Celiac Artery Research Articles

Distal pancreatectomy with splenectomy and celiac artery resection (modified appleby procedure) for locally advanced pancreatic body and tail adenocarcinoma in a 71 year old female

Distal pancreatectomy with splenectomy and celiac artery resection (modified appleby procedure) for locally advanced pancreatic body and tail adenocarcinoma in a 71 year old female

The meta-analysis and systematic review of prevalence and clinical anatomy of the arc of Buhler

The arc of Buhler (AOB) is a direct anastomosis of the celiac axis and superior mesenteric artery. This paper reviews the literature on the AOB and provides accurate and up-to-date data on its prevalence, anatomy, and clinical significance. The main scholarly online databases were carefully searched for relevant studies related to the AOB. Information was gathered and formed the basis of the analysis of this study. In total, 11 studies were used in this meta-study, consisting of 3685 total patients tested and 50 cases of the AOB presented. The pooled prevalence estimate of the AOB was determined to be 1.7% (95% CI 0.9, 2.9). By imaging type, the prevalence of the AOB was 1.8% for radiological studies (n = 3485; 95% CI 0.9, 3.0), 1.4% for computed tomography (CT) studies (n = 1417; 95% CI 0.4, 3.0), and 1.9% for angiography studies (n = 2068; 95% CI 0.5, 4.0). The AOB is sufficiently significant and should be considered when planning surgeries or radiological procedures involving the abdomen.

Mycotic aneurysm of the suprarenal aorta, celiac trunk and superior mesenteric artery. Case study

The article presents a rather rare clinical observation and literature review of surgical interference for mycotic (infectious) aneurysm of the suprarenal aorta with damage to paired and unpaired branches (celiac trunk, superior mesenteric and renal arteries). The authors note the features of the clinical course of aortic lesions (chronic ischemia of the digestive system, cardiorenal hypertension), the mechanisms of the disease development, and indicate the need for open repair of the thoracoabdominal aorta.

Celiac plexus radiosurgery for pain management in advanced cancer: An international phase II trial, health-related quality of life (HRQOL) outcomes.

e16293 Background: Upper abdominal / lower back pain characterizes celiac plexus involvement from pancreatic and other cancers which may impair HRQOL; its satisfactory treatment is an unmet clinical need. We hypothesized that ablative radiation delivered to the celiac plexus would decrease pain and improve HRQOL. Methods: An international single arm Phase II study included patients with an average pain level ≥ 5/11 on the brief pain inventory (BPI), ECOG 0-2, and anatomical involvement of the celiac axis. The intervention was a single fraction of 25Gy delivered to the celiac plexus. The primary endpoint was ‘complete or partial (≥2 points) pain response’ based upon the BPI ‘average pain’ 11-point scale. Changes in Health-related QOL at 3 & 6 weeks compared to baseline were secondary endpoints as measured by FACT-Hep, > 8 point change being the minimal clinically important difference (MCID). Evaluable patients included eligible irradiated subjects, who had stable pain levels pre-treatment, and were alive 3 weeks’ post-treatment. The sample size was 90 evaluable patients, giving 90% power to show response rate ≥ 40%. Opioid usage was assessed using intravenous morphine equivalent dose. Sensitivity HRQOL analyses imputed worsened outcomes (-9 for total FACT-Hep) for missing data. Results: Between 2018 and 2022, 149 patients were enrolled, 90/125 who received treatment were evaluable. Median age was 65.5 years (range 28-88), 65% were female, 92% had pancreatic cancer, and 86% had metastatic disease. Median Zubrod PS was 1, median number of systemic treatment lines was 1 (range 0-5), and median baseline opioid use 31 mg/d. At 3 weeks, 48 (53.3%, 95% CI 42.5-63.9) had at least a partial pain, the BPI ‘average pain’ score decreased by a mean of 2.5 points at 3 weeks (86/90 reported) and 3.2 points at 6 weeks (67/90 reported), both p<0.001. Opioid usage decreased by 0.6 mg/d at 3 weeks (NS) and 16.9 mg/d at 6 weeks (p=0.005). The FACT-Hep total score increased by 7.8 points at 3 weeks (54/90 reported, NS diff. from 8) and 16.6 points at 6 weeks (45/90 reported, sig. > 8, p = 0.01), showing an improvement in patients’ HRQOL. Changes in FACT-Hep were especially noted in the Physical Well Being subscale. The Trial Outcome Index (sum of physical, functional & disease-specific concerns) increased markedly at 3 weeks (6.6 points, p=0.005) after treatment and even more after 6 weeks (14.5 points, p<0.). Sensitivity analyses demonstrated improvements in HRQOL at 3 and 6 weeks (1.1, 3.8), but these were less than MCID. Conclusions: Celiac plexus SBRT decreases pain and opioid use amongst patients with pancreatic cancer and other tumors invading the celiac axis. The treatment appears to improve HRQOL. Clinical trial information: NCT03323489 .

ID: 219777 Neuromodulation in a 10-Year-Old With Chronic Abdominal Pain: A Case Report

Chronic abdominal pain in the pediatric population is complex, and identifiable causes may be difficult to elucidate. Median arcuate ligament syndrome is a rare disease in which diagnosis has been controversial in the medical community. Patients typically present with chronic postprandial abdominal pain accompanied with nausea, vomiting and weight loss. It is a diagnosis of exclusion with unclear pathophysiology typically thought to have both a structural component via compression of the celiac artery by the median arcuate ligament, as well as a neuropathic component mediated by the celiac ganglia. Optimal treatment is also debated but generally involves surgical intervention to decompress the celiac artery with or without neurolysis of the celiac plexus. We present the case of a 10-year-old female with chronic abdominal pain refractory to aggressive medical and surgical treatments, who found relief with spinal cord stimulator implantation. Before evaluation in the pain clinic, the patient received extensive gastroenterological workup and treatments including arcuate ligament release with neurolysis of the celiac ganglion that provided relief for nearly two months. She had increasing abdominal pain since five years of age and required a feeding tube for adequate nutritional intake.

One Year on: Test Your Knowledge from June 2022

1. A systematic review and meta-analysis of 15 observational studies on 236 patients investigated the clinical impact of coeliac artery (CA) coverage during thoracic endovascular aortic repair (TEVAR), with visceral ischaemia, spinal cord ischaemia (SCI), 30 day/in hospital mortality, endoleaks, re-intervention, and caudal stent graft migration following CA coverage as the outcome measures. According to the results of this study, which of the following is correct? 1A)Pooled visceral ischaemia and SCI rates were 13% and 5%, respectively.B)Pooled visceral ischaemia and SCI rates were 15% and 10%, respectively.C)Pooled visceral ischaemia and SCI rates were 20% and 15%, respectively.D)Pooled visceral ischaemia and SCI rates were 4% and 9%, respectively.E)Pooled visceral ischaemia and SCI rates were 8% and 13%, respectively.

PREVALENCE AND DISEASE SPECTRUM OF FIBROMUSCULAR DYSPLASIA IN PATIENTS WITH SPONTANEOUS CEREBROVASCULAR ARTERY DISSECTION

Objective: Spontaneous cervical artery dissection (sCeAD) is the most frequent cause of ischemic stroke in young adults and has been associated to various arteriopathies, such as fibromuscular dysplasia (FMD). The aim of this study was to assess the prevalence of both cervical and extra-cervical FMD in patients with a diagnosis of CeAD. Design and method: All patients discharged from the Stroke Unit of A.O.U. Città della Salute e della Scienza of Turin from 2016 to 2020 with a diagnosis of CeAD underwent a contrast-enhanced CTA from chest to pelvis to look for FMD-related lesions (multifocal stenosis, aneurysms, dissections, arterial tortuosity). FMD diagnosis was assessed in the presence of at least a multifocal stenosis in one of the vascular beds explored. Results: Among 56 patients with spontaneous CeAD, 72.7% were male of middle age (52±8.5 y.o.). According to radiological findings, 43.2% of patients showed extra-cervical arterial lesions, with a prevalence of overall FMD (defined as the presence of at least a multifocal stenosis) reaching 47.3% of the studied sample and affecting carotid (36.4%), renal (18.9%), visceral (16.2%), iliac (22.2%) and coronary arteries (2.7%) respectively. Renal involvement included multifocal renal stenosis (13.5%) and arterial aneurysms (5.4%). Visceral involvement included multifocal stenosis (13.5%), visceral aneurysms (2.7%) and silent mesenteric artery dissection (5.4%). Iliac involvement included multifocal stenosis (2.7%), silent artery dissection (2.7%) and tortuosity (16.7%). Furthermore, two spontaneous dissections, one of the left external iliac artery and the other of the coeliac trunk, clinically asymptomatic, were reported in two males with no multifocal stenosis. Two women suffered also from SCAD. Multivascular extra-cervical involvement was observed in almost one third of the patients (27.0%) with sever lesions (multifocal high degree stenosis and/or arterial dissections) affecting 13.5% of the population. Conclusions: According to our results, we demonstrated that FMD is frequently associated to CeAD and that silent FMD-related lesions, even severe as arterial dissections, may coexist in such patients. Therefore, FMD should always be taken in consideration in the differential diagnosis of spontaneous arterial dissection, especially in young subjects without major cardiovascular risk factors.

Initial experience with a modified "candy-plug" technique for false lumen embolization in chronic type B aortic dissection.

Persistent distal false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) can lead to aneurysmal degeneration and an increased risk of rupture. We have presented our initial experience using a modified "candy-plug" (CP) technique for FL embolization. From February 2021 to July 2022, we treated six patients using the modified CP technique. All the patients had undergone prior or simultaneous TEVAR for chronic TBAD with persistent FL perfusion and aneurysm expansion. Bilateral common femoral artery access was obtained, and intravascular ultrasound was used to confirm wire access in the true lumen (TL) and FL. A conformable TAG device (W.L. Gore & Associates, Flagstaff, AZ) was used in four cases and an Excluder aortic cuff (W.L. Gore & Associates) in two cases. The device was modified by placing a constraining "napkin-ring" suture through the middle segment of the device. Femoral sheaths were placed in the TL and FL. A standard TL TEVAR extension was performed at the level of the celiac artery (zone 5). Next, the CP device was advanced and deployed in the FL, distally aligning it with the TL device. An appropriately sized Amplatzer II plug (Abbot Vascular, Santa Clara, CA) was then deployed in the constrained segment of the modified stent graft. Completion angiography was performed to confirm successful FL embolization. Technical success was defined as successful deployment of the CP device in the FL. The technical success rate was 100% (six of six patients). Clinical success was defined as the cessation of aneurysm growth on follow-up computed tomography angiography. No 30-day mortality, myocardial infarction, stroke, spinal cord ischemia, access site complications, or aortic-related reinterventions occurred. Surveillance imaging at a mean follow-up of 10months confirmed clinical success (stable aneurysm size or shrinkage) for all five patients with follow-up data available. The modified CP embolization technique is a promising solution for persistent distal FL perfusion after TEVAR for TBAD. Further investigation is required to determine the long-term durability of this technique as an adjunct to TEVAR to promote aortic remodeling.

Trauma-Induced Median Arcuate Ligament Syndrome is an Under-Recognized Source of Chronic Abdominal Pain.

Median arcuate ligament syndrome (MALS) can be a debilitating condition resulting in epigastric pain, nausea, difficulty eating due to postprandial pain, weight loss, and malnutrition in otherwise healthy individuals. The pain is caused by the compression of the celiac artery and neural ganglia by the median arcuate ligament as it attaches from the spine to the diaphragm. Diagnostic imaging, either duplex or angiography, can show the abnormality however, vague symptoms can lead to a missed diagnosis. While MALS is a known anatomical variation in the population, to our knowledge, has not been identified to be caused by trauma. Here, we present 4 patients who developed MALS following abdominal or spinal trauma whom all required surgery to alleviate lifestyle-limiting pain.

Conventional partial pancreatoduodenectomy versus an extended pancreatoduodenectomy (triangle operation) for pancreatic head cancers—study protocol for the randomised controlled TRIANGLE trial

BackgroundPancreatic ductal carcinoma (PDAC) is the fourth most frequent cause of cancer-related death in the Western world, and its incidence is rising. In patients that undergo curative resection, local recurrence (LR) is frequent. A recently described surgical technique of extended pancreatoduodenectomy (PD) termed the TRIANGLE operation has been proposed as a promising approach to reduce LR and improve disease-free survival in PDAC patients.MethodsThe TRIANGLE trial is a multicentre confirmatory randomised controlled superiority trial with two parallel study groups. A total of 270 patients with suspected or histologically confirmed pancreatic head cancer scheduled for PD will be included in the trial and randomly assigned to the intervention group (extended PD defined as Inoue level 3 dissection along the superior mesenteric and celiac artery as well as removal of all soft tissue in the so-called triangle between the celiac artery, the SMA and the mesenterico-portal axis) or the control group (conventional PD with lymphadenectomy and removal of soft tissue according to current guidelines). The primary endpoint of the trial will be the disease-free survival of patients. Other perioperative outcomes as well as oncological parameters and patient-reported outcomes will be analysed as secondary outcomes.DiscussionDespite multimodal treatment, LR remains high and disease-free survival is limited following PD for PDAC. The TRIANGLE operation could address these shortcomings of conventional PD as indicated in several retrospective studies. However, this technique could be associated with more adverse events for patients including intractable diarrhoea. The TRIANGLE trial will close the evidence gap as well as offer a risk-benefit assessment of this more radical approach to PD.Trial registrationGerman Clinical Trials Register DRKS00030576 (UTN U1111-1243-4412) 19th December 2022.

Remodeling of the cardiovascular hemodynamic environment by lower limb heat exposure: A computational fluid dynamic study

BackgroundLower limb heat exposure (LLHE) is a promising strategy for the daily management of cardiovascular health because of its non-pharmaceutical advantages. To support the application of this strategy in cardiovascular protection, we examined its impact on the global hemodynamic environment. MethodsSkin blood flow (SBF) of eight locations on the lower limbs was measured before and after LLHE (40 °C and 44 °C) in ten healthy subjects by using a laser Doppler flowmeter. A closed-loop model of circulation uses changes in SBF to quantify the influence of LLHE on the blood flow of the arterial trunk (from ascending aorta to the femoral artery) and visceral branches (coronary, celiac, renal, and mesenteric arteries). ResultsThe SBF in all locations tested on the lower limbs increased significantly (p<0.001) with LLHE and a 3.39-fold and 7.40-fold increase in mean SBF were observed under 40 °C and 44 °C conditions, respectively. In the model, the peak (3.9–25.1%), end-diastolic (13.7–107.3%), and mean blood flow (8.5–86.5%) in the arterial trunk increased with the increase in temperature, but the retrograde flow in the thoracic aorta and abdominal aorta Ⅰ increased at least twice in the diastolic period. Furthermore, LLHE also increased the blood flow of the visceral branches (2.5–20.7%). ConclusionThese findings suggest that LLHE is expected to be a daily strategy for enhancing the functions of both the arterial trunk and visceral arteries, but the increased blood flow reversal in the thoracic and abdominal aortas warrants further investigation.

Median Arcuate Ligament Resection before Surgery for Adult Spinal Deformity in Patient with Preoperative Stenosis of Celiac Artery: A Case Report.

Median Arcuate Ligament Resection before Surgery for Adult Spinal Deformity in Patient with Preoperative Stenosis of Celiac Artery: A Case Report.

Two-Year Outcomes With Bentley BeGraft as Bridging Stent-Grafts for Reno-Visceral Target Vessels During Fenestrated Endovascular Aortic Repair.

The aim of this study was to present the short-term and 2-year outcomes after use of the Bentley BeGraft as bridging stent-graft (BSG) for reno-visceral target vessel (TV) during fenestrated endovascular aortic repair (FEVAR) from a contemporary multicentric experience. A retrospective review of all consecutive patients who underwent elective FEVAR at 7 institutions located in Italy from 2015 to 2021 was performed. The main outcomes of interest for this study were technical success and TV instability, defined in accordance with current reporting standards. Patients' survival was also assessed. Overall, 81 patients received elective FEVAR during the study period. Mean age of patients was 78 years, and 89% were men. Most patients were treated for a juxta-pararenal abdominal aortic aneurysm (AAA) (68%), and 23% had already received an infrarenal aortic reconstruction. Most endografts had 3-vessel or 4-vessel design (27% and 55%, respectively), and a Cook endograft was used in 73% of cases. Overall, 266 Bentley BeGraft were implanted, of which 44 (16.5%) in the celiac trunk, 69 (26%) in the superior mesenteric artery, 79 (29.5%) in the right renal artery, and 74 (28%) in the left renal artery. Technical success was 94%, with 5 instances of technical failure that were recorded and required an additional intraoperative procedure. The early mortality rate was 4%, and acute kidney injury occurred in 14 cases with 1 requiring definitive hemodialysis. Survival at 6, 12, and 24 months in the overall cohort was 98.8%, 95.3%, and 83.4%, respectively. Freedom from TV instability at 6, 12, and 24 months in the overall cohort was 98.4%, 97.9%, and 97.2%, respectively. Events of TV instability included 3 cases of type 1C endoleak and 3 cases of type 3C endoleak, while no events of BSG fracture or thrombosis were noted. Five out of 6 cases of TV instability occurred in renal arteries, and they were all successfully treated by endovascular means. The data from this multicentric study show favorable short-term and 2-year outcomes of the Bentley BeGraft as BSG for reno-visceral TV during FEVAR, with low rates of TV-related endoleak and no stent occlusion up to 2 years. The data from this multicentric study show satsfactory outcomes up to two years of follow-up for the Bentley BeGraft when used for brdiging reno-visceral vessels during fenestrated endovascular aortic repair. Further research will be needed to identify predictors of stent-related reinterventions and ascertain the long-term durability.

The Effect of Desloratadine Upon Ischemia-reperfusion-induced Oxidative and Inflammatory Gastric Injury in Rats

Background: Ischemia-reperfusion (I/R) injury is a pathological process mediated by oxidative stress and inflammation that begins with oxygen deprivation. This study, it was aimed to investigate the protective effect of desloratadine on gastric I/R damage in rats. Methods: Eighteen rats were randomly divided into 3 groups gastric I/R (GIR), gastric I/R + 5 mg/kg oral desloratadine (GIRD) and gastric sham operation (GSG). One hour later desloratadine administration, clips were placed in the celiac arteries of the rats in the GIRD and GIR groups. Ischemia was created by keeping the clips closed for one hour. Afterward, the clips were removed and reperfusion was achieved for three hours. The sham operation was performed on the GSG group. Then, all animals were euthanized with 120 mg/kg ketamine. Malondialdehyde (MDA), total glutathione (tGSH), superoxide dismutase (SOD) catalase (CAT) and interleukin-6 (IL-6) levels were determined in the excised gastric tissues. All tissues were also analyzed histopathologically. Result: When the GIR group was compared with the GSG, an increase in MDA and IL-6 levels and a decrease in tGSH, SOD and CAT levels were observed (p less than 0.001). In addition, severe mucosal degeneration, congestion, polymorphonuclear leukocyte infiltration and mucosal edema were detected in the GIR group. Desloratine significantly inhibited both biochemical and histopathological changes (p less than 0.05).

Renovisceral artery alterations due to branched endovascular aortic repair and respiratory-induced deformations

ObjectiveThis study quantified respiratory-induced dynamics of branch vessels before and after thoracoabdominal aortic aneurysm (TAAA) branched endovascular aneurysm repair (bEVAR). MethodsPatients with TAAA were recruited prospectively and treated with bEVAR, predominantly with Zenith t-Branch and BeGraft Peripheral PLUS bridging stents. Using SimVascular software, three-dimensional geometric models of the vessels and implants were constructed from computed tomography angiograms during both inspiratory and expiratory breath-holds, preoperatively and postoperatively. From these models, branch take-off angles, end-stent angles (transition from distal end of stent to native artery), and curvatures were computed. Paired, two-tailed t tests were performed to compare inspiratory vs expiratory geometry and pre- vs postoperative deformations. ResultsWe evaluated 52 (12 celiac arteries [CA], 15 superior mesenteric arteries [SMA], and 25 renal arteries [RA]) branched renovisceral vessels with bridging stents in 15 patients. Implantation of bridging stents caused branch take-off angle to shift inferiorly in the SMA (P = .015) and RA (P = .014) and decreased the respiratory-induced branch angle motion in the CA and SMA by approximately 50%. End-stent angle increased from before to after bEVAR for the CA (P = .005), SMA (P = .020), and RA (P < .001); however, respiratory-induced deformation was unchanged. Bridging stents did not experience significant bending owing to respiration. ConclusionsThe decrease in respiratory-induced deformation of branch take-off angle from before to after bEVAR should decrease the risk of device disengagement and endoleak. The unchanging respiratory-induced end-stent bending, from before to after bEVAR, means that bEVAR maintains native vessel dynamics distal to the bridging stents. This factor minimizes the risk of tissue irritation owing to respiratory cycles, boding well for branch vessel patency. The longer bridging stent paths associated with bEVAR may enable smoother paths subject to less dynamic bending, and potentially lower fatigue risk, compared with fenestrated EVAR.

Aortic Remodeling Following Hybrid Arch Repair for Complex Arch and Proximal Descending Thoracic Aortopathies

Hybrid aortic arch repair involves debranching of the great vessels to create a zone 0 proximal landing zone for simultaneous or staged thoracic endovascular aortic repair (TEVAR) as a less invasive therapy for complex arch and descending thoracic aortopathies. Data on thoracoabdominal aortic remodeling following hybrid arch repair remains scarce. We aimed to evaluate short-term remodeling of the thoracoabdominal aorta following hybrid arch repair. All patients (n = 38) undergoing hybrid arch repair with planned zones 0 to 5 TEVAR from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after TEVAR, and at the 3- to 6-month follow-up were analyzed for thoracoabdominal aorta remodeling. Aortic true lumen diameter (TLD) for dissections and full lumen diameter for aneurysms were recorded at 12 anatomical levels: left subclavian artery, tracheal carina, left inferior pulmonary vein, inferior left atrium, diaphragm, celiac trunk, superior mesenteric artery, renal arteries, aortic bifurcation, and common iliac arteries. Visceral vessel origin from true/false lumen and extent of false lumen thrombosis were assessed. Mean change in aortic TLD was calculated at every level and paired-samples t test was used to compare means. Of 38 patients, 37 had follow-up imaging at a mean duration of 6 months (mean age, 57.9 ± 10.0 years; 30 males [78.9%]) and one (2.6%) mortality (Table). Four (10.5%) presented with aneurysms (0, 3), 26 (68.4%) with type A aortic dissection (0, 3), and 8 (21.1%) with type B aortic dissection (1, 10). In aneurysm patients (n = 4), there was one postoperative death (2.6%) due to cardiac arrest before staged TEVAR; the remaining three had stable aneurysm sacs without endoleak at last follow-up. For dissection patients, at a mean follow-up of 6 months, there was significant increase in the mean TLD at each level (P < .05), except zones 9 and 10. The largest increase in mean TLD was observed at the left subclavian artery (+5.19 mm; 95% confidence interval [CI], 2.63-7.76), tracheal carina (+6.78 mm; 95% CI, 3.04-10.53), and lower left atrium (+4.49 mm; 95% CI, 2.01-6.97). The left renal artery was the most common vessel originating from the false lumen (14 [36.8%] pre- and post-TEVAR); followed by the right renal artery (7 [18.4%] pre-TEVAR and 5 [13.2%] post-TEVAR). Visceral perfusion remained intact following TEVAR in all patients. False lumen thrombosis to distal zone 5 was observed in 100% of the dissection patients. Hybrid arch repair with zone 0 to 5 TEVAR provides adequate aneurysm exclusion and positive aortic remodeling down to zone 8 in the short term with improved TLD and high rate of false lumen thrombosis. When involved, zones 9 to 11 may require adjunctive or alternative branched or fenestrated strategies for total aortic remodeling and complete false lumen obliteration.TableSummary of included patients and measurements at various anatomic levelsVariableNo. of patients (%); n = 38Patient characteristics Age, years57.9 ± 10.0 Male30 (78.9) Diabetes mellitus11 (28.9) Hypertension35 (92.1) Dyslipidemia19 (50.0) Cerebrovascular disease4 (10.5) Dialysis1 (2.6) Chronic obstructive pulmonary disease7 (18.4) Smoking history22 (57.9) Prior coronary artery bypass grafting3 (7.9) Aortic aneurysm4 (10.5) Type A aortic dissection26 (68.4) Type B aortic dissection8 (21.1) Prior valve surgery10 (26.3) Mortality1 (2.6)Aortic remodeling dataLevelPreoperative true lumen measurements, mmPost-TEVAR true lumen measurements (mean follow-up 6 months), mmRemodeling over mean follow-up of 6 monthsMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMean Change (95% CI) [% change]P valueLeft subclavian artery11.248.322.25 ± 8.83---15.938.427.44 ± 5.33---5.19 (2.63-7.76) [+23.3%].001*Carina3.460.919.78 ± 11.05---3.340.126.59 ± 7.28---6.78 (3.04-10.53) [+34.3%].001*LIPV6.567.317.45 ± 10.61---7.93623.16 ± 6.31---4.27 (0.85-7.69) [+24.5%].016*Left atrium4.966.216.89 ± 11.03---5.461.221.33 ± 9.30---4.49 (2.01-6.97) [+26.6%].001*Diaphragm6.634.715.75 ± 7.15---6.549.119.03 ± 8.22---3.28 (1.53-5.04) [+20.9%].001*Celiac trunk2.828.113.92 ± 6.574 (10.5)25 (65.8)0 (0.0)5.928.915.49 ± 6.204 (10.5)14 (36.8)2 (5.3)2.57 (0.86-4.27) [+18.4%].005*SMA3.427.113.77 ± 5.963 (7.9)24 (63.2)0 (0.0)6.330.114.94 ± 5.673 (7.9)17 (44.7)1 (2.6)1.17 (0.20-2.15) [+8.5%].020*RRA3.126.313.08 ± 6.147 (18.4)24 (63.2)0 (0.0)6.728.614.46 ± 5.645 (13.2)13 (34.2)1 (2.6)1.38 (0.18-2.58) [+10.6%].025*LRA3.130.712.78 ± 6.4714 (36.8)22 (57.9)0 (0.0)6.328.613.80 ± 5.4614 (36.8)13 (34.2)2 (5.3)1.02 (0.02-2.02) [+8.0%].046*Aortic bifurcation7.328.114.06 ± 5.83---7.830.114.45 ± 4.99---0.39 (−0.83 – 1.62) [+2.8%].518RCIA3.517.510.82 ± 3.76---2.717.710.44 ± 3.46---−0.38 (−1.36 – 0.61) [-3.5%].443LCIA3.315.610.28 ± 3.72---3.616.410.67 ± 3.63---0.28 (−0.29 – 0.86) [+2.8%].317LCIA, left common iliac artery; LIPV, left inferior pulmonary vein; LSCA, left subclavian artery; RRA, right renal artery; LRA, left renal artery; RCIA, right common iliac artery; SD, standard deviation SMA, superior mesenteric artery; TEVAR, thoracic endovascular aortic repair. 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Open Median Arcuate Ligament Release With Complete Celiac Plexus Neurolysis Provides Substantial Relief in Symptomatic Patients

Median arcuate ligament syndrome (MALS) is a clinical entity that has historically been met with significant equipoise on how to diagnose and treat the constellation of symptoms. Our objective was to describe distinct patient outcomes following open median arcuate ligament release and complete celiac plexus neurolysis in patients diagnosed with MALS. We performed a prospective analysis of patients referred for MALS at a single institution between February 2020 and January 2022. We assessed duplex ultrasound studies, abdominal computed tomography angiography results, celiac plexus nerve block procedures, and patient reported questionnaires. Patients who experienced symptomatic relief from celiac plexus nerve block were offered surgical release and neurolysis. Their preoperative and postoperative health and quality of life measures were assessed using the 36-item Short-Form Health Survey (RAND). There were 75 patients who were referred for MALS and 29 patients (39%) underwent surgery. Duplex ultrasound examination revealed a significant increase in celiac artery peak systolic velocity at end-expiration (211 cm/s to 276 cm/s), with only 55% having a J-hooked appearance of the celiac artery on computed tomography angiography. All patients underwent transgastric celiac plexus block with a combination of bupivacaine and triamcinolone. After nerve block, surgical patients had a mean relief of 207 hours (48-1008 hours) from their symptoms. Postoperatively, 16 patients completed the 36-item Short-Form Health Survey with significant improvement noted in each category of the questionnaire (Fig 1). Significant quality of life improvement can also be appreciated in Fig 2. Surgical patients had an average weight gain of 8.8 kg (range, 1.3-34 kg) at a mean follow-up of 8 months. There were no perioperative wound healing complications. Our data suggest that patients who are carefully selected for median arcuate ligament release and neurolysis have significant improvement in quality of life and benefit from surgery. Wide surgical neurolysis of the celiac plexus is critical and the same diagnostic imaging findings are not consistent across all patients. Celiac plexus neurolysis is required for accurate patient selection.Fig 2Averages in each domain of the 36-item Short-Form Health Survey.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Explant of an Embolized Left Atrial Appendage Occlusion Device

This case highlights an open retroperitoneal approach to explant an embolized left atrial appendage occlusion device in the visceral aorta. Endovascular retrieval of the device was deemed to be an inferior alternative given the significant mural thrombus that extended toward the superior mesenteric artery and celiac artery from the device, as demonstrated on computed tomography angiogram, and the associated risk of embolizing the visceral vessels or the lower extremities. After explantation of the device and thrombectomy of the visceral aorta and vessels, the aorta was closed with a bovine pericardium patch and the patient had excellent flow in the visceral vessels on Doppler interrogation as well as palpable femoral and dorsalis pedis pulses bilaterally. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkNTNlYmZhY2E0ZmY1Mzg1MmY5NzhlNDZjMTBjZThmNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg0ODU3NjI1fQ.EwSKLOWw5WMOIFl-wvWWwpZ7pG3kMhvd-frnMY9vMsKkaG5adl1pnISOCa7EIYfupXtCwyig2ODvko3HhNvDcJ7kZjuJmGR33n7CmhdTq26386TMs8CE2nUTr4nk1KR-ETkO2MaC35h3oI9NIwT0WL9wxp8HUREcuc5Abtp_sXo1wMPlZvcn3hBHioZ2LDS1R3ujoBhwpG3-O5ALBXldrThyDOO_Gy9dS1se8d-PqiqlTGKAyZpLQhSUKjel8oc81EsIYQ-QfOh1uS3bHWlSzAL3j_LyBHK7drmWFixT0-01ztpO6MLn4fyj01wGEFBW6QFHSsetgmPmwayf3HyrmQ Download .mp4 (107.46 MB) Help with .mp4 files Watchman Case 1.8.23NoTitles.mp4

Midterm Results of Supraceliac vs Infraceliac Sealing for Fenestrated Endovascular Aortic Repair of Juxtarenal Aortic Aneurysms

The complexity of fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms has increased over time including a more proximal sealing zone despite a similar disease extent. Prior studies demonstrated that supraceliac sealing is associated with higher perioperative morbidity, although mortality seems to be similar. Durability of sealing at a supra celiac level vs an infraceliac level remains unknown. The aim of our study was to examine outcomes of FEVAR for juxtarenal abdominal aortic aneurysms comparing a supraceliac vs an infraceliac sealing zone. We included patients undergoing elective juxtarenal FEVAR from 2008 to 2021 at two large hospitals in the Netherlands. The definition of a supraceliac sealing zone was incorporation of the celiac trunk by either a scallop or fenestration. The primary outcome was 5-year aneurysm-related procedures. Secondary outcomes included perioperative complications, 5-year mortality and 1-year aneurysm sac dynamics. These outcomes were analyzed using t tests, Kaplan-Meier methods, multivariable Cox regression analysis, and χ2 tests. One-year aneurysm sac dynamics were evaluated between the groups with imaging data (sac regression/stable sac/sac expansion, based upon 5% volume change compared with 30-day volume). Among 173 patients identified, 114 (66%) had a supraceliac and 59 (34%) had an infraceliac sealing zone. Patients with supraceliac sealing more often had prior EVAR (26.3% vs 12%; P = .045). Furthermore, supraceliac sealing had similar rates of perioperative complications and mortality. No differences were found in one-year aneurysm sac dynamics. Supraceliac sealing was associated with significantly lower risks of secondary aneurysm-related procedures at 5 years compared to use of infraceliac sealing (25% vs 45%; hazard ratio, 0.37; 95% confidence interval, 0.17-0.79; P = .012) (Figure). Finally, supraceliac sealing had similar risks of 5-year mortality compared with infraceliac sealing (hazard ratio, 0.93; 95% confidence interval, 0.49-1.74; P = .813). FEVAR with supraceliac sealing is more durable with less secondary aneurysm-related procedures as compared to infraceliac sealing for juxtarenal aneurysms. Future research has to examine whether supraceliac sealing should be the standard for juxtarenal aneurysms.

Single Center Experience of Operative Management in Isolated Mesenteric Artery Dissections

Isolated mesenteric dissection of vessels is a rare occurrence with management strategies dependent on patient presentation. The study aimed to evaluate a single institution's experience on patient characteristics, treatment modalities, and outcomes on operative vs nonoperative management of mesenteric dissection. Patients from a single institution between January 2017 and November 2022 with diagnosis of superior mesenteric artery (SMA) or celiac artery dissection and its branches were included. Patients with concomitant descending aortic dissection were excluded. Patient demographics, imaging, treatments, and follow-up data was collected and underwent descriptive statistical analysis. All SMA dissections were categorized using the modified Sakamoto classification (types I-VI), with type VI indicating total occlusion of vessel due to dissection. There were 30 patients with diagnosis of isolated mesenteric dissection. Mean age was 61 years, and the majority were male (86%), Asian (60%), and symptomatic (70%). Majority had isolated SMA dissection (n = 19; 63.3%) with the remainder having isolated celiac (n = 9; 30%) or concomitant SMA and celiac dissection (n = 2; 6.7%). Twenty-one patients had involvement of SMA and categorized using the modified Sakamoto Classification (n = 5 type I, n = 0 type II, n = 2 type III, n = 4 type IV, n = 1 type V, n =7 type VI). Nonoperative treatment occurred in 63.3% (n = 19). Operative intervention rate was 33% (n = 10). All patients who underwent an operation were symptomatic with abdominal pain on presentation (P < .01) (Table I). Two patients presented with rupture and five presented with signs of acute mesenteric ischemia necessitating emergent exploration. Two patients required bowel resection for necrosis. Sakamoto classification was also significantly associated with operative intervention (P < .01). Patients presenting with abdominal pain were three times as likely to undergo operative treatment (odds ratio, 3.13; P < .01) (Table II), while patients with a modified Sakamoto classification type V and above were 10 times more likely to undergo an operative intervention (odds ratio, 10.5; P < .02) (Table II). A large majority of operative cases (n = 9; 90%) were diagnosed with involvement of SMA dissection. Unplanned secondary intervention rate was 30% (n = 3). There was 9.5% mortality rate amongst those with SMA vessel involvement (10% overall mortality). Among those patients that followed-up, all were asymptomatic at the time of follow-up (n = 16). Patients with nonoperative interventions had 57% favorable remodeling (n = 4). Symptomatic patient presentation and higher modified Sakamoto classification type (types V and VI) tend to require operative intervention. Although a majority of spontaneous isolated mesenteric dissections may be treated nonoperatively with either medical therapy or observation alone, identifying patient characteristics amongst those that require operative intervention are important considerations for management of this rare disease process.Table IClinical characteristics by operative interventionOverall, n = 30Operative repair, n = 10Nonoperative, n = 20P valueaAge61.00 ± 12.0854.30 ± 13.4164.35 ± 10.11.031Gender.6 Female4 (13)2 (20)2 (10) Male26 (87)8 (80)18 (90)Ethnicity/Race.032 Asian18 (60)5 (50)13 (65) Hispanic5 (17)2 (20)3 (15) Other3 (10)3 (30)0 (0) White4 (13)0 (0)4 (20)Smoking history.7 Yes10 (33)4 (40)6 (30) No20 (67)6 (60)14 (70)Atrial fibrillation.7 Yes7 (23)3 (30)4 (20) No23 (77)7 (70)16 (80)Hypertension.4 Yes10 (33)2 (20)8 (40) No20 (67)8 (80)12 (60)White blood cells.4 >1211 (37)5 (50)6 (30) 4-1219 (63)5 (50)14 (70)Systolic blood pressure groups>.9 High (>140)17 (57)6 (60)11 (55) Normal (100-140)11 (37)3 (30)8 (40) Low (<100)2 (6.7)1 (10)1 (5.0)Modified Sakamoto class (types I-VI).008 Type I5 (24)1 (11)4 (33) Type II0 (0)0 (0)0 (0) Type III2 (9.5)1 (11)1 (8.3) Type IV4 (19)0 (0)4 (33) Type V2 (9.5)0 (0)2 (17) Type VI8 (38)7 (78)1 (8.3)Symptomatic at presentation.011 Yes20 (67)10 (100)10 (50) No10 (33)0 (0)10 (50)Length of stay7.67 ± 8.5614.00 ± 10.424.50 ± 5.35.004Intensive care unit length of stay2.57 ± 4.766.50 ± 6.430.60 ± 1.67<.001Deceased.3 Yes3 (10)2 (20)1 (5) No27 (90)8 (80)19 (95)Values are mean ± SD or number (%).aWilcoxon rank-sum test; Fisher's exact test. Open table in a new tab Table IIOdds ratio analysis of symptomatic presentation and Sakamoto classification with operative interventionOR95% CIP valueSymptomatic at presentation3.131.08-406.55.011Sakamoto class type V-VI10.51.57-105.00.024CI, Confidence interval; OR, odds ratio. Open table in a new tab