Branches Of Inferior Mesenteric Artery Research Articles

Anatomical classification of and laparoscopic surgery for left-sided colorectal cancer with persistent descending mesocolon

Objective: To investigate anatomical morphology and classification of persistent descending mesocolon (PDM) in patients with left-sided colorectal cancer, as well as the safety of laparoscopic radical surgery for these patients. Methods: This is a descriptive study of case series. Relevant clinical data of 995 patients with left colon and rectal cancer who had undergone radical surgery in Fujian Medical University Union Hospital from July 2021 to September 2022 were extracted from the colorectal surgery database of our institution and retrospectively analyzed. Twenty-four (2.4%) were identified as PDM and their imaging data and intra-operative videos were reviewed. We determined the distribution and morphology of the descending colon and mesocolon, and evaluated the feasibility and complications of laparoscopic surgery. We classified PDM according to its anatomical characteristics as follows: Type 0: PDM combined with malrotation of the midgut or persistent ascending mesocolon; Type 1: unfixed mesocolon at the junction between transverse and descending colon; Type 2: PDM with descending colon shifted medially (Type 2A) or to the right side (Type 2B) of the abdominal aorta at the level of the origin of the inferior mesentery artery (IMA); and Type 3: the mesocolon of the descending-sigmoid junction unfixed and the descending colon shifted medially and caudally to the origin of IMA. Results: The diagnosis of PDM was determined based on preoperative imaging findings in 9 of the 24 patients (37.5%) with left-sided colorectal cancer, while the remaining diagnoses were made during intraoperative assessment. Among 24 patients, 22 were male and 2 were female. The mean age was (63±9) years. We classified PDM as follows: Type 0 accounted for 4.2% (1/24); Type 1 for 8.3% (2/24); Types 2A and 2B for 37.5% (9/24) and 25.0% (6/24), respectively; and Type 3 accounted for 25.0% (6/24). All patients with PDM had adhesions of the mesocolon that required adhesiolysis. Additionally, 20 (83.3%) of them had adhesions between the mesentery of the ileum and colon. Twelve patients (50.0%) required mobilization of the splenic flexure. The inferior mesenteric artery branches had a common trunk in 14 patients (58.3%). Twenty-four patients underwent D3 surgery without conversion to laparotomy; the origin of the IMA being preserved in 22 (91.7%) of them. Proximal colon ischemia occurred intraoperatively in two patients (8.3%) who had undergone high ligation at the origin of the IMA. One of these patients had a juxta-anal low rectal cancer and underwent intersphincteric abdominoperineal resection because of poor preoperative anal function. Laparoscopic subtotal colectomy was considered necessary for the other patient. The duration of surgery was (260±100) minutes and the median estimated blood loss was 50 (20-200) mL. The median number of No. 253 lymph nodes harvested was 3 (0-20), and one patient (4.2%) had No.253 nodal metastases. The median postoperative hospital stay was 8 (4-23) days, and the incidence of complications 16.7% (4/24). There were no instances of postoperative colon ischemia or necrosis observed. One patient (4.2%) with stage IIA rectal cancer developed Grade B (Clavien-Dindo III) anastomotic leak and underwent elective ileostomy. The other complications were Grade I-II. Conclusions: PDM is frequently associated with mesenteric adhesions. Our proposed classification can assist surgeons in identifying the descending colon and mesocolon during adhesion lysis in laparoscopic surgery. It is crucial to protect the colorectal blood supply at the resection margin to minimize the need for unplanned extended colectomy, the Hartmann procedure, or permanent stomas.

Selective approach to arterial ligation in radical sigmoid colon cancer surgery with D3 lymph node dissection: A multicenter comparative study.

Radical surgery for sigmoid colon cancer is commonly performed with complete mesocolic excision (CME) and apical lymph node dissection, reached by central vascular ligation (CVL) of the inferior mesenteric artery (IMA) and associated extended left colon resection. However, IMA branches can be ligated selectively according to tumor location with D3 lymph node dissection (LND), economic segmental colon resection and tumorspecific mesocolon excision (TSME) if IMA is skeletonized. This study aimed to compare left hemicolectomy with CME and CVL and segmental colon resection with selective vascular ligation (SVL) and D3 LND. Patients (n= 217) treated with D3 LND for adenocarcinoma of the sigmoid colon between January 2013 and January 2020 were included in the study. The approach to vessel ligation, colon resection and mesocolon excision was based on tumor location in the study group, while in the comparison group, left hemicolectomy with routine CVL was performed. Survival rates were estimated as the primary endpoints of the study. Long- and short-term surgery-related outcomes were evaluated as the secondary endpoints of the study. The studied approach to the IMA branch ligation was associated with a statistically significant decrease in intraoperative complication rates (2 vs 4, p= 0.024), operative procedure length (225.56 ± 80.356 vs 330.69 ± 175.488, p <0.001), and severe postoperative morbidity (6.2% vs 19.1%, p= 0.017). Meanwhile, the number of examined lymph nodes significantly increased (35.67 vs 26.69 per specimen, p <0.001). There were no statistically significant differences in survival rates. Selective IMA branch ligation and TSME resulted in better intraoperative and postoperative outcomes with no difference in survival rates.

Treatment of ruptured rectal artery aneurysm in a patient with neurofibromatosis

BackgroundSuperior rectal artery (SRA) aneurysms are rare. Although melena is the most common symptom, it has not been observed in cases of aneurysms located in the SRA trunk. Here, we report a case of a ruptured SRA trunk aneurysm successfully treated with coil embolization. Including our case, three of the four reported cases of SRA trunk aneurysms were related to neurofibromatosis type 1 (NF1).Case presentationA 52-year-old woman with NF1 was referred to our hospital for the investigation of an abdominal mass with back pain. She had previously undergone a blood transfusion at another hospital for anemia without melena. Computed tomography angiography revealed a ruptured SRA trunk aneurysm measuring 3 cm in diameter and surrounded by a retroperitoneal hematoma. The aneurysm was isolated by embolizing the SRA trunk distally and proximally. Distal embolization was performed retrogradely from the internal iliac artery (IIA) via the middle rectal artery (MRA)-SRA anastomosis because the antegrade approach from the inferior mesenteric artery (IMA) failed. To our knowledge, this is the first case of successful coil embolization of an IMA branch through the IIA.ConclusionSRA trunk aneurysms are rare; however, they are frequently associated with NF1. Antegrade distal embolization beyond the aneurysm is sometimes difficult to achieve. In such cases, a retrograde approach via MRA-SRA anastomosis can be the choice for isolating SRA trunk aneurysms.

A study on spinal level, length, and branch type of the inferior mesenteric artery and the position relationship between the inferior mesenteric artery, left colic artery, and inferior mesenteric vein

BackgroundThis study was aimed to explore the clinical application of dual-energy computed tomography (DECT) monoenergetic plus (mono+) imaging to evaluate anatomical variations in the inferior mesenteric artery (IMA).MethodsThe clinical and imaging data of 212 patients who had undergone total abdominal DECT were retrospectively analyzed. The post-processing mono+ technique was used to obtain 40-keV single-level images in the arterial phase. Three-dimensional reconstruction was performed to evaluate the relationship between the IMA root position and the spinal level, IMA length, and IMA branch type, as well as the position of the left colic artery (LCA) and inferior mesenteric vein (IMV) at the IMA root level.ResultsThe IMA root was located at the L3 level in 78.3% of cases and at the L2/L3 level in 3.3%. The highest vertebral level of IMA origin was L2 (4.2%), and the lowest was L4 (7.1%). The distance from the IMA root to the level of the sacral promontory was 99.58 ± 13.07 mm, which increased with the elevation of the IMA root at the spinal level. Of the patients, 53.8% demonstrated Type I IMA, 23.1% Type II, 20.7% Type III, and 2.4% Type IV. The length of the IMA varied from 13.6 to 66.0 mm. 77.3% of the IMAs belonged to Type A, the adjacent type, and 22.7% to Type B, the distant type.ConclusionDECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA and the positional relationship between the LCA and IMV at the IMA root level, which would help clinicians plan individualized surgery for patients.

905 Inferior Mesenteric Artery Branch Aneurysm Causing Ischemic Colitis – A Sequela of Anabolic Steroid Use

Abstract An inferior mesenteric artery (IMA) aneurysm comprises less than 1% of all reported visceral artery aneurysms. A 34-year-old bodybuilder with a history of anabolic steroid (AS) use of unknown duration, dose and frequency initially presented to the hospital with recurrent bouts of acute onset abdominal pain and alternating episodes of watery-mucous diarrhoea and constipation. Patient’s medical history was otherwise unremarkable with no stigmata of any connective tissue disorders. A diagnosis of ischemic colitis secondary to a distal IMA branch aneurysm measuring 6mm x 5mm x 10mm on CT was made three years after first presentation. Flexible sigmoidoscopy confirmed mucosal changes consistent with sigmoid ischemic colitis. A robotic anterior resection was performed due to two failed attempts at coiling the aneurysm. The histology was consistent with a secondary fibromuscular dysplasia in the IMA and its branches. There was a resolution of symptoms and return to normal stool and bowel function post-operatively. The commonest cause of an IMA aneurysm is the “jet disorder” phenomenon caused by incomplete atherosclerotic occlusion of the superior mesenteric (SMA) and celiac arteries (CA). While the link between AS use and dyslipidaemia is established, the patient’s lipid profile was normal. We believe this case lends valuable insight into atypical causes of ischemic colitis and adds to the literature on AS use and vascular pathology.

Course and Variations in Branches of Inferior Mesenteric Artery

Background : The mesenteric blood supply is a combination of rich collateral networks. There are frequent anatomical variants encountered and these variations are sometimes involved in pathologies. Treatment of which requires a better understanding of the variations in the normal anatomy of the inferior mesenteric artery. Methods : The present study was carried out in the Department of Anatomy, Prathima Institute of Medical Sciences, Karimnagar. A total of n=50 specimens, with n=17 adult males and n=2 adult female cadavers and fetuses of which n=26 were term and n=2, was preterm. Female fetuses n=2 of term and n=1 preterm were included in the study. Results : The following variations were observed in the present study of course and variations in the branches of the inferior mesenteric artery and are grouped into three types. Type I: In this type middle colic artery is arising from the inferior mesenteric artery instead of the superior mesenteric artery. It is a rare-variations and observed in a female fetus. Type-II: Four Sigmoidal arteries are arising from an inferior mesenteric artery, after the origin of the left colic artery. This type is observed in a male fetus. Type-III: Three Sigmoidal arteries are originated from the inferior mesenteric artery. This type was observed in a male adult and a male fetus. Conclusion: Out of the 50 cases included in the study we found type 1 variation of IMA in 2% of cases, type 2 variation was found in 2% samples, and type 3 variation was found in 4% of samples. Based on the variations radiologists and Surgeons should be aware of possible consequences when doing colectomy, right hemicolectomy, left hemicolectomy, sigmoidectomy, en-bloc resection of the head of the pancreas, aneurysm, and chronic bowel ischemia. The present study is also useful for reconstructive surgeries in inferior mesenteric arteries in the case of ischemia.

Robotic Low Anterior Resection and Partial Bladder Resection for Management of Locoregional Endometrial Cancer Recurrence

To demonstrate a robotic tumor debulking for management of locoregional endometrial cancer recurrence. Case report. Tertiary referral center in New Haven, CT. A 70-year-old patient with a history of stage IB endometrioid endometrial cancer presented with rectal bleeding 3 years after the completion of treatment. A mass involving the distal sigmoid colon/upper rectum and bilateral distal periureteral masses were visualized on imaging. There was no distant metastatic disease. Colonoscopic biopsies were consistent with endometrial cancer recurrence. Because the patient was symptomatic with rectal bleeding and had no distant metastasis, it was recommended that she undergo surgical resection for management of this locoregional recurrence. The patient was placed in reverse Trendelenburg position with a rightward tilt to mobilize the splenic flexure. Once the cephalad aspect of the descending colon mobilization was completed, the patient was placed in Trendelenburg lithotomy position to expose the pelvis. A robot was docked at this point and the pelvic avascular spaces were delineated. A medial-to-lateral approach was used in mobilization of the sigmoid colon mesentery. The left ureter was identified and the sigmoid branches of inferior mesenteric artery were sealed. The descending/sigmoid colon junction was stapled. After complete mobilization of the sigmoid colon, the tumor-free upper rectum was delineated and stapled. Attention was then turned to the distal peri-ureteral masses. The 2-cm mass on the right, which was densely adherent to the distal right ureter, was completely resected after extensive ureterolysis. The resection of the 4-cm mass on the left which involved both the distal left ureter and the bladder dome required an intentional cystotomy and a partial cystectomy to attain negative margins (Supplemental Figure 1). The procedure was continued with the bowel anastomosis. The anvil was introduced through the vagina and was placed into the proximal limb through an antimesenteric incision. An end-to-end tension-free anastomosis was performed and adequate vascularization was confirmed with intravenous indocyanine green. Robotic low anterior resection and partial bladder resection were performed without any complications with negative margins. Robotic tumor debulking should be considered in appropriate patients when managing locoregional recurrence of endometrial cancer [1,2].

Inferior Mesenteric Artery Embolization Before Endovascular Aortic Aneurysm Repair Using Amplatzer Vascular Plug Type 4

This study was designed to evaluate the efficacy and safety of Amplatzer Vascular Plug type 4 (AVP-4) for embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR) of the abdominal aorta to prevent endoleaks. A single-center retrospective review of 31 patients who underwent IMA embolizations before EVAR using the AVP-4 was performed. We analyzed the insertion and detachment procedure, the technical success, and the final position of the plug. Technical success was defined as complete occlusion of the IMA. To compare the incidence of IMA-related type II endoleaks in patients with and without preoperative IMA embolization, we additionally reviewed the course of 43 patients with a preoperatively patent IMA who underwent no IMA embolization. Plugs with a diameter of 5, 6, and 8mm were used in 5 (16.1%), 21 (67.7%), and 5 (16.1%) patients, respectively (50-100% oversizing). In 29 of 31 patients (93.5%), we observed complete occlusion of the IMA within 10min (mean 5.1min). Precise placement of the plug in the proximal segment of the IMA without occlusion of the first IMA branches was achievable in all patients. The distance between the AVP-4 and the first branches was on average 12 (range 2-57) mm. Preoperative IMA embolization with AVP-4 significantly reduced the incidence of complex IMA-lumbar type II endoleaks after EVAR (0/31 vs. 11/43; p=0.002). The AVP-4 is a safe, feasible, and technically effective embolization device for IMA embolization before EVAR.

Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization

A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

Inferior mesenteric artery branch embolization via superior mesenteric artery cannulation in the post-endovascular aneurysm repair patient

Sir, Transcatheter arteriography and intervention (TAI) is becoming a more prevalent and accepted treatment of lower gastrointestinal bleeding (LGIB) and is being applied in increasingly complicated patients. The present report describes a case in which surgically altered anatomy—the presence of an aortic endograft—necessitated the use of a collateral vessel to access the source of a LGIB. The patient is an 82-year-old male with a medical history that includes bladder and lung cancer, chronic obstructive pulmonary disease, and abdominal aortic aneurysm (AAA), status post endovascular aneurysm repair (EVAR). He was undergoing chemotherapy and radiation and was on Pradaxa and Plavix when he presented to our hospital with bright red blood per rectum. He was admitted for monitoring and received numerous blood product transfusions; however, the bleeding failed to resolve with conservative means. A technetium-99-tagged red blood cell study localized the bleed to his right pelvis. The patient was referred to our department for diagnostic mesenteric arteriography and transcatheter embolization. The right common femoral artery was accessed using micropuncture technique, and a Bentson wire (Merit Medical, South Jordan, Utah) was advanced into the abdominal aorta under fluoroscopic guidance, with subsequent placement of a 5 French vascular sheath (Merit Medical, South Jordan, Utah). A 5 French visceral selective catheter (Cook, Bloomington, Indiana) was then advanced over the wire. As the patient's Zenith bifurcated, aortic stent graft prevented direct catheterization of the inferior mesenteric artery (IMA); the catheter tip was positioned in the superior mesenteric artery (SMA). Arterial anatomy was delineated with digital subtraction arteriography. The images were reviewed and the catheter tip was advanced beyond the middle colic artery and into the marginal artery of Drummond [Figure 1]. These arteries were hypertrophied and easily accommodated the catheter. Additional arteriography was performed, localizing the bleeding to the sigmoid colon. This corresponded to the nuclear medicine scintigraphy evaluation. Two greater than third order branches of the IMA proved to be implicated in the hemorrhage [Figure ​[Figure2a,2a, ​,b].b]. These were selectively catheterized and embolized using three 3-mm coils (VortX; Boston Scientific, Cork, Ireland) via a microcatheter system (Renegade Hi-Flo; Boston Scientific, Cork, Ireland). Figure 1 Angiography after catheterization of the middle colic artery revealing hypertrophy of the marginal artery of Drummond. There is opacification of the inferior mesenteric artery whose origin is inaccessible from the aorta (circled) by the presence of a ... Figure 2 (a) Inferior mesenteric arteriogram obtained by injection of the marginal artery of Drummond demonstrating active hemorrhage from a sigmoid artery (circled), (b) Superselective angiography of the sigmoid arterial branch responsible for hemorrhage using ... Post-embolization control arteriography was performed [Figure 2c]. This demonstrated cessation of hemorrhage, and the catheter was removed. There were no post-procedural complications and the patient experienced no further episodes of hemorrhage. Our aging population yields increasing numbers of patients with AAAs. A growing majority of these patients are undergoing EVAR instead of traditional open repair.[1,2] This trend is associated with a decrease in AAA-related deaths.[3] Thus, a growing demographic of post-EVAR patients are older, medically complicated patients who are considered poor surgical candidates should they happen to experience a gastrointestinal bleed. TAI has proven to be an effective means of localizing and controlling acute LGIB.[4–6] This technique is frequently superior to endoscopic management, which is technically difficult in the setting of rapid hemorrhage.[7] Unless there is pathology that mandates bowel resection, TAI is preferable to surgery in high-risk patients,[8] such as an elderly post-EVAR patient. Lower gastrointestinal hemorrhage in the post-EVAR population presents the unique challenge of accessing IMA branches should they be the source of bleeding; the stent graft occludes the origin of the IMA. As demonstrated, it is possible to access branches of the IMA by cannulating the SMA. Such a strategy has already been exploited to repair type II endoleaks stemming from the IMA in post-EVAR patients.[9,10] The marginal artery of Drummond follows the arc of the right colon and provides collateral blood flow between the superior and inferior mesenteric arterial territories. In the event that either the SMA or IMA is occluded, the marginal artery hypertrophies to compensate for increased circulatory demand. This dilation facilitates use of the marginal artery as a conduit between the SMA and IMA branches during catheter angiography. As such, we experienced little difficulty in taking this route. Mesenteric arteriography and transcatheter embolization of IMA branches remains possible in patients with aortic stent-grafts. This post-EVAR patient was experiencing gastrointestinal hemorrhage emanating from the sigmoid arteries. Although his IMA origin was occluded, we accessed the bleeding circuitously via the SMA and the marginal artery of Drummond. The procedure successfully treated his LGIB without adverse effects.

Microballoon Occlusion Test to Predict Colonic Ischemia After Transcatheter Embolization of a Ruptured Aneurysm of the Middle Colic Artery

A 76-year-old woman presented with sudden massive melena, and superior mesenteric arteriography showed an aneurysm in the middle colic artery (MCA). Because she had a history of right hemicolectomy and ligation of the inferior mesenteric artery (IMA) during open abdominal aortic aneurysm repair, embolization of the MCA aneurysm was considered to pose a risk comparable to that of colonic ischemia. A microballoon occlusion test during occlusion of the MCA confirmed retrograde visualization of the IMA branches through the collateral arteries by way of the left internal iliac artery, and embolization was successfully performed using microcoils. No colonic ischemia or aneurysm rupture occurred after embolization.

Percutaneous Protective Coil Occlusion of the Proximal Inferior Mesenteric Artery before N-Butyl Cyanoacrylate Embolization of Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks.

One of the complications of endovascular repair of abdominal aortic aneurysm is endoleak from a patent inferior mesenteric artery (IMA). Between 1995 and 2002, of 213 patients who had endografts placed for abdominal aortic aneurysm, 4 (1.8%) had enlarging aneurysms from type II endoleaks involving a patent IMA and underwent a secondary procedure. Two patients had endovascular embolizations through the superior mesenteric artery, and two patients underwent laparoscopic inferior mesenteric artery ligation. In the laparoscopic group, operative time was 85 minutes (range, 35-136 minutes). One laparoscopic procedure had to be redone due to a missed IMA branch. Length of stay was 0 and 3 days. At mean followup at 16 months (range, 2-42 months), all patients had had successful resolution of endoleaks. Laparoscopic ligation is a minimally invasive treatment for IMA-mediated type II endoleaks.

Inferior mesenteric artery branch avulsion from blunt trauma—CT findings case report

Mesenteric arterial injuries are uncommon following blunt abdominal trauma. We describe the computed tomography (CT) findings of a patient with avulsion of a branch of the inferior mesenteric artery following a low-speed motor vehicle accident.