Proximal Superior Mesenteric Artery Research Articles

TOI 6. Heart in Abdomen: Challenge to Deal With Pseudoaneurysm of Superior Mesenteric Artery With Tetralogy of Fallot

A 28-year-old man underwent total correction of tetralogy of Fallot in 2003. He was diagnosed with infective endocarditis 2 months before and received treatment in a cardiac unit. After discharge, he developed periumbilical pain associated with early satiety and decreased appetite. On examination of this thinly built patient, a pulsatile mass (0 × 10 cm) was palpable in the periumbilical region, more on the left side. Echocardiography showed a secundum-type atrial septal defect measuring 17 mm (left to right shunt), residual perimembranous ventricular septal defect (bidirectional shunt), severe mitral regurgitation with eccentric jet, tricuspid regurgitation (moderate), and pulmonary regurgitation (mild). Computed tomography angiography of the abdomen showed leakage of contrast material from the superior mesenteric artery (SMA) into an aneurysmal sac (6.8 × 7 cm) that occupied almost half the capacity of the peritoneum/abdominal cavity. Digital subtraction angiography showed distal SMA aneurysm with high flow; coil embolization could not be done because of the chance of gut ischemia and persistent pressure symptoms afterward; therefore, the open surgical approach was decided on. On opening of the peritoneal cavity, a beating heart wrapped in mesentery with surrounding inflammation was encountered. Proximal SMA control was taken just near to the aneurysm; the sac was opened and the hematoma evacuated, and the SMA was ligated inside the aneurysmal sac. Dusky proximal bowel found intraoperatively improved after evacuation of hematoma and ligation of the SMA aneurysmal branch, suggestive of impaired circulation from pressure of the sac. No revascularization was required. SMA pseudoaneurysm is rarely encountered in vascular practice. An aneurysmal sac of such size with distorted anatomy is a challenge to deal with, especially in a patient with such comorbidities.

Acute Mesenteric Ischaemia and Coralliform Aorta

A 77 year old man presented with acute mesenteric ischaemia and peritonitis. Computed tomography angiography revealed acute thrombosis of the proximal calcified superior mesenteric artery (SMA) arising from a coralliform aorta (A, asterisk). He underwent emergency retrograde open mesenteric stenting (ROMS) using a 7 × 59 mm Atrium Advanta V12 stent graft (Maquet, Rastatt, Germany) with great saphenous vein patch angioplasty (panel B), followed by right colectomy. Ilio-mesenteric bypass was not feasible because of previous iliac kissing stents and femoro-femoral bypass. The patient is alive at 2 months after temporary dialysis. ROMS is a useful bailout technique to treat acute SMA thrombosis despite coralliform aorta.

Celiac Artery Aneurysm With Dissection

A 52-year-old male with no history of vascular disease presented with a celiac artery aneurysm. Incidentally, a celiac artery dissection was discovered. The dissection was a result of the aneurysm. The proximal abdominal aorta, celiac artery, and superior mesenteric artery were examined with gray scale, color flow, and spectral Doppler. The proximal abdominal aorta, celiac artery, and superior mesenteric artery were without evidence of atherosclerotic plaque. There was evidence of a celiac artery aneurysm measuring 1.3 cm, which was stable compared with a previous CT (computed tomography) from April 2014. A dissection was visualized within the celiac artery with color flow aliasing and higher velocities visualized in the false lumen, with the highest measuring 402/142 cm/s. The true lumen highest velocity measured 209/56 cm/s. The superior mesenteric artery was patent with normal flow patterns and velocities measuring from 134 to 189 cm/s. Celiac artery aneurysms and dissections are extremely rare and can be difficult to find and treat. By scanning the aneurysm, the dissection could be found, perhaps reducing the risk of embolus or occlusion.

TCTAP C-185 Successful Endovascular Treatment of Isolated Dissection of Superior Mesenteric Artery with Ambiguous IVUS Finding

### Patient Initials or Identifier Number H.I. ### Relevant Clinical History and Physical Exam A 42-year-old man developed severe abdominal pain. He was sent to the emergency room by ambulance 3 hours from the onset. A CT resealed total occlusion in the proximal superior mesenteric artery (SMA).

Jejunal arterial access for retrograde mesenteric stenting

Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a “mini-laparotomy” and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.

Postpartum Abdominal Pain, With a Twist

Introduction: Intestinal malrotation classically presents in the neonatal period as acute obstruction due to intestinal, or midgut, volvulus. Midgut volvulus due to intestinal malrotation is rare in adults, with an estimated incidence of 0.2-0.6%. We present a case of a young, post-partum woman who presented with two months of abdominal pain and was found to have a midgut volvulus from intestinal malrotation. To our knowledge, this is one of the first cases of intestinal malrotation presenting as midgut volvulus after uterine involution. Case Report: A 22-year-old female with no history presented with progressively worsening post-prandial epigastric pain that started after she gave birth 2 months prior. She had an uncomplicated pregnancy and normal vaginal delivery. Over the past week, the pain had became more severe and persistent, and was accompanied by nausea and bilious vomiting. She denied weight loss and had no other constitutional symptoms. She did note constipation over the past few days but was still passing flatus. Exam revealed tenderness to palpation over the epigastrium without evidence of an acute abdomen. Labs were significant for a blood urea nitrogen of 33, hemoglobin of 16.3, and hematocrit of 50. Hepatic function panel revealed an elevated total bilirubin level of 3.5. A RUQ ultrasound done to rule out biliary obstruction showed a twisting of the proximal superior mesenteric artery (SMA) and vein (SMV) with patent flow. A CT angiography of the abdomen and pelvis showed the classic “whirlpool sign,: confirming a midgut volvulus with intestinal malrotation, with resultant duodenal obstruction. There was no evidence of bowel ischemia or perforation. An emergent surgical consultation was placed and the patient was taken down for an exploratory laparotomy with detorsion of volvulus, lysis of Ladd's bands, broadening of the mesentery, and an appendectomy.Figure: Sonographic evidence of SMV and SMA twisting.Figure: Classic “whirlpool” sign seen on CT angiography of abdomen/pelvis.Figure: Anatomic deviation of congenital malrotation; appendix seen in left upper quadrant.Discussion: Total small intestinal volvulus with malrotation classically (64-80% of the time) presents in neonates, typically within the first month of life. Symptomatic intestinal malrotation is rare in adults. This is often an incidental finding, although symptoms can range from those associated with obstruction or reflux to those found in acute intestinal infarction. CT findings can be pathognomonic if the whirlpool sign is seen. CT also allows for rapid diagnosis and surgical treatment, which is important as delayed diagnosis or treatment can result in bowel necrosis and death.

Rapidly progressive atherosclerosis after domino liver transplantation from a teenage donor with homozygous familial hypercholesterolemia

Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by impaired clearance of low-density lipoprotein cholesterol. Given limitations in pharmacologic therapy and the significant morbidity and mortality associated with this disease, liver transplantation may be offered to select homozygous FH patients in childhood in an effort to slow progression of atherosclerotic cardiovascular disease. In rare cases, domino liver transplantation can be performed, transplanting the livers of patients with various metabolic disorders into elderly recipients whose projected survival precludes prolonged waiting on the transplant list. Herein, we report a case of domino liver transplantation using the liver of a 14-year-old boy with homozygous FH into a 65-year-old man with primary sclerosing cholangitis and cirrhosis who developed rapidly progressive atherosclerotic cardiovascular disease involving the arteries of his proximal bilateral lower extremities, carotid arteries and superior mesenteric artery.

Superior Mesenteric Artery Thrombosis and Partial Dissection Managed Medically

A 44-year old male presented to the ED complaining of abdominal pain. CT angiography of the abdomen showed thrombus extend from the proximal superior mesenteric artery (3 cm distal to the origin), with partial dissection of the superior mesenteric artery. He was given intravenous fluid and was started on intravenous heparin. All hypercoagulable workup was done to rule out the causes of thrombosis or dissection was negative. The patient’s abdominal pain was decreasing, and heparin was bridged with Coumadin. The patient was discharged to home, and advised to check INR regularly and follow up with the vascular surgery department. Conservative management is generally the preferred treatment. For more serious cases, aggressive approaches such as percutaneous endovascular stent placement or surgery would be considered.

Endovascular Stent Graft Repair of a Ruptured Superior Mesenteric Artery Aneurysm

A ruptured aneurysm of the superior mesenteric artery (SMA) is very rare. In recent years, there have been some reports of successful endovascular therapy of SMA aneurysms. However, endovascular stent graft repair of a ruptured SMA aneurysm has not been reported previously. We report on a 50-year-old man with a ruptured aneurysm of the proximal SMA. Using an endovascular approach, the aneurysm was initially excluded with 2 stent grafts. Two weeks following the first procedure, computed tomography angiography revealed a proximal endoleak, which was treated with another stent graft. The endovascular stent graft repair finally resulted in total exclusion of the ruptured aneurysm. Patency of the SMA was maintained and no ischemic complications occurred.

Acute Superior Mesenteric Artery Occlusion – Combined Treatment Strategy

Background Acute occlusion of the proximal superior mesenteric artery is still a life-threatening disease. Different surgical and endovascular treatment strategies exist.

Endovascular Treatment of Proximal Superior Mesenteric Artery Pseudoaneurysm after Stab Injury

Superior mesenteric artery (SMA) injuries remain a challenge to most trauma surgeons and continue to result in significant mortality despite aggressive management. We report successful management of a proximal SMA injury through endovascular treatment in a 56-year-old man. The patient presented with hypotension due to a stab wound after the epigastrium. He underwent emergency laparotomy and repair of the penetrated wall of the stomach. Right retroperitoneal hematoma at the initial laparotomy expanded and ruptured, requiring a massive transfusion. At the second laparotomy, we performed lateral arteriorrhaphy of the proximal SMA. Follow-up abdominal computed tomography angiography on post-injury day 7 showed a pseudoaneurysm on the left side of the SMA trunk. The patient was treated successfully with an endovascular stent graft.

Anatomy of the transverse colon revisited with respect to complete mesocolic excision and possible pathways of aberrant lymphatic tumor spread.

Although lymph node metastases to pancreatic and gastroepiploic lymph node stations in transverse colon cancer have been described, the mode of lymphatic spread in this area remains unclear. This study was undertaken to describe possible pathways of aberrant lymphatic spread in the complex anatomic area of the proximal superior mesenteric artery and vein, the greater omentum, and the lower pancreatic border. Abdominal specimens obtained from four cadaveric donors were dissected according to the principles of complete mesocolic excision. The vascular architecture of the transverse colon was scrutinized in search of possible pathways of lymphatic spread to the pancreatic and gastroepiploic lymph nodes. Vascular connections between the transverse colon and the greater omentum at the level of both the hepatic and the splenic flexures could be identified. In addition, small vessels running from the transverse mesocolon to the lower pancreatic border in the area between the middle colic artery and the inferior mesenteric vein were demonstrated. Moreover, venous tributaries to the gastrocolic trunk could be exposed to highlight its surgical importance as a guiding structure for complete mesocolic excision. The technical feasibility to clearly separate embryologic compartments by predefined tissue planes in complete mesocolic excision was confirmed. However, the vicinity of all three endodermal intestinal segments (foregut, midgut, and hindgut) obviously gives way to vascular connections that might serve as potential pathways for lymphatic metastatic spread of transverse colon cancer.

Pancreatic Ductal Stent Placement for the Palliation of Pain in Patients With Pancreatic Adenocarcinoma, With and Without Pancreatic Ductal Dilatation

Background: Endoscopic pancreatic duct stenting is commonly performed for pancreatic duct strictures and ductal dilatation. Though much less common than celiac plexus block, there are reports of the use of pancreatic duct stenting for the management of pain in patients with pancreatic cancer and pancreatic ductal dilatation. There are no published reports of pain relief with stenting in patients with pancreatic cancer without pancreatic ductal dilatation. Methods: A retrospective review was performed in two patients who underwent pancreatic duct stenting prior to a diagnosis of pancreatic carcinoma. Results: Two patients were evaluated for chronic abdominal pain. The first patient, was a 76 year-old male, with no significant past medical history who presented with greater than 6 months of worsening epigastric abdominal pain and a 22 pound weight loss. At the time of presentation, 2 computed tomography scans and magnetic resonance imaging had revealed pancreas divisum and pancreatic ductal dilatation without a pancreatic mass lesion. The second patient was a 41-year-old male with no significant past medical history who presented with chronic upper abdominal pain. His imaging had revealed an ill-defined retroperitoneal mass surrounding the proximal superior mesenteric artery (SMA). An EUS and biopsy had been negative for malignancy. The main pancreatic duct was not dilatated, and there was no intrahepatic biliary ductal dilatation. Both patients underwent ERCP with pancreatic duct stent placement (via the minor papilla and major papilla, respectively). Both patients experienced complete relief of their pain and their stents were subsequently removed. A diagnosis of adenocarcinoma was subsequently established in both patients by EUS and CT guided biopsy respectively. Conclusion: Relative to celiac plexus block, pancreatic duct stenting is much less commonly used in the palliation of pain in pancreatic adenocarcinoma. In two patients initially with chronic pain but without a diagnosis of malignancy, pancreatic ductal stenting provided complete relief, both in the presence and in the absence of pancreatic ductal dilatation. Further investigation may help determine the role of stent placement as compared to other interventions in patients with and without dilatation of the main pancreatic duct.

A Hybrid Repair of a Superior Mesenteric Artery Pseudoaneurysm Using Open Mesenteric Bypass and Endovascular Exclusion

Superior mesenteric artery (SMA) aneurysms and pseudoaneurysms are uncommonly encountered in vascular surgery practice, but they typically require repair. Historically, they have been repaired with open aneurysmorrhaphy, bypass and exclusion, or simple ligation. More recently, endovascular repair with coil embolization and stent graft exclusion have been advocated. We present a repair of an SMA pseudoaneurysm via a hybrid approach with common hepatic artery to SMA bypass, exclusion of the pseudoaneurysm with ligation of the SMA proximal to the bypass, plug occlusion of the proximal SMA, and coil embolization of the pseudoaneurysm.

Early Detection of a Rare Case: Idiopathic Spontaneous Superior Mesenteric Artery Dissection, by Duplex Ultrasonography

Spontaneous dissection of the superior mesenteric artery (SMA) without involvement of the aorta is an extremely rare condition. It could be a surgical emergency because ischaemic intestine due to artery occlusion is life-threatening and the prognosis is time-dependent. We present a 55-year-old man with a 5-day history of progressive abdominal pain. He had a negative laboratory work-up and pan-endoscopy showed multiple gastric ulcers. Despite treatment, he had persistent severe epigastric pain disproportionate to physical findings. Bedside duplex ultrasonography revealed the absence of color signal in the proximal SMA. Angiography confirmed the diagnosis of SMA dissection. Mesenteric vascular emergency including arterial dissection should be taken into consideration in patients who present with severe abdominal pain of unknown origin. Abdominal bruit may be the only vital clue but is usually difficult in the noisy emergency department. Duplex ultrasonography can be helpful to detect blood flow abnormality whenever in doubt. (Hong Kong j. emerg.med. 2015;22:189-193)

Reappraisal of Nodal Staging and Study of Lymph Node Station Involvement in Pancreaticoduodenectomy with the Standard International Study Group of Pancreatic Surgery Definition of Lymphadenectomy for Cancer

The prognostic role of lymph node (LN) dissection in pancreatic head ductal adenocarcinoma is still unclear. This study reappraised the value of the number of positive LNs and LN ratio in patients undergoing pancreaticoduodenectomy with standard lymphadenectomy according to the recent International Study Group of Pancreatic Surgery definition. In addition, the impact of nodal metastases stratified by LN stations was investigated. After reviewing retrospectively clinical and pathologic data of 758 pancreaticoduodenectomies for pancreatic head ductal adenocarcinoma performed from 2002 through 2011, we extracted patients in whom the LN stations included in the International Study Group of Pancreatic Surgery definition had been sampled. Survival analysis was performed using univariate and multivariate models. The study population consisted of 255 patients. Mean number of harvested LNs was 30.8. Factors with a significant prognostic impact on multivariate analysis were tumor grade, adjuvant therapy, number of positive LNs, LN metastases along station 14a-b (proximal superior mesenteric artery), and the number of metastatic LN stations. Patients with involvement of station 14a-b exhibited worse pathologic features, indicating more aggressive disease. In patients receiving a uniform LN dissection, the number of positive LNs is superior to LN ratio for predicting survival. Lymph node metastases along the proximal superior mesenteric artery have a significant prognostic value, and an increasing number of metastatic stations are associated with a sharp decrease in survival. In future studies, clarification of the pattern of LN metastasis spread could offer valuable insight into the optimal treatment strategies, including selection of patients for neoadjuvant therapies.

A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon.

Superior mesenteric artery (SMA) syndrome is a rare cause of gastrointestinal obstruction, caused by external compression of the third part of the duodenum by the SMA. It may be associated with the Nutcracker phenomenon: external compression of the left renal vein. To our knowledge, there are few reports in the literature describing the coexistence of these two conditions and so we take this opportunity to highlight a rare cause of the acute abdomen that might otherwise be overlooked in cases of nonspecific abdominal findings and potentially unremarkable initial investigations. We report a case of SMA syndrome and Nutcracker phenomenon in a 19-year-old female who presented to our emergency department with a short history of epigastric pain and emesis. The SMA syndrome is thought to develop as the result of an abnormally narrow angle between the proximal SMA and the aorta, for which a number of predisposing factors have been described. Surgical options exist; however, the SMA syndrome is typically managed conservatively in the first instance, consistent with the approach described in this case. The Nutcracker phenomenon may give rise to the Nutcracker syndrome in the presence of typical clinical manifestations; however, these did not feature in this case.

Endovascular treatment of superior mesenteric artery pseudoaneurysms using covered stents in six patients.

The objective of our study was to evaluate our experience with the use of endovascular treatments for superior mesenteric artery (SMA) pseudoaneurysms using covered stents. Between 2002 and 2011, six patients (mean age, 41.7 years; range, 23-65 years) with SMA pseudoaneurysms were treated percutaneously with the placement of covered stents at our institution. The causes of SMA pseudoaneurysms were penetrating trauma (n = 2), blunt trauma (n = 1), and previous surgical procedures (n = 3). The mean diameter of the SMA pseudoaneurysms was 16 mm (range, 4-24 mm). Technical success and clinical success were retrospectively analyzed. Immediate technical success, defined as exclusion of the pseudoaneurysm and lack of active extravasation, was achieved in all six patients. Secondary balloon angioplasty was needed in one patient with residual narrowing. There was a small dissection of the proximal SMA necessitating placement of a second bare stent across the dissection. A second covered stent (Fluency stent, 8 mm) was placed in the same patient because of recurrent bleeding due to a type II endoleak 5 days after the first covered stent had been placed. This patient had no subsequent episodes of bleeding or bowel ischemia. Follow-up CT in the remaining five patients (mean, 21 months; range, 1-58 months) confirmed stent patency and preserved distal arterial flow to the bowel without episodes of bleeding or bowel ischemia during follow-up (mean, 27 months; range, 11-58 months). Percutaneous endovascular treatment using a covered stent may be a safe and feasible tool for SMA pseudoaneurysms.

The Back Table Graft Arterial Anastomosis Between Splenic Artery and Superior Mesenteric Artery: A 13-Year Single-Center Experience of Pancreas Transplantation in Barcelona.

Introduction:Vascular complications following pancreas transplantation are the leading non-immunologic cause of graft loss.The arterial vascular reconstruction including a Y-graft interposition from the donor iliac artery bifurcation is the most used worldwide. Aim:We sought to assess the incidence of vascular complications after using the back-table graft arterial anastomosis between splenic artery (SA) and distal superior mesenteric artery (SMA). Methods:This was a retrospective analysis including all pancreas transplants performed over 13 years (2001-2013).For the bench reconstruction, the SMA was distally dissected and sewn to the SA in an end-to-end fashion (SMA/SA).The proximal SMA with an aortic patch was anastomosed to the recipient common iliac artery. In a few cases the arteries were reconstructed with an iliac arterial “Y” graft. Vascular complications were included, focusing on arterial events. Results: A total of 273 pancreas transplantations were done:223 simultaneous pancreas kidney, 2 pancreas alone,17 pancreas after kidney and 31 retransplantations. At the bench procedure SMA/SA anastomosis was performed in 92.3% of the patients, arterial iliac “Y” graft in 17 patients,and no arterial reconstruction was need in 4 patients because of anatomical variations of the donor pancreas. Sixty-six patients presented vascular complications;venous complications were the most frequent (53 recipients).There were 16 patients with arterial complications (5.55% SMA/SA, 11.76% Y-graft).Eleven were acute arterial complications (1 enteric anastomosis bleeding with SMA thrombosis and 10 thrombosis).Five patients presented late arterial complications(Chronic arterial thrombosis (1);arterial anastomosis pseudoaneurism(1);enteroarterial fistula (3)).The patient survival with SMA/SA anastomosis at 1st and 5th year was 98.8% and 95.4%.The patient survival for arterial “Y” Graft was 100% at 1st and 93 % the 5th year.The graft survival with SMA/SA anastomosis at 1st and 5th year was 87.2% and 76.7%; and 93% using arterial “Y” Graft. Conclusions:The back table procedure used in our institution (SMA/SA) is an easy, effective and safe surgical technique, that can be used as a good alternative for surgeons to arterial “Y” graft.

Congenital superior–inferior mesenteric arterial variation or arc of Riolan due to occlusion of proximal superior mesenteric artery

Congenital superior–inferior mesenteric arterial variation or arc of Riolan due to occlusion of proximal superior mesenteric artery