Colic Artery Research Articles

Classification of the superior mesenteric artery.

The aim of this study was to characterize the branching pattern and morphology of the superior mesenteric artery (SMA), and also to create a new SMA classification, which seems necessary for clinicians performing surgery in this anatomical area. The anatomical variations in the branching patterns of the SMA were examined in 30 cadavers fixed in 10% formalin. Morphometric measurements were then obtained twice by two researchers. In the proposed classification system, Type I, characterized by all normal branches-inferior pancreatoduodenal artery, ileocolic artery, right colic artery, middle colic artery and intestinal arteries-occurred in 53.33% of the specimens. Type II, characterized by absence of the inferior pancreatoduodenal artery, was present in 26.67%. Type III, characterized by absence of the right colic artery, was present in 3.33%. Type IV, characterized by a common trunk for the inferior pancreatoduodenal artery and middle colic arteries, was observed in 3.33%. Type V, characterized by an aberrant hepatic artery and absence of the inferior pancreatoduodenal artery, was observed in 13.33%. The origin of the SMA was at the Th12/L1 level in 10% of cases, at L1 in 43.33%, at L1/L2 in 36.67%, and at L2 in 10%. The SMA is characterized by high morphological variability, the variants being associated with distinct clinical aspects. The introduction of a new, structured, anatomical classification seems necessary for all clinicians.

Anatomical variations of the branches from left colic artery and middle colic artery at splenic flexure.

Variations of the vasculature at splenic flexure by left colic artery (LCA) and middle colic artery (MCA) remain ambiguous. This study aim to investigate the anatomical variations of the branches from LCAand MCA at splenic flexure area. Using ultra-thin CT images (0.5-mm thickness), we traced LCA and MCA till their merging site with paracolic marginal arteries through maximum intensity projection (MIP) reconstruction and computed tomography angiography (3D-CTA). A total of 229 cases were retrospectively enrolled. LCA ascending branch approached upwards till the distal third of the transverse colon in 37.6%, reached the splenic flexure in 37.6%, and reachedthe lower descending colon in 23.1%, and absent in 1.7% of the cases. Areas supplied by MCA left branch and aMCA were 33.2%, 44.5% and 22.3% in the proximal, middle and distal third of transverse colon of the cases, respectively. The accessory MCA separately originated from the superior mesenteric artery was found in 17.9% of the cases. Mutual correlation was found that, when the LCA ascending branch supplied the distal transverse colon, MCA left branch tended to feed the proximal transverse colon; when the LCA ascending branch supplied the lower part of descending colon, MCA left branch was more likely to feed the distal third of transverse colon. Vasculature at splenic flexure by LCA and MCA varied at specific pattern. This study could add more anatomical details for vessel management in surgeries for left-sided colon cancer.

Totally Laparoscopic Left Colectomy With Preoperative Simulation Using 3D CT Angiography and Intraoperative Navigation Using the Indocyanine Green (ICG) Fluorescence Method

Introduction Laparoscopic reconstruction after left colectomy is mostly performed with functional end-to-end anastomosis through about 5–7 cm sized incision. However, this procedure poses some problems, including increased intestinal mobilization range and parietal destruction, insufficient blood flow to the intestinal tract due to arterial arch malformation, and dominant artery dissection. In this paper, we present a case of descending colon cancer for which totally laparoscopic surgery and intracorporeal anastomosis could be performed safely with preoperative simulation and intraoperative navigation. Case presentation A 34-year-old male was complaint fecal occult blood positive and a colonoscopy was performed. The patient was diagnosed with descending colon cancer cT2N0N0 Stage I. Preoperative CT angiography findings showed that the inferior mesenteric artery (IMA) branched into the left colic artery (LCA) and the sigmoid arteries (S1, S2) in order and showed LCA and S1 as the dominant arteries, and a totally laparoscopic descending colectomy (D2 dissection and S2 artery preserving) was scheduled. At his operation, for investigate blood flow of anastomotic region, ICG was used. After an intravenous injection of ICG, blood flow was evaluated and intestinal dissection was performed at the scheduled dissection line. Intracorporeal anastomosis was then performed using the overlap method and a linear stapler. Conclusion Although the intracorporeal anastomosis procedure has a high degree of difficulty, the use of preoperative simulation and intraoperative navigation may reduce the surgeon's intraoperative stress and enable safe and accurate intestinal dissection and anastomosis in the totally laparoscopic surgery.

Terminal Reaches of the Branches from Middle Colic Artery and Their Correlation with Right Colic Artery

Terminal Reaches of the Branches from Middle Colic Artery and Their Correlation with Right Colic Artery

Preservation of the inferior mesenteric artery in laparoscopic nerve-sparing colorectal surgery for endometriosis

Laparoscopic rectosigmoid resection for endometriosis is usually performed with the section of the inferior mesenteric artery (IMA) distal to the left colic artery (low-tie ligation). This study was to determine outcomes in IMA-sparing surgery in endometriosis cases. A single-center retrospective study based on the analysis of clinical notes of women who underwent laparoscopic rectosigmoid segmental resection and IMA-sparing surgery for deep infiltrating endometriosis with bowel involvement between March the 1st, 2018 and February the 29th, 2020 in a referral hospital. During the study period, 1497 patients had major gynecological surgery in our referral center, of whom 253 (17%) for endometriosis. Of the 100 patients (39%) who had bowel endometriosis, 56 underwent laparoscopic nerve-sparing rectosigmoid segmental resection and IMA-sparing surgery was performed in 53 cases (95%). Short-term complications occurred in 4 cases (7%) without any case of anastomotic leak. Preservation of the IMA in colorectal surgery for endometriosis is feasible, safe and enables a tension-free anastomosis without an increase of postoperative complication rates.

A119 ACUTE DIVERTICULITIS & CONCURRENT DIVERTICULAR BLEED: A RARE CLINICAL ENTITY

AimsColonic diverticula are mostly asymptomatic incidental findings on cross sectional imaging or colonoscopy. In the setting of known diverticulosis, complications like diverticulitis and diverticular bleeding occur in only 4% and 1% of patients respectively. It is unusual to see both complications expressed in the same patient and moreover, rare to see them expressed concurrently. We report a case of concurrent diverticulitis with diverticular bleed and expand on the clinical course.MethodsCase reportResultsA 73-year old was diagnosed with sigmoid diverticulitis based on her clinical presentation and an abdominal CT scan. She was discharged home on oral antibiotics but presented a week later with painless rectal bleeding. In view of the ongoing diverticulitis, a colonoscopy was not pursued although it is the typical procedure of choice to manage active gastrointestinal bleeding. A CT scan was recommended as the alternate initial investigation, which revealed active colonic bleeding in the region of the hepatic flexure immediately adjacent to a diverticulum. A subsequent CT angiogram identified the middle colic artery to be the responsible blood supply to the region and embolization coils were deployed within this vessel in an attempt to achieve hemostasis.Despite vascular intervention the patient continued to bleed and resuscitation with blood products was insufficient. A repeat CT scan ruled out any areas of colonic ischemia as well as any further active areas of extravasation. A decision was made to proceed with a total colectomy to provide definitive treatment of the diverticular disease and manage the bleeding. An urgent intraoperative colonoscopy was attempted but quickly abandoned due to suboptimal preparation and ongoing bleeding obscuring the view. The patient underwent a total colectomy with ileorectal anastomosis. On pathology there was extensive diverticulosis of the ascending and the sigmoid colon with diverticulitis and diverticular abscess cavities within the sigmoid colon.ConclusionsDiverticulitis and diverticular bleed are thought to be unrelated complications of diverticulosis involving distinct physiologic pathways (Figure 1). Although diverticular bleed may occur in patients with a history of prior diverticulitis, concurrent presentation of these two entities is extremely rare. In addition, diverticular bleed is mostly self-limiting. While endoscopic and vascular embolization are established treatment options, colectomy is rare for the management of diverticular bleeding.We report a rare case of concurrent diverticulitis and lower GI bleeding. The presence of the sigmoid diverticulitis made interventional radiology a relatively safer option over endoscopy, which is the typical first line diagnostic and interventional procedure. Ongoing bleeding led to total colectomy and provided the patient with a definitive cure for her diverticular disease. Funding AgenciesNone

Radiological Arterial Anatomy in Mature Microminipigs as a Pre-clinical Research Model in Interventional Radiology.

To define the radiological arterial anatomy in mature microminipigs as a pre-clinical research animal model in interventional radiology. Five female microminipigs (weighing 20.9 ± 2.9kg) were used in this study. Under general anesthesia, computed tomography (CT) angiography was performed using a 16-slice CT scanner. CT was performed 12s after initiation of an intravenous injection of 40ml of nonionic contrast media at 3.0ml/second using a power injector. The transverse CT angiography images were evaluated using a digital imaging and communication in medicine viewer, and the diameters of the following 41 arteries were measured.: ascending aorta, descending aorta, thoracoabdominal aorta, abdominal aorta, pulmonary artery trunk, both pulmonary, brachiocephalic artery, short common bicarotid, both common carotid artery, subclavian, bronchial, internal mammary, celiac, common hepatic, left lateral hepatic, middle hepatic, left hepatic, gastroduodenal, cranial duodenopancreatic, splenic, left gastric, cranial mesenteric, ileocolic , bilateral colic artery, caudal mesenteric, cranial rectal, renal, both external iliac arteries, internal iliac common trunk, and both internal iliac and femoral arteries. The microminipigs' vascular anatomy was the same as domestic pig anatomy and similar to human anatomy. The diameter of the aorta (ascending to abdominal) was 17.1-7.0mm, iliac and femoral arteries (internal iliac common trunk to femoral artery): 5.5-3.8mm, pulmonary arteries: 9.3-14.7mm, and major first aortic branches (e.g., celiac or brachiocephalic artery): 2.2-9.2mm. This study defined the microminipig arterial anatomy in the trunk.

Nomogram for benign anastomotic stricture after surgery for rectal cancer

Benign anastomotic stricture remains among the most prevalent complications following surgery for rectal cancer. This study is aimed at identifying risk factors of anastomotic stricture as well as generating an effective nomogram for the stricture. Design: This is a retrospective study. This study was conducted from January 2015 to December 2019 in a single tertiary center for rectal cancer. A total of 117 rectal cancer patients after surgery without recurrence were enrolled in this study, of which 39 with anastomotic stricture and 78 without stricture. Their clinical and pathological data were collected. Multiple logistic regression analysis was conducted to identify risk factors for anastomotic stricture and to generate the nomogram prediction model. Multivariate analysis of the primary cohort led to the identification of LCA (left colic artery) preservation (OR, 0.074; P=0.0015), protective stoma (OR, 5.353; P=0.012), anastomotic leakage (OR, 12.027; P=0.005), and anastomotic distance (OR, 7.578; P=0.012) as independent risk factors for anastomotic stricture. The following predictive model was derived: Logit (anastomotic stricture)=0.074∗ LCA+5.353∗ Protective stoma+12.027∗ Anastomotic leakage+7.578∗ Anastomotic distance. Assessment of the predictive model revealed that the area under the curve (AUC) was 0.871, while the cutoff value was 15.444 with a sensitivity of 64.1% and a specificity of 94.8%. The main limitation is the research design of a retrospective and case-controlled study with a small sample size from a single center. LCA preservation, protective stoma, anastomotic leakage, and anastomotic distance may affect the occurrence of anastomotic stricture following surgery for rectal cancer. The nomogram model generated in the present study can be valuable in the prediction of anastomotic stricture. This study has been registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/, ChiCTR 2100043775).

PREOPERATIVE THREE-DIMENSIONAL COMPUTED TOMOGRAPHY OF LEFT COLIC ARTERY IN PATIENT WITH LEFT-SIDED COLON AND RECTAL CANCER

Background: There is still a discussion in the literature about the location of inferior mesenteric artery (IMA) ligation during D3 lymph node dissection for colorectal cancer (CRC). Ligation of the IMA below the branching of left colic artery (LCA) preserves this important vessel for adequate blood supply to the left colon and thus reduces the risk of anastomotic leakage [1,2].

Multidisciplinary personalized approach to D3 lymph node dissection with preservation of left colic artery in patients with left sided colorectal cancer: surgical and radiological point of view.

Widely implemented in clinical practice 3D-CT angiography allows to conduct the analysis of vascular anatomy at the preoperative stage. The aim of this study was to carry out a detailed analysis of variants of the anatomy of the LCA, its relationship with the surrounding structures and to study the nuances that may complicate and increase the time of D3 lymph node dissection with preservation of LCA. In this study, we included 103 patients with left sided colon and rectal cancer who underwent preoperative 3D-CT angiography. According to Zebrowski Classification, 8 most frequent variants of IMA branching patterns are allocated: type A (35 patients [34%]); type B (28 patients [27.2%]); type C (3 patients [2.9%]); type D (4 patients [3.9%]); type E (7 patients [6.8%]); type F (7 patients [6.8%]); type G (6 patients [5.8%]); and type H (13 patients [12.6%]). The average distance from the root of the IMA to the branch of the LCA was 35.29±10.18 mm (11-66 mm). There are 3 types of anatomical relationship between IMA-LCA-IMV system. Medial type was in 10 (9.7%) cases, lateral in 64 (62.1%), distal in 29 (28.2%). LCA intersects with the IMV at a distance of 20.97±13.59 mm (2-65) in patients with lateral and distal type. Careful preoperative analysis of vascular anatomy will assess the difficulty of performing D3 lymph node dissection with LCA preservation. Moreover, it reduces the time during the operation to identify structures and to develop a personalized strategy for the operation.

Colo-enteric fistula associated with diffuse large B cell lymphoma that resulted in gastrointestinal bleeding: A case report and literature review

Introduction and importanceThe most common symptoms of primary gastrointestinal (GI) lymphoma are non-specific, such as nausea, vomiting, diarrhea, weight loss, and abdominal pain. The rare acute symptoms include bowel obstruction, intussusception, and perforation. Primary small bowel lymphoma accounts for the smallest proportion of all GI malignancies. We report a case of intestinal lymphoma presenting with bloody stools and anemia.Case presentationThe patient initially underwent both duodenoscopy and colonoscopy with negative findings. Isotopic red blood cell (RBC) scan was then performed due to persistent bleeding along with computed tomography angiography (CTA) because of suspected bleeding in the left abdomen. Successful embolization over the arcade of the sigmoid and left colic arteries was performed. However, the bleeding did not stop, and ischemic colitis was diagnosed by repeat colonoscopy. A coloenteric fistula was finally discovered during emergent laparotomy.Clinical discussionGI lymphomas are a rare disease entity among the all GI malignancies. Despite acute abdominal symptoms including obstruction, perforation, bleeding and intussusception, enteral fistula is also one of the complications. It was seen to be a long-term complication after treatment or disease process in most of cases, however it could occur as the initial manifestation. GI bleeding is a life-threatening condition and commonly needs prompt decision making. There were no standard managements for these patients, it depends on clinical judgements from physician individually.ConclusionThis is a rare condition that has not been previously described in Taiwan. Early diagnosis and timely management will decrease morbidity and mortality in the GI lymphoma population.

Single-Incision Laparoscopic Complete Mesocolic Excision With Central Vascular Ligation for Descending Colon Cancer.

Single-incision laparoscopic complete mesocolic excision with central vascular ligation for descending colon cancer is technically challenging. Standardization of the surgical procedures is therefore needed. In a Trendelenburg position with left side elevated, the sigmoid mesocolon is mobilized using a medial-to-lateral approach, and the left colic artery and inferior mesenteric vein (IMV) are divided after radical lymphadenectomy along the inferior mesenteric artery, preserving the superior rectal artery. The descending mesocolon is mobilized from the retroperitoneal planes up to the dorsal surface of the pancreas using medial and lateral approaches. Next, changing the surgical position to a reverse Trendelenburg position with left side elevated, the omental bursa is opened, and the transverse mesocolon is separated from the inferior border of the pancreas. The splenocolic ligament and lateral attachment are then divided, matching the previous medial dissection of the retroperitoneum, and the splenic flexure is fully mobilized. The IMV is divided again at the inferior border of the pancreas. The left branch of the middle colic artery is also divided. Forty-seven consecutive patients with DCC underwent single-incision laparoscopic CME with CVL. One patient required an additional port. Median operative time, blood loss, and number of harvested lymph nodes were 240min (interquartile range [IQR], 195-257min), 5mL (IQR, 5-52mL), and 21 (IQR, 13-29), respectively. Morbidity rate was 5.9%. Median duration of hospitalization was 9days (IQR, 7-11days). Single-incision laparoscopic CME with CVL is safe and feasible for DCC.

Unstable right colic artery between East and West conception of D3 lymphadenectomy: surgical and radiological analysis

Unstable right colic artery between East and West conception of D3 lymphadenectomy: surgical and radiological analysis

PREOPERATIVE COMPUTED TOMOGRAPHY ANGIOGRAPHY IN MULTIDISCIPLINARY PERSONALIZED ASSESSMENT OF PATIENT WITH RIGHT-SIDED COLON CANCER: SURGEON AND RADIOLOGIST POINT OF VIEW.

ABSTRACTBACKGROUND:3D-CT angiography has made it possible to reach a qualitatively new level in the determination of treatment tactics for patients with colorectal cancer.AIMS:This study aimed to analyze the clinical and radiological aspects that need to be discussed before surgery by a multidisciplinary team in patients with right-sided colon cancer.METHODSThis study involved 103 patients with colorectal cancer who underwent preoperative 3D-CT angiography from 2016 to 2021RESULTS:All patients underwent radical D3 right hemicolectomy. The median quantity of removal lymph nodes were 24.71±10.04. Anastomotic leakage was diagnosed in one patient. We have identified eight most common types of superior mesenteric artery. The ileocolic artery crossed the superior mesenteric vein on the anterior surface in 64 (62.1%) patients and on the posterior surface in 39 (37.9%). In 58 (56.3%) patients, the right colic artery was either absent or was a nonindependent branch of superior mesenteric artery. The distance from the root of the superior mesenteric artery to the root of the middle colic artery was 37.8±12.8 mm and that from the root of the middle colic artery to the root of the ileocolic artery was 29.5±15.7 mm. The trunk of Henle was above the root of the middle colic artery in 66 (64.1%) patients, at the same level with the middle colic artery in 16 (15.5%), and below the middle colic artery in 18 (17.5%) patients.CONCLUSIONS:Preoperative analysis of 3D-CT angiography is a key pattern in assessment of vascular anatomy and can potentially show the complexity of future lymphadenectomy and reduce the risk of anastomotic leakage.

Mesenteric Vascular Evaluation with Pre-operative Multidetector Computed Tomographic Angiography and Intraoperative Indocyanine Green Angiography to Reduce Anastomotic Leaks after Minimally Invasive Surgery for Colorectal Cancer

Background:The aim of this prospective study was to determine the effect of mesenteric vascular evaluation using pre-operative multidetector computed tomography angiography (MDCTA) and intraoperative indocyanine green (ICG) angiography on reducing the anastomotic leak rate of colorectal cancer patients undergoing minimally invasive resection.Methods:Twenty-seven consecutive patients with colorectal cancer were studied, 18 males and 9 females, average age 69.1 ± 3.9 years. All patients underwent pre-operative mesenteric vascular evaluation using MDCTA with three-dimensional (3D) reconstruction and intraoperative evaluation of perfusion using ICG angiography. Twelve patients underwent laparoscopic resection (Olympus Visera Elite II OTV-S200) and 15 patients underwent robotic resection (DaVinci Si). Colorectal resection lines and anastomoses were guided by intraoperative ICG perfusion. Postoperative anastomotic leaks were assessed.Results:Pre-operative MDCTA 3D reconstructions defined the left colic and sigmoid artery anatomy and guided operative planning. The intraoperative ICG angiography resulted in a change of the planned lines of resection in seven patients (26%). The rate of postoperative anastomotic leaks in this study was 0% (0/27), compared to a leak rate of 6.8% at our institution in the preceding two years.Conclusion:Pre-operative evaluation of mesenteric vascular anatomy using MDCTA with 3D reconstruction and intraoperative evaluation of perfusion using ICG angiography were found to be technically feasible and safe. An appropriately designed study should be undertaken to prove whether it was truly effective at reducing the postoperative anastomotic leak rate in colorectal cancer patients undergoing minimally invasive resection at our institution.

Early Term Results of the Preservation of Left Colic Artery in Colorectal Cancer Surgery

Early Term Results of the Preservation of Left Colic Artery in Colorectal Cancer Surgery

Carbon nanoparticle-assisted natural orifice specimen extraction surgery with left colic artery preservation: a retrospective study.

IntroductionNatural orifice specimen extraction surgery (NOSES) has been widely regarded as a new technology in minimally invasive surgery. Meanwhile, carbon nanoparticles have been increasingly used for lymph node tracing in colorectal cancer surgery.AimTo evaluate the effectiveness and feasibility of carbon nanoparticle-assisted natural orifice specimen extraction surgery with left colic artery preservation for total laparoscopic colorectal resection.Material and methodsWe retrospectively reviewed the medical records of 83 patients diagnosed with sigmoid colon cancer or mid- and upper-rectal cancer from October 2017 to June 2020. These patients were divided into the NOSES group who underwent left colic artery preservation NOSES, being injected with a carbon nanoparticle suspension under colonoscopy the day before surgery, and the LA group, who underwent left colic artery preservation laparoscopic surgery. Surgical outcomes were retrospectively analyzed.ResultsThe mean number of harvested lymph nodes (p < 0.001) in the NOSES group was higher than in the LA group. Conversely, as regards pain score (p < 0.001) and postoperative hospital stay (p = 0.035), the LA group has higher mean values. The incidence of perioperative complications (p = 0.385) was 5.3% for the NOSES group compared to 13.3% for the LA group.ConclusionsPreoperative colonoscopic injection of a carbon nanoparticle suspension is a feasible and practical solution to dissect lymph nodes surrounding the inferior mesenteric artery without affecting the left colic artery in patients with colorectal cancer and about to receive NOSES. Moreover, NOSES combined with this approach leads to less postoperative pain and shorter hospital stays.

Exploring Central Vascular Anatomy With Axial Computed Tomography During Surgery for Sigmoid Colon and Rectal Cancer: New Insights Into the Anatomical Relationship Between the Inferior Mesenteric Artery and the Duodenum

Background: In some individuals, the inferior mesenteric artery (IMA) originates from the aorta above the lower edge of the duodenum. This anatomical feature has rarely been reported but may be important in guiding central vascular ligation and lymph node dissection in colorectal surgery. This retrospective study aimed to explore the anatomical relationship between the IMA and the duodenum and evaluate its potential impact on the efficacy of D3 lymph node dissection.Methods: A total of 439 patients undergoing laparoscopic colorectal surgery at the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively enrolled. Clinical data from axial computed tomography (CT) scans were collected and analysed.Results: In 27.69% of patients, the IMA originated at or above the lower edge of the duodenum (median distance: −8 mm). These patients were characterised by a shorter superior mesenteric artery to aortic bifurcation distance, a superiorly located IMA origin, and a greater distance between the IMA and both the left colic artery and the inferior mesenteric vein. The number of harvested lymph nodes was not significantly associated with the distance between the IMA and the duodenum (P = 0.858).Conclusions: Preoperative axial CT scans can provide a great deal of information regarding central vascular anatomy in the context of sigmoid colon and rectal cancer surgery. Nearly one-third of patients have the IMA originating at or above the duodenum. Whether this anatomical feature affects D3 lymph node dissection warrants further investigation.

Types of inferior mesenteric artery: a proposal for a new classification.

The inferior mesenteric artery (IMA) is the third main branch of the abdominal aorta and arises at the level of L3, supplying the large intestine from the distal transverse colon to the upper part of the anal canal. The aim of this study was to characterise the course and morphology of the terminal branches of the IMA, and also creating a new IMA classification, which seems to be necessary for clinicians performing surgery in this area. The anatomical variations in the branching patterns of the IMA were examined in 40 cadavers fixed in a 10% formalin solution. Morphometric measurements were then obtained twice by two researchers. Due to the proposed classification system, type I characterised by a common trunk preceding bifurcation into sigmoidal branches and the superior rectal artery after giving left colic artery (LCA) occurred in 57.5% of cases, type II, trifurcation type, in 25%, type III with the superior rectal arteries originating firstly from the IMA in 5%, type IV with the ascending lumbar artery in 10% of cases and type V, a novelty, in 2.5%. The origin of IMA was observed at the level of L2/L3 in 22.5% of cases, at L3 in 25% of cases, at L3/L4 in 15% of cases, at L4 in 35% of cases and at the level of L5 in 2.5% of cases. More than one third (38.1%) of total cases with additional arteries and rapidly bifurcating branches occurred in types III, IV, and V. In women, only the IMA and LCA were significantly narrower than in men. Only the diameter of the IMA correlated with the diameter of the superior rectal artery. The IMA is characterised by high morphological variability. The introduction of a new, structured, anatomical classification seems necessary for all clinicians.

Contained Rupture of a Large Colic Aneurysm

<h3>Introduction and Objective</h3> Visceral artery aneurysms are infrequently encountered with a reported incidence of 0.1-1% in the general population. Despite their rarity, they can pose a significant threat to those afflicted; available literature suggests a 25-70% mortality rate with rupture. They predominantly occur in the splenic and hepatic arteries. However, colic aneurysms are exceptionally unusual, and their etiology is not completely understood. Genetic disorders and systemic conditions including polyarteritis nodosa, fibromuscular dysplasia, and infection have all been implicated. We present a case of a large colic aneurysm rupture as the first manifestation in an otherwise healthy patient with suspected rheumatological origin. <h3>Case Report</h3> A retrospective chart review was performed on a single patient in a tertiary care institution. A 54-year-old female was transferred to our facility with one week of progressively worsening abdominal pain, malaise and bilious emesis. She presented with tachycardia in the 110s and newly discovered hypertension at 176/104 requiring nicardipine titration. Her hemoglobin was stable at 10.4 g/dL with a normal vascular exam. Her abdomen was mildly distended but otherwise unremarkable. The patient did not take any medications, denied any smoking history or illicit drug use, and her only past surgery was a caesarean section. She underwent a computed tomographic angiography (CTA) scan of the abdomen significant for a large 7.7 cm aneurysm of the right colic artery with a collateral branch from an Arc of Buhler variant. Other aneurysms included a 1.2 cm celiac trunk aneurysm and a 4 mm left colic artery aneurysm. Additional vascular findings included beaded appearance of mesenteric vessels, pulmonary arteriovenous malformations, and a portovenous fistula. Due to the hemoperitoneum, symptomatic presentation, and large size, the patient underwent emergent embolization of her right colic aneurysm. Coil embolization was successfully performed as well to the Arc of Buhler. The patient's symptoms resolved, and she was discharged home after 4 days. <h3>Discussion</h3> Large colic aneurysms are extremely rare, and a presentation of rupture in the context of several other vascular aneurysms and malformations has not yet been described. Though most visceral aneurysms are discovered when symptomatic, their rupture can be life-threatening and the need for expeditious recognition and treatment is critical. CTA of the abdomen is invaluable, and most patients can be treated with coil embolization. Etiological workup can be performed when patients are stable and may involve a multidisciplinary approach.