Branch Of Superior Mesenteric Artery Research Articles

Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair.

The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

A case of duodenal perforation and pancreatic bleeding after flexible ureteroscopy for right renal pelvis UTUC

Upper tract urothelial carcinoma (UTUC) can be managed by flexible ureteroscopy (f-URS) and tumor laser ablation if kidney-sparing surgery is possible. This procedure can be affected by minor to serious complications, including life-threatening sepsis, ureteral strictures, and ureteral and renal pelvis injuries. The case of a 53-year-old man with history of high grade right renal pelvis and bladder tumor who undergone multiple endoscopic treatments and has already refused radical surgery is reported. F-URS and laser ablation with Thulium: YAG laser for UTUC recurrence of the right renal pelvis was performed, but the procedure was stopped due to significant bleeding which impaired vision. Postoperatively, the patient developed hematemesis and hemodynamic instability due to duodenal lesion and active bleeding documented at CT scan. An emergency exploratory laparotomy was performed to drain hemoperitoneum, repair duodenal lesion and concurrent radical right nephroureterectomy was carried out. A second surgery was necessary for repairing duodenal fistula. After 1 week the patient presented again with recurrent hematemesis and hemorrhagic shock. He underwent angiography and selective embolization of the duodenal branch of superior mesenteric artery and as well as branches of gastroduodenal artery successfully and the patient recovered with no other complications. This is the first case of duodenal perforation and pancreatic bleeding due to flexible ureteroscopy and laser ablation of right renal pelvis urothelial carcinoma.

Development of human pancreas

Pancreas is an exocrine and endocrine organ. Exocrine portion secretes digestive fluid. Endocrine portion secreting insulin and glucagon etc. Pancreas developed from dorsal and ventral pancreatic buds, which arise from either side of distal foregut. When duodenum rotates to right, ventral pancreatic bud(VPB) rotates posterior along with common bile duct(CBD) and finally lies below and behind the dorsal pancreatic bud(DPB). In humans, DPB forms major part and VPB forms inferior part of head and uncinate process of pancreas. Main duct (Duct of Wirsung) is derived from whole of ventral pancreatic duct(VPD) and distal part of dorsal pancreatic duct(DPD). Main duct joins with CBD and it perforated posteromedial side of second part of duodenum at major duodenal papilla. Occasionally accessory duct might originate from proximal part of DPD and open into minor papilla. Sometimes two buds do not fuse and lead to pancreatic divisum. Abnormal rotation and fusion of buds might lead to annular pancreas. A few endodermal pancreatic evaginations may remain and migrate in bowel wall and form accessory(heterotopic) pancreas. Islets originating from DPB have more insulin synthesis. Neck, body and tail of pancreas is supplied by coeliac trunk. Derivatives of right VPB are supplied by branches of superior mesenteric artery. During rotation of VPB, superior mesenteric vessels(SMV) were engaged in between DPB and VPB. Lastly, SMV is located posterior to neck but it is anterior to uncinate process of pancreas. Detailed study of development of exocrine and endocrine portions is required for successful management of pathology of the pancreas.

Calcified pancreatoduodenal artery aneurysm with filiform celiac stenosis: Follow up for ~6 years (70 months) with no intervention

A 72-year-old male patient was investigated with abdominal ultrasound (US) imaging before the coronary artery bypass graft surgery (CABG). The incidental finding on ultrasound was an aneurysm of the superior mesenteric artery branch. Consequent CT angiography confirmed aneurysm of the inferior pancreaticoduodenal artery (PDAA, size = 25,5x31,0x28,5mm) with filiform celiac artery stenosis. According to the European Guideline asymptomatic >25mm sized PDAA are treated with an urgent repair. However, the discrepancy between PDAA size and risk of rupture and individual parameters of the patient led the multifunctional team to assign regular follow-ups with US imaging. This case report describes rare pathology, which has been followed up for the last ~6 years (70 months) annually with no intervention, and discusses complexities in making decisions in the management of PDAA with celiac artery stenosis.

A Comparison of the Celiacomesenteric Trunk in the Caribbean with Global Prevalence Calculated by a Systematic Review.

Background Typically, the celiac trunk and superior mesenteric artery branch off separately from the anterior aspect of the abdominal aorta. The celiacomesenteric trunk (CMT) is a rare variant in which those arteries share a common origin. We sought to compare the prevalence of CMT in the Caribbean with the global prevalence as calculated by a systematic review. Methods In this study, we evaluated all consecutive patients who had multiphase contrast-enhanced CT scans at two major referral centres in the Caribbean from August 30, 2017, to September 1, 2019. In patients with a CMT, we recorded demographic and anatomic details. We then conducted a systematic literature search and retrieved raw data to calculate the global prevalence (number of individuals with a CMT divided by the sum total of study samples). We compared CMT prevalence in our sample with the global prevalence using Pearson's chi-square and Fisher's exact tests. Statistical significance was considered to be present when the P value was <0.05. Results From 832 CTs, 665 scans met the inclusion criteria. There were 16 (2.41%) CMTs: 3 (0.45%) classic CMTs, 12 (1.8%) hepato-mesenteric trunks, and 1 (0.15%) hepato-spleno-mesenteric trunk. Forty-two studies reported on CMTs in a total of 74,320 persons. The global CMT prevalence was comparable (3.88%; P = 0.054), but the incidence of hepato-mesenteric variants was significantly lower in our sample (1.8% vs. 3.24%; P = 0.0352). Conclusion There was no difference in the prevalence of a classic CMT in the Caribbean compared to the global prevalence. However, the hepato-mesenteric trunk (incomplete CMT variant) was significantly less prevalent in the Caribbean. Advances in Knowledge: Healthcare professionals performing hepatobiliary interventions must be aware of these differences in order to minimize morbidity during their interventions.

Ileal long-segment ischemia after the unintended ligation of variant ileal branch during laparoscopic right hemicolectomy.

The variant terminal trunk of the superior mesenteric artery (SMA) could be confused with the ileocolic artery (ICA) as it runs on the right side of the superior mesenteric vein. If the variant ileal branch of SMA is mistaken for the ICA, unintentional ligation could cause long-segment ischemia in the ileum. We encountered a rare case of ileal ischemia caused by unintentional ligation of the variant ileal branch of the SMA during laparoscopic right hemicolectomy, which was confirmed by indocyanine green (ICG) angiography and hyperspectral imaging (HSI). Intraoperative real-time perfusion monitoring using ICG angiography and tissue oxygen saturation monitoring using HSI could help detect segments of hypoperfusion and prevent hypoperfusion-related anastomotic complications.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy

BackgroundEndovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC.MethodsA total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA).ResultsAll cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05).ConclusionET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

Novel endovascular technique for repair of superior mesenteric arteriovenous fistula with portal vein aneurysm

BackgroundA superior mesenteric arteriovenous fistula (SMAVF) is a rare, aberrant connection between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). Management includes either open surgical repair or endovascular repair with embolization coils or covered stents. We report a novel in-stent coil embolization technique successfully used for repair of a challenging SMAVF. Case presentationA 56-year-old man presented with an enlarging SMV and portal vein aneurysm. His history was significant for a small bowel resection of a desmoid tumor 14 years prior. Computed tomography (CT) angiography revealed a high-flow SMAVF in the midsegment of the SMA, and the patient was taken to the operating room for endovascular repair. Embolization was initially attempted with detachable coils, but this approach was aborted as the coils did not have sufficient purchase to anchor securely and would migrate into the portal venous system prior to full release and deployment. Placement of a covered stent in the SMA to exclude the fistulous connection was not feasible due to the presence of multiple adjacent major SMA branches. Therefore, a balloon-expandable covered stent was placed across the fistula and crushed distally to create a blind end into which embolization coils were able to nest without migrating. This was achieved with the use of multiple buddy wires to deploy a VBX balloon-expandable stent graft (WL Gore, Flagstaff, AZ) across the fistulous connection and crush the distal end of the stent with a buddy balloon. The funneled covered stent then served as a backstop for packing with embolization coils, and completion angiography demonstrated complete occlusion of the SMAVF and filling of all SMA branches. Both 6-month and 1-year postoperative surveillance CT scans confirmed continued resolution of the fistula. ConclusionThis case demonstrates a novel endovascular technique to create a funneled covered stent across a high-flow SMAVF as a platform to enable embolization and prevent coil migration. This in-stent coil embolization technique is a viable option for cases in which embolization coils and covered stents fail or are unsuitable.

Large Fenestrations Versus Scallops for the Superior Mesenteric Artery during Fenestrated Endovascular Aneurysm Repair: Does it Matter?

Fenestrated endovascular aneurysm repair is an established customized treatment for aortic aneurysms with 3 current commercially available configurations for the superior mesenteric artery (SMA)-a single-wide scallop, large fenestration, or small fenestration, with the scallop or large fenestration most utilized. Outcomes comparing SMA single-wide scallops to large fenestrations with the Zenith fenestrated (ZFEN) device are scarce. As large fenestrations have the benefit of extending the proximal seal zone compared to scalloped configurations, we sought to determine the differences in seal zone and sac regression outcomes between the 2 SMA configurations. We retrospectively reviewed our prospectively maintained complex endovascular aneurysm repair database and included all patients treated with the Cook ZFEN device with an SMA scallop or large fenestration configuration at its most proximal build. All first postoperative computed tomography scans (1-30days) were analyzed on TeraRecon to determine precise proximal seal zone lengths, and standard follow-up anatomic and clinical metrics were tabulated. A total of 234 consecutive ZFEN patients from 2012 to 2021 were reviewed, and 137 had either a scallop or a large fenestration for the SMA as the proximal-most configuration (72 scallops and 65 large fenestrations) with imaging available for analysis. The mean follow-up was 35months. The mean proximal seal zone length was 19.5±7.9mm for scallop versus 41.7±14.4mm for large fenestration groups (P<0.001). There was no difference in sac regression between the scallop and large fenestration at 1year (10.1±10.9mm vs. 11.0±12.1, P=0.63). Overall, 30-day mortality (1.3% vs. 2.5%, P=0.51) and all-cause 3-year mortality (72.5% vs. 81.7%, P=0.77) were not significantly different. Reinterventions within 30days were primarily secondary to renal artery branch occlusions, with only 1 patient in the scallop group requiring reintervention for an SMA branch occlusion. Despite attaining longer proximal seal lengths, large SMA fenestrations were not associated with a difference in sac regression compared to scalloped SMA configurations at a one-year follow-up. There were no significant differences in reinterventions or overall long-term survival between the 2 SMA strategies.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer.

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

The return process of physiological umbilical herniation in human fetuses: The possible role of the vascular tree and umbilical ring.

The human intestine elongates during the early fetal period, herniates into the extraembryonic coelom (EC), and subsequently returns to the abdominal cavity (AC). The process by which the intestinal loop returns to the abdomen remains unclear. This study aimed to document positional changes in the intestinal tract with the superior mesenteric artery (SMA) and branches in 3D to elucidate the intestinal loop return process (transition phase). Serial histological cross-sections from human fetuses (crown-rump length [CRL] range: 30-50 mm) in the herniation (n=1), transition (n=7), and return (n=2) phases were selected from the Blechschmidt Collection. The distribution of the SMA trunk and all intestinal and sister branches entering the intestines was visualized so that positional changes in branches were continuous from the herniation to return phases. Positional changes in SMA branches proceeded in an orderly and structured manner; this is essential for continuous blood supply via the SMA to the intestine during transition and for safe intestinal return. Changes in the SMA distribution proceeded prior to the detection of initiation of intestinal tract return, which might start earlier and last much longer than our consensus (i.e., that the return of the herniated intestine begins when the CRL is approximately 40 mm and ends within a short time). In the cross-section of the umbilical ring in the herniation and transition phases, one proximal limb and one distal limb were observed with SMA intestinal branches, which were fully packed in the umbilical ring. The SMA branches were aligned from inferior to superior along the SMA main trunk. In the herniation phase, the distribution of 3rd-13th branches aligned from proximal inferior medial to distal superior left with a slight spiral in the EC, the tips of which suggested an orderly running course of the small intestine. In the transition phase, SMA branches running across the umbilical ring that fed the small intestine were observed, suggesting that the intestine was uncoiled and ran across the umbilical ring almost vertically. The estimated curvature value supported the phenomenon of uncoiling at the umbilical ring; the value at the umbilical ring was lesser than that in the AC and EC. During the transition phase, the proximal and distal limbs transversely ran side by side in the AC, umbilical ring, limbs on the cranial side, and mesentery on the caudal side. The SMA trunk and its branches ran in parallel, cranially to caudally aligned in the mesentery. This layout of the umbilical ring was maintained during the transition phase. In the return phase, the SMA trunk was gently curved from the upper left to the lower right of the AC; around 12 branches spread with a winding staircase appearance. The intestinal tract reached its definitive position immediately after all tissues crossed the umbilical ring and released any restriction. Each SMA branch and the corresponding region of the intestinal tract form a unit and change their position, though the conformation may change within each unit when running across the umbilical ring. We suggest that the slide-stack model requires revision.

Analysis of the Variations in the Colic Branching Pattern of the Superior Mesenteric Artery: A Cadaveric Study With Proposal to Modify Its Current Anatomical Classification

Background: Vascular anatomy of the ascending colon is more complex and variable as compared to the left. Variations range from the mode of origin, branching to territorial supply. The present study was undertaken to learn the anatomical variations of the superior mesenteric artery (SMA) and its colic branches in detail.Materials and methods: The study included 50 formalin fixed cadavers aged between 40 and 65 years. The colic branches arising from SMA were dissected to trace their mode of origin, branching pattern, and territorial supply. Based on the mode of origin of the colic branches, the SMA anatomy was classified into four patterns: I; II a, b, c; III; and IV.Results: SMA itself showed variations in its origin (as celiacomesenteric and hepatomesenteric trunk), so the colic branches arising from it. In most of the cases, middle (MCA), right (RCA), and ileocolic artery (ICA) originated independently from SMA (I). A common stem (CS) was reported between MCA and RCA (IIa) in seven cases; RCA and ICA in one (IIb); MCA and LCA in one. MCA originated from the coeliac trunk (CT) in one case. In one case, each of absent RCA (III) and accessory artery arising from SMA (IV) was also noticed. In one case, the right branch of MCA gave origin to RCA. Additionally, close association was observed between pattern IIa and incomplete inter-colic anastomosis.Conclusion: Variations in the origin of SMA may potentially influence branching patterns of colic arteries. MCA is the most variant and ICA is the most consistent branch of SMA. Distinctive variations like MCA arising from CT or arising as CS with LCA and incomplete inter-colic anastomosis in pattern IIa are of outrageous importance for operating surgeons during surgical procedures of colon. Based on study results, we propose a modification in the classification of SMA anatomy to include the CS of MCA and LCA as type IId; however, its success relies upon universal acceptance.

Endovascular Management of Hematomas in Pediatric Transplant Patients.

Transcatheter arterial embolization is used to control active hemorrhage at different anatomic locations. Because hematomas can suddenly deteriorate and become life threatening for transplant patients, they require prompt diagnosis and intervention rather than conservative management. Here, we evaluated computed tomography in treatment planning and transcatheter embolization effectiveness for hematoma management in pediatric liver transplant patients. Between June 2012 and December 2021, 10 pediatric liver transplant patients were referred to our interventional radiology unit. Computed tomography and angiograms were reviewed for hematoma location and presence of extravasation. We analyzed correlations between computed tomography and angiography findings and technical and clinical success of the endovascular interventions. Active leak of contrast material during arterial phase was detected on 9/10 CT scans. Although there was no active bleeding on CT in 1 patient, active arterial bleeding was detected on angiography. On the contrary, in 2 patients, although active bleeding was observed on computed tomography, it was not detected on angiography. Source of bleeding was superior mesenteric artery branches in 4, hepatic artery branch in 2, superior epigastric artery in 1, and phrenic artery in 1 patient. Six of 8 patients with active bleeding were treated with endovascular procedures. The remaining 2 patients received surgery: 1 had bleeding from liver cut surface originating from a hepatic artery branch and received open surgery because the bleeding branch was too thin for catheterization, and 1 was hemodynamically unstable and selective catheterization of the internal thoracic artery would take time. Two patients received embolization procedures with N-butyl 2-cyanoacrylate (glue) diluted with iodized oil, and 1 patient had coil and glue with iodized oil. Embolization with coils was performed in 3 patients. Rate of success with transcatheter arterial embolization was 75%. No complications related to patient comorbidities or embolization procedures were shown. No deaths occurred due to progression of the hematoma. Transcatheter arterial embolization is effective and safe for treatment of pediatric liver transplant patients with hematomas. Computed tomography has value in identifying the bleeding source and its anatomic relationships and may enhance our intervention abilities to become quicker, more effective, and more secured.

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis

BackgroundSuperior mesenteric artery plexus (SMAP) injury is reported to cause postoperative intractable diarrhea after pancreatic/colonic surgery with extended lymphadenectomy. This study aims to describe the SMAP microanatomy and extent of injury after right colectomy with extended D3 mesenterectomy for cancer.MethodsThree groups (I) anatomical dissection, (II) postmortem histology, and (III) surgical specimen histology were included. Nerve count and area were compared between groups II and III and paravascular sheath thickness between groups I and II. 3D models were generated through 3D histology, nanoCT scanning, and finally through 3D printing.ResultsA total of 21 specimens were included as follows: Group (I): 5 (3 females, 80–93 years), the SMAP is a complex mesh surrounding the superior mesenteric artery (SMA), branching out, following peripheral arteries and intertwining between them, (II): 7 (5 females, 71–86 years), nerve count: 53 ± 12.42 (38–68), and area: 1.84 ± 0.50 mm2 (1.16–2.29), and (III): 9 (5 females, 55–69 years), nerve count: 31.6 ± 6.74 (range 23–43), and area: 0.889 ± 0.45 mm2 (range 0.479–1.668). SMAP transection injury is 59% of nerve count and 48% of nerve area at middle colic artery origin level. The median values of paravascular sheath thickness decreased caudally from 2.05 to 1.04 mm (anatomical dissection) and from 2.65 to 1.17 mm (postmortem histology). 3D histology models present nerve fibers exclusively within the paravascular sheath, and lymph nodes were observed only outside. NanoCT-derived models reveal oblique nerve fiber trajectories with inclinations between 35° and 55°. Two 3D-printed models of the SMAP were also achieved in a 1:2 scale.ConclusionSMAP surrounds the SMA and branches within the paravascular sheath, while bowel lymph nodes and vessels lie outside. Extent of SMAP injury on histological slides (transection only) was 48% nerve area and 59% nerve count. The 35°–55° inclination range of SMAP nerves possibly imply an even larger injury when plexus excision is performed (lymphadenectomy). Reasons for later improvement of bowel function in these patients can lie in the interarterial nerve fibers between SMA branches.

Rare cause of duodenal obstruction in a young-age female: a case report

BackgroundGastrointestinal tract can be compressed by many vascular structures in the abdomen; such compressions may be incidentally found or may result in compression symptoms like abdominal pain and vomiting.Case presentationWe illustrate an uncommon cause of extrinsic compression of the third part of the duodenum by jejunal branches of the superior mesenteric artery in an 18-year-old female, presented with dull-aching epigastric pain and vomiting. Contrast Enhanced Computerized Tomography (CECT) showed atypical origin of the jejunal branches of superior mesenteric artery with relative space narrowing between it and the aorta, causing significant compression on the third part of the duodenum. Barium follow-through confirmed indentation of the duodenal lumen at the same level of the aberrant vessel. Conservative treatment failed to control her symptoms, and the patient referred to the surgery.ConclusionHigh index of suspicion is required for diagnosis of atypical causes of upper abdominal pain and vomiting. CECT guided by a well-descriptive comment of the treating doctor is very helpful diagnostic tool for detecting such rare condition. Barium studies still have a valuable role for determining the level of obstruction and confirming the diagnosis of such rare cases.

Aneurysms of the superior mesenteric artery and its branches

ObjectiveAneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6% to 15% of all visceral artery aneurysms. In the present report, we have described our 30-year experience with the management of aneurysms of the SMA and its branches at a high-volume referral center. MethodsA retrospective review of all patients with a diagnosis of an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. The clinical presentation, etiology, aneurysm shape and size, treatment modalities, and outcomes were analyzed. The growth rate of the aneurysms was estimated using linear regression. ResultsA total of 131 patients with 144 aneurysms were reviewed. The patients were primarily men (64%), with a median age of 60 years. Of the 144 aneurysms, 57 were fusiform, 30 were saccular, and 57 were dissection-associated aneurysms. Of the 131 patients, 41 had had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). A total of 35 patients (27%) were symptomatic at presentation. Of the 144 aneurysms, 111 had multiple computed tomography angiograms available, with a median follow-up of 43.6 months (interquartile range, 10.6-87.2 months). Only 18 aneurysms (16%) had had an estimated growth rate of ≥1.0 mm/y. The initial aneurysm size was significantly associated with the growth rate for the fusiform aneurysms (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.0-1.3]; P = .02) but not for the saccular (OR, 0.91; 95% CI, 0.76-1.1; P = 1.1) or dissection-associated (OR, 1.2; 95% CI, 0.91-1.5; P = .20) aneurysms. Acute abdominal pain (OR, 5.9; 95% CI, 1.6-22; P = .01) and chronic abdominal pain (OR, 3.7; 95% CI, 1.1-13; P = .04) were associated with aneurysm growth. Only two patients had a ruptured aneurysm, both of whom presented with rupture with no prior imaging studies. These two patients had a diagnosis of fibromuscular dysplasia and systemic lupus erythematosus, respectively. Of the 131 patients, 46 (34%) had undergone operative repair, including 36 open revascularizations and 8 endovascular procedures. The average aneurysm size for these 46 patients was 24.0 ± 8.6 mm. One patient died perioperatively, and nine patients experienced perioperative complications (25%). Of the 144 aneurysms, 91 were <20 mm, with an average size of 13.4 ± 3.1 mm. These 91 aneurysms had been followed up for a median of 120.8 months (interquartile range, 30.5-232.2 months), with no ruptures within this cohort during the follow-up period. ConclusionsThe present study represents one of the largest series on aneurysms of the SMA and its branches. Our results showed that aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms had a greater risk of growth. Aneurysms <20 mm with a degenerative etiology can be safely monitored without treatment.

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

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

Surgical glance at pancreatic arterial anatomy

Aim. Study of anatomical variations of the pancreatic neck blood supply, which may affect the results of pancreaticoduodenectomy.Material and methods. Anatomic characteristics of arterial blood supply of pancreas were studied in 42 autopsied cases, who died from diseases not associated with abdominal organs failure. Clinical part of our study included 62 patients. Arterial anatomy was examined during early arterial phase of computer tomography. Options of the origin of the dorsa pancreatic artery were noted. All patients had “soft” pancreas confirmed by morphological examination and computer tomography. Main group included 20 patients. Dissection of the pancreas during pancreatoduodenectomy in this group were performed 10–15 mm left of portal vein confluence. Control (retrospective) group included 42 patients performed standard procedure, when pancreas was dissected above the portal vein confluence.Results. It was found that the neck of pancreas was supplied from dorsal pancreatic artery, found in all specimens. In 76% of cases it was a branch of splenic artery, in other cases – a branch of superior mesenteric artery. CT scan revealed the dorsal pancreatic artery in 54 (87.1%) people, in 8 patients the artery could not be identified. The dorsal pancreatic artery was a branch of the splenic artery in 64.8% of cases. In other cases it was a branch of the superior mesenteric artery, common hepatic artery, gastroduodenal artery and middle colon artery. If the dorsal pancreatic artery was a branch of the superior mesenteric, common hepatic, gastroduodenal artery, it was transected during lymphadenectomy. This led to higher frequency of postoperative pancreatic fistula.Conclusion. Localization of dorsal pancreatic artery must be taken into account during the pancreatoduodenectomy. That allows to decrease probability of postoperative pancreatic fistula.

Gastrointestinal bleeding due to pseudoaneurysms in children.

Radiological embolization is the treatment of choice in adults with visceral artery pseudoaneurysm (PSA) and gastrointestinal bleeding, but pediatric data is scanty. We analyzed the etiology, clinical presentation, and outcome of radiological intervention in children with PSA of celiac (CA) or superior mesenteric artery (SMA) branches. Electronic records of children with PSA of CA or SMA branches were reviewed and data on clinical and laboratory profile, radiological intervention, and outcome was recorded. Eleven children with PSA (5 boys, 11 [7-17] years) were studied. Etiology was liver abscess (n 4), abdominal trauma (n 3), pancreatitis (n 3), and indeterminate in 1 case. Ten (91%) patients were symptomatic: abdominal pain (10, 91%), hematemesis/melena (9, 81%), and Quincke's triad (1, 9%). One child with pancreatic pseudocyst was diagnosed incidentally on imaging. Doppler ultrasound identified PSA only in 3 cases, while computed tomography angiography (CTA) picked all cases. Children with liver abscess, trauma, and unknown etiology had PSA from CA (right hepatic artery 7, left hepatic artery 1). Of the 3 pancreatitis cases, 2 had PSA from SMA (inferior pancreatico-duodenal artery and ileal branch) and 1 from CA (left gastric artery). Radiological embolization was done in 9 (81%) cases (coil 6, glue 2, both 1), without any complications or failure. One case resolved spontaneously and 1 died pre-intervention. Nine intervened cases were asymptomatic in follow-up [6 (1-24) months].Conclusion: Liver abscess, trauma, and pancreatitis are causes of PSA of CA and SMA branches in children. A majority present with gastrointestinal bleeding and are identified on CTA. Radiological embolization was safe with 100% success. What is Known: • Pseudoaneurysm of visceral artery is an uncommon cause of gastrointestinal bleeding. • Endoluminal intervention is an established and efficacious treatment modality in adults and preferred over surgery. What is New: • Liver abscess, abdominal trauma and pancreatitis are common causes of celiac artery and superior mesenteric artery branch pseudoaneurysm in children and computed tomography angiography has high sensitivity in identifying these pseudoaneurysms. •Minimally invasive radiological angio-embolization, in the hands of trained radiologists, is a safe and successful modality of treatment in children.

The New Concept of Physiological "Riolan's Arch" and the Reconstruction Mechanism of Pathological Riolan's Arch After High Ligation of the Inferior Mesenteric Artery by CT Angiography-Based Small Vessel Imaging.

BackgroundDue to the complexity of anatomical relationship between superior mesenteric artery (SMA) and left colic artery (LCA), there is no unified anatomical concept of “Riolan’s arch.” There is no consensus as to tie off the inferior mesenteric artery (IMA) at its origin or just below the origin of the left colic artery during radical surgery of sigmoid colon and rectal cancers. The aim of the study is to investigate the anatomy of shortcut anastomotic branches (adjacent branches) of SMA at splenic flexure and to explore how the shortcut pathway (Riolan’s arch) was formed, as the compensation of anastomotic branches between MCA and LCA under pathological conditions and the reconstruction and the mechanism of pathological Riolan’s arch after high ligation of the inferior mesenteric artery.MethodsBetween January 2018 and May 2020, patients with colorectal cancer who underwent CTA before surgery were enrolled in the study. The anatomy of shortcut anastomotic branch of SMA and LCA was investigated by volume rendering technique (VR) and maximum-intensity projection (MIP). GE’s small vessel extraction technology (selected VR) was used to directly display these shortcut anastomotic branches on a map and to establish their three-dimensional anatomical classification. Then, we used the axonometric drawing to make the model more exact. Next, combining with some cases of pathological Riolan’s arch and basing on hydrodynamic principle, we speculate the mechanism of collateral circulation. Finally, based on the retrospective study of high ligation cases and combined principles of fluid mechanics, we show how these shortcut anastomotic branches evolved into Riolan’s arch.ResultsWe report the classification of the ascending branch of LCA (which approaches the splenic flexure) and the left branch of MCA, display these shortcut anastomotic branches on a map, and establish their three-dimensional anatomical classification. We found that Riolan’s arch is a shortcut pathway for the compensation of anastomotic branches, between MCA and LCA under pathological conditions, and that the formation mechanism of shortcut path accords with the principle of hydrodynamics.ConclusionsOur results show the mechanism of pathological Riolan’s arch formation and provide new anatomic thinking for the battle between high and low ligation of IMA in colorectal cancer surgery.