Ectopic spleen, or Wandering Spleen (WS), is a rare condition caused by laxity of splenic suspensory ligaments. While often asymptomatic, it may present with life-threatening complications such as torsion and infarction. We present a case of a 41- year-old female with a history of breast cancer who developed left-sided abdominal pain. Imaging confirmed an ectopic spleen in the pelvis resting on the urinary bladder, receiving its blood supply from the coeliac trunk. Computed Tomography (CT) also showed a well-demarcated area of non-enhancement at its inferior pole, along with twisting of the vascular pedicle associated with surrounding free fluid representing splenic volvulus and infarction. Enoxaparin 72 mg SQ BID was initiated for concurrent splenic vein thrombosis, and the patient was discharged on Rivaroxaban 20 mg PO OD. Over 16 months, serial imaging showed resolution of infarction and maintained splenic vascularity without surgical intervention. This case demonstrates that conservative management of WS with infarction may be viable with close monitoring and anticoagulation.

Anatomical and microscopic evaluation of the liver in migratory shoveler ducks (Spatula clypeata): A multi-modal study using gross anatomy, vascular casting, morphometric analysis, and histochemistry techniques.

Median arcuate ligament syndrome (MALS) is a complex vascular condition that results in generalized abdominal pain resulting from compression of the celiac artery (CA). Early reports of the treatment of MALS described open surgical release of the MAL and decompression of the CA. The treatment of MALS has evolved over the past 2 decades, and laparoscopic as well as robotic techniques have been utilized. These studies enrolled patients treated by multiple surgeons from several institutions using a variety of techniques. This study was undertaken to examine and report contemporary surgical results, clinical response and outcomes from open decompression, and revascularization of the celiac axis for MALS performed by a single surgeon using a standardized surgical technique. Between March 2017 and May 2024, patients diagnosed with MALS associated with chronic abdominal pain were treated with open surgical decompression and CA bypass and were retrospectively reviewed. Data collected included demographics, morbidity, mortality, operative variables, and anatomic and clinical responses to surgery. Preoperative CA diameter stenosis was measured, graded (I-IV), and compared to postoperative stenosis levels. Patients' clinical response to surgery was determined at several points in the postoperative period by questionnaires at office follow-up as well as telehealth visits. Associations between preoperative and operative variables with anatomic and clinical outcomes were evaluated and analyzed. Sixty-two patients met the inclusion criteria and underwent open surgical release of the MAL using a standardized technique. Five patients required an additional aorto-celiac bypass (8.1%). Twelve (19.4%) were males and 50 (80.6%) were females. The median age was 40.6 (range, 15-71 years). Presenting symptoms were generalized abdominal pain in 62 (100%), postprandial pain in 48 (77.4%), and weight loss in 38 (61.3%). Preoperative grading of the level of the CA stenosis revealed severe stenosis (>99%) grade IV in three (4.8%), high grade stenosis (70-99%) grade III in 48 (77.4%), and moderate stenosis (50-69%) grade II in 11 (17.7%). Thirty-day mortality and reoperations were zero. Median hospital length of stay (LOS) was 3 days (range, 1-8 days). Fifty (83.3%) were found to have a reduced stenosis of the CA to grade I (<50%). Fifty-three (88.3%) patients were deemed to have had a favorable response. Seven patients (11.3%) were judged to have an unfavorable response. Two patients were lost to follow-up. Average follow-up of the remaining 60 patients was 28.8 months. Open surgical decompression is an effective method for the treatment of MALS and is associated with low morbidity. Most patients experienced significant reduction in abdominal pain and overall sustained clinical improvement with restoration to normal CA diameters after decompression.

Emergency Deceased Donor Liver Transplantation Using a PTFE Graft for Complex Arterial Reconstruction: A Technical Note.

Robotic-assisted decompression of the celiac trunk via the common hepatic artery approach for median arcuate ligament syndrome.

Median arcuate ligament syndrome (MALS) is a rare vascular disorder. We report the case of a 72-year-old man with MALS who was found to have an anomalous right inferior phrenic artery originating from the celiac artery (CA), which was not detected on preoperative computed tomography angiography. During laparoscopic decompression, this vessel was encountered unexpectedly. A temporary clamping test was performed, confirming no diaphragmatic or hepatic ischemia, after which the vessel was safely ligated. The CA was then fully decompressed. Postoperatively, the patient's symptoms resolved completely. This case underscores that significant vascular anomalies may only be revealed intraoperatively. The described clamping technique provides a simple and safe method for real-time functional assessment, aiding critical surgical decisions when managing unforeseen anatomical variations.

Covered stents commercially available are frequently used off-label in conjunction with fenestrated and branched aortic stent grafts, but there is a lack of dedicated devices. This study aims to assess the safety and mid-term clinical performance of a new dedicated covered stent, the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (VBX stent graft), when used as a bridging stent with branched and fenestrated aortic endografts in treating complex abdominal aortic and thoraco-abdominal aneurysms. A retrospective, multicenter, single-arm study in the European Union (ClinicalTrials.gov NCT05143138) enrolled patients treated with the VBX stent graft as a bridging stent in branched endovascular repair (BEVAR) and fenestrated endovascular repair (FEVAR) to allow endovascular aneurysm repair between January 2017 and December 2021. Up to 15 sites in Europe were required to enroll a minimum of 220 patients. Patients' medical records were reviewed by the investigator, and specific data were collected ambispectively for up to 5 years of follow-up from the index procedure. The primary end point is target vessel patency (patient level) through 12 months. The registry was designed to statistically test target vessel patency at 12 months in both FEVAR and BEVAR populations. The hypothesis will be tested separately in the 2 cohorts (fenestrated or branched endovascular repair), using patients with core laboratory imaging results available annually through 5 years. The binomial exact test will be used with a 1-sided 2.5% level of significance to test the null hypothesis. In total, 259 patients were retrospectively enrolled for a prospective follow-up of 5 years: 136 patients (n=99, 72.8% male; mean age 73, SD 8.9 y) in the BEVAR cohort, 92 patients (n=80, 87.0% male, mean age 72.7, SD 8.1 y) in the FEVAR cohort, and 31 patients (n=17, 54.8% male, mean age 70.9, SD 9.4 y) in the mixed fenestrated or branched endovascular repair cohort. Overall, 662 target vessels were stented with the investigational covered stents: 163 (24.6%) celiac trunk, 192 (29.0%) superior mesenteric artery, and 307 (46.4%) renal arteries. The VBX stent grafts were paired with branches in 451 (68.1%) cases or fenestrations in 211 (31.9%) cases among all Cook Medical stent graft cases. The 1-year results will be published in the fourth quarter of 2025, and the 5-year follow-up results will be analyzed by mid-year 2028. This study will investigate the VBX stent graft performance in combination with fenestrated and branched aortic grafts to corroborate its use in complex aortic endovascular procedures and support the modification of current device instructions for use.

We report an incidental finding of a coeliac trunk (CeT) hexafurcation in a 62-year-old female during computed tomography angiography, where the trunk sequentially branches off the left and right inferior phrenic arteries (IPAs) and the left gastric artery (LGA) as collateral branches, before a terminal trifurcation into the common hepatic (CHA), splenic (SA), and dorsal pancreatic (DPA) arteries. While the CeT typically trifurcates, hexafurcation is exceedingly rare. This variation likely stems from the failure of standard regression of primitive splanchnic arteries. The aberrant branches (IPA and DPA) are involved in numerous surgical and interventional procedures. Therefore, this image emphasizes the necessity of high-resolution preoperative imaging and three-dimensional reconstruction to identify complex vascular morphologies.

Background: Asymptomatic compression of celiac artery (CA) by median arcuate ligament (MAL) is quite common, but simultaneous compression of other arteries by MAL is very rare. Case details: A 20-year-old man presented with post-prandial epigastric pain for the past 1 year and a 5kg weight loss. On examination, he had a body mass index of 17.2kg/m2 and was normotensive. Blood tests were unremarkable except for a mildly raised serum creatinine. A CT angiography (CTA) showed MAL-related 60% proximal CA narrowing and 40% proximal right renal artery (RRA) narrowing with a small right kidney. After multi-disciplinary team discussion, surgical MAL release at both sites was planned. The surgery was started laparoscopically to identify CA origin by a 'top to down' approach. The CA origin could not be visualised as it was looping behind the pancreatic neck caudally; hence the procedure was converted to open. CA origin was identified and overlying MAL divided. After kocherisation, RRA origin was found compressed by right limb of MAL and was divided. The operative duration was 200 mins with 50mL blood loss. Results: The patient had an uneventful recovery. At 12-month, he is asymptomatic with serum creatinine normalised and gained 8kg weight. A follow-up CTA at 2months showed a normal CA and RRA. In this report, we discuss briefly about the current presentation, diagnosis and treatment of MAL compression of CA and other upper abdominal arteries. Conclusions: The learning point from this case is that one should carefully inspect all upper abdominal arteries in CTA for MAL-related compression as they may be asymptomatic, and this enables simultaneous treatment at these sites too in a single surgery.

ASO Author Reflections: Integrating Stenosis Severity and Arcade Development in the Assessment of Celiac Axis Stenosis During Pancreatoduodenectomy.

To elucidate morphological characteristics of the splenic artery (SA) arising from the superior mesenteric artery (SMA). Contrast-enhanced CT images of 13 patients with SA arising from SMA were retrospectively analyzed. Gross appearance of SA arising from SMA was observed on volume-rendering 3D images. Additionally, we measured the following lengths m each patient on the appropriate multiplanar reformation (MPR) images; (A) the distance from the origin of SMA to the origin of SA, (B) SA length from the origin of SA to the point which is at the shortest distance from the celiac artery (CA), (C) the shortest distance between CA and SA, (D) the distance from the origin of SA to the origin of the middle colic artery. In all 13 patients, SA arising from SMA showed similar course. It first runs cranially toward the point which is very close to CA, and then curves toward the left and afterwards runs along almost the same course as the conventional SA. The shortest distance between SA and CA (distance C) was 3.3 ± 1.4 [mm]. SA arising from SMA invariably shows characteristic morphology. This characteristic morphology suggests that longitudinal anastomosis between primitive CA and SMA may be the developmental basis of this variant vascular anatomy.

Spontaneous isolated celiac artery dissection: a rare mimicker of pancreatic mass masquerading as neoplasm

Vascular resection and reconstruction during pancreatoduodenectomy (PD) have evolved from rare and controversial procedures into essential components of surgical management for selected patients with locally advanced pancreatic ductal adenocarcinoma (PDAC). Venous resection is now widely accepted and routinely performed in high-volume centers, whereas arterial resection and artery-sparing divestment remain selectively applied because of their technical demands and concerns regarding perioperative risk and oncologic benefit. Accumulating contemporary evidence indicates that venous resection can be performed with acceptable safety, with 30-day mortality rates generally ranging from 3% to 5% and median overall survival of approximately 18-26 months when margin-negative (R0) resection is achieved. Arterial resections, most commonly involving the common hepatic, celiac, or superior mesenteric arteries, have been increasingly utilized in highly selected patients, particularly following neoadjuvant therapy, achieving R0 resection rates of approximately 65-75% and median overall survival of 20-28 months. Arterial divestment has emerged as a promising artery-sparing strategy, offering comparable oncologic outcomes with reduced surgical morbidity in appropriately selected cases. Collectively, these advances have expanded the boundaries of resectability in PDAC, enabling surgical intervention in patients previously deemed inoperable. Venous resection is now considered an oncologically sound extension of standard PD, whereas arterial resection and divestment should remain restricted to carefully selected patients demonstrating favorable biologic behavior and response to neoadjuvant therapy. Future progress in this field will likely depend on improved biologic stratification, enhanced intraoperative perfusion assessment, and the integration of hybrid open and endovascular techniques.

Celiac axis stenosis (CAS) is a significant vascular condition in patients undergoing pancreatoduodenectomy due to division of the celiac circulation during the procedure. However, the reliable conditions for when to intervene remain undefined. We retrospectively analyzed 1,042 consecutive patients who underwent pancreatoduodenectomy. The stenosis diameter and maximum diameter of the celiac axis were measured on preoperative multidetector CT to calculate the stenosis rate (SR). In the patients with CAS (SR ≥ 50%), two additional CT-based markers of arcade development were quantified: 1) the gastroduodenal-to-common hepatic artery diameter (GDA/CHA) ratio and 2) the diameter of the collateral artery connecting the GDA and inferior pancreatoduodenal artery. Four factors (stenosis diameter ≤2mm, SR ≥70%, GDA/CHA ratio ≥1.0, collateral artery diameter ≥3mm) were assessed as predictors of intraoperative intervention. Eighty-five patients (8.2%) had CAS (SR ≥50%), of which only 11 (1.1% of the entire cohort) required intervention: median arcuate ligament division (n = 4), arterial reconstruction (n = 5), or collateral preservation (n = 2). Each of the four factors (stenosis diameter ≤2mm, SR ≥70%, GDA/CHA ratio ≥1.0, collateral artery diameter ≥3mm) was associated with the need for intervention. Intervention for CAS was not required in any case in which none of the four factors were present. In contrast, all patients with three or more positive factors required intervention. The four factors (stenosis diameter, SR, GDA/CHA ratio, and collateral artery diameter) may serve as important predictors of CAS intervention. Incorporating these factors into preoperative planning enables surgeons to prepare necessary resources.

ASO Author Reflections: Class Ia Pancreatosplenectomy with Class Ia Celiac Axis Resection, SMA Isolation, and Lateral Venous Reconstruction with Peritoneal Patch: A Standardized Technique.

ASO Author Reflections: Arterial Reconstruction in Distal Pancreatectomy with Celiac Axis Resection.

This article reports the case of a male patient in his 70s with middle aortic syndrome (MAS). The patient was admitted with abdominal pain, abdominal distension, vomiting, and cessation of defecation for 2 days as chief complaints and was diagnosed with intestinal obstruction. Enhanced computed tomography and vascular reconstruction revealed distal occlusion of the abdominal aorta. The celiac trunk, superior mesenteric artery, and inferior mesenteric artery were not visualized, whereas bilateral renal arteries maintained blood flow. Given the patient's history of intermittent claudication and uncontrolled hypertension, the condition was ultimately diagnosed as MAS secondary to Takayasu's arteritis, with bowel obstruction identified as a secondary manifestation of MAS. After insertion of a nasointestinal obstruction catheter, the patient's symptoms of intestinal obstruction were relieved. However, the obstruction recurred, and the patient subsequently improved following vascular reconstruction. During postoperative follow-up to date, intestinal obstruction has recurred only once due to improper diet and resolved after dietary modifications. MAS is relatively rare in clinical practice, particularly among older patients. We hope that this case study provides clinicians with an opportunity for learning and knowledge exchange, thereby contributing to improved diagnostic and therapeutic approaches for patients with similar conditions.

Impact of a new stepped balloon for bridging stent implantation on procedural time and radiation exposure in fenestrated endovascular aortic repair.

Outcomes of Median Arcuate Ligament Release and Celiac Plexus Neurolysis in 72 Patients with Median Arcuate Ligament Syndrome.

Large visceral collaterals due to median arcuate ligament chronic celiac and superior mesenteric artery occlusion.