Abdominal Vasculature Research Articles

ABDOMINAL SPLANCHNIC ARTERIAL MAPPING OF Cerdocyon thous: HELPING IN SURGICAL PLANNING

Inconceivable that in the 21st century, veterinary extrapolate knowledge of domestic animal anatomy to wild animals, neglecting the patient, especially in the face of the increasing number of professionals claiming to be wild animal specialists. Thus, we mapped the abdominal splanchnic arterial vasculature of Cerdocyon thous, with the aim of contributing to professionals who work directly with wild animal surgery. In specimens whose arterial system was evidenced by stained latex, we identified anatomical variations when compared to other species. The jejunal arteries issued nine branches, and the caudal abdominal phrenic and cranial arteries arose from the common trunk of the abdominal aorta. The cranial abdominal artery was bifurcated and inserted into the cranial pole of the left kidney, while the left renal artery was bifurcated in one specimen; in another specimen, the left renal artery was double and penetrated the renal pelvis. One specimen had the right kidney more caudally in relation to the left kidney, similar to the corresponding renal artery. The left renal artery originated from the left adrenal artery, and the right internal iliac artery was bifurcated. Given these findings, such knowledge is crucial in the clinical and surgical care of this species, as it will allow for the greatest success of the professionals involved.

Non-contrast-enhanced MR-angiography of the abdominal arteries: intraindividual comparison between relaxation-enhanced angiography without contrast and triggering (REACT) and 4D contrast-enhanced MR-angiography.

To evaluate Relaxation-Enhanced Angiography without Contrast and Triggering (REACT), a novel 3D isotropic flow-independent non-contrast-enhanced magnetic resonance angiography (non-CE-MRA) for imaging of the abdominal arteries, by comparing image quality and assessment of vessel stenosis intraindidually with 4D CE-MRA. Thirty patients (mean age 35.7 ± 16.8years; 20 females) referred for the assessment of the arterial abdominal vasculature at 3T were included in this retrospective, single-centre study. The protocol comprised both 4D CE-MRA and REACT (navigator-triggering, Compressed SENSE factor 10, nominal scan time 02:54min, and reconstructed voxel size 0.78 × 0.78 × 0.85 mm3). Two radiologists independently evaluated 14 abdominal artery segments for stenoses, anatomical variants, and vascular findings (aortic dissection, abdominal aorta aneurysms and its branches). Subjective image quality was assessed using a 4-point Likert scale (1 = non-diagnostic, 4 = excellent). REACT had a total acquisition time of 5:36 ± 00:40min, while 4D CE-MRA showed a total acquisition time (including the native scan and bolus tracking sequence) of 3:45 ± 00:59min (p = 0.001). Considering 4D CE-MRA as the reference standard, REACT achieved a sensitivity of 87.5% and specificity of 100.0% for relevant (≥ 50%) stenosis while detecting 89.5% of all vascular findings other than stenosis. For all vessels combined, subjective vessel quality was slightly higher in 4D CE-MRA (3.0 [IQR: 2.0; 4.0.]; P = 0.040), although comparable to REACT (3.0 [IQR: 2.0; 3.5]). In a short scan time of about 5min, REACT provides good diagnostic performance for detection of relevant stenoses, variants, and vascular findings of the abdominal arteries, while yielding to 4D CE-MRA comparable image quality.

Coeliaco-Mesenteric Trunk-- A Rare Anomaly of the Coeliac Trunk

Abstract The Coeliaco-mesenteric trunk, characterized by the shared origin of the coeliac trunk and the superior mesenteric artery, represents a rare but clinically important anatomical variation within the abdominal vasculature. Knowledge of variations of the abdominal vascular system and their origins is of great importance to surgeons to ensure optimal patient outcomes and also to mitigate the potential complications that may arise due to this lack of knowledge. Present case: During routine dissection for 1st year MBBS (2022-23), of the abdominal region of a 60 year-old male cadaver, there was an unusual presentation of multiple blood vessels at the level of origin of the coeliac trunk. Upon further dissection, the superior mesenteric artery was found to be originating from this group of arteries. This artery was found to be passing through mesentery upto transverse colon. No other distinct blood vessel was found at the level where the superior mesenteric artery usually originates. Conclusion: This case underscores the importance of thorough pre-operative assessment and awareness of anatomical anomalies to facilitate safe and effective management strategies.

Extending the emission peak tail of indole cyanine for deep-near-infrared bioimaging

We propose a novel strategy for tailoring the structure of fluorescent molecules to achieve emission at the tail end of the NIR-II window. The favorable spectroscopic properties and low cytotoxicity of YNs make them powerful tools for bioimaging. Notably, YN-4 exhibits a brightness 2.5 times greater than YN-3, 6 times that of IR-783, and 5 times that of ICG. This enhanced brightness enabled high-resolution imaging of mouse thoracic and abdominal cavities, tumor vasculature, and real-time monitoring of gastrointestinal motility using YN-4. Furthermore, covalent grafting of glucose onto the YN-Glu scaffold significantly improved tumor-targeting capability and facilitated tracking of glucose metabolism. This work aims to extend the application of fluorescent molecule imaging beyond the NIR-IIa window.

Multiwavelength laser diode based portable photoacoustic and ultrasound imaging system for point of care applications.

Vascular diseases are a leading cause of death and disability worldwide. Despite having precursor conditions like peripheral arterial disease (PAD), they are often only diagnosed after the onset of stroke or heart attack. Low-cost, portable, noninvasive, point-of-care (POC), label-free assessment of deep vascular function benefits PAD diagnosis, especially in resource poor settings of the world. Doppler ultrasound-based blood flow measurements can diagnose PAD, albeit with limited sensitivity and specificity. To overcome this, here, we propose the first-of-its-kind dual-modality photoacoustic-and-ultrasound (PAUS) imaging system that integrates a multiwavelength pulsed laser diode (PLD) with a compact ultrasound data acquisition unit. The mesoscopic imaging depth of the portable PLD-PAUS system was validated using tissue phantoms, and its multispectral photoacoustic imaging capabilities were validated using an atherosclerosis-mimicking phantom. Furthermore, we demonstrated high-contrast volumetric in vivo photoacoustic imaging of rodent abdominal vasculature and quantified vessel reactivity due to hypercapnia stimulation. The multiparametric functional and molecular imaging capabilities of the PLD-PAUS system holds promise for POC applications.

Impact of Breathing Control Training Program on sonographic quantification of abdominal vasculature.

To compare vascular scanning parameters (vessel diameter, peak systolic velocity, end-diastolic velocity, and resistive index) and scanning time before and after breathing control training program for selected abdominal vessels. This study was pre and post quasi-experimental. The researchers designed a breathing training program that gives participants instructions through a video describing breathing maneuvers. Data were collected at the ultrasound laboratory/College of Health and Rehabilitation Sciences in Princess Nourah bint Abdul Rahman University, Riyadh, Saudi Arabia from January 2023 to November 2023. About 49 volunteers at the university participated in the study. Scanning was performed two times for the right renal artery, upper abdominal aorta, inferior vena cava, and superior mesenteric artery. Scanning time was measured before and after the program as well. A paired sample t-test was used to compare the parameters means and time before and after the program. The program had a significant effect on the following parameters: right renal artery peak systolic velocity (p=0.042), upper abdominal aortic peak systolic velocity, and resistive index (p=0.014, p=0.014 respectively), superior mesenteric artery and inferior vena cava diameters (p=0.010 and p=0.020). The scanning time was reduced significantly (p<0.001). The breathing training program saves time and improves ultrasound measurement quality. Hospitals and health centers should consider the importance of breathing control training programs before abdominal scanning.

Evidences on the clinical and anatomical aspects of situs inversus

Introduction: situs inversus is a rare congenital anomaly characterized by the transposition of the abdominal organs, viscera and vasculature, in relation to the sagittal direction, offering an image called “mirror image”. It is classified as total when associated with dextrocardia, while partial situs inversus affects only one or more organs. Objective: to answer what is the evidence about the clinical and anatomical aspects of situs inversus. Methodology: this is an integrative literature review. The research was carried out through online access to the National Library of Medicine (PubMed MEDLINE), Scientific Electronic Library Online (Scielo), Cochrane Database of Systematic Reviews (CDSR), Google Scholar, Virtual Health Library (BVS) and EBSCO databases. Information Services Results and Discussion: In situs solitus, the right lung has three lobes and an eparterial bronchus (bronchi above the pulmonary artery), while the left lung has two lobes with a hyarterial bronchus (bronchi below the pulmonary artery), the stomach and the spleen are on the left and the greater lobe of the liver is on the right. The morphological left atrium is to the left of the morphological right atrium. With situs inversus, the left lung has three lobes with an eparterial bronchus and the right lung has two lobes with a hyperarterial bronchus, the stomach and spleen are on the right side of the body, the larger lobe of the liver is on the left, and the morphological left atrium is to the right of the morphological right atrium. Final considerations: it is known that this anatomical asymmetry is established during embryonic formation, specifically, in organ rotation. However, it is worth noting that individuals with total situs inversus alone do not have clinical repercussions, with the exception of cases associated with heart disease. Therefore, almost always, its diagnosis is a finding in imaging tests, such as radiographs, CT scans and ultrasounds.

Contrast-enhanced CT evaluation of intra-abdominal vessels in sickle cell anemia

BackgroundSickle cell anemia (SCA) is a hereditary hematological disorder that affects millions of people worldwide. Abdominal crisis can result in significant morbidity and mortality if bowel infarction is present. Vaso-occlusive crisis is the most common pathological process accounting for morbidities. However, another mechanism was recently proposed for the arteriovascular changes associated with SCA. The terminology “sickle cell vasculopathy” was raised. Unlike the intra-cranial arterial vascular abnormalities associated with SCA (frequently reported findings of Moyamoya syndrome), there is scarce radiology literature describing the intra-abdominal vascular changes during or outside a crisis in SCA. Contrast-enhanced CT is a frequently used modality to assess abdominal vasculature and end-organ damage in acute abdominal crisis. Knowledge of the morphology of intra-abdominal vessels, especially the arteries may explain the underlying mechanism of abdominal crisis and potentially alter the management. The study aims to evaluate the structure of the intra-abdominal vasculature in SCA patients using contrast-enhanced computed tomography (CT) images.MethodsThis retrospective study reviewed the medical records of SCA patients who underwent contrast-enhanced CT of the abdomen and pelvis between 2003 and 2020 irrespective of abdominal crisis status. The CT studies were reviewed for the presence of vascular abnormalities, ischemic bowel changes, or other end-organ ischemic changes.ResultsOut of 509 patients, only 78 met the inclusion criteria. Two patients showed diffuse small caliber of the intra-abdominal arteries in the setting of abdominal crisis with end-organ ischemia but no bowel changes. None of the CT studies showed arteriovascular manifestations like advanced intra-cranial vasculopathy in SCA (Moyamoya syndrome-like changes) and none had vasculitis-like abnormalities. None of the patients had bowel ischemia, but six patients had renal and splenic infarcts in the absence of vascular abnormalities. One patient had venous varices secondary to superior mesenteric vein thrombosis.ConclusionsThe vast majority of SCA patients demonstrate no noticeable arteriovascular abnormality on a contrast-enhanced CT of the abdomen. Diffuse intra-abdominal vasospasm is present in a very small percentage of SCA abdominal crisis patients.

HoloLens in Breast Reconstruction: What Is the Future?

Autologous breast reconstruction using the deep inferior epigastric perforator flap has been established as the standard for perforator-based free-flap breast reconstruction. This technique relies on the surgeon's ability to identify the patient's relevant abdominal vasculature to facilitate accurate dissection, optimize surgical outcomes, and minimize morbidity. A technique is described in which the authors incorporate augmented reality using HoloLens technology in their surgical planning to identify epigastric arteries and perforators. This technology allows the surgeon to superimpose computed tomography angiography images directly onto the patient, facilitating an in vivo appreciation of underlying anatomy before incision and dissection. This allows real-time surgical planning, increasing the value and tangibility of preoperative computed tomography angiography with the potential to enhance the accuracy and efficiency of the operative technique. Although the authors did not use the HoloLens technology to make clinical decisions, they provide evidence of its accuracy and ease of use, offering a proof of concept. The potential of this technology is demonstrated, and the authors encourage future application in free-flap breast reconstruction and beyond.

Panniculus retractor use during scheduled cesarean section: potential neonatal impact

Use of a disposable panniculus retractor (DPR) during cesarean section (CS) improves surgical site visualization in obese women. However, whether this redistribution of weight onto the uterus and abdominal vasculature just prior to delivery impacts neonatal outcomes is unclear. To assess the potential downstream effect of DPR, we investigated neonatal outcomes after scheduled CS for deliveries using DPR. A retrospective cohort study of term pregnant patients with body mass index (BMI) ≥ 40.00 kg/m2 who underwent a scheduled CS at a tertiary care center from June, 2018 to May, 2019. CS using a DPR were compared to those without. Exclusion criteria included multiple gestation, fetal anomalies and general anesthesia. Universal umbilical artery (UA) cord gas collection is performed at our institution. The primary outcome was UA pH. Secondary outcomes were UA pH< 7.1, APGAR scores at 1 min and 5 min, neonatal intensive care (NICU) admission, and other UA gas parameters. Descriptive statistics and univariate analysis were performed. Multivariable logistic regression was used to adjust for potential confounders. 91 patients met inclusion criteria, including 23 (25.3%) with intraoperative DPR use and 68 (74.7%) without. Patients in the DPR group had a higher BMI (49.4 kg/m2 ±7.8 vs 45.9 kg/m2±6.1 [p=0.03]), and higher rates of drug use (47.8% vs 16.2% [p< 0.01]). UA pH was similar between groups (7.21±0.09 vs 7.24±0.06 [p=0.13]) as was UA pH < 7.1 (4.3% vs 1.5% [p=0.56]). UA lactate was significantly higher in the DPR group (4.0mmol/l±1.9 vs 3.2mmol/l±1.2 [p=0.02]). However, the risk of UA lactate > 4 mmol/l and NICU admission were similar between groups (aRR 2.52 [0.81, 3.53] and aRR 1.92 [0.31, 8.59], respectively). Intraoperative use of DPR did not significantly impact rates of neonatal acidemia at time of delivery. However, as elevated UA lactate represents early hypoxemia, more research is needed to assess the impact of increased lactate and whether this indicates an emerging trend.

Situs inversus: anatomical and clinical study

Introduction: situs inversus is a rare congenital anomaly characterized by the transposition of the abdominal organs, viscera and vasculature, in relation to the sagittal direction, offering an image called “mirror image”. It is classified as total when associated with dextrocardia, while partial situs inversus affects only one or more organs. Objective: to answer what is the evidence about the clinical and anatomical aspects of situs inversus. Methodology: this is an integrative literature review. The research was carried out through online access to the National Library of Medicine (PubMed MEDLINE), Scientific Electronic Library Online (Scielo), Cochrane Database of Systematic Reviews (CDSR), Google Scholar, Virtual Health Library (BVS) and EBSCO databases. Information Services Results and Discussion: In situs solitus, the right lung has three lobes and an eparterial bronchus (bronchi above the pulmonary artery), while the left lung has two lobes with a hyarterial bronchus (bronchi below the pulmonary artery), the stomach and the spleen are on the left and the greater lobe of the liver is on the right. The morphological left atrium is to the left of the morphological right atrium. With situs inversus, the left lung has three lobes with an eparterial bronchus and the right lung has two lobes with a hyperarterial bronchus, the stomach and spleen are on the right side of the body, the larger lobe of the liver is on the left, and the morphological left atrium is to the right of the morphological right atrium. Final considerations: it is known that this anatomical asymmetry is established during embryonic formation, specifically, in organ rotation. However, it is worth noting that individuals with total situs inversus alone do not have clinical repercussions, with the exception of cases associated with heart disease. Therefore, almost always, its diagnosis is a finding in imaging tests, such as radiographs, CT scans and ultrasounds.

PRES REVEALING A TAKAYASU ARTERITIS IN THE EMERGENCY DEPARTMENT : A CASE REPORT

Posterior reversible encephalopathy syndrome is a rare clinical and radiological entity which can lead to seizures. Some of its risk factors are hypertension and vasculitis, as in the case of Takayasu Arteritis, a large vessel arteritis which damages the abdominal vasculature. We report the case of a patient who presented in a generalized convulsive status epilepticus secondary to a PRES, which was induced by a renovascular hypertension secondary to Takayasu Arteritis. The aim of this study is to report the case of a rare association of Takayasu Arteritis and PRES, and discuss the timeline of the assessment of our patients condition, which allowed us to start the treatment as quickly as possible.

S2302 Dysphagia Lusoria as a Rare Cause of Dysphagia Due to ARSA and KD With Esophageal Compression

Introduction: Dysphagia lusoria (DL) is a rare cause of dysphagia in which abnormal vasculature, most often an aberrant right subclavian artery (ARSA) with a retroesophageal course, leads to esophageal compression. We report a case of DL caused by an ARSA and Kommerell diverticulum (KD). Case Description/Methods: A 64-year-old male with a history of Celiac disease, Sjogren’s syndrome, gastroesophageal reflux disease, and rheumatoid arthritis presented with weight loss and worsening solid food dysphagia. Current medications included naproxen and omeprazole. Esophagogastroduodenoscopy (EGD) showed no lesions but a slight narrowing of the proximal esophagus, for which mild dilation was performed. Six months later the patient presented for persistent dysphagia. An esophagus barium swallow found a 5 cm long narrowing of the esophagus, the narrowest portion measuring 0.9 cm (Figure 1A). No mucosal abnormalities, gastroesophageal reflux, or hiatal hernia were detected. Chest computed tomography angiogram (CTA) revealed an ARSA which emerged from a fusiform aneurysmal dilation of the left aortic arch and followed a retroesophageal course. This vasculature resulted in compression and displacement of the esophagus (Figure 1B). The left subclavian artery also arose from the dilation, and a common origin of the right and left common carotid arteries was observed. The patient was diagnosed with DL, caused by an ARSA and KD. As EGD with dilation would not alleviate this source of external compression, the patient was referred to vascular surgery for definitive management. Discussion: KD is a remnant of the fourth aortic arch which forms a dilation at the point of which an abnormal subclavian artery arises, and is noted in about 15% of patients with an ARSA. DL diagnosis is complicated by the fact that many vascular abnormalities do not result in dysphagia. While CTA confirms the presence of abnormal vasculature, a thorough workup of esophageal function including assessments like EGD and barium esophagram are necessary to confirm DL diagnosis. Typically for DL patients, diet modifications and endoscopic or medical interventions like PPI use should be utilized before surgery, as targeting abdominal vasculature may not prove beneficial. This case is distinguished by the presence of a KD, which makes surgical intervention the best treatment option to relieve a clear source of external compression and avoid possible KD rupture or dissection.Figure 1.: (A) Barium esophagram showing a narrowing of the cervical and thoracic esophagus. (B) 3-dimensional CT showing aneurysmal Kommerell diverticulum (KD) and emerging aberrant right subclavian artery (ARSA), which followed a retroesophageal course.

S3472 Rumble in the Tummy: Atypical Location of Abdominal Thrombosis Post-COVID

Introduction: More than 532 million cases of COVID-19 infection have been documented, and hundreds of thousands are being added every day. COVID-19 is linked to a number of co-morbidities, one of which, hypercoagulability, has piqued the interest of many researchers. Here, we present a case of a portal vein and superior mesenteric vein thrombosis in a patient with subclinical COVID-19 infection. Case Description/Methods: A healthy 30-year-old male presented 3 weeks after having mild, asymptomatic COVID with epigastric abdominal pain, nausea, and vomiting. His only complaints when he had COVID was a decreased appetite, but no other gastrointestinal (GI) or respiratory symptoms. Upon admission, initial CT with contrast showed thrombophlebitis of superior mesenteric vein (SMV) and portal vein (PV), decreased contrast within the intrahepatic PVs; follow up MR Angiography revealed PV intraluminal filling defect beginning just distal to the superior mesenteric vein and splenic vein confluence and involving the intrahepatic PV with periportal edema. He denied any prior clots nor family history of clotting disorder. GI and hematology were consulted. He received catheter-directed tPA for 2 days due to abdominal pain and follow up CT angiogram with no evidence of occlusion in arteries. The cause for his extensive abdominal vasculature thrombosis is thought to be secondary to COVID hypercoagulability, and the location has not been well delineated. Abdominal pain improved, he continued anticoagulation (AC), did not require repeat sessions with plans for close follow up imaging. (Figure) Discussion: Klok et al. reported a crude cumulative thrombosis incidence in COVID19 ICU patients is of 57% (95% CI 47–67%). In terms of intestinal damage, prothrombotic effects of the virus rises the incidence of mesenteric ischemia from 0.09–0.2% in the normal population to 1.9–3.8% in COVID-19 patients. Thrombosis is a known outcome, but in our case, this location is atypical, and he required catheter directed tPA by IR due to abdominal pain, that is a large measure and not typically done for thrombosis so it is also an aggressive management for thrombosis (done due to unrelenting abdominal pain). Hereby, we conclude that any vascular complication without an underlying reason should raise suspicion of an underlying COVID-19 infection, and more research should be done to determine the risk of such complications.Figure 1.: A,B: MRI Coronal view. Portal vein intraluminal filling defect beginning just distal to the superior mesenteric vein and splenic vein confluence and involving the intrahepatic portal vein with periportal edema Figure C,D: MRI Axial View of portal vein intraluminal filling defect with periportal edema Figure E: CT images post tPA show The portal vein, and SMV appear prominent in size and demonstrate perivascular stranding which can be seen with thrombosis.

Pattern Recognition of Abdominal Vasculature on Color Doppler in the Fetus as a Tool for Early Diagnosis of Bladder Exstrophy in the First and Early-Second Trimester: Initial Observations.

Early prenatal diagnosis of bladder exstrophy is challenging because of its variable size and presentation. This article brings forth new signs on color Doppler (CD) to help establish the diagnosis in a suspected case. Two cases of omphalocele-exstrophy-imperforate anus-spinal defects complex presenting as a solid-cystic ventral mass at 11 weeks and a solid lower abdominal wall mass at 20 weeks, with nonvisualization of the urinary bladder, were studied by gray-scale and CD in sagittal and transverse-bladder views of the abdomen. The sagittal view on CD revealed an altered intrafetal course of umbilical artery (UA), widened UA-aorta angle (K angle), a break in the intersection of UA, and umbilical vein (UV) at the umbilicus—broken “X-sign” with distortion of the equilateral triangle normally formed by aorta, UA, and UV. The transverse-bladder view showed an altered divergent course of single-UA. Combination of these findings substantiated early diagnosis of bladder exstrophy, thus facilitating prenatal counseling. Key Messages Early prenatal diagnosis of bladder exstrophy is possible by pattern recognition of abdominal vasculature on color Doppler.The new signs—“X” and “Y” derived on color Doppler, as a clue to early diagnosis of bladder exstrophy—have not been identified in the current literature that makes this article unique.

Median Arcuate Ligament Syndrome with Common Hepatic and Splenic Arteries Directly Originating from the Abdominal Aorta: A Case Report

Introduction: Knowledge of the unpaired abdominal vasculature is important for uncomplicated operations. The absent celiac trunk has previously been reported; however, developmental alterations can result in a variety of branching patterns of the downstream arteries from the abdominal aorta. Case Presentation: A 53-year-old female patient with lymphoma underwent abdominopelvic computed tomography (CT) for staging. She had a history of postprandial off-and-on abdominal pain since her youth. CT scan revealed an absent celiac trunk with common hepatic and splenic arteries directly originating from the abdominal aorta. Compression of the median arcuate ligament had narrowed and angulated the 2 branches. Conclusions: When the celiac trunk is absent, its main branches may separately arise from the abdominal aorta. Also, due to the displacement of these branches, their path and diameter can vary from the normal.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Axillary IABP Migration into SMA

<h3>Introduction</h3> Percutaneous insertion of IABP through the axillary artery has been validated as a bridge to transplant strategy in patients who require MCS. This strategy allows patients to participate with physical therapy preventing deconditioning while awaiting advanced therapies or recovery from primary insult. With this technique relatively low adverse events were reported which mostly pertained to upper extremity vascular or neurologic complications. Although rare, there have been few reports of migration into the abdominal vasculature which can lead to severe complications such as mesenteric ischemia. <h3>Case Report</h3> 60 yo M with CAD s/p CABG, ICM who presented with cardiogenic shock. IABP was placed in the axillary position after poor response to inotropes and the patient was listed for transplant after stabilization. 10 days after placement the patient had developed severe diffuse non-positional abdominal pain. There were no peritoneal signs such as rebound or guarding. Serum lactate was within normal range. Abdominal x-ray showed stable position from initial placement and days prior. Given a high clinical suspicion the patient was taken to the cardiac catheterization lab in urgent fashion. Under fluoroscopic guidance a Steelcore wire was advanced revealing migration of the distal tip into the superior mesenteric artery. The IABP was exchanged and the patient had complete resolution of abdominal pain. Two days later a suitable donor was identified and he was successfully transplanted. <h3>Summary</h3> Review articles which describe placement technique of IABP from the axillary position lack descriptions for optimal positioning of the distal tip. Unexplained abdominal pain can be the first clinical presentation of IABP migration. In patients with cardiogenic shock this can be confounded as abdominal pain can be attributed to hepatic congestion and decreased perfusion. Despite imaging and serum lactate a high clinical suspicion is necessary to identify and prevent complications of IABP migration into the abdominal vasculature.

Abdominal apoplexy: rupture of short gastric artery after retching

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. A 30-year-old woman presented with acute abdominal pain and breathlessness and was in class II hypovolemic shock. She had a history of multiple episodes of retching with non-bilious vomiting prior to that. Computed tomography (CT) reported a non-rotation of the gut, gross intraperitoneal free fluid with debris, and possible perforated appendicitis. Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with bowel findings consistent with non-rotation of the gut, but technical difficulty in identifying the source of bleeding led to conversion to laparotomy. A ruptured short gastric artery was ascertained to be the source of bleeding and was successfully ligated. A retrospective review of the preoperative CT showed intraperitoneal free fluid with Hounsfield unit measurements of 48 and 52, suggestive of acute hemoperitoneum. ISIH is often a delayed diagnosis or missed diagnosis due to its low incidence. The presence of vomiting and abdominal pain with hypovolemic shock, especially in a young individual, should raise the suspicion of ISIH, which can be confirmed via early CT imaging to facilitate achieving hemostasis during surgery.

Description of the arterial supply and venous drainage of the abdominal viscera in the puma (Puma concolor) (Linnaeus, 1771).

Detailed descriptions of the abdominal vasculature have not been reported on Puma concolor; thus, herein we provided a thorough description. Our findings include the following: a celiac artery branching into the hepatic and gastrolienal arteries, and this latter further branched into the left gastric, the left gastroepiploic, the lienal and three more arteries that supplied the greater omentum. We also found a cystic artery that derived from the right gastroduodenal artery; a right gastric artery that derived from the right hepatic artery; and an antimesenteric ileal artery that derived from the lateral cecal artery. The right gastric vein did not form the gastroduodenal vein as in other species, but it drained directly into the portal vein. Also, a middle pancreaticoduodenal vein was identified as the last branch of the cranial mesenteric vein. Finally, the left caudal phrenic vein drained into the left renal vein. The abdominal blood supply described herein corresponds to a single individual; further reviews are desirable to corroborate our observations and to detect potential intraspecific anatomical variations.