 57.8 ± 7.6 kgs) were included, six per group. Baseline weight, HR, MAP and GDA flows were not different. Within 5 min following SMA clamping, all 12 animals had an increase in MAP without other intervention from 81.7 to 105.5 mmHg (29.1%, P < 0.01) with a concomitant 74.9% increase in GDA flow as compared to baseline (P < 0.01). Beyond 45 min postclamp, MAP was greater in the MP group as intended, as were GDA flows. Median time to irreversibly ischemic bowel was 31% longer for MAP push animals (CT: 178 versus MP: 233 min, P = 0.006), Hazard Ratio of CT 8.85 (95% CI: 1.86-42.06); 3/6 MP animals versus 0/6 CT animals with bowel survived to predetermined end point. CONCLUSIONS In this swine model of acute complete proximal SMA occlusion, increasing MAP >90 mmHg with norepinephrine was associated with an increase in macrovascular blood flow through the GDA and bowel survival. Norepinephrine was not associated with worse bowel survival and a MAP push may increase the time window where ischemic bowel can be salvaged.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Rebecca Treffalls
- University of the Incarnate Word School of Medicine (R.N.T.), San Antonio, Texas
| | - Patrick Walker
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Zafirovski A, Zafirovska M, Kuhelj D, Pintar T. The Impact of Biomarkers on the Early Detection of Acute Mesenteric Ischemia. Biomedicines 2023; 12:85. [PMID: 38255192 PMCID: PMC10812952 DOI: 10.3390/biomedicines12010085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/14/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND acute mesenteric ischemia (AMI) is a life-threatening condition that is caused by inadequate blood flow through the mesenteric vessel and is related to high mortality rates due to systemic complications. This study aims to systematically review the available literature concerning the major findings of possible biomarkers for early detection of acute mesenteric ischemia in the human population. METHODS studies that measured the performance of biomarkers during acute mesenteric ischemia were identified with the search of PubMed, Embase, Medline, and Cochrane library. RESULTS from a total of 654 articles, 46 articles examining 14 different biomarkers were filtered, falling within our inclusion criteria. Intestinal fatty acid-binding protein (I-FABP) was the most commonly researched biomarker regarding AMI, with sensitivity ranging from 61.5% to 100% and specificity ranging from 40% to 100%. The second most commonly researched biomarker was D-dimer, with a sensitivity of 60-100% and a specificity of 18-85.71%. L-lactate had a sensitivity of 36.6-90.91% and a specificity of 64.29-96%. Several parameters within the blood count were examined as potential markers for AMI, including NLR, PLR, MPV, RDW, DNI, and IG. Citrulline, interleukin 6 (IL-6), and procalcitonin (PCT) were the least-researched biomarkers. CONCLUSION different biomarkers showed different accuracies in detecting AMI. I-FABP and D-dimer have been the most researched and shown to be valuable in the diagnosis of AMI, whereas L-lactate could be used as an additional tool. Ischemia-modified albumin (IMA), alpha glutathione S-transferase (αGST), interleukin 6 (IL-6), and citrulline showed potential use in their respective studies. However, further research needs to be done on larger sample sizes and with controls to reduce bias. Several studies showed that neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), red-cell distribution width (RDW), delta neutrophil index (DNI), and immature granulocytes (IGs) might be useful, as well at the same time be widely distributed and affordable in combination with other markers presenting higher specificity and sensitivity.
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Affiliation(s)
- Aleksandar Zafirovski
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (A.Z.); (M.Z.); (D.K.)
- Department of Radiology, General Hospital Jesenice, Cesta Maršala Tita 112, 4270 Jesenice, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Marija Zafirovska
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (A.Z.); (M.Z.); (D.K.)
| | - Dimitrij Kuhelj
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (A.Z.); (M.Z.); (D.K.)
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Tadeja Pintar
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (A.Z.); (M.Z.); (D.K.)
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia
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Fei K, Zani S, Ronald JS, Shortell CK, Southerland KW. A minimally invasive approach for management of pancreaticoduodenal artery and gastroduodenal artery aneurysm with celiac artery occlusion. J Vasc Surg Cases Innov Tech 2023; 9:101180. [PMID: 37388670 PMCID: PMC10300390 DOI: 10.1016/j.jvscit.2023.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/23/2023] [Indexed: 07/01/2023] Open
Abstract
Management of pancreaticoduodenal artery aneurysms (PDAAs) and gastroduodenal artery aneurysms (GDAAs) with concomitant celiac occlusion represents a challenging clinical scenario. Here, we describe a 62-year-old female with PDAA and GDAA complicated by celiac artery occlusion due to median arcuate ligament syndrome. We used a staged, minimally invasive approach consisting of: (1) a robotic median arcuate ligament release; (2) endovascular celiac artery stenting; and (3) visceral aneurysm coiling. The findings from this case report represent a novel treatment strategy for the management of PDAA/GDAA with celiac artery compression secondary to median arcuate ligament syndrome.
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Affiliation(s)
- Kaileen Fei
- Duke University School of Medicine, Durham, NC
| | - Sabino Zani
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC
| | - James S. Ronald
- Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, NC
| | - Cynthia K. Shortell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Kevin W. Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Kowalczyk KA, Pękala J, Kawzowicz M, Pękala PA, Tomaszewski KA. The meta-analysis and systematic review of prevalence and clinical anatomy of the arc of Buhler. Sci Rep 2023; 13:9183. [PMID: 37280432 DOI: 10.1038/s41598-023-36316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 05/31/2023] [Indexed: 06/08/2023] Open
Abstract
The arc of Buhler (AOB) is a direct anastomosis of the celiac axis and superior mesenteric artery. This paper reviews the literature on the AOB and provides accurate and up-to-date data on its prevalence, anatomy, and clinical significance. The main scholarly online databases were carefully searched for relevant studies related to the AOB. Information was gathered and formed the basis of the analysis of this study. In total, 11 studies were used in this meta-study, consisting of 3685 total patients tested and 50 cases of the AOB presented. The pooled prevalence estimate of the AOB was determined to be 1.7% (95% CI 0.9, 2.9). By imaging type, the prevalence of the AOB was 1.8% for radiological studies (n = 3485; 95% CI 0.9, 3.0), 1.4% for computed tomography (CT) studies (n = 1417; 95% CI 0.4, 3.0), and 1.9% for angiography studies (n = 2068; 95% CI 0.5, 4.0). The AOB is sufficiently significant and should be considered when planning surgeries or radiological procedures involving the abdomen.
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Affiliation(s)
- Katarzyna A Kowalczyk
- Department of General and Oncological Surgery, 5th Military Clinical Hospital in Cracow, 30-901, Cracow, Poland.
- Department of Anatomy, Jagiellonian University Medical College, 31-034, Cracow, Poland.
- Faculty of Medicine and Health Sciences, Andrzej Frycz-Modrzewski Krakow University, 30-705, Cracow, Poland.
| | - Jakub Pękala
- Department of Anatomy, Jagiellonian University Medical College, 31-034, Cracow, Poland
| | | | - Przemysław A Pękala
- Department of Anatomy, Jagiellonian University Medical College, 31-034, Cracow, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz-Modrzewski Krakow University, 30-705, Cracow, Poland
| | - Krzysztof A Tomaszewski
- Department of Anatomy, Jagiellonian University Medical College, 31-034, Cracow, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz-Modrzewski Krakow University, 30-705, Cracow, Poland
- Scanmed St. Raphael Hospital, 30-693, Cracow, Poland
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Salim H, Ozgur O, Erman K, Ozturk S, Sarikaya Dogan M, Sindel T, Sindel M. Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery. Surg Radiol Anat 2023; 45:479-486. [PMID: 36781442 DOI: 10.1007/s00276-023-03104-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations. METHODS A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels. RESULTS Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients. CONCLUSION It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.
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Affiliation(s)
- Hande Salim
- Faculty of Medicine, Department of Anatomy, Akdeniz University, Antalya, Turkey
| | - Ozhan Ozgur
- Faculty of Medicine, Department of Radiology, Akdeniz University, Antalya, Turkey
| | - Kursat Erman
- Faculty of Medicine, Department of Radiology, Akdeniz University, Antalya, Turkey
| | - Serra Ozturk
- Faculty of Medicine, Department of Anatomy, Akdeniz University, Antalya, Turkey
| | | | - Timur Sindel
- Faculty of Medicine, Department of Radiology, Akdeniz University, Antalya, Turkey
| | - Muzaffer Sindel
- Faculty of Medicine, Department of Anatomy, Akdeniz University, Antalya, Turkey.
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Molyneux K, Beck-Esmay J, Koyfman A, Long B. High risk and low prevalence diseases: Mesenteric ischemia. Am J Emerg Med 2023; 65:154-161. [PMID: 36638612 DOI: 10.1016/j.ajem.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment. CONCLUSIONS An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Kevin Molyneux
- Department of Emergency Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Jennifer Beck-Esmay
- Department of Emergency Medicine, Mount Sinai Morningside - Mount Sinai West, 1111 Amsterdam Ave, New York, NY 10025, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Muacevic A, Adler JR. Chronic Mesenteric Ischemia in a Patient With Limited Systemic Sclerosis. Cureus 2023; 15:e34209. [PMID: 36843818 PMCID: PMC9957581 DOI: 10.7759/cureus.34209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/27/2023] Open
Abstract
Chronic mesenteric ischemia typically develops secondary to the development of atherosclerosis within mesenteric vessels leading to the insufficient blood supply. While autoimmune conditions are an established independent risk factor for developing atherosclerotic plaques, the association between scleroderma and chronic mesenteric ischemia has been less studied. We present a case of a 64-year-old female with limited systemic sclerosis and atherosclerotic cardiovascular disease who presented to the Gastroenterology Clinic with progressive abdominal pain who was subsequently diagnosed with chronic mesenteric ischemia secondary to superior mesenteric artery stenosis and successfully treated with endovascular stenting.
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Otto CC, Czigany Z, Heise D, Bruners P, Kotelis D, Lang SA, Ulmer TF, Neumann UP, Klink C, Bednarsch J. Prognostic Factors for Mortality in Acute Mesenteric Ischemia. J Clin Med 2022; 11:jcm11133619. [PMID: 35806904 PMCID: PMC9267588 DOI: 10.3390/jcm11133619] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/07/2022] [Accepted: 06/20/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.
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Affiliation(s)
- Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany;
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany;
- Department of Vascular Surgery, University Hospital Bern, 3010 Bern, Switzerland
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Maastricht University Medical Center (MUMC), 6229 HX Maastricht, The Netherlands
| | - Christian Klink
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer, 67346 Speyer, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Correspondence: ; Tel.: +49-241-80-89501
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Kazmi SSH, Safi N, Berge ST, Kazmi M, Sundhagen JO, Hisdal J. Laparoscopic Surgery for Median Arcuate Ligament Syndrome (MALS): A Prospective Cohort of 52 Patients. Vasc Health Risk Manag 2022; 18:139-151. [PMID: 35356549 PMCID: PMC8959725 DOI: 10.2147/vhrm.s350841] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background The selection of patients with MALS for surgical treatment depends upon the reliability of the symptom interpretation and the diagnostic work-up. We aimed to follow up the results of the laparoscopic decompression of the patients with MALS. Patients and Methods In a single-center, 52 consecutive MALS patients were followed-up, prospectively, after transperitoneal laparoscopic decompression. MALS was diagnosed with a computed tomography angiography (CTA) verified stenosis, ≥50% of the celiac artery (CA), and with duplex ultrasound, a peak systolic velocity (PSV) ≥2.0 m/s. Postoperative, CTA, and duplex ultrasound were performed, and the patients were followed-up at 3, 6, 12 months, and yearly after that. Results Mean age of the patients was 47 ±21 years, and 65% were females. The patients had a mean weight loss of 8.4 ±7.2 kg. Fifty-one patients had the laparoscopic operation with a mean operation time of 102 ± 28 minutes. Forty-seven patients (90%) achieved relief from the symptoms either completely (67%) or partially (23%) at 3–6 months of follow-up. Significant improvement in postoperative PSV was found compared to the preoperative values, p<0.001. Five patients (10%) with no immediate effect of the operation, but two of them became free from symptoms during the mean study follow-up of 2.4 ± 2 years. Five patients (10%) had operative complications, including one trocar injury to the liver, one pneumothorax, and three cases of bleeding from the branches of CA. Two patients died of cancer disease during the study period. Only two patients (4%) had symptoms relapse, both later treated successfully. Conclusion Laparoscopic transperitoneal decompression provides most of the patients a persistent relief from MALS symptoms.
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Affiliation(s)
- Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Simen Tveten Berge
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway
| | - Marryam Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Faculty 2, Poznan University of Medical Sciences, Poznan, Poland
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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12
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Mesenteric occlusive disease of the inferior mesenteric artery is associated with anastomotic leak after left-sided colon and rectal cancer surgery: a retrospective cohort study. Int J Colorectal Dis 2022; 37:631-638. [PMID: 34997304 PMCID: PMC8885551 DOI: 10.1007/s00384-021-04089-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak (AL) is a serious complication following colorectal surgery. Atherosclerosis causes inadequate anastomotic perfusion and is suggested to be a risk factor for AL. The aim of this study was to investigate the association of mesenteric occlusive disease on preoperative computed tomography (CT) scan with AL after left-sided colon or rectal cancer surgery. METHODS This was a retrospective, multicenter cohort study including 1273 patients that underwent left-sided or rectal cancer resection between 2009 and 2018 from three hospitals in the Netherlands. AL patients were 1:1 matched with non-leak patients and preoperative contrast-enhanced CT-scans were retrospectively analyzed for mesenteric atherosclerotic lesions. The main outcome measure was the presence of mesenteric occlusive disease on the preoperative CT-scan. RESULTS Anastomotic leak developed in 6% of 1273 patients (N = 76). Low anterior resection and stage I-III disease were statistically significant associated with AL (p = 0.01, p = 0.04). No other statistically significant differences in patient characteristics between AL and non-leak patients were found. A clinically significant stenosis (≥ 70-100%) of the inferior mesenteric artery was statistically significant more frequent present in AL patients, compared to non-leak patients (p < 0.01). No statistically significant differences in the presence of mesenteric occlusive disease of the celiac artery and superior mesenteric artery between AL patients and non-leak patients were found. CONCLUSION Mesenteric occlusive disease of the IMA on preoperative CT-scan is associated with AL after left-sided colon or rectal resection for cancer. Preoperative identification of high-risk patients with a preoperative CT-scan of the mesenteric vasculature might be useful to reduce the risk of AL.
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13
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Abstract
Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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14
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Schoettler JJ, Kirschning T, Hagmann M, Hahn B, Fairley AM, Centner FS, Schneider-Lindner V, Herrle F, Tzatzarakis E, Thiel M, Krebs J. Maintaining oxygen delivery is crucial to prevent intestinal ischemia in critical ill patients. PLoS One 2021; 16:e0254352. [PMID: 34242347 PMCID: PMC8270469 DOI: 10.1371/journal.pone.0254352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/24/2021] [Indexed: 01/16/2023] Open
Abstract
Background Intestinal ischemia is a common complication with obscure pathophysiology in critically ill patients. Since insufficient delivery of oxygen is discussed, we investigated the influence of oxygen delivery, hemoglobin, arterial oxygen saturation, cardiac index and the systemic vascular resistance index on the development of intestinal ischemia. Furthermore, we evaluated the predictive power of elevated lactate levels for the diagnosis of intestinal ischemia. Methods In a retrospective case-control study data (mean oxygen delivery, minimum oxygen delivery, systemic vascular resistance index) of critical ill patients from 02/2009–07/2017 were analyzed using a proportional hazard model. General model fit and linearity were tested by likelihood ratio tests. The components of oxygen delivery (hemoglobin, arterial oxygen saturation and cardiac index) were individually tested in models. Results 59 out of 874 patients developed intestinal ischemia. A mean oxygen delivery less than 250ml/min/m2 (LRT vs. null model: p = 0.018; LRT for non-linearity: p = 0.012) as well as a minimum oxygen delivery less than 400ml/min/m2 (LRT vs null model: p = 0.016; LRT for linearity: p = 0.019) were associated with increased risk of the development of intestinal ischemia. We found no significant influence of hemoglobin, arterial oxygen saturation, cardiac index or systemic vascular resistance index. Receiver operating characteristics analysis for elevated lactate levels, pH, CO2 and central venous saturation was poor with an area under the receiver operating characteristic of 0.5324, 0.52, 0.6017 and 0.6786. Conclusion There was a significant correlation for mean and minimum oxygen delivery with the incidence of intestinal ischemia for values below 250ml/min/m2 respectively 400ml/min/m2. Neither hemoglobin, arterial oxygen saturation, cardiac index, systemic vascular resistance index nor elevated lactate levels could be identified as individual risk factors.
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Affiliation(s)
- Jochen J. Schoettler
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
- * E-mail:
| | - Thomas Kirschning
- Clinic for Thorax- and Cardiovascular Surgery HDZ NRW, University of Ruhr-University Bochum, Bochum, Germany
| | - Michael Hagmann
- Interdisciplinary Center for Scientific Computing, Heidelberg University, Heidelberg, Germany
| | - Bianka Hahn
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Anna-Meagan Fairley
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Franz-Simon Centner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Verena Schneider-Lindner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Florian Herrle
- Surgical Department, University Medical Center Mannheim, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Surgical Department, University Medical Center Mannheim, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Joerg Krebs
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
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15
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Tang W, Zhang J, Kuang LQ, Yi KM, Li CX, Wang Y. Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia. Quant Imaging Med Surg 2021; 11:3120-3132. [PMID: 34249639 DOI: 10.21037/qims-20-604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 03/12/2021] [Indexed: 01/16/2023]
Abstract
Background Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism. Methods In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis. Results Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71). Conclusions In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.
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Affiliation(s)
- Wei Tang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China.,Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Lian-Qin Kuang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Kun-Ming Yi
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chun-Xue Li
- Department of Gastrointestinal Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yi Wang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
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16
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Endovascular Revascularization with Stent Implantation in Patients with Acute Mesenteric Ischemia due to Acute Arterial Thrombosis: Clinical Outcome and Predictive Factors. Cardiovasc Intervent Radiol 2021; 44:1030-1038. [PMID: 33825061 PMCID: PMC8190006 DOI: 10.1007/s00270-021-02824-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/10/2021] [Indexed: 02/07/2023]
Abstract
Purpose To determine 30-day-mortality rates and identify predictors for survival in patients undergoing endovascular revascularization for acute mesenteric ischemia (AMI) due to occlusion of the celiac (CA) or superior mesenteric artery (SMA) from arterial thrombosis in the setting of atherosclerosis at the vessel origin. Materials and Methods A retrospective analysis on patients who underwent acute endovascular revascularization to treat AMI caused by thrombotic occlusion of the CA and/or SMA between January 2011 and December 2019 was conducted. 30-day-mortality rates were calculated. Univariate binomial logistic regression analyses (p < 0.05) were performed to assess whether the following factors were associated with 30-day mortality: sex, age, history of smoking, history of abdominal angina, signs of bowel necrosis on pre-interventional CT, one- vs. two-vessel disease, patency of the inferior mesenteric artery, outpatient or inpatient occurrence of ischemia, onset of AMI during ITU stay, elevated pre-interventional serum lactate levels, total leukocyte count, platelet/lymphocyte ratio and neutrophil/lymphocyte ratio. Results 40 patients were included in this analysis. 30-day-mortality rate was 25/40 (62.5%). Median overall survival of patients who survived the first 30 days was 36 ± 18 months. None of the analyzed factors was statistically significantly associated with 30-day mortality. Conclusion Although mortality of patients with AMI due to acute arterial thrombosis remains high, almost 40% of patient who underwent emergent endovascular revascularization survived longer than one month. Since no predictors for the outcome in these patients were identified, all patients with AMI should be offered an immediate revascularization effort.
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17
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Bordet M, Tresson P, Huvelle U, Long A, Passot G, Bergoin C, Lermusiaux P, Millon A, Della Schiava N. Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery Status. Eur J Vasc Endovasc Surg 2021; 61:810-818. [PMID: 33810975 DOI: 10.1016/j.ejvs.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/09/2021] [Accepted: 03/01/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. METHODS This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI). RESULTS Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups. CONCLUSION Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.
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Affiliation(s)
- Marine Bordet
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France.
| | - Philippe Tresson
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Ugo Huvelle
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Anne Long
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Internal Medicine and Vascular Medicine, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Team Vascular biology and Red Blood Cell, Villeurbanne, France
| | - Guillaume Passot
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Digestive Surgery, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, France
| | - Charlotte Bergoin
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Nutrition Intensive Care Unit, Hospices Civils de Lyon, Lyon Sud University Hospital, Pierre Bénite, France
| | - Patrick Lermusiaux
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Antoine Millon
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Nellie Della Schiava
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
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18
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Median arcuate ligament as an incidental finding. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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19
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Tang W, Jin B, Kuang LQ, Zhang J, Li CX, Wang Y. Risk factors of geriatrics index of comorbidity and MDCT findings for predicting mortality in patients with acute mesenteric ischemia due to superior mesenteric artery thromboembolism. Br J Radiol 2020; 93:20190605. [PMID: 32886528 DOI: 10.1259/bjr.20190605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify risk factors of geriatrics index of comorbidity (GIC) and multidetector CT (MDCT) findings for predicting mortality in patients with acute mesenteric ischemia (AMI) due to superior mesenteric artery (SMA) thromboembolism. METHODS 33 patients with AMI due to SMA thromboembolism underwent abdominal MDCT and angiography. Patients' comorbidities and MDCT findings of ischemic bowel/mesenteric injuries, regions of SMA involved by thromboembolism, and degrees of SMA stenosis were retrospectively reviewed. The comorbidities were classified into 1-4 levels according to GIC. The association of MDCT signs and GIC classification with mortality were analyzed. Diagnostic performances of risk factors associated with mortality were evaluated by receiver operating characteristic (ROC) curve analyses. RESULTS Eighteen patients (54.5%) died during hospitalization or follow-up, including one patient with class 1, two patients with class 2, eight patients with class 3, and seven patients with class 4 according to GIC. Three risk factors significantly associated with mortality were identified, including pneumatosis and/or portomesenteric venous gas (PPMVG) (p = 0.017), four regions of SMA involved by thromboembolism (region I + II + III + IV) (p = 0.036), and class 3 + 4 of comorbidities (p = 0.001). The sensitivity and specificity of PPMVG, region I + II + III + IV, class 3 + 4 of comorbidities, and the three risk factors combined for diagnosing mortality were 33.3 and 100%, 27.8 and 100%, 83.3 and 73.3%, and 88.9 and 73.3%, respectively. The areas under the ROC curve (AUC) of the three risk factors combined (0.88) and class 3 + 4 of comorbidities (0.78) were larger than that of PPMVG (0.67) and region I + II + III + IV (0.64). The mortality rate rose from 15.4% in patients without risk factor to 66.7%, 100%, and 100% in patients with one, two, and three factors, respectively. CONCLUSION Three risk factors for mortality were identified in patients with AMI due to SMA thromboembolism, including PPMVG and four regions of SMA involved by thromboembolism on MDCT images, and class 3 + 4 of comorbidities. Close monitoring of these risk factors could possibly lower the mortality. ADVANCES IN KNOWLEDGE Risk factors based on GIC and MDCT findings may be used to predict mortality in patients with AMI. Close monitoring of these risk factors could possibly lower the mortality.
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Affiliation(s)
- Wei Tang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China.,Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Bo Jin
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Lian-Qin Kuang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Jing Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Chun-Xue Li
- Department of Gastrointestinal Surgery, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Yi Wang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
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20
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Dembinski J, Robert B, Sevestre MA, Freyermuth M, Yzet T, Dokmak S, Regimbeau JM. Celiac axis stenosis and digestive disease: Diagnosis, consequences and management. J Visc Surg 2020; 158:133-144. [PMID: 33191149 DOI: 10.1016/j.jviscsurg.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
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Affiliation(s)
- J Dembinski
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France
| | - B Robert
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M-A Sevestre
- Vascular Medicine Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M Freyermuth
- Vascular Surgery Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - T Yzet
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - S Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation, Assistance Publique-Hôpitaux de Paris and Paris University, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France.
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21
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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Zhang L, Zhang X, Chang P, Yang J, Zheng D, Zhang D, Wen S, Jing S. A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy-6-year Follow-up. Urology 2020; 144:241-244. [PMID: 32717246 DOI: 10.1016/j.urology.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/27/2020] [Accepted: 07/12/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature. MATERIALS AND METHODS The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump. RESULTS At the 6-year follow-up, the patient had no intestine-related sequelae. CONCLUSION Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.
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Affiliation(s)
- Liyuan Zhang
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China
| | - Xiaokang Zhang
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China
| | - Pengcheng Chang
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China
| | - Jie Yang
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China
| | - Duo Zheng
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China
| | - Deng Zhang
- Jinchang hospital of integrated traditional Chinese and western medicine, Jinchang, China
| | - Siqi Wen
- The art academy of Lanzhou university, Lanzhou, China
| | - Suoshi Jing
- Department of Urology, the first hospital of Lanzhou university, Lanzhou, China.
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Abstract
PURPOSE OF REVIEW Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders. RECENT FINDINGS There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.
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Affiliation(s)
| | - Paul Feuerstadt
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA. .,Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, CT, USA.
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Birkl J, Kahl T, Thielemann H, Mutze S, Goelz L. Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery. Ann Vasc Surg 2020; 66:250-262. [PMID: 31923601 DOI: 10.1016/j.avsg.2020.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/14/2019] [Accepted: 01/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes. METHODS Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com. RESULTS Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid. CONCLUSIONS Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications. LEVEL OF EVIDENCE III (Retrospective therapeutic study and systematic literature review).
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Affiliation(s)
- Jens Birkl
- Department of General Surgery, Unfallkrankenhaus Berlin, Berlin, Germany; Department of General Surgery, Albertinen Krankenhaus Hamburg, Hamburg, Germany
| | - Thomas Kahl
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Henryk Thielemann
- Department of General Surgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Sven Mutze
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Berlin, Germany; Department for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Leonie Goelz
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Berlin, Germany; Department for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany.
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Fukuda W, Fukuda I, Murakami T, Saito Y, Taniguchi S, Minakawa M. Reimplantation of a Stenotic Inferior Mesenteric Artery for Chronic Visceral Artery Occlusion after Failed Bypass to the Superior Mesenteric Artery. Ann Vasc Dis 2019; 12:559-561. [PMID: 31942221 PMCID: PMC6957906 DOI: 10.3400/avd.cr.19-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The patient was a 71-year-old man complaining of postprandial abdominal pain and weight loss. Computed tomography angiography showed occlusion of the superior mesenteric artery and the celiac axis. The inferior mesenteric artery, supplying the mesenteric circulation, was stenotic at its origin. The patient had portal vein thrombosis and was diagnosed as having antiphospholipid antibody syndrome. The reimplantation of the inferior mesenteric artery was successfully performed after failed bypass grafting to the superior mesenteric artery from the abdominal aorta.
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Affiliation(s)
- Wakako Fukuda
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takeshi Murakami
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshiaki Saito
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Satoshi Taniguchi
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masahito Minakawa
- Department of Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Ohtsuka R, Amano H, Hashimoto M, Iwao T. Pancreaticoduodenectomy following total occlusion of the superior mesenteric artery: a case report and literature review. Surg Case Rep 2019; 5:168. [PMID: 31686292 PMCID: PMC6828884 DOI: 10.1186/s40792-019-0718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Patients with chronic occlusion of the celiac artery and superior mesenteric artery (SMA) are often asymptomatic, and occlusion may be caused by arteriosclerosis or median arcuate ligament compression. Pancreaticoduodenectomy (PD) is occasionally performed for patients with celiac artery occlusion; however, reports on patients with SMA occlusion are rare. We report a patient with cholangiocarcinoma and total atherosclerotic occlusion of the SMA without preoperative stenting or bypass. Case presentation A 73-year-old man suspected to have lower bile duct carcinoma was admitted to our hospital for further treatment. Three-dimensional computed tomography (3DCT) showed a common bile duct tumor and total occlusion of the SMA with collateral circulation of the gastroduodenal artery (GDA) and inferior mesenteric artery (IMA). We performed a PD. During the operation, we used test clamping of the GDA, which revealed no bowel ischemia. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 30. 3DCT on POD 98 and POD 307 showed development of collateral circulation between the IMA and SMA. Conclusion Here, we report the case of a patient with total occlusion of the SMA who subsequently underwent PD. 3DCT was instrumental in gathering vascular collateral information and thus we conclude that the assessment of collateral circulation before surgery is important.
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Affiliation(s)
- Reo Ohtsuka
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan
| | - Hodaka Amano
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Michiyo Hashimoto
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Toshiyasu Iwao
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
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Lacey J, Hughes R, Noble V. Abdominal Pain in the Elderly: An Unusual Case of Chronic Mesenteric Ischemia in the Emergency Department. Clin Pract Cases Emerg Med 2019; 3:275-277. [PMID: 31403102 PMCID: PMC6682238 DOI: 10.5811/cpcem.2019.5.41886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 05/02/2019] [Accepted: 05/16/2019] [Indexed: 11/29/2022] Open
Abstract
Chronic mesenteric ischemia (CMI) is a rare cause of abdominal pain with the potential for significant morbidity and mortality. An infrequently described complication of CMI is acalculous cholecystitis. Historically, acalculous cholecystitis is thought to be multifactorial and usually occurs in the setting of severe illness. In CMI, the etiology is more likely chronic ischemia to the gallbladder leading to inflammation. We present a case of acalculous cholecystitis that presented insidiously in a patient with CMI.
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Affiliation(s)
- Julieta Lacey
- University Hospitals Cleveland Medical Center, Department of Emergency Medicine, Cleveland, Ohio
| | - Robert Hughes
- University Hospitals Cleveland Medical Center, Department of Emergency Medicine, Cleveland, Ohio
| | - Vicki Noble
- University Hospitals Cleveland Medical Center, Department of Emergency Medicine, Cleveland, Ohio
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Brinkmann S, Chang DH, Kuhr K, Hoelscher AH, Spiro J, Bruns CJ, Schroeder W. Stenosis of the celiac trunk is associated with anastomotic leak after Ivor-Lewis esophagectomy. Dis Esophagus 2019; 32:5367736. [PMID: 30820543 DOI: 10.1093/dote/doy107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transthoracic esophagectomy with gastric tube formation is the surgical treatment of choice for esophageal cancer. The surgical reconstruction induces changes of gastric microcirculation, which are recognized as potential risk factors of anastomotic leak. This prospective observational study investigates the association of celiac trunk (TC) stenosis with postoperative anastomotic leak. One hundred fifty-four consecutive patients with esophageal cancer scheduled for Ivor-Lewis esophagectomy were included. Preoperative staging computed tomography (CT) was used to identify TC stenosis. Any narrowing of the lumen due to atherosclerotic changes was classified as stenosis. Percentage of stenotic changes was calculated using the North American Symptomatic Carotid Endarterectomy Trial formula. Multivariable analysis was used to identify possible risk factors for leak. The overall incidence of TC stenosis was 40.9%. Anastomotic leak was identified in 15 patients (9.7%). Incidence of anastomotic leak in patients with stenosis was 19.4% compared to 2.3% in patients without stenosis. Incidence of stenosis in patients with leak was 86.7% (13 of 15 patients) and significantly higher than 38.8% (54 of 139 patients) in patients without leak (P < 0.001). There was a significant difference in median degree of TC stenosis (50.0% vs 39.4%; P = 0.032) in patients with and without leak. In the multivariable model, TC stenosis was an independent risk factor for anastomotic leak (odds ratio: 5.98, 95% CI: 1.58-22.61). TC stenosis is associated with postoperative anastomotic leak after Ivor-Lewis esophagectomy. Routine assessment of TC for possible stenosis is recommended to identify patients at risk.
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Affiliation(s)
- S Brinkmann
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - D H Chang
- Department of Radiology, University of Cologne, Germany
| | - K Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
| | - A H Hoelscher
- Department of Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - J Spiro
- Department of Radiology, University of Cologne, Germany
| | - C J Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - W Schroeder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
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Watanabe M, Takahashi S, Katayama K, Sueda T. Abdominal aortic aneurysm with occlusion of three primary mesenteric vessels treated by surgery with perfusion of the left iliac artery†. Interact Cardiovasc Thorac Surg 2019; 28:489-490. [PMID: 30204877 DOI: 10.1093/icvts/ivy272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 01/16/2023] Open
Abstract
A 64-year-old woman who underwent thoraco-abdominal aortic replacement for a Crawford type II aneurysm 11 years ago was referred to our hospital because of a residual juxtarenal abdominal aortic aneurysm. The coeliac, superior mesenteric and inferior mesenteric arteries were occluded. Collateral vessels from the left internal iliac artery to these 3 mesenteric arteries had developed. We performed open aneurysm repair using an extracorporeal circuit to maintain collateral flow to these mesenteric arteries.
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Affiliation(s)
- Masazumi Watanabe
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Taijiro Sueda
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan
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Duplex ultrasound in the early diagnosis of acute mesenteric ischemia: a longitudinal cohort multicentric study. Eur J Emerg Med 2018; 24:e21-e26. [PMID: 26891086 DOI: 10.1097/mej.0000000000000378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) is a life-threatening condition requiring time-dependent treatment; thus, early recognition may improve outcomes. We hypothesized that clinician-performed mesenteric vessels duplex ultrasound (DUS) could facilitate early identification of patients with AMI in high-risk patients presenting with abdominal pain. METHODS This was a single-operator, observational, prospective cohort study. Patients aged at least 65 presenting to Emergency Departments with acute abdominal pain and no clear diagnosis after an initial work-up were enrolled. All patients underwent multidetector computed tomography and these findings provided the reference standard in this study. DUS of the celiac artery and superior mesenteric artery (SMA) were obtained to measure the peak systolic velocity (PSV) and were performed within 24 h of admission. PSVs outside the normal range were considered to indicate AMI. RESULTS Of 49 patients identified, 47 were consented to enrollment and diagnostic images were obtained in 45 (96%). Fifteen patients (33%) had AMI (six occlusive, nine nonocclusive disease). Among these, 12 (80%) had abnormal DUS velocities. SMA PSV showed a sensitivity of 78.57% [95% confidence interval (CI): 49.2-95.34], a specificity of 64.52% (95% CI: 45.37-80.77), a positive predictive value of 50% (95% CI: 28.22-71.78), and a negative predictive value of 86.96% (95% CI: 66.41-97.22) for AMI. DUS had a sensitivity of 100%, a specificity of 64%, and a negative predictive value of 100% for occlusive AMI. Assessment of celiac artery PSV did not improve diagnostic performance. CONCLUSION In this single-operator pilot study, mesenteric vessel DUS was performed successfully in the Emergency Department, with a high proportion of diagnostic images obtained. A normal SMA PSV was associated with a low risk of occlusive AMI.
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Kueht ML, Wu DL, Mills JL, Gilani R. Symptomatic Celiomesenteric Trunk: Variable Presentations and Outcomes in 2 Patients. Tex Heart Inst J 2018; 45:35-38. [PMID: 29556150 DOI: 10.14503/thij-16-6155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mesenteric ischemia can be difficult to diagnose without a high degree of suspicion because it presents in a variety of ways. Visceral vascular collaterals between the fore- and midgut often provide protection against ischemia; however, the presence of anatomic variations, such as celiomesenteric trunk, can undermine the expected redundancy. Misdiagnosis can result in prolonged suffering or death, as evidenced in 2 of our patients with celiomesenteric trunk. The first patient with chronic mesenteric ischemia was diagnosed in the clinic and underwent successful surgical correction; the other had overwhelming, acute mesenteric ischemia, which resulted in death. Our cases show that successful diagnosis and management of mesenteric ischemia require astute interpretation of radiologic images.
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Arif R, Verch M, Farag M, Karck M. Mesenterialischämie nach herzchirurgischen Eingriffen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0217-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Sanddal Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Geelkerken B, Gloviczki P, Huber T, Naylor R. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 53:460-510. [PMID: 28359440 DOI: 10.1016/j.ejvs.2017.01.010] [Citation(s) in RCA: 329] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Bala M, Kashuk J, Moore EE, Kluger Y, Biffl W, Gomes CA, Ben-Ishay O, Rubinstein C, Balogh ZJ, Civil I, Coccolini F, Leppaniemi A, Peitzman A, Ansaloni L, Sugrue M, Sartelli M, Di Saverio S, Fraga GP, Catena F. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12:38. [PMID: 28794797 PMCID: PMC5545843 DOI: 10.1186/s13017-017-0150-5] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process. Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.
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Affiliation(s)
- Miklosh Bala
- Acute Care Surgery and Trauma Unit, General Surgery Department, Hadassah - Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel
| | - Jeffry Kashuk
- Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, USA
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, Queens Medical Center, Honolulu, Hi USA
| | - Carlos Augusto Gomes
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Chen Rubinstein
- Department of Vascular Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Ian Civil
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | | | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinica, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fausto Catena
- Emergency Department, Maggiore University Hospital, Parma, Italy
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van Petersen AS, Kolkman JJ, Gerrits DG, van der Palen J, Zeebregts CJ, Geelkerken RH, Bruno M, van Dijk L, Moelker A, Peppelenbosch M, Verhagen H, Blauw J, Geelkerken R, Kolkman J, van Petersen A, Bakker O. Clinical significance of mesenteric arterial collateral circulation in patients with celiac artery compression syndrome. J Vasc Surg 2017; 65:1366-1374. [DOI: 10.1016/j.jvs.2016.11.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
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Multidetector Computed Tomographic Angiography for Optimal Cartography of the Visceral Abdominal Arterial Network: An Extensive Pictorial Review with Emphasis on Common and Uncommon Collateral Pathways, Complications and some Specific Syndromes. J Belg Soc Radiol 2017; 101:6. [PMID: 30038999 PMCID: PMC5854326 DOI: 10.5334/jbr-btr.1203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Multidetector computed tomographic angiography (MDCTA) is the new gold standard for diagnostic evaluation of the abdominal and/or mesenteric arteries. It is not invasive and provides a 2D and 3D global cartography of all abdominal arteries and that with only a limited amount of contrast media. MDCTA allows the optimal diagnosis of single or multiple arterial stenosis and easily analyses sometimes very complex collateral pathways. It constitutes a major advance to plan the arterial visceral safety of major commonly performed abdominal surgical procedures such as aorto-iliac surgery, endovascular aneurysm repair (EVAR), but also complex pancreatic and gastrointestinal or colonic surgery. It also allows to plan the most optimal strategy for revascularization of the mesenteric system through percutaneous angioplasty, stent placement or surgical bypass. This extensive pictorial review illustrates a large variety of situations which may be found during clinical practise. Single compression or stenosis of each digestive artery, combined and/or complex associations of stenosis and/or compressions of several arteries, secondary complications like aneurysms and classical but also sometimes unusual patterns of collateralization are richly illustrated. Specific syndromes comprising the median arcuate ligament syndrome (MALS) and the Leriche’s syndrome are also discussed.
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van Noord D, Kolkman JJ. Functional testing in the diagnosis of chronic mesenteric ischemia. Best Pract Res Clin Gastroenterol 2017; 31:59-68. [PMID: 28395789 DOI: 10.1016/j.bpg.2016.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/03/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Chronic mesenteric ischemia (CMI) results from insufficient oxygen delivery or utilization to meet metabolic demand. Two main mechanisms may lead to mesenteric ischemia: occlusion in the arteries or veins of the gastrointestinal tract, or reduced blood flow from shock states or increased intra-abdominal pressure, so-called non-occlusive mesenteric ischemia. Severe stenoses in the three main mesenteric vessels as demonstrated with CT-angiography or MR-angiography are sufficient to proof mesenteric ischemia, for example in patients who present with weight loss, postprandial pain and diarrhea. Still in many clinical situations mesenteric ischemia is only one of many possible explanations. Especially in patients with a single vessel stenosis in the celiac artery or superior mesenteric artery with postprandial pain, mesenteric ischemia remains a diagnosis of probability or assumption without functional proof of actual ischemia. This review is aimed to provide an overview of all past, present and future ways to functionally proof CMI.
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Affiliation(s)
- Desirée van Noord
- Erasmus MC University Medical Center Rotterdam, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands; Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands.
| | - Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology and Hepatology, Enschede, The Netherlands; Universitair Medisch Centrum Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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Vascular imaging of the mesenteric vasculature. Best Pract Res Clin Gastroenterol 2017; 31:3-14. [PMID: 28395786 DOI: 10.1016/j.bpg.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 10/31/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Imaging of the mesenteric vasculature is crucial in diagnosing vascular disease of the gastro-intestinal tract such as acute or chronic mesenteric ischemia caused by arterial stenosis, embolism or thrombosis, mesenteric vein thrombosis and mesenteric aneurysm or dissection. The reference standard for imaging of the mesenteric vasculature is digital subtraction angiography. However, modalities as duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are developing rapidly and may provide accurate imaging non-invasively. This review provides an up-to-date overview of the anatomic resolution, clinical application, emerging techniques and future perspectives of these four radiological modalities for imaging of the mesenteric vasculature.
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Blauw JTM, Bulut T, Oderich GS, Geelkerken BRH. Mesenteric vascular treatment 2016: from open surgical repair to endovascular revascularization. Best Pract Res Clin Gastroenterol 2017; 31:75-84. [PMID: 28395791 DOI: 10.1016/j.bpg.2017.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 01/31/2023]
Abstract
The rise of endovascular techniques has improved the outcome of mesenteric ischemia. Key principle in reduction of morbidity and mortality is "revascularization first, resection later". We believe that mesenteric ischemia is a clinical challenge demanding 24/7 multidisciplinary team availability. This article describes the current insights into treatment of mesenteric ischemia.
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Affiliation(s)
- Juliëtte T M Blauw
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, The Netherlands; Department of Surgery, Isala Clinics, Zwolle, The Netherlands.
| | - Tomas Bulut
- Department of Radiology, Medical Spectrum Twente, Enschede, The Netherlands.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Bob R H Geelkerken
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, The Netherlands; Experimental Centre for Technical Medicine, University of Twente, Enschede, The Netherlands.
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Baek MS, Kim JH, Song D, Ahn SJ, Suh KD, Lee KY. Two cases of Superior Mesenteric Artery Occlusion in Acute Cerebral Infarction patients with Atrial Fibrillation. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Arazińska A, Polguj M, Wojciechowski A, Trębiński Ł, Stefańczyk L. Median arcuate ligament syndrome: Predictor of ischemic complications? Clin Anat 2016; 29:1025-1030. [DOI: 10.1002/ca.22773] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Agata Arazińska
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Michał Polguj
- Department of Angiology; Medical University of Łódź; Narutowicza 60 Łódź 90-136 Poland
| | - Andrzej Wojciechowski
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Łukasz Trębiński
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Ludomir Stefańczyk
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
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Morbi AHM, Nordon IM. Emergency revascularisation in a patient with acute mesenteric ischaemia: the role of open revascularisation and compensatory blood flow. Acta Chir Belg 2016; 116:234-238. [PMID: 27426671 DOI: 10.1080/00015458.2016.1139837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This case highlights the importance of timely diagnosis and management of acute mesenteric ischaemia and illustrates the compensatory mechanisms of the mesenteric vasculature. CASE REPORT A 53-year-old female presented with fever, abdominal pain, and vomiting. The patient had no risk factors for atherosclerosis and was a non-smoker in sinus rhythm with no history of coagulopathy. She was initially treated for viral gastroenteritis. Due to lack of clinical improvement and a rising C-Reactive Protein (416), a CT scan was performed. This demonstrated small bowel ischaemia, chronic occlusion of the coeliac axis, and a long acute-on-chronic occlusion of the superior mesenteric artery (SMA). The length and morphology of the SMA occlusion precluded endovascular treatment. Emergency laparotomy demonstrated 1 m of necrotic small bowel and a pulseless mesentery. An aorto-SMA bypass, using good-quality long saphenous vein was performed, with segmental small bowel resection. Postoperative nutritional support was required with discharge on the 23rd post-operative day. Interval surveillance confirmed graft patency. One year post-discharge, she presented to routine clinic with paroxysmal right iliac fossa pain and decreased appetite. CT angiography showed a long tight 75% stenosis of the graft and she was admitted for mesenteric angioplasty. Angiography confirmed a significantly hypertrophied inferior mesenteric artery, which was now the dominant mesenteric supply. CONCLUSIONS This case demonstrates the importance of emergency mesenteric revascularisation and how it acts as a bridge to anatomical compensation, allowing the collateral circulation to develop and the IMA to hypertrophy, becoming the dominant mesenteric supply.
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Jaster A, Choudhery S, Ahn R, Sutphin P, Kalva S, Anderson M, Pillai AK. Anatomic and radiologic review of chronic mesenteric ischemia and its treatment. Clin Imaging 2016; 40:961-9. [PMID: 27232932 DOI: 10.1016/j.clinimag.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 01/01/2023]
Abstract
Chronic mesenteric ischemia (CMI) is a vascular occlusive disease process that generally affects the elderly population. Clinical presentation occurs when two of the three mesenteric arteries are affected and includes non-specific abdominal pain and weight loss. The most common cause of CMI is atherosclerotic arterial occlusion. The aim of this review is to present the vascular anatomy of the mesenteric arterial circulation including the different collateral pathways. The imaging findings and the different treatment options with a brief review of the literature is presented.
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Affiliation(s)
- Adam Jaster
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX.
| | - Sadia Choudhery
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Richard Ahn
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Patrick Sutphin
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Sanjeeva Kalva
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Matthew Anderson
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Anil K Pillai
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
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Foley TR, Rogers RK. Endovascular Therapy for Chronic Mesenteric Ischemia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:39. [DOI: 10.1007/s11936-016-0463-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rose MK, Pearce BJ, Matthews TC, Patterson MA, Passman MA, Jordan WD. Outcomes after celiac artery coverage during thoracic endovascular aortic aneurysm repair. J Vasc Surg 2015; 62:36-42. [DOI: 10.1016/j.jvs.2015.02.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
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