Proximal Superior Mesenteric Artery Research Articles

Raising Systemic Blood Pressure to Delay Irreversible Intestinal Ischemia in a Swine Model of Proximal Superior Mesenteric Artery Occlusion

IntroductionAcute proximal superior mesenteric artery (SMA) occlusion is highly lethal, and adjuncts are needed to mitigate ischemic injury until definitive therapy. We hypothesized that raising mean arterial pressure (MAP) >90 mmHg with norepinephrine may delay irreversible bowel ischemia by increasing gastroduodenal artery (GDA) flow despite possible pressor-induced vasospasm. Methods12 anesthetized swine underwent laparotomy, GDA flow probe placement, and proximal SMA exposure and clamping. Animals were randomized between conventional therapy (CT) versus targeted MAP >90 mmHg (MAP push; MP) where norepinephrine was titrated after 45 min of SMA occlusion. Animals were followed until bowel death or 4 h. Kaplan–Meier bowel survival, mean normalized GDA flow, and histology were compared. Results12 swine (mean 57.8 ± 7.6 kgs) were included, six per group. Baseline weight, HR, MAP and GDA flows were not different. Within 5 min following SMA clamping, all 12 animals had an increase in MAP without other intervention from 81.7 to 105.5 mmHg (29.1%, P < 0.01) with a concomitant 74.9% increase in GDA flow as compared to baseline (P < 0.01). Beyond 45 min postclamp, MAP was greater in the MP group as intended, as were GDA flows. Median time to irreversibly ischemic bowel was 31% longer for MAP push animals (CT: 178 versus MP: 233 min, P = 0.006), Hazard Ratio of CT 8.85 (95% CI: 1.86-42.06); 3/6 MP animals versus 0/6 CT animals with bowel survived to predetermined end point. ConclusionsIn this swine model of acute complete proximal SMA occlusion, increasing MAP >90 mmHg with norepinephrine was associated with an increase in macrovascular blood flow through the GDA and bowel survival. Norepinephrine was not associated with worse bowel survival and a MAP push may increase the time window where ischemic bowel can be salvaged.

CT Arterioportography for Complex Portomesenteric Venous Interventions

AbstractAuthors report the use of computed tomography arterioportography (CTAP) in the diagnosis and endovascular treatment of portomesenteric venous occlusion. Three patients (2 male and 1 female; median age: 51 years) with an extrahepatic portal or mesenteric venous occlusion and variceal bleeding were included in this institutional review boards-approved retrospective study. CTAP was performed with an angiographic catheter positioned in the proximal superior mesenteric artery, and CT was obtained during the venous phase following the intra-arterial injection of contrast material. CTAP provided excellent opacification and delineation of portomesenteric veins, including occlusion length, intravascular webs, venous collaterals, and bleeding varices. This enabled preoperative planning for complex recanalization or extra-anatomic bypass to treat extrahepatic portal and mesenteric venous obstruction. There were no complications related to CTAP.

Endovascular Treatment of Superior Mesenteric Artery Pseudoaneurysm Due to Infective Endocarditis With Stent-Graft.

To report a successful case of pseudoaneurysm of the superior mesenteric artery (SMA) caused by infected endocarditis treated with a covered stent. A patient was diagnosed with infective endocarditis and 2 months later a proximal SMA pseudoaneurysm was identified on computed tomography. Daptomycin was started on admission and continued for approximately 4 months until the inflammatory markers normalized, and then the SMA pseudoaneurysm was successfully excluded with a stent-graft and antibiotics were continued for 1 year after the procedure. There were no associated complications or recurrences at the 3-year follow-up. Placing a covered stent with a full course of antibiotics before and after surgery may be a successful alternative to open surgery in the treatment of pseudoaneurysms of the SMA due to infective endocarditis. This case report reports a rare case of pseudoaneurysm of the superior mesenteric artery due to infective endocarditis, which was successfully treated with an overlapping stent and confirmed by complete imaging data at a three-year follow-up. This report suggests that endovascular treatment may be an alternative to open surgery in the treatment of pseudoaneurysms of the superior mesenteric artery caused by infective endocarditis.

Variations of the Cystohepatic Blood Supply in American Midwestern Donor Cadavers.

Knowledge of right hepatic artery (RHA) and cystic artery (CA) variations is crucial for surgeons performing procedures on the hepatobiliary system, pancreas, and duodenum. Commonly, the RHA originates from the superior mesenteric artery (SMA), while the CA originates from the RHA and is found within the cystic triangle during laparoscopic cholecystectomies. Here we investigated variations in the origin and path of the RHA and CA in a sample of American midwestern cadavers (n = 18) from the Gift of Body Program at A.T. Still University's Kirksville College of Osteopathic Medicine. Portal triads and associated vessels were dissected to reveal the artery pathways. The origin, branching pattern, and course of the RHA and CA were documented, and descriptive measurements were taken. We describe four cases where the RHA originated from the anterolateral proximal SMA, traveled deep to the pancreatic neck, and had a slightly variable but close relationship with the portal triad structures. The CA was present in the cystic triangle in all 18 donors, typically originating from the RHA except for one case where it originated from the left hepatic artery. In six cases, the CA originated outside of the cystic triangle, crossing either superficially or deeply to the common hepatic duct to enter the cystic triangle. Knowledge of these variations will enhance preoperative planning and the overall safety of surgical procedures in this area.

Microsurgical replacement of the right hepatic artery with the donor superior mesenteric artery in cadaveric donor pediatric liver transplantation.

To present our experience of using the pediatric donor superior mesenteric artery (SMA) as the interpositioning vessel to reconstruct the hepatic artery in pediatric deceased donor liver transplantation. Pediatric patients who received pediatric deceased donor livers from December 2019 to June 2021 were enrolled. A total of 43 pediatric recipients received pediatric deceased donor livers during the study period. Thirty-four (79.1%) pediatric donors had normal hepatic artery anatomy, while nine (20.9%) showed variant anatomies. The SMAs of the pediatric donors were interposed in the latter eight cases. The anastomosis between the donor distal SMA and the donor celiac trunk artery (CTA) was initially performed in the back-table period, after which the other anastomosis between the donor proximal SMA and recipient CHA was performed. Only one case showed HAT occurrence (incidence rate, 2.3%). However, no arterial complications occurred in pediatric recipients with donor grafts that showed the variation of RHA replacement from the SMA and had undergone usage of the donor's SMA as an interpositioning vessel. In pediatric deceased donor liver transplantation, the use of SMA as an interpositioning medium can solve the problems related to a tiny caliber and anatomical variations of the donor hepatic artery.

Skin to origin of mesenteric artery study (STOMA): prospective study of distances between stoma location and proximal superior mesenteric artery.

Traditional siting of stomas, in the lower abdomen, has been guided by surgical dogma lacking evidence. In the lower abdomen, the combination of a thick and pendulous abdominal apron, can create a challenging and suboptimal site for a stoma. The anatomical determinant limiting delivery of a stoma to the abdominal skin is the distance of the SMA from the lower border of the pancreas. The aim of this cross-sectional study was to compare the distance between the traditional stoma site, and upper abdominal stoma sites, to both the superior mesenteric artery (SMA) origin and SMA at the inferior border of the pancreas on abdominal computed tomography (CT). A cross-sectional study at a single academic university hospital of adult patients who underwent abdominal CT in Australia. Two hundred and thirteen patients were included. Stoma sites in the upper abdomen were 57-76 mm shorter to the origin of the SMA and inferior border of the pancreas than those positioned at the traditional stoma site (P< 0.001). The mean panniculus thickness in the upper abdomen was 10 mm thinner than in the lower abdomen and increased with increasing BMI (P< 0.001). The ratio between the distance from the xiphisternum to umbilicus, and the umbilicus to pubic symphysis, was 1.10; this ratio increased with increasing BMI. The distance of the SMA to the skin is always shorter in the upper abdomen compared to the traditional stoma site. Consideration should be given to placing stomas in the upper abdomen, particularly in overweight or obese patients.

Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery

Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.

Imaging Evaluation of Mesenteric Ischemia: Is There a Golden Period for This Entity?

Background.The study was aimed at assessing the role of ultrasonography and multidetector computed tomography angiography in evaluating patients with suspected mesenteric ischemia, as well as assessing the effect of the time from presentation to management on mortality and morbidity.&#x0D; Materials and Methods. Patients with clinically suspected mesenteric ischemia underwent Doppler ultrasound and contrast-enhanced computed tomography. On ultrasonography, we assessed any filling defect in the superior mesenteric artery/vein, narrowing or occlusion of the proximal superior mesenteric artery, ascites, bowel wall thickening, and pneumatosis/portal venous gas. Computed tomography angiography was performed looking for any filling defect in the superior mesenteric artery/vein, superior mesenteric artery/vein calibre, bowel wall thickening, calibre and enhancement and pneumatosis/portal vein gas. Most of our patients underwent emergency surgery and the findings correlated with imaging. All the patients were divided into Group A (n=30) and Group B (n=17) based on the time from presentation to management: within 48 hours of presentation and 48 hours after presentation, respectively.&#x0D; Results. On computed tomography scan, mesenteric vascular involvement was seen in 27 (55%) patients, mesenteric/intestinal twist was observed in 12 (25%) patients, and non-occlusive mesenteric ischemia was found in 6% of patients. The computed tomography findings were found to have a sensitivity of 86%, a specificity of 94% and an accuracy of 90% in cases of mesenteric ischemia. Among 35 patients operated on, those presenting within 48 hours, had a significantly less mortality (63%) in comparison to those presenting after 48 hours (90%).&#x0D; Conclusions. Clinical, laboratory and ultrasound features are non-specific in diagnosing mesenteric ischemia. Computed tomography angiography is a sine qua non in mesenteric ischemia diagnosis. Patients with venous ischemia respond well to conservative management. Early intervention within the first 48 hours is associated with better prognosis.

A locally advanced pancreatic body cancer presenting common bile duct invasion resected via distal pancreatectomy after gemcitabine plus nab-paclitaxel chemotherapy: A case report.

IntroductionThe locally advanced pancreatic cancer has been steadily recognized as a potentially curable disease by a combination of chemotherapy and surgery. The remarkable effect of advanced chemotherapy would help surgeons do a function-preserving operation for advanced pancreatic cancer.Presentation of caseA 73-year-old woman presenting with obstructive jaundice was diagnosed to have a 3-cm pancreatic body cancer invading the celiac axis (CA), superior mesenteric artery (SMA), portal/splenic vein confluence, and the common bile duct (CBD). A plastic internal stent tube was placed endoscopically. After 11 cycles (231 days) of a weekly doublet chemotherapy with 1000 mg/m2 of gemcitabine and 125 mg/m2 of albumin-bound paclitaxel, the tumor shrunk based on imaging done every four months during chemotherapy, with residual periarterial high-density area around CA and proximal SMA and the patient was referred for surgery. During the operation, the absence of cancer cells was confirmed at (1) the origin of the proper hepatic artery, gastroduodenal artery and the left gastric artery, and (2) pancreatic cut stump along the right border of the portal vein; thus, distal pancreatectomy with coeliac axis resection was done. The patient had postoperative adjuvant chemotherapy with 100 mg/day of tegafur/gimeracil/oteracil for half a year and is currently alive and well, without signs of recurrence and diabetes mellitus a year after surgery.DiscussionAlthough surgical techniques aimed at local radicality are important, especially for conversion surgery for locally advanced pancreatic cancer, surgeons should consider the balance between radicality, safety, and functional preservation of surgery.

Open Repair of Isolated Pancreaticoduodenal Aneurysm

Figure 1A 58 year old man presented with a three year history of intermittent upper abdominal pain with no history of trauma or pancreatitis. (A) Computed tomography angiography (CTA) revealed a 3.5 cm pancreaticoduodenal artery (PDA) aneurysm (arrow). There was no suitable aneurysm neck or landing zone for coil embolisation or exclusion using a covered stent. Open surgical repair was indicated. (B) The aneurysm was resected, and the PDA was re-implanted into the proximal superior mesenteric artery (SMA). The post-operative course was uneventful. Follow up CTA showed that the PDA and SMA were widely patent. The patient’s symptoms were completely resolved.Image 1

A Hybrid Approach to Treatment of a Superior Mesenteric Artery Aneurysm

Superior mesenteric artery (SMA) aneurysms represent ∼6% of mesenteric aneurysms and carry a risk of rupture. These can be repaired with open surgery or endovascular repair. We present the case of a patient who had developed aneurysmal degeneration of the SMA after dissection requiring hybrid open and endovascular repair. A 54-year-old man had presented to the emergency department with epigastric pain. He was noted to have a 7-cm-long SMA dissection with aneurysmal dilatation. He was treated nonoperatively with anticoagulation and serial imaging until his SMA aneurysm had increased to 2 cm. Preoperative imaging showed the patient had two major jejunal branches originating from the true lumen, with the remaining branches fed from the false lumen. In addition, the aneurysm degeneration extended through the SMA to just distal to the origin (Fig 1). Because of this complex anatomy, we believed a hybrid approach would be needed with a short interposition bypass, reimplantation of jejunal branches, and covered stent placement for proximal coverage. The patient underwent laparotomy with anterior exposure of the SMA. After establishing proximal and distal control, a longitudinal arteriotomy was made. The true and false lumens were noted and fenestrated. An 8-mm polytetrafluoroethylene graft was sewn in an end to end fashion. This was followed by reimplantation of the two jejunal branches as a patch. Flow was confirmed with Doppler ultrasound. Next, the polytetrafluoroethylene graft was accessed with a needle, and a sheath was placed. Angiography and intravascular ultrasound were used to confirm and delineate the anatomy. Next, we upsized to an 8F sheath and placed two 10 × 5 Viabahn stents (W.L. Gore & Associates, Flagstaff, Ariz) overlapping into the aorta and covering the proximal SMA. We postdilated with a 9-mm balloon. Completion imaging revealed good flow with exclusion of the aneurysm (Fig 2). The bowel appeared healthy at that time. The patient tolerated the procedure well and was extubated at the conclusion of the case. He required a nasogastric tube postoperatively until the return of bowel function, at which point he was allowed a regular diet. He was discharged home in sTable condition on postoperative day 6 from the hospital. A hybrid approach to complex SMA aneurysms is a feasible option for repair.Fig 2Completion angiogram at conclusion of the case.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Anomalous Celiac Trunk Variation Encountered in Y-90 Radioembolization

Background: &#x0D; Yttrium-90 microsphere embolization is a selective internal radiation therapy (SIRT) used in the treatment of hepatocellular carcinoma and liver metastases. Current literature recommends lobar, or more selective, infusion of SIRT to allow for precise radiation administration and to mitigate risk of non-target embolization. Lobar infusion requires knowledge of anatomical variations of hepatic arterial supply. The trifurcation of the celiac trunk into the left gastric artery, splenic artery, and common hepatic artery is the most common presentation representing 51% to 89% of patient anatomy. A replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA) is one of the most common variants of hepatic arterial supply with a prevalence of 10.6% to 15%. Common variations such as these are well described and easily mapped using catheter angiography, but rarer variations are not as well described and more challenging to map. &#x0D; &#x0D; Project Methods: &#x0D; Mapping catheter angiogram of the celiac trunk and SMA was obtained. Additional aortogram and CT angiogram were obtained to further elucidate patient’s anatomy. &#x0D; &#x0D; Results: &#x0D; Initial mapping angiogram was only partially successful because the RHA could not be selected. Abdominal aortogram and CT angiogram of the abdomen and pelvis revealed a replaced RHA arising directly from the distal celiac trunk. Additionally, the patient had a replaced cystic artery arising from the left hepatic artery and an arc of Buhler connecting the proximal SMA to the proximal aspect of the right hepatic artery. &#x0D; &#x0D; Conclusion: &#x0D; Radiologists need to be aware of rare variations in hepatic arterial supply for the safe and effective treatment of hepatic neoplasms, whether primary or metastatic. Description of arterial variation and informed selection of arterial branches will remain a critical aspect of improving efficiency and reducing risks of hepatic embolization procedures.

En bloc proximal peri-mesenteric clearance for pancreatic head cancer surgery

The superior mesenteric artery (SMA) first approach and meso-pancreas excision (MPE) during pancreatoduodenectomy (PD) for pancreatic head cancer have been suggested for complete local tumor control, less operative blood loss, and early determination of resectability. However, SMA-first approach is merely a mode of approach and the concept of MPE has been challenged due to its anatomical obscurity. Dissection around proximal mesenteric vessels, superior mesenteric vein and SMA, is a critical procedure point for local tumor control as tumor infiltration is frequently observed both at the time of initial diagnosis and recurrence. The meso-pancreas, which encompasses the soft tissue between the uncinated process and SMA, does not include all the aforementioned points of proximal mesenteric areas. Therefore, the authors propose a new terminology named, “en bloc proximal peri-mesenteric clearance (PPMC)”, to describe the removal of all the lymph nodes including soft tissue around proximal mesenteric vessels, especially the SMA, to ensure complete local tumor control of pancreatic head cancer. The SMA-first approach applied either by the mesenteric approach or supra-colic approach can make this procedure more feasible. The extent of the circumferential dissection of the peri-SMA nerve plexus can be adjusted according to the primary disease. PPMC including the removal of all lymph nodes around the proximal SMA may be considered as a standard extent of PD for pancreatic head cancer.

S2957 Chronic Mesenteric Ischemia: A Rarer Cause of Refractory Gastric Ulceration

INTRODUCTION: H. pylori and non-steroidal anti-inflammatory drug (NSAID) use are common causes of peptic ulcer disease (PUD). In cases of refractory PUD after addressing these factors and treatment with a proton pump inhibitor (PPI), mesenteric ischemia should be considered. CASE DESCRIPTION/METHODS: A 74 year-old male experienced a non-ST segment myocardial infarction, underwent drug eluding coronary stenting, and was initiated on clopidogrel and aspirin therapy. That admission, he developed epigastric abdominal pain and “dark stools”. H. pylori serology was positive, and he was treated with high dose pantoprazole and amoxicillin. Despite twice daily PPI and NSAID avoidance, his epigastric pain persisted, so EGD was performed, revealing superficial, non-bleeding ulcerations and erythema in the gastric body; biopsies showed reactive gastropathy and congestion without H. pylori. 2 weeks later he developed overt melena, and small bowel enteroscopy revealed gastric mucosa pallor and an adherent clot overlying a 1 cm oozing peptic ulcer along the greater curvature. The ulcer was successfully treated with epinephrine and hemostatic clips. His pain symptoms and bleeding resolved, though a surveillance EGD 12 weeks later revealed persistent smaller ulcers, flat pigmented spots, and congestion adjacent to site of the larger ulcer. Sucralfate thus was added to his PPI regimen. He remained asymptomatic until his clopidogrel was discontinued, shortly thereafter developing severe epigastric pain. Physical exam was unremarkable and labs were notable for lactate 1.6 mmol/dL, hemoglobin 12.2 g/d, and gastrin 169 pg/ml (on PPI). CT angiogram showed 90% stenosis at the superior mesenteric artery (SMA) origin, high grade stenosis of the celiac and inferior mesenteric arteries, and dilated bowel. Endovascular intervention was attempted, but revascularization failed due to extent of disease, leading to open mesenteric bypass graft from the external iliac artery to proximal SMA. His dyspeptic symptoms completely resolved at 1 month follow up. DISCUSSION: Chronic ischemia rarely causes PUD due to highly-vascularized gastric mucosa. However, in cases such as this with severe stenosis of the major branches of the aorta this rare complication may occur. Mesenteric ischemia is an important diagnosis to consider in patients with refractory gastric ulcers, especially in the setting of known atherosclerotic disease. Mesenteric ischemia and its associated symptoms and mucosal injury can be successfully managed by revascularization.Figure 1.: EGD with superficial, non-bleeding ulcerations and erythema in the gastric body.Figure 2.: CT angiogram with stenosis of the superior mesenteric artery.Figure 3.: CT angiogram with stenosis of the superior mesenteric artery.

Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era

Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Isolated spontaneous superior mesenteric artery dissection: A rare cause of unexplained abdominal pain

AbstractIsolated spontaneous superior mesenteric artery dissection is a rare disease. The natural history of this rare vascular disease is not well established. Herein, we report the case of a 41‐year‐old male presented with intermittent epigastric pain. A computed tomography scan showed a proximal superior mesenteric artery dissection with jejunal branches involvement. The symptom was improved after prostaglandin E1 therapy. A follow‐up of abdominal computed tomography showed stationary lesion of superior mesenteric artery. Gastroenterologists should recognize and pay attention to this rare cause of unexplained abdominal pain. Management of isolated superior mesenteric artery dissection is varied on the clinical presentation. Conservative treatment may be the first choice for the patients without evidence of bowel ischemia.

3212 Weight Loss Due to Chronic Mesenteric Ischemia

INTRODUCTION: Chronic Mesenteric Ischemia, also known as abdominal angina, is an uncommon condition defined by a state of attenuated blood circulation in the mesenteric vasculature affecting one or more abdominal viscera, and is more common in the female and elderly populations. CASE DESCRIPTION/METHODS: An 81-year-old woman presented with low blood pressure, she had a six month history of alternating constipation and diarrhea and lost 40 pounds. She appeared cachectic and abdominal examination revealed a bruit on auscultation, positive bowel sounds. Her blood work was unremarkable. Computed Tomography Angiography (CTA) of abdomen/pelvis showed chronic occlusion of the proximal celiac axis and proximal superior mesenteric artery. The distal portions of the vessels were reconstituted through large inferior mesenteric artery collaterals. CTA also revealed chronic occlusion of the proximal celiac axis and proximal superior mesenteric artery with reconstitution of the distal portions of the vessels via large inferior mesenteric artery collaterals. Patient was provided gentle hydration with intravenous fluids, and symptomatically treated with ondansetron and proton pump inhibitor. After the confirmation of diagnosis of mesenteric ischemia by CTA, cardiology was taken on board and patient underwent successful mesenteric artery bypass surgery. DISCUSSION: Chronic Mesenteric ischemia is a rare condition but can lead to considerable malnutrition and weight loss, and have fatal consequences such as bowel infarction, necrosis, perforation, sepsis and death. Timely diagnosis is associated with a better prognosis, which can be done with imaging or invasive angiography (gold standard).

PC174. Presentation and Management of a Rare and Fatal Disease: Saccular Superior Mesenteric Artery Aneurysms

Superior mesenteric artery aneurysm (SMAA) is a fatal degeneration of the visceral arteries. Although a rarely encountered entity, it requires timely management because of the high mortality rate associated with rupture, particularly when the aneurysm is saccular in nature. As such, urgent treatment is generally indicated. We present five cases of SMAA that were managed operatively. This study was a retrospective case series completed at a single, large academic institution from January 2016 to January 2019. We describe the presentation, operative management, postoperative outcomes, and follow-up from a series of five patients with SMAA. Five patients (80% female) with true SMAA were identified and diagnosed by computed tomography angiography. All cases involved saccular aneurysms. Three presented emergently with severe abdominal pain, one of whom was to have ruptured SMAA. Two elective cases were incidentally identified on imaging. Two cases were mycotic in etiology, secondary to intravenous drug abuse and infective endocarditis. The remainder were cryptogenic. There were no patients with history of atherosclerosis or elastin or collagen disorders. All of the SMAAs involved branches or branch points of the superior mesenteric artery (SMA). The largest SMAA was 3.2 cm in a proximal SMA branch point. All cases were treated with open surgical resection of the SMAA. Interposition reversed saphenous vein graft was used for reconstruction in a single case involving the main SMA trunk. None of the cases required bowel resection for ischemia. The operative mortality was 20% and related to ruptured SMAA. SMAAs are particularly prone to rupture, at which point intraoperative mortality can reach up to 30%. Accordingly, many authors suggest repairing SMAAs even in asymptomatic patients. Earlier studies supported revascularization, but this has more recently shifted to ligation alone because of the dense collateralization network. In addition, bowel should be closely examined for ischemic changes whenever the integrity is in question. The presenting and management features in our case series are supportive of this literature, with the exception that our population of patients was predominantly female. Future studies will continue to determine factors associated with rupture and poor outcomes, along with the optimizing surgical approach.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

SUN-LB048 Takayasu Arteritis in a Young Woman with Type 1 Diabetes

Takayasu arteritis (TAK) is a rare, chronic large-vessel vasculitis affecting primarily the aorta and its branches. It is uncommon in children and non-Asian ethnic groups. Co-incidence of TAK and type 1 diabetes (T1DM) is rare. We present a case of a 19-year-old Hispanic woman with longstanding T1DM and autoimmune thyroiditis who was diagnosed with TAK. She presented with T1DM and subclinical autoimmune thyroiditis at age 9. She was poorly adherent to diabetes care plan and admitted multiple times for DKA due to insulin omission. HbA1C average over 10 yrs was approximately 11%. At age 18 she presented to an outside hospital with severe abdominal pain and was diagnosed with appendicitis. Appendectomy was complicated by identification of an ischemic segment of small bowel, which was resected, and also for finding a thrombosis in the superior mesenteric artery (SMA). The SMA thrombosis was initially felt to be related to the prothrombotic state of poorly controlled DM1; she had a high atypical p-ANCA titer but erythrocyte sedimentation rate (ESR) had been normal. Her clinical course was complicated by severe cachexia resulting in multiple readmissions to address chronic abdominal complaints, malnutrition and diarrhea. She was also admitted for an episode of pyelonephritis during which she developed severe liver dysfunction of unclear cause. Diabetes remained poorly controlled. At age 19 she was admitted for DKA and weight loss. An abdominal bruit was identified on exam. There was no hypertension. Labs demonstrated a significant elevation of ESR of 101 mm/hr. A diagnostic evaluation was initiated. Imaging (CT and MR angiography) revealed chronic occlusion of the proximal SMA as well as vasculitis of the infrarenal aorta and inferior mesenteric artery. Conventional angiogram did not show vasculitis distal to the origin of the aortic vessels. Based on the constellation of findings including constitutional and gastrointestinal symptoms, the arterial bruit on exam, the high ESR, and findings on imaging, a diagnosis of large-vessel vasculitis (TAK) was made. She was treated with azathioprine and a taper of oral prednisone. Weight increased and ESR decreased initially down to 20 mm/hr, but ESR again increased (up to 40 mm/hr) with imaging evidence of ongoing vasculitis when steroids were weaned. This case adds to the sparse literature describing the association between TAK and T1DM. It highlights that TAK may occur in very young adults of non-Asian descent. It also showcases the difficulty in diagnosis of TAK, which may have a subacute and nonspecific presentation, in an individual with poorly controlled DM1 as well as SMA thrombosis, which has been described as an acute complication of DKA in case reports. The use of systemic glucocorticoids as a mainstay of TAK therapy may present additional challenges in an individual with DM1. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Surgical resection of locally advanced paravisceral neuroganglioma

Background: Neurogangliomas are rare, benign tumors of neural crest origin most commonly seen in the mediastinum/retroperitoneum and can involve critical vasculature. They are indolent and slow-growing tumors that present with symptoms based on mass effect and location. A 29-year old male presented with 2 months of worsening abdominal pain, early satiety, and diarrhea. Initial outside imaging revealed an indeterminate abdominal mass with EUS biopsy consistent with neuroganglioma. Triple phase CT revealed a large (10 x 7 x 9 cm) abdominal mass that appeared to arise from the right diaphragmatic crus and involving the paravisceral arteries of the abdominal aorta. Methods: The mass spared the left gastric artery but circumferentially encased the common hepatic artery with extension to the proper hepatic/gastroduodenal artery bifurcation, and circumferential encasement of the proximal splenic artery and superior mesenteric artery origin from the aorta extending down to the middle colic artery take-off with sparing of distal superior mesenteric root branches. The mass abutted the body/tail of the pancreas and anteriorly displaced the main portal, splenic vein and distal superior mesenteric vein with narrowing and there was encasement of the coronary vein. The left renal vein was involved and two right renal arteries were abutted but left renal artery uninvolved. After multidisciplinary discussion with no other viable treatment options in a highly symptomatic patient with a paravisceral ganglioneuroma, surgical resection was recommended Results: The patient was taken to the operating room for attempted vascular-sparing resection with plan for en bloc multi-arterial resection and reconstruction. A midline laparotomy was performed, the left lateral bisector was mobilized from its diaphragmatic attachments and reflected medially. The omentum was taken off transverse mesocolon, lesser sac entered and gastro-hepatic ligament divided. The right and left colon were mobilized and full Kocher maneuver performed. The medial wall of IVC and left renal vein and right renal arteries were dissected from the mass arising from the right diaphragmatic crus. The distal CHA at the proper hepatic/gastroduodenal bifurcation was dissected free and GDA was ligated. The omentum was divided close to the spleen and short gastric vessels ligated. The spleen and distal pancreas were dissected,mobilized in a retrograde fashion along left kidney/adrenal gland andIMV was ligated. The left diaphragmatic crus was divided and left renal artery preserved. Dissection was carried onto the aorta and the origins of the variant visceral vessels were isolated The splenic artery required ligation at its origin but the CHA and SMA origins preserved. Splenectomy was performed preserving the distal pancreas.The distal uninvolved SMA from the mesenteric root was dissected identifying the middle colic artery. The tumor was divided over the course of the SMA distally to its origin from the aorta circumferentially dissecting it from the encased SMA ligating several lateral pancreaticoduodenal branches going to the uncinate of the pancreas preserving distal jejunal mesenteric branches. Similarly the mass was dissected where it was encasing the common hepatic from the proper hepatic to the CHA origin with circumferential dissection of the vessel. Tumor was adherent to the portal vein and pancreas. Conclusion: Ligation of various venous tributaries including coronary vein was performed and tumor was carefully dissected off the uncinate and the specimen removed en bloc. Despite ligation of short gastric arteries and GDA there was still adequate arterial gastric inflow via the preserved right and left gastric arcade and this was confirmed with intraoperative Doppler signals and ICG injection under SPY device revealing good perfusion. Ganglioneuromas are rare, benign tumors that can arise in challenging anatomic locations with no other effective options other than resection. In our case pathology revealed benign paravisceral ganglioneuroma. Tumors involving visceral aortic branches require careful preoperative planning, experience with advanced resection and anatomical dissection, and attention to anatomical variants that can assist with R0 resection with minimal morbidity.