The Efficiency of Serum Biomarkers in Predicting the Clinical Outcome of Patients with Mesenteric Ischemia during Follow-Up: A Systematic Review

The initial clinical manifestation of acute mesenteric ischemia poses a diagnostic challenge, often leading to delays in identification and subsequent surgical intervention, contributing to adverse outcomes. Serum biomarkers, offering insights into the underlying pathophysiology, hold promise as prognostic indicators for acute mesenteric ischemia. This systematic review comprehensively explores the role of blood biomarkers in predicting clinical outcomes during follow-up for patients with mesenteric ischemia. A thorough literature search across the PubMed, Cochrane Library, and EMBASE databases yielded 33 relevant publications investigating the efficacy of serum biomarkers in predicting outcomes for mesenteric ischemia. Numerous studies underscore the utility of blood biomarkers in swiftly and accurately differentiating between causes of mesenteric ischemia, facilitating a prompt diagnosis. Elevated levels of specific biomarkers, particularly D-dimers, consistently correlate with heightened mortality risk and poorer clinical outcomes. While certain serum indicators exhibit substantial potential in associating with mesenteric ischemia, further research through rigorous human trials is imperative to enhance their consistent predictive ability during the follow-up period. This study underscores the diagnostic and prognostic significance of specific biomarkers for mesenteric ischemia, emphasizing the necessity for standardized procedures in future investigations.

Stercoral Colitis-Induced Ischemia Mimicking acute Mesenteric Ischemia: A case report and Literature Review

Stercoral colitis is a rare but serious condition characterized by inflammation of the colonic mucosa due to impacted and hardened faecal material. The word "stercoral" means "related to faeces". This condition usually develops due to the accumulation of hard stool masses in the colon, which cause localized inflammation and irritation. These faecalomas can exert persistent pressure on the colonic wall, causing damage and inflammation. Stercoral colitis presenting symptoms that mimic acute mesenteric ischemia is a diagnostic challenge for clinicians due to the overlap in clinical manifestations. Changes in bowel habits, bloating, and excruciating abdominal pain are potential manifestations of both illnesses, making it difficult to distinguish between them using clinical presentation. Diagnostic imaging, such as computed tomography scans, significantly discriminates between stercoral colitis and acute mesenteric ischemia. In cases where stercoral colitis mimics acute mesenteric ischemia, a thorough evaluation is essential to rule out vascular compromise. Timely and accurate diagnosis is crucial, as the management strategies for these two conditions differ significantly. Stercoral colitis often requires bowel evacuation and addressing the underlying faecal impaction. Acute mesenteric ischemia demands prompt vascular intervention to restore blood flow and prevent severe complications like bowel infarction. Given the potential overlap in symptoms and the critical importance of distinguishing between stercoral colitis and acute mesenteric ischemia, a multidisciplinary approach involving radiological imaging, clinical expertise, and timely intervention is essential for optimal patient care. This case highlights the importance of considering stercoral colitis when evaluating a patient with an acute abdomen, especially elderly patients with history of constipation.

LEARNING POINTS

Constipation is a common condition that can lead to serious complications, especially in older people, and should be addressed as soon as possible.Early recognition of stercoral colitis and appropriate treatment can prevent critical consequences.Stercoral colitis can induce bowel ischemia, causing acute abdominal pain mimicking acute mesenteric ischemia.

Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition's variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed.

PURPOSE

Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia.

METHODS

A narrative review of all relevant studies from January 2022 through September 2023.

RESULTS

A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review.

CONCLUSIONS

Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Background

Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

Objectives

To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Methods

Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature.

Results

All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Conclusions

Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Navigating the Gut-Cardiac Axis: Understanding Cardiovascular Complications in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) presents a complex interplay of chronic inflammation in the gastrointestinal tract and is associated with various extraintestinal manifestations, including cardiovascular complications (CVCs). IBD patients face an elevated risk of CVCs, including coronary artery disease, heart failure, arrhythmias, stroke, peripheral artery disease, venous thromboembolism, and mesenteric ischemia, necessitating comprehensive cardiovascular risk assessment and management. The intricate interplay between chronic inflammation, genetic predisposition, environmental factors, and immune dysregulation likely contributes to the development of CVCs in IBD patients. While the exact mechanisms linking IBD and CVCs remain speculative, potential pathways may involve shared inflammatory pathways, endothelial dysfunction, dysbiosis of the gut microbiome, and traditional cardiovascular risk factors exacerbated by the chronic inflammatory state. Moreover, IBD medications, particularly corticosteroids, may impact cardiovascular health by inducing hypertension, insulin resistance, and dyslipidemia, further amplifying the overall CVC risk. Lifestyle factors such as smoking, obesity, and dietary habits may also exacerbate cardiovascular risks in individuals with IBD. Lifestyle modifications, including smoking cessation, adoption of a heart-healthy diet, regular exercise, and optimization of traditional cardiovascular risk factors, play a fundamental role in mitigating CVC risk. Emerging preventive strategies targeting inflammation modulation and gut microbiome interventions hold promise for future interventions, although further research is warranted to elucidate their efficacy and safety profiles in the context of IBD. Continued interdisciplinary collaboration, advanced research methodologies, and innovative interventions are essential to address the growing burden of CVCs in individuals living with IBD and to improve their long-term cardiovascular outcomes.

The geriatric index of comorbidity as an outcome predictor of patients with acute mesenteric ischemia due to superior mesentery artery thromboembolism

OBJECTIVE

To describe the impact of comorbidities on in-hospital mortality and overall survival in patients with acute mesenteric ischemia (AMI) due to superior mesentery artery (SMA) thromboembolism.

METHODS

A retrospective study was conducted for 40 patients with AMI due to SMA thromboembolism who were treated in our hospital between February 2013 and December 2019. The presence of comorbidities was described and their severities were classified into 1-4 levels by Geriatric Index of Comorbidity (GIC), the comorbidities were defined as any distinct additional clinical entity that has existed. Univariate and cox proportional-hazards analyses were performed to determine the effect of comorbidities on in-hospital mortality and overall survival.

RESULTS

During a mean follow-up of 15.05 ± 18.02 months (range from 0.3 to 58 months) for the 40 patients with AMI due to SMA thromboembolism, In-hospital mortality rate was 52.5% (21/40). One-year, 2-year, and 3-year overall estimated survival rates by the Kaplan-Meier method were 45%, 34%, and 26.5%, respectively, the average overall survival time was 20.84 ± 3.95 (95% CI: 13.10-28.58) months. In-hospital mortality was significantly related to the GIC classification (χ2 = 7.86, p = 0.049). The average overall survival was significantly related to the malignant tumor in pre-existing comorbidities and GIC classification (log-rank, p = 0.001). Cox proportional-hazards regressions analysis showed that the class 4 of comorbidities was an independent prognostic factor of mortality (p = 0.031, HR = 10.45 [95% CI: 1.24-87.70]).

CONCLUSION

Comorbidity is common and an important factor associated with all-cause mortality in AMI patients due to SMA thromboembolism. In managing AMI patients, we recommend a timely diagnosis of both AMI condition and its associated comorbidities.

Association of COVID 19 pneumonitis and acute mesenteric ischemia

Key Clinical Message

D. dimer could be useful as an indicator in diagnosis of mesenteric ischemia in COVID patients. A two staged damage control emergency laparotomy is of good benefits in such patients.

Abstract

Bowel ischemia in COVID 19 patients is extremely rare condition results from migrating thrombus formed by a hypercoagulable inflammatory state that is frequently associated COVID 19 infection. A two staged damage control emergency laparotomy is of good benefits in general especially in those with active COVID 19 infection.

Exploring D-Lactate as a Biomarker for Acute Intestinal Necrosis in 2958 Patients: A Prospective Cross-Sectional Study

BACKGROUND

Timely diagnosis of acute intestinal necrosis (AIN) is lifesaving, but challenging due to unclear clinical presentation. D-lactate has been proposed as an AIN biomarker.

OBJECTIVES

We aimed to test the diagnostic performance in a clinical setting.

METHODS

We performed a cross-sectional prospective study, including all adult patients with acute referral to a single tertiary gastrointestinal surgical department during 2015-2016 and supplemented by enrollment of high-risk in-hospital patients suspected of having AIN during 2016-2019. AIN was verified intraoperatively, and D-lactate was analyzed using an automatic spectrophotometric set-up. A D-lactate cut-off for AIN was estimated using the receiver operating characteristic curve. The performance according to patient subgroups was estimated using the area under the receiver operating characteristic curve (AUC). Given the exploratory nature of this study, a formal power calculation was not feasible.

RESULTS

Forty-four AIN patients and 2914 controls were enrolled. The D-lactate cut-off was found to be 0.0925 mM. Due to lipemic interference, D-lactate could not be quantified in half of the patients, leaving 23 AIN patients and 1456 controls for analysis. The AUC for the diagnosis of AIN by D-lactate was 0.588 (95% confidence interval 0.475-0.712), with a sensitivity of 0.261 and specificity of 0.892. Analysis of high-risk patients showed similar results (AUC 0.579; 95% confidence interval 0.422-0.736).

CONCLUSION

D-lactate showed low sensitivity for AIN in both average-risk and high-risk patients. Moreover, lipemic interference precluded valid spectrophotometric assessment of D-lactate in half of the patients, further disqualifying the clinical utility of D-lactate as a diagnostic marker for AIN.

Mesenteric Arteriovenous Dysplasia/Vasculopathy: Deciphering a Rare, Deceptive, Diagnostic Dilemma

Mesenteric arteriovenous dysplasia/vasculopathy (MAVD/V) is an exceedingly rare noninflammatory vascular disorder affecting small-calibre mesenteric arteries and veins. This report details a case of a 51-year-old male diagnosed with MAVD/V following abdominal pain and vomiting. Surgical exploration revealed distinctive smooth muscle collarette around subserosal arteries and veins. The rarity of this condition, with only 13 cases reported globally, underscores the importance of recognizing this rare entity to prevent misdiagnosis. Surgical resection remains the curative approach, ensuring a disease-free state after surgery. Awareness of MAVD/V is crucial for accurate diagnosis and avoiding unnecessary prolonged management.

Long-term aspirin use in patients hospitalized with ischemic colitis

Background

Ischemic colitis is a form of mesenteric ischemia that often presents in patients with vascular disease. Long-term aspirin use has been shown to improve the outcomes in patients with cardiovascular or cerebrovascular disease. However, the relationship between aspirin use and ischemic colitis is unclear.

Methods

Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample. Patients were stratified by long-term aspirin use at the time of hospitalization. Data were collected regarding mortality, bowel perforation, peritonitis, shock, blood transfusion, length of stay in days (LOS), hospital charges, age, sex, race, primary insurance, median income, hospital region, hospital size, and comorbidities. The relationship between aspirin use and outcomes was analyzed using multivariate regression analysis.

Results

A total of 67,685 patients were included. Aspirin users had a mean age of 72.8 years compared to 66.8 years for non-aspirin users. Long-term aspirin use was associated with a lower risk of in-hospital mortality (P<0.001), bowel perforation (P<0.001), peritonitis (P=0.01), shock (P<0.001), and blood transfusion (P<0.001). The mean LOS was 6.1 days in the aspirin group compared to 9.4 days in the non-aspirin group. Ischemic colitis patients taking aspirin had a mean hospitalization charge of $87,123 compared to $161,610 for those not using aspirin.

Conclusions

Our study examined the impact of aspirin use in ischemic colitis patients. Among patients hospitalized with ischemic colitis, we found that long-term aspirin use was associated with a lower risk of in-hospital mortality and adverse events.

Superior mesenteric artery clinical classification and morphometrical analysis

BACKGROUND

The superior mesenteric artery is one of the most important arteries in the abdominal cavity, which is of great clinical importance, especially in surgical procedures and fatal ischemic complications. The aim of this study was to develop a clinical classification of the superior mesenteric artery.

MATERIALS AND METHODS

Postmortem contrast-enhanced computed tomography of 104 (29.8% female, age 50.7±18.7) human bodies were analyzed. Based on anatomic predisposition to ischemic and iatrogenic complications, a three-tiered clinical classification of the superior mesenteric artery was developed. Type 0 was defined as standard risk for ischemic and iatrogenic complications. Type 1 was defined as increased thromboembolic risk with decreased risk of iatrogenic bleeding, and type 2 was defined as decreased ischemic risk with increased risk of iatrogenic bleeding. The supply area of the superior mesenteric artery was divided into 4 regions: pancreas, caecum, ascending colon, and transverse colon.

RESULTS

Type 0 (standard risk) was found in 62.5% of cases. Type 1 was most frequently observed in the ascending colon region (15.4%). Type 2 was most frequently observed in the pancreatic region (17.3%). Regarding type, most abnormalities were found in the region of the ascending colon (18.3%), pancreas region (17.3%), and transverse colon (16.3%).

CONCLUSIONS

The proposed clinical classification of SMA links anatomic variations in morphology with their clinical significance. A simple, three-level classification can be easily applied in daily practice and serve as a great support for preoperative evaluation and recognition of patients at risk of iatrogenic or thromboembolic complications.

Conservatively Treated Mesenteric Vein Thrombosis in a 48-Year-Old Obese Female: A Case Report

Mesenteric vein thrombosis (MVT) is a rare pathological entity that results in compromised venous return from the intestine due to involvement, in most cases, of the superior mesenteric vein. Its diagnosis is not straightforward, since the findings on physical examination are often disproportionate to the patient's pain complaints, leading to it being undervalued by clinicians. The patient is a 48-year-old female with a medical history of essential arterial hypertension, dyslipidemia, class II obesity, and Hashimoto's thyroiditis. She also had a family history of gastric and colon cancer, with an age at diagnosis of over 70 years. She went to an appointment at a primary care facility for abdominal pain located in the left hypochondrium and flank, with ipsilateral lumbar irradiation and no other accompanying symptoms. Physical examination revealed a globose, depressible abdomen, painful on palpation of the left quadrants, with no other associated signs of peritoneal irritation. Due to suspicion of acute diverticulitis, the patient was referred to the emergency department (ED) for assessment by general surgery. In the emergency department, given the patient's body type and the fact that the physical examination findings were disproportionate to her symptoms, an abdominal and pelvic computed tomography (CT) scan was ordered, which revealed complete thrombosis of the entire length of the inferior mesenteric vein, with a focal extension of the thrombus, partially obstructing the confluence with the superior mesenteric and portal veins. Various complementary diagnostic tests were requested, which revealed no clinically significant findings, and obesity was therefore identified as the only risk factor. In this context, the patient started anticoagulation with warfarin, with the indication that it should be ad aeternum. To date, the patient remains asymptomatic, and there have been no new thrombotic events. Given the high morbidity and mortality rates of this pathological entity, it is imperative that clinicians are trained to recognize the typical signs of mesenteric venous thrombosis, in the characteristic epidemiological context, in order to establish a timely diagnosis and carry out early targeted therapeutic intervention.

Postoperative Distal Enteral Tube Refeeding in Stoma Patients: A Comparative Analysis of Clinical Outcomes

<b><br>Introduction:</b> Stoma surgery, which involves creating a diversion of the small intestine through an abdominal wall opening, poses challenges in managing fluid and electrolyte imbalances. Patients with high proximal stoma often rely on costly and risky parenteral nutrition (PN). Distal enteral tube feeding, a method of delivering nutrition to the small intestine, is intended to improve clinical outcomes and reduce complications. This study presents a comparative analysis of clinical outcomes between postoperative distal enteral tube refeeding and traditional enteral and PN approaches in stoma patients with distal mucous fistula.</br> <b><br>Aim:</b> To evaluate the effectiveness of distal enteral tube refeeding in improving postoperative outcomes after stoma surgery and to examine the impact of distal enteral tube refeeding on total hospitalization stay, ICU length of stay, TPN duration, and time to closure of the stoma.</br> <b><br>Material and methods:</b> The study is a retrospective, single-center trial involving 84 patients who had undergone stoma surgery. The patients were divided into two groups: those receiving postoperative distal enteral tube refeeding (n = 42) and the control group (n = 42), with standard mucous fistula creation. The data was collected retrospectively from January 2012 to January 2022 and the statistical analysis was performed using descriptive statistics, the chi-square test, and the t-test.</br> <b><br>Results:</b> The results of our study show that the patients who had undergone postoperative distal enteral tube refeeding had a significantly shorter total hospitalization stay (p = 0.0002), a significantly shorter ICU length of stay (p = 0.0006), a significantly shorter TPN duration (p= 0.0004), and a significantly faster time to closure (p = 0.0002).</br>.

Mesenteric Arterial Thrombosis Revealing Relapse of Nephrotic Syndrome in Young Women

Background

Nephrotic syndrome (NS) is associated with a hypercoagulable state and may be complicated by thrombotic events. Venous thrombosis is well-acknowledged, while arterial thrombosis is rather unusual.

Case Presentation

We present the case of a 20-year-old woman with a 12-year history of idiopathic NS revealed by extensive cerebral venous thrombosis with pulmonary embolism treated with anticoagulation therapy and oral corticosteroid therapy followed by mycophenolate mofetil (MMF). The thrombophilia assessment did not show any abnormalities. The evolution was marked by the occurrence of several NS relapses controlled by oral corticosteroid therapy until 2017. Subsequently, the patient had not presented a relapse of her disease. The anticoagulant treatment and the MMF were therefore stopped. One year later, the patient presented with severe diffuse acute abdominal pain associated with postprandial vomiting and bilateral lower limb edema. Laboratory results confirmed a NS relapse. An abdominal CT scan revealed acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. Intraoperative exploration showed mesenteric ischemia with extensive necrosis of the small intestine making their resections incompatible with life. The patient died after 48 hours.

Conclusion

Mesenteric arterial thrombosis, which is a rare but life-threatening NS complication, should always be considered, especially in the case of acute non-specific digestive symptoms.

The Global Burden of Vascular Intestinal Disorders in 204 Countries and Territories From 1990 to 2019: Global Burden of Diseases Study

Objectives: Assess the prevalence, mortality, and disability-adjusted life years (DALYs) of vascular intestinal disorders (VID) from 1990 to 2019. Methods: This study conducted a secondary data analysis utilizing the Global Burden of Diseases Study 2019. The prevalence, mortality and DALYs of VID were analyzed by sex, age and socio-demographic index (SDI), respectively. Analyses were performed by using R software. Results: Globally, the number of prevalent VID cases increased from 100,158 (95% uncertainty interval: 89,428-114,013) in 1,990-175,740 (157,941-198,969) in 2019. However, the age-standardized rates (ASR) of VID prevalence declined from 2.47 (95% uncertainty interval: 2.24-2.76) per 100,000 population to 2.21 (1.98-2.48) per 100,000 population between 1990 and 2019. Furthermore, the ASR of mortality also decreased from 1990 to 2019. Between 1990 and 2019, the regions with high and high-middle level exhibited the highest diseases burden. Conclusion: Globally, the diseases burden associated with VID demonstrated a decline from 1990 to 2019. However, concerted efforts are still required to enhance measures to combat VID within countries categorized as high and high-middle SDI.

A Lethal Combination: Legionnaires' Disease Complicated by Rhabdomyolysis, Acute Kidney Injury, and Non-Occlusive Mesenteric Ischemia

BACKGROUND Legionnaires' disease is one of the most common types of community-acquired pneumonia. It can cause acute kidney injury and also occasionally become severe enough to require continuous renal replacement therapy (CRRT). Non-occlusive mesenteric ischemia (NOMI) is a condition characterized by ischemia and necrosis of the intestinal tract without organic obstruction of the mesenteric vessels and is known to have a high mortality rate. CASE REPORT A 72-year-old man with fatigue and dyspnea was diagnosed with Legionnaires' disease after a positive result in the Legionella urinary antigen test pneumonia confirmed by chest radiography and computed tomography. He developed acute kidney injury, with anuria, rhabdomyolysis, septic shock, respiratory failure, and metabolic acidosis. We initiated treatment with antibiotics, catecholamines, mechanical ventilation, CRRT, steroid therapy, and endotoxin absorption therapy in the Intensive Care Unit. Despite ongoing CRRT, metabolic acidosis did not improve. The patient was unresponsive to treatment and died 5 days after admission. The autopsy revealed myoglobin nephropathy, multiple organ failure, and NOMI. CONCLUSIONS We report a fatal case of Legionnaires' disease complicated by rhabdomyolysis, acute kidney injury, myoglobin cast nephropathy, and NOMI. Legionella pneumonia complicated by acute kidney injury is associated with a high mortality rate. In the present case, this may have been further exacerbated by the complication of NOMI. In our clinical practice, CRRT is a treatment option for septic shock complicated by acute kidney injury. Thus, it is crucial to suspect the presence of NOMI when persistent metabolic acidosis is observed, despite continuous CRRT treatment.

Severe ischemic gastritis caused by chronic mesenteric ischemia

Ischemic gastritis is a rare illness caused by localized or systemic vascular insufficiency. This condition is rarely seen in medical practice due to the vast arterial collateral blood supply to the stomach through the celiac trunk and superior mesenteric artery and also because other etiologies are much more frequent. The classic presentation of chronic ischemia is comprises the triad of postprandial pain, weight loss, and abdominal bruit. Intervention is indicated in symptomatic patients and endovascular treatment is an alternative to surgery in patients with high comorbidity that offers good results. We report a case of a 71-year-old female patient with severe ischemic gastritis with ulcers and bleeding caused by chronic mesenteric ischemia with occlusion of the celiac trunk and inferior mesenteric artery and critical stenosis of the superior mesenteric artery. The diagnosis was confirmed by imaging, and the patient underwent endovascular treatment. This is a rare condition that is difficult to diagnose and treat and a multidisciplinary team is needed for proper management.

Mesenteric Ischemia in a Splenectomized Patient with Auto-Immune Hemolytic Anemia: Case Report

Mesenteric ischemia is a serious complication that can occur after splenectomy for hemolytic anemia, potentially leading to lifelong intestinal problems such as ischemia and/or portal hypertension. We present the case of a 33-year-old man with a history of autoimmune hemolytic anemia and splenectomy who developed mesenteric ischemia. The patient experienced abdominal pain and diarrhea, and imaging studies revealed mesenteric vein thrombosis. Surgical intervention confirmed the diagnosis. This case significantly contributes to the existing literature by providing insights into the occurrence of mesenteric ischemia in younger individuals with predisposing factors, as well as its clinical presentation, diagnostic challenges, and severity. Moreover, it has implications for the future diagnosis and management of long-term mesenteric ischemia in patients who have undergone splenectomy for hemolytic anemia.

Retrograde mesenteric perfusion from the deep femoral artery in a patient with a recurrent anastomotic aneurysm in the groin: a case report

In patients with atherosclerotic disease in two of the three main vessels in the splanchnic circulation, symptoms of chronic mesenteric ischemia may arise, depending on the disease chronicity and the presence of mesenteric collateral pathways. The most commonly described collateral pathways are between the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA); and between the IMA and the internal iliac artery (IIA). Another collateral network between the deep femoral artery and the IIA can also become important, especially in patients with aorto-iliac occlusion. Here we report a patient with a symptomatic anastomotic aneurysm of the right femoral artery after a previous aorto-bi-femoral bypass. This patient's bowel viability relied on a well-developed collateral network from the ipsilateral deep femoral artery. This unusual anatomy required special surgical considerations and planning, to minimize the risk of perioperative mesenteric ischemia. During open repair, distal femoral debranching with a distal-to-proximal anastomotic sequence allowed minimizing of the ischemic time, and avoidance of potential ischemic complications from the visceral circulation. This case emphasizes the importance and benefit of the deep femoral artery and its collaterals as a reserve network of the splanchnic circulation. Favorable outcomes can be achieved with careful analysis of the preoperative imaging and proper planning, with adaptation of the surgical strategy.

Erector Spinae Plane Block (ESPB) as an Alternative for Celiac Plexus Blocks: Expanding ESPB Indications for Mesenteric Ischemia Relief

Mesenteric ischemia is a severe condition associated with abdominal pain which often requires multimodal analgesia, including opioids or sympathetic blocks such as celiac plexus blocks. The erector spinae plane (ESPB) has emerged as a potentially effective alternative for managing pain in various surgical and non-surgical conditions. This case report explores the use of ultrasound-guided ESPB as a novel approach to pain management in a patient with acute on chronic mesenteric ischemia. A 70-year-old male with a history of mesenteric ischemia and multiple comorbidities presented with worsening diffuse abdominal pain. Despite medical and surgical treatment, the patient required a high dose of opioids for pain control. Bilateral ESPBs with continuous infusions were performed at the T6 level under ultrasound guidance. The patient reported immediate and complete relief from abdominal pain following the block, with a significant drop in the pain score. The use of opioids was significantly reduced. This case report demonstrates the potential benefits of ultrasound-guided ESPB as an alternative to traditional pain management techniques in patients with mesenteric ischemia. ESPB may provide safe, simple, and effective analgesia, reducing the need for high-dose opioids and their associated side effects. Further studies are warranted to validate these findings and explore the broader application of ESPB in the management of mesenteric ischemia pain.

Management of spontaneous isolated mesenteric artery dissection

Spontaneous isolated mesenteric arterial dissection (SIMAD) is an uncommon subset of non-traumatic dissection of the mesenteric arteries without concurrent aortic dissection. Due to the widespread use of computer tomography angiography, SIMAD cases have been increasingly reported in the past 20 years. Common risk factors associated with SIMAD include male gender, age 50-60 years, hypertension and smoking. This review summarises the diagnostic pathway and management of SIMAD based on contemporary literature and proposes a treatment algorithm for SIMAD. The presentation of SIMAD can be divided into symptomatic and asymptomatic cases. Symptomatic patients should be carefully assessed to detect the development of complications, particularly bowel ischemia or vessel rupture. Although these complications are rare, they necessitate urgent surgical management. The vast majority of symptomatic SIMAD cases are uncomplicated and can be managed safely with conservative treatment that includes antihypertensive therapy, bowel rest, with or without antithrombotic therapy. For asymptomatic SIMAD cases, expectant management with outpatient surveillance imaging appears to be a safe strategy.

Worsening Isolated Superior Mesenteric Artery Dissection on the Day After Discharge

A 59-year-old male was transported to the emergency department by ambulance with complaints of left-sided abdominal pain. Blood gas analysis revealed elevated lactate, and plain computed tomography revealed no bowel ischemic change. Contrast-enhanced computed tomography revealed isolated superior mesenteric artery dissection with mildly stenosed true lumen. The patient was treated with conservative management on admission. Staged fluid intake, oral prescriptions, and diet were commenced with attention to the symptoms. After four days of hospitalization, the patient was discharged with a stable condition. However, the patient returned to our hospital complaining of left lower back pain three hours after discharge. Contrast-enhanced computed tomography revealed an enlarged false lumen with a moderately stenosed true lumen. After a thorough discussion between vascular surgeons and interventional radiologists, conservative management was commenced on the second admission. The clinical course was uneventful, with proof of improved imaging findings.

Conservative Treatment for Isolated Superior Mesenteric Artery Dissection With Severely Narrowed True Lumen

A 59-year-old male presented to the emergency department with distressing epigastric pain after seeking medical attention at a nearby clinic three hours prior. Upon examination, the attending physician noticed edematous changes in the proximal segment of the superior mesenteric artery, and a subsequent enhanced computed tomography (CT) scan confirmed the diagnosis of an isolated dissection of the artery. Notably, the true lumen of the vessel was significantly narrowed, raising concerns for potential vascular compromise. After extensive consultation between a vascular surgeon and a radiologist, a decision was made to adopt a conservative management approach. The patient was closely monitored with meticulous bowel rest, hydration management, and carefully curated dietary modifications. Over time, subsequent CT scans revealed progressive enlargement of the true lumen, which was highly reassuring to the medical team. As a result of the expert management and diligent care provided, the patient was eventually discharged home without any adverse events or complications. This case highlights the critical role of a multidisciplinary approach in managing complex vascular pathology and underscores the importance of thoughtful clinical decision-making and meticulous monitoring in achieving favorable outcomes.

Acute mesenteric ischemia and COVID-19: an integrative review of the literature

The novel coronavirus disease 2019 (COVID-19) has spread rapidly around the world after the first cases were reported in December 2019 in China. Despite the prevention of the symptoms presented, extrapulmonary manifestations were identified. In particular, there was an increase in cases of Acute Mesenteric Ischemia (AMI), raising its incidence to 1.9%-3.8% in infected patients. The aim of this study was to investigate the existence of an association between IMA and COVID-19 through the literature. An Integrative Literature Review was carried out. The research question was "mesenteric ischemia in patients with COVID-19: coincidence or association?". After searching the database and applying the inclusion and exclusion criteria, 44 were selected for analysis. COVID-19 was confirmed by RT-PCR and imaging tests, gastrointestinal manifestations, alterations and primarily tomographic imaging findings were identified. Most patients were accelerated to laparotomy. As explanations include direct endothelial and injury by the binding of the ACE-2 virus, between hyperinflammation and hypercoagulability, dysregulation of the renin-angiotensin-aldosterone system and factors associated with the severity of the virus. IMA is an emergency with high associated morbidity and mortality, these cases may be a consequence mainly of the thromboinflammatory mechanism associated with SARS-CoV-2. An early diagnosis, diagnosis and diagnoses are crucial to clinical treatment; an assessment regime should be considered in accordance with current evidence and guidelines.

MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model

BACKGROUND

MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known.

PURPOSE

To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI.

STUDY TYPE

Prospective/cohort.

ANIMAL MODEL

Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs).

FIELD STRENGTH/SEQUENCE

A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spin-echo, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI).

ASSESSMENT

T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed.

STATISTICAL TESTS

Paired Student's t-test or Mann-Whitney U-test, significance at P < 0.05.

RESULTS

One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (-31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours.

DATA CONCLUSION

Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Enterocolic phlebitis: a rare cause of bowel ischemia and review of the literature

Enterocolic phlebitis (EP) is a rare cause of bowel ischemia due to isolated venulitis of the bowel wall and mesentery without arterial involvement. EP is often misdiagnosed as inflammatory bowel disease, carcinoma, or diverticulitis due to non-specific symptoms as well as non-specific clinical and radiological findings. While unresponsive to pharmacotherapy, surgical resection of the affected bowel appears to be the only successful therapy with a very low recurrence rate. Etiology of EP remains unknown. We report a case of EP with rare presentation in the left hemicolon and unusual histological findings emphasizing the heterogeneity of this cause of enterocolic ischemia. The review and comparison of the three entities-EP, mesenteric inflammatory veno-occlusive disease (MIVOD), and idiopathic myointimal hyperplasia of mesenteric veins (IMHMV), all describing patterns of bowel ischemia due to isolated pathology of mesenteric veins-reveal that the current terminology is unclear. EP and MIVOD are very similar and may be considered the same disease. IMHMV, though, differs in localization, symptom duration, and histological findings but also shares features with EP and MIVOD. Further studies and harmonized terminology are inevitable for better understanding of the disease, prevention of unnecessary pharmacotherapy, and reduction in time to diagnosis.

Imaging of Bowel Ischemia: An Update, From the AJR Special Series on Emergency Radiology

Acute mesenteric ischemia is a life-threatening condition that results from abrupt reduction in or cessation of blood flow to the bowel. Characterized by nonspecific abdominal symptoms, mesenteric ischemia is infrequently encountered and commonly misdiagnosed, with potentially catastrophic consequences. Prompt clinical diagnosis and early implementation of therapeutic interventions are critical to improving patient outcomes. Because cross-sectional imaging plays a key role in the diagnosis of mesenteric ischemia, radiologists must be familiar with the varied imaging manifestations of intestinal ischemia. Thus, the objectives of this article are to review the various types and common causes of mesenteric ischemia and to describe its spectrum of multimodality imaging findings, with special attention to novel imaging techniques and emerging diagnoses.

Short-Term Outcomes and Risk Factors of In-Hospital Mortality in Patients Suffering Acute Mesenteric Ischemia after Cardiac Surgery: Role of Opioids and Lactic Acid

Acute mesenteric ischemia (AMI) is associated with poor clinical results after cardiac surgery. The aim of this study was to analyse the influence of AMI on short-term outcomes and all relevant risk factors of in-hospital mortality after cardiac surgery. Moreover, we aimed to investigate the role of opioids and lactic acid in the detection and prevention of AMI. Between August 2011 and September 2015, 176 consecutive patients with gastrointestinal complications after undergoing open-heart surgery were identified and included in this study. All patients were divided into two groups: AMI group (n = 39) and non-AMI group (n = 137). In terms of comorbidities, the groups were fairly equal and showed no significant differences. Dialysis was significantly higher (p < 0.001) in patients that suffered from AMI. Moreover, gastro-intestinal symptoms such as muscular defense (p = 0.004) and the laparotomy rate (p < 0.001) were significantly higher in the AMI group. Likewise, in-hospital mortality (p < 0.001) was significantly higher in patients with detected AMI. Univariate (p < 0.001) and multivariate analysis (p = 0.025) of both groups revealed that lactic acid value >2 mmol/L and present treatment with opioids are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Moreover, multivariate analysis showed peripheral vascular disease (p = 0.004), dialysis (p = 0.010), and septic shock (p = 0.003) as relevant predictors of in-hospital mortality. Prolonged analgetic treatment with opioids and sudden increase of lactic acid levels are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Furthermore, peripheral vascular disease, dialysis, and septic shock are relevant predictors for in-hospital mortality.

Effects of N-acetylcysteine on the inflammatory response and bacterial translocation in a model of intestinal obstruction and ischemia in rats

PURPOSE

To evaluate effect of N-acetylcysteine (NAC) associated with Ringer lactate or hypertonic saline in inflammation and bacterial translocation on experimental intestinal obstruction (IO).

METHODS

Wistar rats was subjected to IO. Six or 24 hours after, rats were subjected to enterectomy and fluid resuscitation: IO, RL (subjected to the same procedures but with fluid resuscitation using Ringer's lactate solution); RLNAC (added NAC to Ringer's solution); and HSNAC (surgical procedure + fluid reposition with 7.5% hypertonic saline and NAC). After 24 h, tissues were collected to cytokines, bacterial translocation, and histological assessments.

RESULTS

In kidney, interleukin-1beta (IL-1beta) was lower in the groups with fluid resuscitation compared to IO group. The RLNAC showed lower levels compared to the RL. Interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-alpha), and (IFN-gamma) were lower in the treatment groups than in IO. In lung, IL-1beta and IL-6 were lower in RLNAC compared to IO. IL-10 was lower in RL, RLNAC and HSNAC compared to IO. TNF-alpha was higher in HSNAC compared to both RL and RLNAC. Bacterial translocation was observed in all animals of IO group. In kidneys, inflammation and congestion degrees were lower in HSNAC compared to RL. In lungs, inflammation levels were higher in RLNAC compared with the sham group.

CONCLUSIONS

The data indicates that NAC associated with RL can promote a decrease in the inflammatory process in the kidneys and lungs in rats, following intestinal obstruction and ischemia in rats.

A rare complication of IgA vasculitis: renal and intestinal ischemia successfully treated with plasmapheresis

BACKGROUND

IgA vasculitis (IgAV) is a multisystemic small vessel vasculitis and is the most common vasculitis in childhood. The characteristic findings of IgAV are palpable purpuric rash, abdominal pain, arthralgia or arthritis, and hematuria. Ischemic complications are very rare in IgAV. Thrombotic complications can be observed after a COVID-19 infection. Also in the presence of familial Mediterranean fever, IgAV may have an atypical or more severe course.

CASE

We present a case of IgAV complicated with renal infarction and intestinal ischemia. There was no recent or distant history of COVID-19 in the patient or family members, but the patient`s COVID-19 antibody was positive. In addition, MEFV gene analysis of the patient showed homozygous M694V mutation. The patient did not respond to enoxaparin, pulse methylprednisolone, intravenous immunoglobulin (IVIG), iloprost, and cyclophosphamide treatments. She was successfully treated with six sessions of plasmapheresis.

CONCLUSIONS

Plasmapheresis seems to be an effective treatment option in IgAV-related ischemic findings that do not respond to intensive immunosuppressive therapy.

Open revascularization in a patient with chronic mesenteric ischemia and a history of aorto-bifemoral bypass - a case report

INTRODUCTION

This case report describes surgical treatment of chronic mesenteric ischemia in a polymorbid patient with the history of an aorto-bifemoral bypass implant.

CASE REPORT

The patient suffered from chronic occlusions of the mesenteric arteries. He experienced postprandial pain and significant weight loss. Endovascular repair of the occlusions failed. Open single retrograde bypass from the left branch of the aorto-bifemoral graft to the superior mesenteric artery was implanted successfully.

CONCLUSION

The discussion briefly mentions current trends in the treatment of chronic mesenteric ischemia. Despite the development of interventional radiology, surgical treatment remains a relevant alternative for the management of chronic mesenteric ischemia.

Clostridium ramosum Bacteremia With Mesenteric Ischemia Secondary to Superior and Inferior Mesenteric Arteries Occlusion

Clostridium ramosum, despite being a common enteric bacterium, is not commonly identified as the cause of pathologic infections in humans. It was first identified by Veillion and Zuber in 1898 from a patient with pulmonary gangrene and appendicitis. After performing an extensive literature search of major databases, only a few cases of pathologic C. ramosum infection were found in the medical literature. In this piece of work, we add to existing research by presenting a case report of an 83-year-old female who presented with abdominal pain, fever, and shortness of breath, requiring ICU admission due to mesenteric ischemia and C. ramosum bacteremia.

[Computed tomography diagnostics of acute and chronic mesenteric ischemia]

BACKGRAUND

Chronic mesenteric ischemia is more often accompanied by clinical signs characteristic of colitis. Acute mesenteric ischemia, unlike chronic, is accompanied by nonspecific symptoms and is a serious disease that requires urgent diagnosis.

AIMS

The aim of the study was to evaluate the effectiveness of MSCT in the diagnosis of acute and chronic mesenteric ischemia based on our observations.

MATERIALS AND METHODS

The retrospective study included 135 patients with abdominalgia and suspected mesenteric ischemia who underwent multiphase CT of the abdominal cavity with intravenous bolus contrast enhancement. Group 1 included 105 patients with mesenteric ischemia; group 2 included 30, without confirmed mesenteric ischemia, with the presence of a symptom of mesenteric ischemia in the form of abdominalgia.

RESULTS

We studied 135 patients, including 105 patients with mesenteric ischemia, 59 women and 46 men of average age 60±14.9 years. The acute form of ischemia (58%) was determined 1.5 times more often than the chronic one. Occlusive and nonocclusive acute mesenteric ischemia occurred in equal proportions. Mesenteric arterial thrombosis was the cause of acute mesenteric ischemia in 23% of cases. Mesenteric venous thrombosis was the cause of chronic intestinal ischemia in 61%, in 5% - acute form. Mixed arterial-venous genesis of mesenteric ischemia was determined in 4% against the background of strangulation obstruction. Dunbar syndrome as a cause of chronic intestinal ischemia was diagnosed in 16%. Chronic ischemic enterocolitis accounted for 10% of all cases of mesenteric ischemia and 23% of chronic ischemia. Symptoms and symptom complexes characteristic of the studied series of diseases with acute or chronic mesenteric ischemia were delineated. Sensitivity, specificity and prognostic value of CT with intravenous bolus contrast enhancement in diagnostics of diseases accompanied by mesenteric ischemia reached 100%.

CONCLUSIONS

Multiphase CT of the abdominal cavity with bolus contrast enhancement is highly informative in the diagnosis of acute and chronic forms of mesenteric ischemia. Direct CT signs of impaired blood flow in the arteries or veins of the mesentery were indisputable. Indirect signs of mesenteric ischemia were aimed at a thorough analysis of the condition of mesenteric vessels.

Are the conventional scoring systems efficient in predicting mortality of acute mesenteric ischemia?: Mortality estimation in patients with AMI

Acute mesenteric ischemia is a surgical emergency with high morbidity and mortality rates. Therefore, it is important to determine the prognosis for this disease. In the present study, we aimed to compare the prediction accuracy of 3 scoring systems: Acute physiology and chronic health evaluation II, sequential organ failure assessment score and simplified acute physiology score II (SAPS II). The retrospective cohort study was conducted in a university hospital. Eighty-two acute mesenteric ischemia patients were evaluated retrospectively. The mortality prediction abilities of the scoring systems were evaluated by comparing the prediction rates of > 10%, 30% and 50% and the actual mortality among survivors and non-survivors in pairs. Predicted mortality rates among survivors and non-survivors differed among the 3 classification systems. The mortality estimates of the SAPS II were closer to the actual mortality rates. Analysis of the estimated mortality rates as mortality risk limits showed that acute physiology and chronic health evaluation II was superior to sequential organ failure assessment score and SAPS II in estimating mortality rates, whereas SAPS II was more successful in detecting survivors. The estimated mortality rates of the 3 rating systems, the estimated mortality rates were higher in the non-survivor group than in the survivor group. The accuracy of the SAPS II in determining prognosis was relatively better.

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio use in detecting bowel ischaemia in adhesional small bowel obstruction

BACKGROUND

Bowel ischaemia significantly increases morbidity and mortality from adhesional small bowel obstruction. Current biomarkers and clinical parameters have poor predictive value for ischaemia. Our study investigated whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) could be used to predict bowel ischaemia in adhesional small bowel obstruction.

METHODS

This single-centre retrospective study collected clinical, biochemical and radiological data from patients with adhesional small bowel obstruction between 2017 and 2020 who underwent operative management. The presence or absence of bowel ischaemia/infarction was used to distinguish two populations. Biochemical markers on admission and immediately prior to operation were collected to give platelet-lymphocyte ratio (PLR₀ and PLR_PRE-OP , respectively) and neutrophil-lymphocyte ratio (NLR₀ and NLR_PRE-OP , respectively). SAS 9.4 (SAS Institute Inc., Cary, NC) software was used for data analysis with Mann-Whitney U testing for continuous variables and Pearson Chi-square test for categorical variables. Sensitivity and specificity for PLR and NLR were calculated by means of receiver operating characteristic (ROC) curve analysis.

RESULTS

Twenty-seven patients had intra-operative bowel ischaemia whilst the remaining 73 had no evidence of bowel ischaemia. Both median PLR_PRE-OP and NLR_PRE-OP were significantly higher in patients with bowel ischaemia compared to those without (PLR_PRE-OP 272 [IQR 224-433] and 231 [IQR 146-295] respectively, P = 0.027; NLR_PRE-OP 12.5 [IQR 8.6-21.3] v. 5.5 [IQR 3.5-10.2] respectively, P ≤ 0.001). Area under the receiver operator characteristic curve (AUC) was 0.762 for NLR_PRE-OP , with a sensitivity of 85.1% and specificity of 63% for NLR 7.4.

CONCLUSION

Raised NLR is predictive of bowel ischaemia in patients with adhesional small bowel obstruction.

Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis

PURPOSE

Thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive alternative option in the treatment of thoracoabdominal aortic aneurysm (TAAA) diseases, reporting lower morbidity and mortality rates compared with open or hybrid repair. A challenging situation arises when the aneurysm involves the celiac artery (CA), precluding a safe distal landing zone. We investigated the safety and efficacy of CA coverage in the treatment of complex TAAA diseases during endovascular management.

MATERIALS AND METHODS

A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The electronic bibliographic sources searched were MEDLINE and SCOPUS databases. Primary outcomes of interest were perioperative and 30-day mortality. Any type of endoleak, mesenteric ischemia, perioperative spinal cord ischemia, and reintervention rates were secondary end points. A random-effects meta-analysis was performed. Summary statistics of event risks were expressed as proportions and 95% confidence interval (CI).

RESULTS

Ten observational cohort studies published between 2009 and 2020, reporting a total of 175 patients, were eligible for quantitative synthesis. Indications for TEVAR were primary TAAAs in 82% of patients, aortic dissection in 14% of patients, type Ib endoleak after previous endograft deployment in 3% of patients, and penetrating aortic ulcer in 1 patient. Reintervention rate was 9% (95% CI, 4%-20%) and spinal cord ischemia was 7% (95% CI, 4%--12%). Type II endoleak was the predominant type of endoleak in 10% of patients (95% CI, 4%-22%), followed by type I endoleak in 5% of patients (95% CI, 2%-12%) and type III endoleak in 1% (95% CI, 0%-16%) of patients. Mesenteric ischemia occurred in 6% of patients (95% CI, 3%-10%). Thirty-day mortality was 5% (95% CI, 2%-13%) and the pooled estimate for overall mortality was 21% (95% CI, 14%-31%).

CONCLUSIONS

Celiac artery coverage during TEVAR is a challenging but feasible option for the treatment of TAAA diseases, providing acceptable morbidity and mortality rates. Demonstration of adequate visceral collateral pathways before definitive CA coverage is the sine quo non for the success of the technique.

The Association of Cannabis Use Disorder with Acute Limb Ischemia and Critical Limb Ischemia

OBJECTIVES

Heavy cannabis use has been associated with the development of acute myocardial infarction and stroke. The objective of this study was to determine if heavy, chronic cannabis use is associated with the development of acute limb ischemia (ALI) or critical limb ischemia (CLI).

METHODS

We conducted a retrospective cohort study within the National Inpatient Sample (2006-2015). Patients without cannabis use disorder (CUD) were matched to patients with CUD in a 2:1 ratio using propensity scores. Our primary outcomes were incidence of ALI and CLI. Secondary outcomes included incidence of acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), frequency of open or endovascular interventions, length of stay, and total costs. Sensitivity analyses were performed with alternative models, including in the entire unmatched cohort with regression models utilizing survey weights to account for sampling methodology.

RESULTS

We identified a cohort of 46,297 857 unmatched patients. Patients with CUD in the unmatched cohort were younger, with less cardiovascular risk factors, but higher rates of smoking and substance abuse. The matched cohort included 824,856 patients with CUD and 1,610,497 controls. Those with CUD had a higher incidence of ALI (OR 1.20 95% CI: 1.04-1.38 P=.016). Following multiple sensitivity analyses, there was no robust association between CLI and CUD. We observed no robust association of CUD with AMI, CMI, procedures performed, frequency of amputation, costs, or total length of stay.

CONCLUSIONS

Cannabis use disorder was associated with a significantly higher incidence of admission for acute limb ischemia. CUD was not associated with an increased risk of critical limb ischemia following sensitivity analysis. Given CUD is often seen in younger, less co-morbid patients it provides an important target for intervention in this population.

COVID-19 and Intestinal Ischemia: A Multicenter Case Series

Introduction

Gastrointestinal symptoms are common among COVID-19 patients. Although gastrointestinal involvements are mostly benign, they rarely indicate a severe pathology like intestinal ischemia. The present case series describes 21 patients with bowel ischemia, necrosis, or perforation.

Methods

The present case series was conducted from April 2020 to February 2022 in the surgical wards of two Iranian hospitals. We retrospectively included adult patients with concomitant COVID-19 and intestinal ischemia. Primary outcomes were defined as the length of stay and survival.

Results

Twenty-four patients with a median age of 61.5 years were included in the study. Sixteen (67%) patients were male, and 13 (54%) were without any comorbidities. Macrovascular mesenteric ischemia was not identified in 21 patients (87.5%). Gastrointestinal manifestations appeared on the median of seven days (range 2–21) after the diagnosis of COVID-19, with the most common symptom being abdominal pain. All the patients had a significantly elevated C-Reactive Protein prior to surgery, ranging from 68 to 362. D-dimer was measured in eight patients and was significantly elevated, ranging from 1,878 to over 5,000 ng/mL. One patient was managed conservatively due to a good clinical condition. Except for one patient with angioinvasive mucormycosis and one other with leukocytoclastic vasculitis, pathologic evaluation revealed general features of intestinal necrosis, including ulcer, hemorrhage, necrosis, neutrophilic infiltration (in seven patients), neutrophilic abscess (in four patients), and edema. Bowel necrosis accompanied mortality of 15 (62.5%) patients and a median of 6.5 days of hospital stay.

Conclusion

Intestinal ischemia in COVID-19 patients is associated with a high mortality rate. Further research is needed to elucidate the dynamics of intestinal ischemia in the setting of COVID-19.

Vasopressors and Risk of Acute Mesenteric Ischemia: A Worldwide Pharmacovigilance Analysis and Comprehensive Literature Review

Vasodilatory shock, such as septic shock, requires personalized management which include adequate fluid therapy and vasopressor treatments. While these potent drugs are numerous, they all aim to counterbalance the vasodilatory effects of a systemic inflammatory response syndrome. Their specific receptors include α- and β-adrenergic receptors, arginine-vasopressin receptors, angiotensin II receptors and dopamine receptors. Consequently, these may be associated with severe adverse effects, including acute mesenteric ischemia (AMI). As the risk of AMI depends on drug class, we aimed to review the evidence of plausible associations by performing a worldwide pharmacovigilance analysis based on the World Health Organization database, VigiBase®. Among 24 million reports, 104 AMI events were reported, and disproportionality analyses yielded significant association with all vasopressors, to the exception of selepressin. Furthermore, in a comprehensive literature review, we detailed mechanistic phenomena which may enhance vasopressor selection, in the course of treating vasodilatory shock.

Incidence and Diagnostic Challenges of Bowel Ischemia after Continuous-flow Left Ventricular Assist Device Therapy

Long-term continuous-flow left ventricular assist device (CFLVAD) therapy is limited by complications. Compared with stroke and renal dysfunction, post-CFLVAD bowel ischemia is poorly characterized. Adult patients who underwent first-time durable CFLVAD implantation at our institution between 2008 and 2018 were identified and screened for bowel ischemia using Current Procedural Terminology codes for abdominal surgical exploration and International Classification of Disease codes for intestinal vascular insufficiency. Patients who developed biopsy-proven bowel ischemia (cases) were matched to controls (1:1, nearest neighbor, caliper = 0.29) based on preoperative characteristics. Incidences of postoperative right heart failure and renal replacement therapy were compared using McNemar's test. One year survival was estimated using the Kaplan-Meier method. Overall, 711 patients underwent CFLVAD implantation. Nineteen (2.7%) developed bowel ischemia (cases) median 17 days postimplantation (IQR 8-71). The majority of cases were male (78.9%), Black (63.2%), received HeartMate II (57.9%), treated as destination therapy (78.9%), and had a history of hypertension (89.5%), chronic kidney disease (84.2%), hyperlipidemia (84.2%), smoking (78.9%), and atrial fibrillation (57.9%). Post-LVAD, case patients were more likely to develop moderate-severe right heart failure (89.5% vs. 68.4%, p = 0.005), require renal replacement therapy (21.1% vs. 0%, p < 0.001), and less likely to survive to discharge (52.6% vs. 89.5%, p = 0.02) compared with controls. Case subjects demonstrated worse 1 year survival. While less common than stroke and renal dysfunction, post-CFLVAD bowel ischemia is associated with high 1 year mortality. Multi-institutional registries should consider reporting abdominal complications such as bowel ischemia as an adverse event to further investigate these trends and identify predictors of this complication to reduce patient mortality.

Predicting outcomes of mesenteric ischemia postcardiac surgery: A systematic review

OBJECTIVE

This systematic review aims to identify predictors of outcomes of mesenteric ischemia in patients following cardiac surgery.

METHODS

A comprehensive literature search was done on EMBASE, PubMed, Ovid MEDLINE, and SCOPUS using keywords relating to bowel ischemia and cardiac surgery. Database search results were screened by at least two authors and 32 articles were selected for inclusion in this review.

RESULTS

Data on 1907 patients were analyzed. The mean age was 70.0 ± 2.99 years and the prevalence of bowel ischemia was 1.74%. Advanced age was a significant risk factor. 63.16% of patients reported were men, and 58.4% of patients died in hospital. There was heterogeneity in the reported significance of the following preoperative risk factors: hypertension, smoking status, type 2 diabetes mellitus, end-stage renal disease, preoperative left ventricular ejection fraction <35%. Cardiopulmonary bypass (CPB) time, preoperative/operative intra-aortic balloon pump (IABP) support, and inotrope usage were significantly associated with the development of mesenteric ischemia; however, other intraoperative factors including the type of cardiac surgery and duration of aortic cross-clamping had varying levels of reported significance. There were discrepancies in the reported significance of leukocytosis and metabolic acidosis (pH <7.3) as postoperative markers. Postoperative vasopressor use, prolonged ventilation time, and elevation in lactate, transaminases, creatinine, and intestinal fatty acid-binding protein (IFABP) levels were found to be strongly associated with bowel ischemia.

CONCLUSION

This systematic review found the strongest associations of mesenteric ischemia postcardiac surgery to be advanced age, CPB time, rise in lactate, transaminases, creatinine, and IFABP. IABP support, vasopressor, and inotrope use as well as prolonged ventilation were strongly linked too.

Tube Feeding-Related Bowel Ischemia Presenting As Extensive Intestinal Pneumatosis Complicated With Hepatic Portal Venous Gas

Hepatic portal venous gas (HPVG) is a condition where air embolization from disrupted intestinal mucosa reaches the portal system. It is an uncommon finding and denotes severity. This report describes HPVG as a rare and lethal complication of enteral nutrition. The patient had a history of pancreatic adenocarcinoma (PADC) managed with Whipple's surgery, complicated with poor oral intake, requiring percutaneous jejunostomy. Subsequently, the patient presented with severe abdominal pain and distension. On imaging, he was found to have diffuse pneumatosis intestinalis (PI) and HPVG. The patient underwent exploratory laparotomy with intraoperative findings of bowel ischemia starting at the distal point of the enteral tube feeding. Despite aggressive intensive support, the patient died. The aim of this case description is to highlight a rare complication of enteral feeding with impressive imaging findings. Intensive care providers should consider this complication in patients with acute abdominal symptoms, who are under enteral feeding.

Laparoscopic Surgery for Median Arcuate Ligament Syndrome (MALS): A Prospective Cohort of 52 Patients

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.

An Improbable Thromboembolic Manifestation of COVID-19: A Case Report

The coronavirus disease 2019 (COVID-19) disease is a multisystem disease and recent studies have shown an increase in reported thromboembolic complications as deep venous thrombosis, pulmonary embolism (PE), stroke, and less frequently mesenteric artery thrombosis. We present a case of a 75-year-old woman, COVID-19 positive with five days of evolution, who was admitted to the emergency room due to diffuse abdominal pain with several days of progression, along with diarrhea and biliary vomit. Abdominal computed tomography presented images of subtraction of the lumen of the upper mesenteric artery. With the reported clinical case the authors intend to clarify the importance of differential diagnosis in patients with a typical severe acute respiratory syndrome coronavirus 2 (SARS CoV2) infection presentation. The gastrointestinal symptoms of SARS CoV2 infection can mask a more severe condition, so a high index suspicion for abdominal thromboembolic events is required once this complication may threaten patient’s life.

Risk factors for ischemic gastrointestinal complications in patients undergoing open cardiac surgical procedures: A single-center retrospective experience

BACKGROUND

Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery.

METHODS

All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC.

RESULTS

Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC.

CONCLUSIONS

We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.

Post-COVID-19 superior mesenteric artery and jejunal branches thromboembolism

The World Health Organization has declared the novel coronavirus disease 2019 (COVID-19) a global public health emergency. Despite the predominating respiratory symptoms occurring in COVID-19, thrombosis can occur in some patients, with morbidity and mortality increase due to the respiratory worsening. This article reports the case of a 62-year-old man with a flu-like illness that was diagnosed as COVID-19 by RT-PCR of SARS-CoV-2. After three weeks, he subsequently developed abdominal pain in addition to bloating, nausea, and vomiting. He underwent exploratory laparotomy after imaging tests suggested mesenteric ischemia. Intestinal ischemia was evident, due to the absence of flow in the superior mesenteric artery and jejunal branches. Embolectomy and enterectomy were performed and they resulted in a favorable outcome, with clinical improvement. This case adds data to the limited literature on extrapulmonary complications of COVID-19, notably those related to thromboembolic events.

Retrograde Superior Mesenteric Artery Stenting in Case of SMA Shuttering

This case describes a patient who underwent endovascular repair for an extent V thoracoabdominal aneurysm with planned coverage of the celiac artery. Following deployment of the stent graft, the superior mesenteric artery was shuttered, and the patient subsequently developed signs and symptoms of bowel ischemia. The patient underwent successful retrograde open superior mesenteric artery stenting with resolution of her symptoms. Although retrograde open mesenteric artery stenting (ROMS) has been primarily shown to be effective in acute mesenteric ischemia, this case demonstrates that ROMS can be used as a salvage option for shuttering during endovascular procedures.