Branch Of Superior Mesenteric Artery Research Articles

Сlinical case of pancreatic cancer

Description of a rare case of pancreas body tumor, which was grown into celiac trunk, is presented. The patient was saved due toanftomy of right hepatic artery, which was a branch of superior mesenteric artery.
 Patient Z.V, 60 years old, came to the clinic with such complaints as pain, heaviness in abdomen and waist area,weakness.4–5 cm tumor of pancreas body was detectedduring surgery. The tumor had grown into celiac trunk and into left adrenal gland.
 The friable tissue of hepato-duodenal ligament was dissected duringthe surgery.Thesurgeons mobilized duodenum usingKoxertechnique. As a result of this manipulation, the followingblood vesselswere visualized:inferior vena cava and abdominal aorta, celiac trunk, superior mesentericartery. Surgical team opened ligament of Treitz and excisedpancreas body2.5 cm away from thetumor proximally. The stump was sewed with “mattress stich”, celiac trunk was sectioned and entangled, surgeons also dissected common hepatic artery. After section they checked blood supply of liver. The pressure of blood flowing from gastro-duodenal and pancreato-duodenal artery was enough for providing normal blood flow in the left hepatic artery.
 Morphological result of the excisedtissue — Ductal adenocarcinoma (No 672).
 The patient’sstate was satisfactory when he left the clinic. He underwent medical check-up three times next year. He feels well, his state of health is normal. Patient is capable of working.
 This case is interesting due to the anatomy of right hepatic artery (which was a branch of superior mesenteric artery) that saved patient’s life.

P3.26: Complications of the aortic conduit after intestinal transplantation with liver containing grafts - A single center experience

Introduction: Complications originating from the aortic conduit after intestinal transplantation (ITx) are currently not well described in the literature. The aim of this study was therefore to report a single center experience with diagnosis and management of complications affecting the donor aortic conduit after ITx with liver containing grafts. Methods: From 1998 to 2018, 35 ITx were performed in Gothenburg, Sweden. 29 of 35 grafts were liver containing intestinal allografts supplied by an aortic conduit (figure 1). The recipients were 24 adults (median age 38 years, range 16 – 66 years) and 5 children (median age 8 years, range 3– 10 years). The aortic conduit was anastomosed to either the aorta (n=20) or the iliac artery (n=9). The most common underlying conditions were intestinal failure (n=18) and non-resectable neuroendocrine pancreatic malignancies with liver metastases (n=6). Immunosuppression consisted primarily of ATG induction, tacrolimus and steroid bolus and tapering. Median donor age was 23 years (range 2–56 years) and median cold ischemic time was 443 min (range 90 - 873 min). Results: Four patients (4/29, 14%) presented with some type of complication originating from the aortic conduit requiring intervention (figure 2). The complications were: stenosis at the origin of the superior mesenteric artery (SMA) branch (n=1), acute bleeding caused by bacterial and fungal arteritis of the conduit (n=1), stenosis of the conduit caused by kinking of the conduit close to the aortic anastomosis (n=1), inflammatory aneurysm of the donor conduit, affecting the origins of the coeliac trunk and the SMA (n=1). The complications were diagnosed from months up to several years after ITx. Discussion In our experience, complications affecting the donor aortic conduit after ITx may present in the early or late post-transplantation period. The insidious clinical presentation and the relatively high prevalence (14%) may warrant specific post-transplantation surveillance of the donor aortic conduit. A timely multidisciplinary therapeutic approach involving interventional radiology was crucial. Figure 1. Donor aortic conduit anastomosed to the recipient aorta Figure 2. Complications affecting the donor conduit of 29 ITx with liver containing grafts

PC174. Presentation and Management of a Rare and Fatal Disease: Saccular Superior Mesenteric Artery Aneurysms

Superior mesenteric artery aneurysm (SMAA) is a fatal degeneration of the visceral arteries. Although a rarely encountered entity, it requires timely management because of the high mortality rate associated with rupture, particularly when the aneurysm is saccular in nature. As such, urgent treatment is generally indicated. We present five cases of SMAA that were managed operatively. This study was a retrospective case series completed at a single, large academic institution from January 2016 to January 2019. We describe the presentation, operative management, postoperative outcomes, and follow-up from a series of five patients with SMAA. Five patients (80% female) with true SMAA were identified and diagnosed by computed tomography angiography. All cases involved saccular aneurysms. Three presented emergently with severe abdominal pain, one of whom was to have ruptured SMAA. Two elective cases were incidentally identified on imaging. Two cases were mycotic in etiology, secondary to intravenous drug abuse and infective endocarditis. The remainder were cryptogenic. There were no patients with history of atherosclerosis or elastin or collagen disorders. All of the SMAAs involved branches or branch points of the superior mesenteric artery (SMA). The largest SMAA was 3.2 cm in a proximal SMA branch point. All cases were treated with open surgical resection of the SMAA. Interposition reversed saphenous vein graft was used for reconstruction in a single case involving the main SMA trunk. None of the cases required bowel resection for ischemia. The operative mortality was 20% and related to ruptured SMAA. SMAAs are particularly prone to rupture, at which point intraoperative mortality can reach up to 30%. Accordingly, many authors suggest repairing SMAAs even in asymptomatic patients. Earlier studies supported revascularization, but this has more recently shifted to ligation alone because of the dense collateralization network. In addition, bowel should be closely examined for ischemic changes whenever the integrity is in question. The presenting and management features in our case series are supportive of this literature, with the exception that our population of patients was predominantly female. Future studies will continue to determine factors associated with rupture and poor outcomes, along with the optimizing surgical approach.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Intravascular Papillary Endothelial Hyperplasia in the Coronary Artery: An Unusual Cause of Massive Myocardial Infarction in Hypoplastic Left Heart Syndrome

Background: Intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion that usually involves the head and neck or extremities. Involvement of the coronary arterial system is unreported. Case: A 1-month-old patient born with hypoplastic left heart syndrome died from a massive myocardial infarction shortly after first stage palliation with Norwood/Sano. Autopsy demonstrated a massive univentricular hemorrhagic infarction with complete occlusion of the left main coronary artery and its intramural branches by intraluminal papillary endothelial hyperplasia (IPEH). Immunostaining with CD34 and CD31 confirmed the diagnosis. The inferior and superior mesenteric artery branches also had IPEH. Conclusion: IPEH can involve the coronary vasculature, can be multifocal and can occur in the newborn.

Acute pancreatitis caused by postcholecystectomic pseudoaneurysmatic hemobilia

A 50 year old bangladeshi female, came to our emergency with hematemasis ,jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 1 month ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. She also had a vascular abnormaly (Her left lobe of liver is supplied by hepatic artery and right love of liver is supplied by accessory hepatic artery which is a branch of superior mesenteric artery, and a sacular aneurysm developed in accessory hepatic artery near the gall bladder fossa (near postcholecystectomy clipping). We are reporting another case of acute pancreatitis after laparoscopic cholecystectomy caused by hemobilia secondary to pseudoaneurysm in accessory hepatic artery originating from superior mesenteric artery. This is probably second such reported case.
 Bangladesh Crit Care J March 2019; 7(1): 55-57

High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.

The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ©RSNA, 2019.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

ObjectiveThe objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. MethodsThere were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. ResultsMean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. ConclusionsTotal endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.

The Riolan arch compensates for infra-renal abdominal aorta occlusion

The patient was a 66-year-old woman. She suffered from Takayasu's arteritis 30 years ago and hypertension 5 years ago. Her main complaint was intermittent claudication of bilateral lower limbs; the claudication distance was approximately 500 m. Ankle-brachial index of bilateral lower extremities were 0.6(R) and 0.5(L), respectively. Computed tomography angiography of the abdominal aorta showed infrarenal abdominal aorta occlusion (A-C). The branch of superior mesenteric artery was compensatory enlargement. The blood flow was through the middle colic artery, the riolan arch, and the inferior mesenteric artery, which compensated for the distal abdominal aorta. The informed consent had been obtained from the patient before submit the image.

Application value of multiple imaging techniques in the MDCT combined with assessment of vascular invasion using a tumor-to-vessel contact computed tomography grading system in preoperative evaluation of pancreatic cancer

Application value of multiple imaging techniques in the MDCT combined with assessment of vascular invasion using a tumor-to-vessel contact computed tomography grading system in preoperative evaluation of pancreatic cancer

Value of the multi-slice spiral CT angiography, CT colonography and image fusion technology in preoperative evaluation of laparoscopic right colon cancer

Objective To observe the distribution and variation of right colonic vessels, and investigate the clinical value of computed tomography angiography (CTA), computed tomography colonography (CTC) and image fusion technology in preoperative evaluation of laparoscopic right colonic cancer (RCC). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 38 patients who underwent laparoscopic extended radical resection of RCC + D3 lymphadenectomy in the Affiliated Wuxi Second People′s Hospital of Nanjing Medical University between January 2015 and July 2017 were collected. Patients received preoperative plain and enhanced scans of abdominal and pelvic CT. The original images were reconstructed and fused by CTA and CTC, and then coming out with three-dimensional images of blood vessels and gut. Observation indicators: (1) branches of superior mesenteric artery (SMA); (2) positional relationship between SMA and superior mesenteric vein (SMV); (3) composition of gastrocolic venous trunk. Results Scan images of 38 patients had fused with scan images of vessels and primary tumors and reached the diagnostic standard, with a good imaging performance. Distribution of blood vessels of virtual reality (VR) images and were compared with that of naked blood vessels under intraoperative laparoscopy, showing a coincidence rate of 100.0%(38/38). (1) Branches of SMA: results of CTA and intraoperative anatomy showed that the occurrence rate of the right colonic artery, middle colonic artery and ileocolic artery were respectively 94.7%(36/38), 92.1%(35/38) and 100.0%(38/38). A right colonic artery was found in 28 patients. Ten patients had structure variation of right colonic artery, including 3 with 2 right colonic arteries and 2 without right colonic artery. The right colonic artery and middle colonic artery merged into the same trunk and then flowed into SMA were detected in 2 patients; the right colonic artery and ileocolic artery merged into the same trunk and then flowed into SMA were detected in 3 patients. (2) Positional relationship between SMA and SMV: results of CTA and intraoperative anatomy showed that the occurrence rate of both SMA and SMV was 100.0%(38/38). The SMA in 20 patients was located in the ventral side of SMV; SMA in 18 patients was located in the dorsal side of SMV. (3) Composition of gastrocolic venous trunk: results of CTA and intraoperative anatomy showed that 29 of 38 patients had gastrocolic venous trunks, which belonged to four sources, including right colonic vein, middle colonic vein, right gastric epiploic vein and anterior superior pancreaticoduodenal vein. Among 29 patients, 18 had 2- or 3-branch type of gastrocolic trunk that consisted of the right gastric epiploic vein, middle colonic vein and right colonic vein; 3 had 2-branch type of gastric pancreatic trunk that consisted of the right gastric epiploic vein and anterior superior pancreaticoduodenal vein; 8 had 3- or 4-branch type of stomach-pancreas-colon trunk that consisted of right gastric epiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein and middle colonic vein. Conclusion CTA, CTC and image fusion technology can intuitively show the anatomy and variation of right colonic vessels, with a high clinical value. Key words: Colonic neoplasms; Preoperative evaluation; Vascular reconstruction; Computed tomography angiography; Computed tomography colonography; Extend right hemicolectomy; Laparoscopy

Mechanisms underlying the relaxation by A484954, a eukaryotic elongation factor 2 kinase inhibitor, in rat isolated mesenteric artery

Eukaryotic elongation factor 2 kinase (eEF2K) is a calmodulin-related protein kinase which regulates protein translation. A484954 is an inhibitor of eEF2K. In the present study, we investigated the acute effects of A484954 on contractility of isolated blood vessels. Isometric contraction of rat isolated aorta and main branch of superior mesenteric artery (MA) was measured. Expression of an inward rectifier K+ (Kir) channel subtype mRNA and protein was examined. A484954 caused relaxation in endothelium-intact [E (+)] and -denuded [E (−)] aorta or MA precontracted with noradrenaline (NA). The relaxation was higher in MA than aorta. The relaxation was partially inhibited by a nitric oxide (NO) synthase inhibitor, NG-nitro-l-arginine methyl ester (300 μM) in E (+) MA. The relaxation was significantly smaller in MA precontracted with high K+ than NA. The A484954-induced relaxation was significantly inhibited by a Kir channel blocker, BaCl2 (1 mM) compared with vehicle control in E (−) MA. Expression of Kir2.2 mRNA and protein was significantly higher in MA than aorta. We for the first time revealed that A484954 induces relaxation through opening smooth muscle Kir (Kir2.2) channel and through endothelium-derived NO in MA.

Etanercept restores vasocontractile sensitivity affected by mesenteric ischemia reperfusion

BackgroundThe aim of the study is to evaluate in vivo and in vitro effects of etanercept, a soluble tumor necrosis factor receptor, on the contractile responses of superior mesenteric artery in an experimental mesenteric ischemia and reperfusion model. Material and methodsAfter obtaining animal ethics committee approval, 24 Sprague–Dawley rats were allocated to three groups. Control group (Gr C, n = 6) underwent a sham operation, whereas ischemia/reperfusion and treatment groups underwent 90 min ischemia and 24-h reperfusion (Gr I/R, n = 12; Gr I/R+E, n = 6). The treatment group received 5 mg/kg etanercept intravenously at the beginning of reperfusion. At the end of reperfusion, all animals were sacrificed, and third branch of superior mesenteric artery was dissected for evaluation of contractile responses. In vitro effects of etanercept on vasocontractile responses were also evaluated. The excised ileums were analyzed under light microscope. Two-way analysis of variance following Bonferroni post hoc test was used for evaluation of contractile responses. ResultsEndothelin-1 and phenylephrine-mediated vasocontractile sensitivity were found increased in Gr I/R when compared with Gr C. Both intravenous administration and organ bath incubation of etanercept decreased the sensitivity of contractile agents for Gr I/R. Mucosal injury, lamina propria disintegration, and denuded villous tips were observed in Gr I/R, whereas the epithelial injury and the subepithelial edema were found to be milder in Gr I/R+E. ConclusionsEtanercept can be a promising agent in mesenteric ischemic reperfusion injury as it does not only inhibit inflammation by blocking tumor necrosis factor-α in circulation but also restores vascular contractility during reflow. These findings support an unexplained recuperative effect of drug beyond its anti-inflammatory effects.

Anatomske variacije vej, ki izhajajo iz zgornje mezenterične arterije

Superior mesenteric artery, the second ventral branch of the abdominal aorta, supplies the distal duodenum, the small intestine, and the large intestine to the mid transverse colon. Superior mesenteric artery branches include the inferior anterior and inferior posterior pancreaticoduodenal arteries, middle colic artery, right colic artery, ileocolic artery, jejunal and ileal branches. The vascular anatomy of superior mesenteric branches is frequently variant. The explanation of variant vascular anatomy of branches and pathological consequences of diseases which impact the mesenteric vasculature might be due to the changes that appear in the development of ventral splanchnic arteries and their blood supply. Knowledge of mesenterical variations is valuable to radiologists and surgeons.

Endovascular procedures in pancreatic surgery

To evaluate an effectiveness of endovascular techniques in pancreatic surgery. For the period 1995-2017 at Vishnevsky Institute of Surgery endovascular treatment (EVT) was applied in 51 patients with chronic pancreatitis complicated by false aneurysms (FA) and postoperative hemorrhage after pancreatectomy. Various methods of embolization and stenting were used in 24 and 11 cases respectively in order to exclude FA of celiac trunk and superior mesenteric artery from blood flow. Endovascular hemostasis for postoperative hemorrhage was carried out with embolization of damaged vessel in 11 patients. Stent-grafts were deployed in 5 patients with marginal defect of the wall of hepatic/superior mesenteric arteries. In all 35 patients with chronic pancreatitis complicated by false aneurysms EVT ensured thrombosis of the aneurysm's cavity. EVT was final in 14 patients with FA and absent communication with pancreatic duct. Radical surgical treatment was required after 7-10 days for FA communicated with pancreatic duct due to lysis of thrombotic masses by pancreatic enzymes. Spleen infarction was diagnosed in 3 patients. Two of them did not require treatment while 1 patient underwent splenectomy in view of splenic abscess. 1 patient died from liver cirrhosis followed by severe hepatic failure, death was not associated with bleeding. In 16 patients with post-pancreatectomy bleeding hemostasis was achieved in all cases with EVT. However, recurrent bleeding occurred in 2 patients who underwent successful redo endovascular intervention. Complications after EVT were observed in 2 patients: duodenal wall necrosis followed by fistula which was closed spontaneously (n=1); advanced intestinal infarction (n=1) followed by fatal outcome; pulsating hematoma within cubital fossa that required brachial artery ligation and autovenous bypass. EVT provides thrombosis of FAs of celiac trunk and superior mesenteric artery branches in patients with chronic pancreatitis, as well as hemostasis for postoperative bleeding after pancreatectomy.

Non-occlusive mesenteric ischaemia: CT findings, clinical outcomes and assessment of the diameter of the superior mesenteric artery.

Review of the experience of a tertiary care centre for almost 10 years in the CT diagnosis of non-occlusive mesenteric ischaemia (NOMI). Analysis of CT findings, correlation with clinical outcomes and evaluation of the usefulness of measuring the superior mesenteric artery (SMA) diameter for the diagnosis of NOMI. 106 patients were diagnosed with NOMI in a biphasic CT examination from 2008 to 2017 in our hospital. Clinical outcomes and CT findings were reviewed. In 55 patients, the diameter of the SMA was compared with a previous CT scan where NOMI was not the diagnosis, and statistical analysis using paired t-test was performed. 81 patients (76%) had findings consistent with small bowel ischaemia and the ileum was the segment most commonly involved (47%). Lack of wall enhancement, pneumoperitoneum, pneumatosis intestinalis and portal venous gas were all considered signs of bowel necrosis and surgery was performed promptly. 70 patients had signs of vascular narrowing of the SMA branches and in the 55 cases with a previous CT scan, there were statistically significant differences regarding the SMA diameter with a mean reduction of the artery calibre and standard deviation of 1.93 ± 1.1 mm between the NOMI and non-NOMI scans (p < 0.001). Acknowledgment of characteristic bowel necrosis CT findings is crucial for determining the therapeutic attitude and the use of previous CT scans to compare the SMA diameter may help the radiologist to achieve an early diagnosis of NOMI in an often critically ill patient population. Advances in knowledge: Diagnosis of NOMI can be difficult in cases of partial mural ischaemia, thus objective data (diameter of the SMA) should be useful for the radiologist to include NOMI as the first diagnostic option in the differential diagnosis.

Antioxidant and vasorelaxant activities induced by northeastern Brazilian fermented grape skins

BackgroundIn northeastern Brazil, grape pomace has become a potential alternative byproduct because of the recover phenolic compounds from the vinification process. Comparative analyses were performed between lyophilized extract of grape skins from pomace, described as fermented (FGS), and fresh, unfermented (UGS) grape skins to show the relevant brand’s composition upon the first maceration in winemaking.MethodsThe use of in vitro testing such as Folin-Ciocalteu’s, DPPH free radical scavenger and HPLC methods were performed to evidence antioxidant effect and phenolic compounds. Additionally, vascular reactivity studies were performed in third-order branches of rat superior mesenteric arteries, which were obtained and placed in organ baths containing Krebs-Henseleit solution, maintained at 37 °C, gassed with a mixture of 95% O2 and 5% CO2, and maintained at pH 7.4. The in situ formation of reactive oxygen species (ROS) was evaluated in small mesenteric rings using oxidative fluorescent dihydroethidium dye.ResultsWe found higher phenolic content and antioxidant activity in FGS when compared to UGS. HPLC analyses identified a significant number of phenolic compounds with antioxidant potential in both samples. The vasorelaxant effect induced by FGS was more potent than that induced by UGS, and the activity was attenuated after removal of vascular endothelium or by blockade of endothelium-derived relaxing factors, such as NO and EDHF.ConclusionsThe FGS extract may be a great source of natural polyphenol products with potent antioxidant effects and endothelium-dependent vasodilatory actions involving NO and EDHF pathways.

ANATOMIC VARIATIONS OF HEPATIC ARTERY: A STUDY IN 479 LIVER TRANSPLANTATIONS.

ABSTRACTBackground:The incidence of anatomic variations of hepatic artery ranges from 20-50% in different series. Variations are especially important in the context of liver orthotopic transplantation, since, besides being an ideal opportunity for surgical anatomical study, their precise identification is crucial to the success of the procedure. Aim:To identify the anatomical variations in the hepatic arterial system in hepatic transplantation. Methods: 479 medical records of transplanted adult patients in the 13-year period were retrospectively analyzed, and collected data on hepatic arterial anatomy of the deceased donor. Results:It was identified normal hepatic arterial anatomy in 416 donors (86.84%). The other 63 patients (13.15%) showed some variation. According to the Michels classification, the most frequently observed abnormalities were: right hepatic artery branch of superior mesenteric artery (Type III, n=27, 5.63%); left hepatic artery branch of the left gastric artery (Type II, n=13, 2.71%); right hepatic artery arising from the superior mesenteric artery associated with the left hepatic artery arising from the left gastric artery (Type IV, n=4, 0.83%). Similarly, in relation to Hiatt classification, the most prevalent changes were: right hepatic accessory artery or substitute of the superior mesenteric artery (Type III, n=28, 6.05%)), followed by liver ancillary left artery or replacement of gastric artery left (Type II, n=16, 3.34. Fourteen donors (2.92%) showed no anatomical abnormalities defined in classifications, the highest frequency being hepatomesenteric trunk identified in five (01.04%). Conclusion:Detailed knowledge of the variations of hepatic arterial anatomy is of utmost importance to surgeons who perform approaches in this area, particularly in liver transplantation, since their identification and proper management are critical to the success of the procedure.

Partial Zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in Management of Multiple Trauma with Combined Abdominal and Pelvic Injury

Introduction: Resuscitative endovascular balloon occlusion of the aorta has been used in various clinical settings to elevate blood pressure in the setting of shock, even if the evidence base is weak with no clear indications. Case presentation: We report a case of traumatic hemorrhagic shock in which this technique was used in an unusual manner, treating obvious arterial abdominal bleeding associated with suspected pelvic arterial bleeding, in a Trauma Center where hybrid angiographic-surgical suite is not available. A 35-year-old man was involved in a traffic accident within 2 trucks. He was transported to the Major Trauma Center of an Integrated Trauma System where emergent laparotomy confirmed massive hepatic rupture and a bleeding control was obtained by large abdominal packing. Trauma team decided to considerate Resuscitative Endovascular Balloon Occlusion of the Aorta, positioning a deflated balloon in zone III to eventually manage a pelvic arterial hemorrhage, while performing Bogota Bag. Suddenly a new abdominal arterial bleeding was noted through Bogota Bag. Because Pringle maneuver was considered too difficult in this case because of liver hilum injury, the balloon was moved cranially with the aim to reach zone I. Introducer sheath displacement occurred at this time, and the balloon was then only partially inflated in zone II, usually considered too dangerous, and immediately the target systolic blood pressure of 90 mmHg was obtained. Transfer the patient into interventional radiology suite was then feasible and embolization of active bleeding by right hepatic artery and superior mesenteric artery branch, missed during first laparotomy, were performed. Balloon was definitely deflated after 50 minutes. The patient was discharged by the hospital 113 days later, fully recovered with long lasting motor rehabilitation program. Discussion: Partial zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in this particular case allowed overcoming procedural mistakes without major complications and with good clinical outcome. Conclusion: Judicious manage of REBOA inflation time and amount, together with multidisciplinary contemporary damage control strategy with clear and effective team leading, is the key to effectively resuscitate multiple trauma shocked patients.

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases.

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications. During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n=38), polyvinyl alcohol (PVA) particles (n=2), isobutyl cyanoacrylate (n=2), coils plus PVA particles (n=1), and coils plus isobutyl cyanoacrylate (n=1). Outcome measures included technical success, clinical success, and the rate of complications. Identified bleeding sources included gastroduodenal artery (n=14), splenic artery (n=9), pancreaticoduodenal artery (n=6), common hepatic artery (n=5), superior mesenteric artery branches (n=4), proper hepatic artery (n=3), and dorsal/transverse pancreatic artery (n=3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93%). Clinical success attributed to TAE alone was documented in 40/44 patients (91%). The rate of major complications was 2% including death in one patient. Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

Absence of middle colic artery from the superior mesenteric artery

The knowledge of branches of superior mesenteric artery important for Surgeon and radiologists who deals abdominal diseases. Superior mesenteric artery is second ventral branch of abdominal aorta which arises from 1 cm below coelic trunk, opposite L1 vertebrae and supplies lower portion of duodenum, whole jejunum, ileum caecum, appendix, ascending colon and major portion transverse colon. Actually it is the artery for derivates of midgut. [1] Superior mesenteric artery gives inferior pancreatic duodenal artery, middle colic artery, right colic artery and ileo colic artery from its right concave side some ileo-jejunal artery from convex left side. Usually middle colic artery arises from superior mesenteric artery at the lower border of pancreas and immediately enters the root of transverse mesocolon and divides into right and left branch. The right branch anastomose with ascending branch of right colic artery near right colic flexure and left anastomose with ascending branch of left colic. Here we present a case of absence of mid colic artery from superior mesenteric artery and right colic artery shows some extra branches from its proximal part which supplies transverse colon.