Impact of Riolan arch and mesenteric vascular anatomy on tissue oxygenation in rectal cancer surgery: A prospective study on inferior mesenteric artery ligation strategies.

Background: Visceral artery aneurysms (VAAs) are rare vascular lesions associated with a substantial risk of rupture and high mortality. Splenic artery aneurysms (SAAs) are the most common and best studied, with relatively well-established risk factors and management strategies. In contrast, uncommon VAAs arising from the hepatic, celiac, superior mesenteric, gastroduodenal, pancreaticoduodenal, gastroepiploic, gastric, jejunal, ileal, colic, and inferior mesenteric arteries are exceedingly rare, and their natural history and rupture predictors remain poorly defined. Rupture has been reported at small diameters, challenging size-based thresholds derived largely from SAA data. Objectives: This systematic review and pooled analysis aims to determine rupture rates, predictors of rupture, and rupture-related mortality of uncommon true VAAs, and to compare these outcomes with those reported for SAAs, which will serve as reference lesions. Methods: The review will be conducted in accordance with PRISMA 2020 guidelines and is registered in PROSPERO (CRD420251155062). A comprehensive search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and Google Scholar will be performed. For uncommon VAAs, eligible studies will include meta-analyses, systematic reviews, cohort studies, case series, and case reports. For SAAs, only meta-analyses, systematic reviews, and large cohort studies will be included. Pooled patient-level data will be extracted where available. Primary outcomes are rupture rate and rupture-related mortality; secondary outcomes include predictors of rupture according to aneurysm location, size, patient characteristics, and clinical presentation. Risk of bias will be assessed using JBI, ROBINS-I, and AMSTAR 2 tools. Expected Impact: This review aims to clarify rupture behaviour of uncommon VAAs, identify clinically relevant predictors, and provide a stronger evidence base to support risk stratification and harmonisation of clinical decision-making.

Colon cancer located at the splenic flexure exhibits dual lymphatic drainage via the left middle colic artery (lt-MCA) to the superior mesenteric artery (SMA) system and the left colic artery (LCA) to the inferior mesenteric artery (IMA) system. However, an additional pathway-the Arc of Riolan (AoR) artery, central anastomotic vessels connecting the SMA and IMA-may also serve as a route for metastasis. This case highlights the importance of central vascular ligation of the AoR in splenic flexure cancer. We present a rare case of isolated AoR lymph node metastasis in a 72-year-old male with advanced splenic flexure cancer. The patient presented with multiple synchronous tumors (splenic flexure, sigmoid, and rectum) and underwent extended left hemicolectomy with central vascular ligation (CVL) of the AoR, revealing metastatic involvement exclusively in AoR nodes. This represents the first documented case of isolated AoR nodal metastasis, emphasizing the need for AoR lymphadenectomy when present. Recent studies suggest that accessory middle colic arteries (aMCA) and AoR may represent the same anatomical structure, with metastasis rates of 3.7-6.3% in corresponding nodes. Our findings support that AoR should be considered a critical target for CVL in splenic flexure cancer, particularly when identified pre- or intraoperatively. Surgeons should recognize AoR as a possible isolated metastatic pathway and perform thorough nodal dissection along this vessel when present to ensure optimal oncologic outcomes.

PurposeThe optimal vascular ligation strategy and lymphadenectomy level in oncological sigmoidectomy remain controversial, with inconsistent definitions and a lack of standardized postoperative assessment. This study aimed to anatomically and radiologically define D2 and D3 lymphadenectomy in sigmoid colon cancer and to develop an objective multimodal protocol for postoperative classification of vascular ligation and recurrence patterns.MethodsA three-phase multimodal anatomical study was conducted. Phase 1 involved cadaveric dissections simulating D2 lymphadenectomy and D3 dissection with either low or high ligation of the inferior mesenteric artery (IMA). Phase 2 retrospectively assessed 14 patients with pre- and postoperative contrast-enhanced CT scans to classify vascular ligation type and recurrence pattern. Phase 3 validated these findings through AI-assisted computational segmentation and 3D reconstruction.ResultsIn cadaveric simulation, each vascular strategy (D2, D3-low tie, D3-high tie) was anatomically characterized in terms of arterial division point, venous drainage control, and residual mesocolon, allowing systematic differentiation of the three approaches. Radiological evaluation successfully identified the level of vascular ligation in all cases. Among patients with recurrence (n = 5), the classification protocol distinguished mesenteric from non-mesenteric recurrences based on vascular territory. The 3D reconstruction phase showed full concordance between the radiological classification and the 3D model regarding both the level of inferior mesenteric artery ligation and the anatomical localization of locoregional recurrence.ConclusionThis standardized anatomical–radiological workflow, integrating cadaveric dissection, CT-based vascular analysis, and AI-assisted 3D reconstruction, provides an objective tool to classify the level of vascular ligation performed in oncological sigmoidectomy and to anatomically categorize locoregional recurrence, establishing a foundation for future surgical audit and outcome studies, and representing a step toward AI-supported surgical audit systems capable of standardizing vascular ligation classification and recurrence mapping.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00384-025-05046-x.

To evaluate the impact of pre-emptive embolization of inferior mesenteric and lumbar arteries on the incidence of type II endoleak and aneurysm sac dimensions after EVAR. A retrospective single-center cohort study included 145 patients who underwent EVAR between 2023 and 2025. Patients were divided into two groups: with pre-emptive embolization (n=32) and without this procedure (n=113). Follow-up CT angiography was performed after 12 months. Primary endpoint was the incidence of type II endoleak; secondary endpoints included changes in maximal aneurysm diameter and infrarenal aortic volume. After 12 months, type II endoleak was observed in 3.1% and 17.7% of cases, respectively (p=0.045). Aneurysm sac growth occurred in 6.3% and 15.9% of patients, respectively (p=0.246). Embolization procedures were associated with longer surgery time, increased fluoroscopy duration and greater contrast volume. Pre-emptive embolization of inferior mesenteric and lumbar arteries in EVAR reduces the incidence of type II endoleak and shows a trend towards less aneurysm sac growth despite higher technical complexity and contrast volume.

The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) are of critical significance in colorectal surgery; however, their anatomical variations and classification systems remain undefined. Additionally, existing studies lack open-source image datasets, which significantly hinder research reproducibility and academic collaboration in this field. In the dataset, we retrospectively collected 3D reconstructed images of IMA/IMV from 147 colorectal cancer patients, which were validated intraoperatively, and openly shared their variation types. As the first 3D image dataset focusing on IMA/IMV anatomical variations to date, this dataset serves as a valuable resource for research on IMA/IMV anatomical variations and an important reference for clinical training of colorectal surgeons.

ABSTRACTAbdominal aortic aneurysm (AAA) is a vascular disease that often remains asymptomatic until rupture or the occurrence of complications. The mortality rate of rupture exceeds 80%. Most AAAs are discovered incidentally; rare presentations may occur due to peripheral embolization from intra‐aneurysmal thrombi. One of the manifestations is blue toe syndrome. It is painful cyanotic toes with preserved peripheral pulses. We report the case of a 67‐year‐old man with a history of ischemic heart disease, smoking, and opium addiction who presented with bilateral toe pain, numbness, and cyanosis without abdominal symptoms or claudication. peripheral pulses were present in the physical examination. The laboratory tests excluded vasculitis and hypercoagulable states. CT angiography demonstrated a large (75 mm) infrarenal AAA with mural thrombosis, specifying the source of emboli. The patient underwent successful endovascular aortic aneurysm repair (EVAR) with adjunctive coil embolization of the inferior mesenteric artery. Postoperatively, limb perfusion was restored, symptoms resolved, and the patient was discharged on dual antiplatelet and statin therapy. At 12‐month follow‐up, he was symptom‐free with no evidence of ischemia or endoleak. This case explains an uncommon presentation of AAA as blue toe syndrome. Diagnosis of peripheral embolic events as a symptom of AAA is necessary for timely imaging and treatment. Timely diagnosis and intervention prevent ischemic complications and decrease the risk of aneurysm rupture. EVAR is a safe and effective intervention, especially in cases with significant comorbidities.

Chronic mesenteric ischemia is a rare condition accounting for less than 1 in 1,000 hospital admissions secondary to abdominal pain. Usually, at least two of the three visceral vessels need to be affected before a patient develops symptoms. We describe a patient diagnosed with decompensated liver disease secondary to liver schistosomiasis and was admitted and managed as chronic mesenteric ischemia secondary to superior mesenteric artery (SMA) thrombosis and inferior mesenteric artery (IMA) atherosclerosis. With the patient’s consent, this case is presented to contribute to current knowledge about mesenteric ischemia. Case description. A 47-year-old male diagnosed with liver cirrhosis secondary to liver schistosomiasis came in due to 1-month abdominal pain associated with 2 days’ melena, diarrhea, vomiting, and 1-day disorientation. Three days post admission, he was noted with resolution of melena, diarrhea, vomiting, and disorientation; however, persistence of abdominal pain prompted consideration of chronic mesenteric ischemia and was confirmed via plain computed tomography scan. Exploratory laparotomy revealed diffuse discoloration of the small bowel but with peristalsis, thrombosis at SMA, and atherosclerosis at IMA. Heparin drip was given as management for portal vein thrombosis. He recuperated well and eventually was discharged improved. Conclusion. Chronic mesenteric ischemia is a rare clinical symptom that occurs in less than 1 of 1,000 hospitalizations that are caused by abdominal pain. It has vague abdominal symptoms and is associated with a high mortality rate of 60% to 100%. Prognosis depends on early detection and intervention, and surgical treatment remains the option of choice. Keywords. Chronic mesenteric ischemia, Mesenteric thrombosis, Liver cirrhosis, Mesenteric ischemia, Intestinal angina, Liver schistosomiasis, Case report

Rationale:The inferior mesenteric arteriovenous fistula (IMAV AVF) is an anomalous connection between the arteries and veins of the mesentery, bypassing the capillary network and typically involving the hepatic, superior mesenteric, and splenic arteries.Patient concerns:A 64-year-old previously healthy male presents with a 2-month history of bloody and watery diarrhea with lower abdominal pain, and a notable 10-kg weight loss.Diagnoses:A diagnosis of ischemic colitis (IC) was supported by a colonoscopy that revealed diffuse ulcerations and stenosis from the sigmoid-descending colon junction to the upper rectum. The nidus of the inferior mesenteric artery (IMA)V AVF was observed by digital subtraction angiography to emerge from the IMA and empty into the inferior mesenteric vein. IC and IMAV AVF were confirmed pathologically.Interventions:We performed a low anterior resection to completely resect the AVM and postoperative pathology confirmed IMAV AVF. An end colostomy was created.Outcomes:The patient was ultimately diagnosed with IMAV AVF.Lessons:The diagnosis of exclusion is commonly used for idiopathic IMAV AVF. Clinicians should consider patients exhibiting gastrointestinal symptoms similar to those associated with IC as potential candidates for the diagnosis of this disease. Based on the patient’s condition, rational selection of endovascular and surgical treatment is necessary.

The combination of abdominal aortic occlusion and inferior vena cava thrombosis is quite rare in clinical practice. We present the experience of treating a patient with chronic ischemia threatening limb loss, atherosclerotic occlusion of the infrarenal aorta combined with thrombosis of deep veins of the left lower limb, iliac veins on the left side, thrombus invasion into the inferior vena cava and the presenting 60-mm-flotating segment in it. After hospitalization and examination, a decision was made to perform a one-stage open intervention on the aorta and inferior vena cava. An aorto-femoral bifurcation alloprosthesis with reimplantation of the inferior mesenteric artery into the prosthesis main branche and open thrombectomy from the inferior vena cava were performed successfully. The course of the postoperative period was favorable. The main blood flow in the lower limbs was restored, rest ischemia of the left lower limb was suppressed. The control MSCT-angiography demonstrated that the thrombosis of iliac veins was occlusive, inferior vena cava was without thrombomasses. The patient was discharged in satisfactory condition in 11 days after the operation. The presented clinical case demonstrates high efficiency of the open treatment option in providing care to patients with combined pathology of the aorta and inferior vena cava.

230eP Inferior mesenteric artery remodelling in colorectal cancer: A preoperative 3D angiographic and postoperative WELLBEING follow-up study

Long-term Results from the LEA Randomized Trial: Extended Versus Standard Lymph Node Dissection in Patients with Bladder Cancer Undergoing Radical Cystectomy.

Background: Indocyanine green (ICG)-guided surgery is an emerging technique to enhance intraoperative visualization of nodes and tumor location. However, there is no uniform protocol regarding the optimal timing, dosage, or injection site for ICG in colorectal cancer surgery. We assess the feasibility of ICG injection at the anorectal junction immediately before surgery to safely identify the inferior mesenteric artery (IMA). Methods: This was a prospective study involving robotic left hemicolectomy or anterior resection of the rectum for primary colorectal cancer in 2024 in a single center. A total of 10–20 mg was injected into the anorectal submucosa at four quadrants circumferentially using an anoscope immediately before robot docking. Results: In this first study, ICG allowed us to identify the IMA in 84.6% of 26 patients (mean age 66.5 years; BMI 26.7 kg/m2), without intraoperative medical and surgical complications. Elevated BMI correlated with failure of IMA detection (r = −0.77, p < 0.001), despite high ICG doses trending toward improved vascular visualization (p = 0.097). A mean of 22 lymph nodes was harvested after ICG injection, with yields unaffected by the quality of IMA visualization. Conclusions: Submucosal injection of ICG is a feasible and easily adoptable option for early identification of the IMA, thereby preventing major vascular injuries, particularly in patients with challenging anatomy. A standardized protocol was implemented to improve reliability.

Background. The diagnosis of medium-vessel vasculitis often requires a thorough differential diagnosis to exclude non-inflammatory vasculopathies. We describe a case of Segmental Arteriolar Mediolysis (SAM), a non-inflammatory arteriopathy that can mimic medium-vessel vasculitis. Materials and Methods. A 54-year-old woman presented to the Emergency Department with acute abdominal pain radiating posteriorly. Laboratory tests showed CRP 21.7 mg/dl and ESR 106 mm/h. Abdominal CT angiography revealed dissection of the superior mesenteric artery and partial occlusion of the inferior mesenteric artery at the proximal and mid-distal segments. A positive urine culture for Klebsiella pneumoniae confirmed a urinary tract infection, treated with targeted antibiotics. A week later, a second abdominal CT angiography showed celiac trunk ectasia, circumferential thickening of the inferior mesenteric artery (reported by the radiologist to be suggestive of vasculitis, see Figure 1), and reduced caliber of the left hypogastric artery, with thrombotic appositions in the right internal mammary, inferior mesenteric, and segmental renal arteries. Further investigations revealed negative ANA and ANCA, equivocal lupus anticoagulant (not confirmed on repeat testing), and negative anticardiolipin and anti-beta2-glycoprotein antibodies. CRP measured approximately 10 days after antibiotic therapy was 0.9 mg/dL. Given the suspicion of medium-vessel vasculitis, high-dose corticosteroids were started, later combined with methotrexate. At the 4-month follow-up, methotrexate had been discontinued due to elevated liver enzymes, and the patient was on low-dose prednisone (5 mg/day). She was asymptomatic, with persistently normal inflammatory markers. The normalization of CRP before corticosteroid initiation, the absence of vascular lesions typical of polyarteritis nodosa, and full clinical and laboratory remission without maintenance therapy raised suspicion for SAM. A new abdominal CT angiography showed near-complete resolution of the circumferential thickening of the inferior mesenteric artery and full resolution of thrombotic appositions. After multidisciplinary discussion with radiologists and vascular surgeons, a diagnosis of SAM was confirmed. Conclusions. Segmental dissections of the celiac, mesenteric, and/or renal arteries are the key distinguishing feature of SAM (figure 2). This rare condition typically affects individuals aged 40–60 years, with a slight male predominance, and carries a high mortality rate (up to 50%) in cases of aneurysmal rupture. There are no established guidelines for treatment or follow-up, but optimal blood pressure control is essential to prevent vascular complications. The differential diagnosis from vasculitic diseases is challenging and relies on radiological, clinical, and laboratory assessment [1,2]. Correct identification of SAM, excluding vasculitic processes, has major implications for prognosis, treatment, and follow-up.

IntroductionTotal mesorectal excision has been adopted as standard procedure for resectable rectal cancer. However, there is no regulation in the current guidelines on the sequence of ligation of the inferior mesenteric artery and vein during rectal cancer surgery owing to a lack of sufficient evidence. Circulating tumour cells (CTCs) in peripheral blood can be used as potential indicators for predicting postoperative recurrence and prognosis in patients with colorectal cancer. The aim of the study is to investigate whether vascular ligation sequence affects the dissemination of CTCs into the bloodstream and survival during minimally invasive rectal cancer surgery.Methods and analysisThis study is a prospective, multicentre, randomised controlled trial investigating the effect of ligation sequence (inferior mesenteric artery vs vein priority) on CTC levels and survival outcomes in minimally invasive rectal cancer surgery. 268 eligible patients with rectal cancer will be randomly assigned to the priority ligation of the inferior mesenteric vein group or priority ligation of the inferior mesenteric artery group during minimally invasive rectal cancer surgery. The primary endpoint of this study is the change of peripheral blood CTC levels before and after surgery, analysed using the Wilcoxon rank sum test. Secondary endpoints are 3-year disease-free survival, 3-year overall survival, 3-year recurrence pattern, intraoperative blood loss, operation duration, conversion rate, number of lymph nodes collected, intraoperative morbidity and mortality, postoperative morbidity and mortality and postoperative recovery course.Ethics and disseminationThe study has been approved by the ethics committee of Sichuan Cancer Hospital (Approval number: SCCHEC-02-2024-102), all participants of the study will be well informed and written informed consent will be obtained from all participants. Findings from this trial will be published in peer-reviewed publications.Trial registration numberNCT05807646.

Textbooks locate the junction between the midgut and hindgut where the vascular beds of the superior (SMA) and inferior (IMA) mesenteric arteries meet. In a previous study, we observed that the formation of the midgut corresponded with a pronounced thinning of its dorsal mesentery. We re-investigated, therefore, the location of the distal boundary of the midgut, making use of 3D reconstructions of serial sections of 36 human embryos between 4 and 13 weeks of development. Using the boundaries of the thin mesentery of the midgut as a criterion, the midgut-hindgut junction corresponds in 10-week and older foetuses with the rectosigmoid junction. In addition, we established that the 3D orientation of the trunk of the IMA (between its aortic root and first branching node) also identifies the position of the midgut-hindgut junction in the gut. The growth rate of the early colon is exponential, whereas that of the rectum is linear. Initially, the foetal colon has ascending and descending limbs only, of which the descending limb grows fastest. The mesentery of the ascending colic limb adheres to the ventral surfaces of the duodenum, stomach and dorsal pancreas shortly after the hernial return into the abdomen during the 10th week, which rules out an effect of differential growth on the position of the junction. We, therefore, postulate that the rectum is the sole descendant of the embryonic hindgut. The rectum is unique in that its differentiation follows a caudocranial direction. Vascular connections between the perfusion areas of the SMA and IMA expand to form the first colic arterial arcade only at 10 weeks.

The inferior mesenteric artery (IMA) serves as the primary blood supply for the hindgut, extending from the distal transverse colon to the rectum. Variations in the anatomy of the IMA are well-documented, and numerous classification systems have been developed to describe these anatomical differences. These variations can involve differences in the origin, course, and branching patterns of the IMA. The present study aimed to analyze the anatomy of the IMA with respect to the available classification systems in the literature. Results from 74 consecutive patients who underwent abdominal computed tomography angiography (CTA) were evaluated. The most common vertebral level of departure of the IMA was found to be the body of the L3 vertebra. The most common IMA type according to the Zhang classification was found to be Type IA, which occurred in 25 of the studied patients (35.71%). The most common IMA type according to the Zebrowski classification was found to be Type B (n = 26; 41.27%), followed by Types C and H (n = 14; 22.22%). The most common order of departure of the branches of the IMA was found to be the left colic artery (LCA) followed by the common departure of the sigmoid trunk and superior rectal artery (SRA). The median diameter of the IMA at its origin was found to be 3.49 mm (LQ = 3.09; HQ = 3.70) in females and 3.74 mm (LQ = 3.44; HQ = 4.05) in males (p = 0.01). The results of the present study demonstrate that the most comprehensive but also specific classification system of the IMA was the McSweeney classification. It is hoped that the results of the present study may be useful to physicians performing various gastrointestinal and endovascular procedures, such as laparoscopic ligation of the IMA or embolization procedures.

To compare the efficacy of sac embolization (SACE) versus inferior mesenteric artery embolization (IMAE) in preventing persistent Type II endoleaks (pT2EL) and promoting aneurysmal sac shrinkage following endovascular aneurysm repair (EVAR) in high-risk patients. From January 2018 to December 2022, 273 EVAR patients were screened, and 75 with patent IMA and high T2EL risk were included. Patients were divided into 2 groups: EVAR with IMAE (33 cases) and EVAR with SACE (42 cases). The primary endpoint was the incidence of pT2EL. Secondary endpoints included sac enlargement, shrinkage, and T2EL-related reintervention. Kaplan-Meier analysis and multivariate regression were used for comparisons. SACE was associated with a significantly lower incidence of pT2EL than IMAE (2.4% vs 21.2%, p=0.007; HR: 0.140, 95% CI: 0.034-0.578) and a higher rate of sac shrinkage (>5 mm reduction) (83.3% vs 57.6%, p=0.005; HR: 2.272, 95% CI: 1.286-4.014). Sac enlargement (>5 mm) occurred only in the IMAE group (6.1%, p=0.097). SACE required less contrast use (113.7 ± 24.5 vs 140.5 ± 29.6 mL, P < 0.001) and exhibited a trend toward fewer reinterventions. No ruptures or AAA-related deaths occurred in either group. SACE is more effective than IMAE in preventing pT2EL and promoting sac shrinkage in high-risk EVAR patients. These results support SACE as the preferred adjunctive strategy, warranting further multicenter studies with longer follow-up to confirm its benefits and optimize techniques.Clinical ImpactThis study provides comparative evidence on two adjunctive techniques used during EVAR for high-risk patients. Sac embolization (SACE) demonstrated a lower incidence of persistent type II endoleaks and a higher rate of aneurysm sac shrinkage compared with inferior mesenteric artery embolization (IMAE), with reduced contrast use and comparable safety. These findings suggest that SACE may offer a more effective and practical approach for type II endoleak prevention and sac regression, potentially improving long-term outcomes and procedural efficiency in EVAR practice.

Type II endoleaks (T2EL) are common complications after fenestrated or branched endovascular aortic repair (F/BEVAR) and occur typically through the inferior mesenteric artery (IMA) and lumbar arteries (LA). Accessory renal arteries (aRAs) are found in about one-third of patients. The aim of this study was to investigate whether patients with aRAs are at higher risk of T2EL-related complications than those without aRA. All patients treated with F/BEVAR at Karolinska University Hospital during 2009-2022 were included in this single-center cohort study with prospectively collected data. Patients with at least one aRA ≥2 mm were compared to those without aRA. Furthermore, patients with aRA were subdivided into groups depending on the location of the origin (neck vs sac). Endpoints included change in maximal aortic diameter, incidence of T2EL, reinterventions, and overall mortality during follow-up. All CT scans were reviewed preoperatively, 30 days postoperatively, and at 1, 3, and 5 years after the procedure. A total of 199 consecutive patients treated with F/BEVAR were included, 76.4% male, mean age 74 years. Fifty-one patients (25.6%) had at least one aRA ≥2 mm, and 148 patients (74.4%) had no aRA ≥2 mm. The median aneurysm diameter at baseline was 61 mm in both groups (with and without aRA, p=0.468). There were no significant differences in comorbidities or demographic details between the groups. At 3 years, patients with aRA had a larger increase in maximal aortic diameter (+4 mm vs -7.5 mm, p=0.004) and a higher incidence of T2ELs (50% vs 17.9%, p=0.019) as compared to patients without aRA. Reinterventions due to T2EL was also higher in the aRA group (29.6% vs 10.9%, p=0.011). Overall mortality did not differ between the groups. The presence of at least one aRA ≥2 mm is associated with an increased risk of persistent T2EL, sac expansion, and need for reinterventions.Clinical ImpactIn this single-centre series of 199 consecutive F/BEVAR procedures, accessory renal arteries ≥2 mm were independently associated with an increased risk of aneurysm sac expansion and subsequent reintervention. In particular, accessory renal arteries originating from the aneurysm sac were correlated with treatment failure and should be considered for preemptive embolization at the time of the index procedure.

Description of Case: An 82-year-old female with coronary artery disease (CAD) and obesity status post Roux-en-Y gastric bypass was hospitalized with months of postprandial abdominal pain, nausea, and vomiting. The exam revealed mid-left abdominal and umbilical tenderness. CTA revealed bulky calcifications with severe short-segment stenosis in the proximal superior mesenteric artery (SMA), minor proximal narrowing in the celiac artery, and some calcifications at the origin of the inferior mesenteric artery (Image 1). Right femoral arterial access was obtained, and SMA was engaged using a 6-French IMA guide catheter. Angiogram showed a 99% heavily calcified proximal SMA stenosis with a patent celiac artery (Image 2A). A BMW wire was used to cross the proximal SMA lesion. Multiple balloons were tried, but were unable to cross the lesion. Turnpike and Finecross catheters were attempted for Rotawire exchange without success. The lesion was then crossed with a Rotawire. A 1.5 mm RotaPro burr was used to perform two passes of rotational atherectomy for 110 seconds. The Rotawire was exchanged for a Grandslam wire using a Finecross catheter. Balloon angioplasty was performed with 4.0 x 27 mm and 5.0 x 20 mm noncompliant Trek balloons. IVUS showed severe nodular calcific stenosis with fractures in calcium (Image 3). After vessel sizing, a 6.0 x 29 mm Omnilink stent was deployed in ostial-proximal SMA. Post-dilation was performed with a 6.0 x 20 mm Dorado balloon. Final angiography showed the reduction of stenosis to 20% with significantly improved flow (Image 2B). The patient had an uneventful recovery and complete symptom resolution. Discussion: Both surgical and endovascular revascularization are established treatments for chronic mesenteric ischemia, with endovascular therapy often favored in high-risk surgical candidates. Heavily calcified lesions challenge conventional angioplasty and stenting. While rotational atherectomy is established in CAD interventions, peripheral artery use is more conservative, reserving it for select cases. Its use in SMA is rarely reported. This case demonstrates the feasibility and benefit of rotational atherectomy in severe calcific SMA stenosis. It adds to the limited literature supporting this technique as an adjunct in complex abdominal artery interventions, particularly when standard endovascular methods are insufficient and surgical risk is high. The patient was treated without surgery, underscoring its role in high-risk cases.