Superior Mesenteric Artery Injury Research Articles

Superior Mesenteric Artery Injury during Robotic Radical Nephrectomy: Scenarios and Management Strategies.

Injury to the superior mesenteric artery (SMA) is a rare, underreported, and potentially devastating complication. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. Three different instances of intraoperative injury to the SMA are described in an accompanying video. All three occurred when the SMA was misidentified as the left renal artery during left robotic radical nephrectomy. In the first case, the SMA was mistakenly identified as the renal artery, but after further dissection, the real renal artery was identified and SMA injury was prevented. In the second case, the SMA was clipped and the real left renal artery was subsequently identified, requiring clip removal. In the third case, the SMA was clipped and completely transected, requiring prompt repair by vascular surgery with a successful outcome. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. The proper anatomic recognition of the SMA may prevent its injury. Intraoperative SMA injury should be promptly identified and repaired to avoid its devastating consequences.

Isolated superior mesenteric artery rupture caused by abdominal trauma.

The superior mesenteric artery (SMA) is one of the visceral branches of the abdominal aorta. It has multiple branches to supply blood and nutrition to the intestinal segment, and these form an anastomosis with each other. SMA injuries are usually classified as major visceral artery injuries, and have an incidence of <1%. The clinical manifestations of patients with SMA injuries include intra-abdominal bleeding and peritoneal irritation. The compromised blood supply can lead to intestinal ischemia and perforation. These injuries are often not diagnosed in time and have significant mortality rates of 25%‍-‍68% due to the lack of specific features (Maithel et al., 2020). Not only that, but patients with less severe trauma or no visible damage on initial examination may still have clinically significant intra-abdominal injuries (Nishijima et al., 2012). Emergency departments often encounter multiple cases that require urgent diagnosis and treatment (Li et al., 2021; Zhang et al., 2021; Zhou et al., 2021), and therefore, it is imperative to diagnose and manage these rare injuries expeditiously.

V13-01 SUPERIOR MESENTERIC ARTERY INJURY DURING ROBOTIC LEFT RADICAL NEPHRECTOMY: PREVENTION AND MANAGEMENT

You have accessJournal of UrologyCME1 May 2022V13-01 SUPERIOR MESENTERIC ARTERY INJURY DURING ROBOTIC LEFT RADICAL NEPHRECTOMY: PREVENTION AND MANAGEMENT Aref S. Sayegh, Anibal La Riva, Laura C. Perez, Luis G. Medina, Edward Forsyth, Ryan Powers, Ben Challacombe, Michael Stifelman, Inderbir S. Gill, and Rene Sotelo Aref S. SayeghAref S. Sayegh More articles by this author , Anibal La RivaAnibal La Riva More articles by this author , Laura C. PerezLaura C. Perez More articles by this author , Luis G. MedinaLuis G. Medina More articles by this author , Edward ForsythEdward Forsyth More articles by this author , Ryan PowersRyan Powers More articles by this author , Ben ChallacombeBen Challacombe More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , and Rene SoteloRene Sotelo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Injury to the Superior Mesenteric Artery (SMA) during renal surgery is a rare but potentially devastating complication. It can rarely occur in patients with large left renal tumors and bulky lymphadenopathy, or in the setting of re-do surgery with significant retroperitoneal and intraabdominal scarring, which may distort the vascular anatomy. In most cases, the inadvertent injury occurs due to misidentification of the SMA as the renal artery. Failure to recognize and repair an SMA injury may result in ischemic bowel and/or mortality. Herein, we present three different scenarios of injury to the SMA when misidentified as the left renal artery during left robotic radical nephrectomy. We also describe how to avoid and manage SMA injury. METHODS: A compilation of three video clips were collected anonymously from different surgeons to demonstrate how the SMA was misidentified, injured, recognized intraoperatively, and repaired either in a transperitoneal or retroperitoneal robotic approach to left nephrectomy. RESULTS: Left robotic radical nephrectomy was started as usual. Descending colon was reflected medially, gonadal vein and ureter were used as landmarks to trace the left renal hilum. An artery arising from the aorta was apparently coursing towards the kidney and was assumed to be the left renal artery in all cases. In the first case, the SMA misidentification was timely recognized, and the injury was avoided. The second case demonstrates the SMA being clipped. Suspicious was raised after a dilated left renal vein was seen; therefore, clip removal was performed. Lastly, the third case involved a complete transection of the SMA, and it was repair intraoperatively because of awareness of severe consequences. Increases in operative time of patients experiencing an intraoperative complication are expected. Increases in length of hospital stay may occur depending on the type of complication, and sequelae can occur. CONCLUSIONS: Proper anatomic identification and recognition of the SMA may prevent its injury. Intra-operative SMA injury should be promptly identified and repaired to avoid its severe consequences. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1031 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aref S. Sayegh More articles by this author Anibal La Riva More articles by this author Laura C. Perez More articles by this author Luis G. Medina More articles by this author Edward Forsyth More articles by this author Ryan Powers More articles by this author Ben Challacombe More articles by this author Michael Stifelman More articles by this author Inderbir S. Gill More articles by this author Rene Sotelo More articles by this author Expand All Advertisement PDF DownloadLoading ...

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes.

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

479 Penetrating Chest Trauma Causing A Superior Mesenteric Artery-Inferior Vena Cava Fistula and Pancreatic Injury: A Case Report

Abstract Penetrating traumatic injuries can present a challenging scenario due to the potential for multisystem involvement requiring swift collaboration between surgical specialities. We present the case of a 66-year-old female who was stabbed in the right posterior chest. CT revealed a diaphragmatic injury, liver laceration involving segments 6/7 with active bleeding, and a posterior superior mesenteric artery (SMA) to anterior inferior vena cava (IVC) fistula. Due to the proximity of the SMA injury to a replaced right hepatic artery origin, the fistulous connection with the suprarenal IVC, and suspected pancreatic and duodenal injuries, a hybrid rather than a purely endovascular approach was taken. A large compliant occlusion balloon was placed percutaneously in the hepatic IVC. Subsequent trauma laparotomy and right medial visceral rotation identified SMA and SMV injuries, which were repaired with temporary supracoeliac aortic clamping. Further kocherisation of the duodenum revealed a 10 cm longitudinal IVC laceration causing sudden large volume venous haemorrhage. This was repaired after control was gained with supracoeliac aortic clamping, infrarenal IVC vessel loop and balloon inflation. An abdominal VAC dressing was applied. Before transfer to ICU, however, 1L of blood was noted in the VAC cannister and a relook laparotomy demonstrated more than 1L of intrabdominal fresh blood. Bleeding vessels around the uncinate process were ligated. After 48 hours, a relook laparotomy revealed no significant bleeding, and the abdomen was closed. A post-operative MRCP demonstrated pancreatic divisum and likely laceration of the aberrant ventral duct. A subsequent peripancreatic collection was managed conservatively.

A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy—6-year Follow-up

To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature. The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12-×15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump. At the 6-year follow-up, the patient had no intestine-related sequelae. Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

Blunt Abdominal Aorta, Celiac Artery, and Superior Mesenteric Artery Injuries Treated Endovascularly

Blunt Abdominal Aorta, Celiac Artery, and Superior Mesenteric Artery Injuries Treated Endovascularly

Superior mesenteric artery injury during laparoscopic radical nephrectomy

The authors present to your a en on a rare clinical case of complete intersec on of the superior mesenteric artery in laparoscopic radical nephrectomy. This complica on emerged in the process of learning the technique of laparoscopic radical nephrectomy, before reaching the “plateau” of the learning curve, in condi ons of poor vision and in the interposi on of tissues due to paratumorous infitiltra on. This type of injury has a high risk of total necrosis of the small intestine. However, due to the concerted ac ons of the surgical service and the readiness of surgeons to complete the vascular suture of the main vessels, a successful reimplanta on of the superior mesenteric artery into the aorta was performed. This is confi rmed by postopera ve observa on and examina on, which included CT angiography. It should be noted that descrip ons of cases of aor c reimplanta on of the superior mesenteric artery are extremely rare in the world and national literature, except for cases of mesenteric ischemia. This case contributes to the description of rare cases of aor c reimplanta on of the superior mesenteric artery and shows the correctness of the selected surgical tactics.

Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries.

Mesenteric vessels, including the superior mesenteric artery (SMA) and vein (SMV), provide and drain the rich blood supply of the midgut and hindgut. SMA and SMV injuries are rare and often lethal. Clinical management of these injuries is not well established, but treatment options include operative, non-operative, and endovascular strategies. A narrative review of the literature was conducted using MEDLINE Complete-EBSCO. Relevant studies, specifically those focusing on diagnosis and management of SMA and SMV injuries, were selected. Only original reports and collected series were selected to prevent duplication of cases. A search of the literature for mesenteric arterial injuries yielded 87 studies. Vessel-specific breakdown of the studies yielded 40 with SMA injuries and 41 with SMV injuries. These searches were winnowed to 26 individual studies, which were included in this collective review. Limitations of this study are similar to all narrative literature reviews: the dependence on previously published research and availability of references as outlined in our methodology. Although historically rare, mesenteric vessel injuries are seen with increasing incidence and continue to present a challenge to trauma surgeons due to their daunting mortality rates. Currently, universal treatment guidelines do not exist, but the various options for their management have been extensively reviewed in the literature.

SMA Balloon OcclusionとDamage Control Surgeryが奏効した外傷性SMA損傷の1救命例

SMA Balloon OcclusionとDamage Control Surgeryが奏効した外傷性SMA損傷の1救命例

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.

Damage control surgery after severe superior mesenteric artery injury

Objective To determine the effect of different surgical modalities on hemodynamics,systemic major organ injury and survival rate following superior mesenteric artery (SMA) injury in an attempt to search a modality that conforms to principles of damage control surgery (DCS).Methods SMA was exposed in 30 domestic hybrid pigs,leaving the blood flow blocked using non-invasive vessel forceps.The animals were divided into control group,primary anastomosis group (anastomosis group) and temporary intravascular shunt (TIVS) group according to random number table.TIVS group was further divided into three subgroups:shunting for 6 hours group (TIVS-6 h group),9 hours group (TIVS-9 h group) and 12 hours group (TIVS-12 h group).At each time point,the angiography was performed for evaluation of shunt patency; hemodynamic parameters were detected,terminal ileum and SMA samples were harvested for pathological analysis.Results All groups suffered extreme physiological conditions including hypothermia,severe acidosis,hypotension,low cardiac output and low oxygen supply.Less requirement of resuscitation fluid,faster restoration of SMA blood flow,earlier clearance of lactate,milder intestinal ischemia-reperfusion injury and higher survival rate were observed in TIVS-6 h and TIVS-9 h groups,compared with anastomosis group.Patency rate in TIVS-6 h,9 h and 12 h groups was 100％,50％ and 0％ respectively.Pathologic outcome of intestine revealed diffuse intestinal necrosis in TIVS-12 h group and reversible intestinal ischemia-reperfusion injury in TIVS-6 h and 9 h groups.Conclusion For SMA injury in severe hemodynamic disarrangement and jeopardized condition,TIVS shortens intestinal ischemia time,maintains systemic hemodynamic stability,relieves intestinal injury,improves early survival rate and keeps long-term intestine patency when compared with primary vascular anastomosis. Key words: Shock;  Mesenteric artery, superior;  Damage control surgery

Splenik artery to mesenteric artery bypass due to intraoperative injury

Iatrogenic injury of the superior mesenteric artery (SMA) during pancreatectomy is a serious vascular condition with increased morbidity and mortality rates. In this article, we report a 47-year-old female case with pancreatic head carcinoma who had SMA injury during pancreaticoduodenectomy. Splenectomy was performed on the patient and splenic artery was used for revascularization of SMA. The patient had no complications after discharge. The overall condition of the patient was good without postprandial abdominal pain at six months after discharge.

Prolonged Indwelling Time of Temporary Vascular Shunts Is Associated With Increased Endothelial Injury in the Porcine Mesenteric Artery

Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity. After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4). Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58). When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.

Abstract No. 367: Covered stent placement for superior mesenteric artery injuries in five patients

Abstract No. 367: Covered stent placement for superior mesenteric artery injuries in five patients

Time Course Study on the Use of Temporary Intravascular Shunts as a Damage Control Adjunct in a Superior Mesenteric Artery Injury Model

Temporary intravascular shunts (TIVS) are now widely used in vessels injuries. Little information concerned how long TIVS can safely maintain patency for in the setting of damage control surgery (DCS). We compared four different shunt-indwelling times in previous established superior mesenteric artery (SMA) injury models and aimed to find out the safest duration in the setting of DCS. SMA was clamped and completely transected while pigs were hemorrhaged. TIVS was inserted to the proximal and distal end of the transected SMA to restore blood flow. Twenty-four animals were resuscitated and randomized into four groups: group A (shunt for 3 hours), group B (shunt for 6 hours), group C (shunt for 9 hours), and group D (shunt for 12 hours). Angiography and duplex ultrasonography were periodically used to detect the patency of TIVS. Systemic hemodynamic parameters were recorded hourly, and intestine was collected at the end of the experiment. Shunts in groups A and B maintained patency in all the six animals (100%) compared with only 50% (3 of 6) in group C and 0% (0 of 6) in group D. Intestine necrosis developed in all shunt-occluded animals, whereas reversible intestine ischemia-reperfusion injuries were found if shunts remained patency at the end of the experiment. Our study suggests that TIVS can be used as an important DCS adjunct to maintain patency safely for 6 hours in SMA injury model.

Comparisons of Three Surgical Procedures on Intestine Ischemia Reperfusion Injury in a Superior Mesenteric Artery Injury Model

Temporary ligation, primary anastomosis, and temporary shunt have been reported to deal with superior mesenteric artery (SMA) injuries. We aimed to investigate which brought minimal ischemia reperfusion injury in a hypothermic traumatic shock swine model. SMA was completely clamped while pigs were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg. Animals were then randomized into temporary ligation (A, n=8), primary anastomosis (B, n=8), temporary shunt (C, n=8), and control groups (n=4). Animals in group A remained SMA interrupted for additional 1h while the other groups underwent the corresponding procedures immediately. Intestine injury was assessed by histologic examination and measurement of lipid peroxidations at the end of ischemia and experiment. Overall mortality rate was 50%, 25%, and 0% in groups A, B, and C, respectively (P<0.05). The total intestine ischemia time was predominantly shorter in group C in the other groups. Remarkable elevations of malonaldehyde (MDA) in small intestine were noted after reperfusion in group A. Animals in other groups, however, did not exacerbate during the 6-h reperfusion (resuscitation period). Group C showed the lowest MDA level at the end of experiment. Myeloperoxidase (MPO) levels showed no significant elevations during the ischemia or early reperfusion period; nevertheless, it reached approximately 3- to 6-fold in groups A and B (compared with baseline, P<0.01), and remained unchanged in group C at the end of experiment. Our study suggests that temporary shunt insertion might be preferred as it shortens ischemia time, alleviates intestinal ischemia/reperfusion injury, and thus decreases early mortality in this animal model.

Temporary intravascular shunting improves survival in a hypothermic traumatic shock swine model with superior mesenteric artery injuries

Repairs of superior mesenteric artery (SMA) injuries are difficult and often result in high mortality. Our group has employed temporary intravascular shunts (TIVS) as a damage control procedure in a SMA transection model and hypothesized that TIVS would improve survival when compared with primary vascular anastomosis in the setting of a damage control surgery. The SMA was clamped and completely transected while pigs were hemorrhaged to a mean arterial pressure of 40 mmHg and maintained in shock for 30 minutes. Cold lactated Ringer's solution was gradually infused while the abdomen was open to induce hypothermia. Animals were randomized to control (no resuscitation), primary anastomosis (PA), or temporary shunting (TS) of the SMA. Animals were resuscitated for 6 hours with the shed blood and lactated Ringer's solution. Delayed anastomosis was performed in TS animals after resuscitation. Surviving animals were humanely killed 2 days after operation. Systemic hemodynamic parameters were recorded hourly. The ileum was harvested at the end of resuscitation and experiment for pathologic evaluation. All animals suffered extreme physiologic conditions: hypothermia, severe acidosis, hypotension, and depressed cardiac output and oxygen delivery. Control animals suffered 100% mortality. Compared with the PA group, TS animals required less resuscitation fluid, retained higher SMA flow rates, normalized lactate levels faster, suffered less severe intestine histopathology, and had greater early survival. Damage control surgery in the setting of SMA transection seems better managed with TS than with PA. Further validation of this model is required before generalization to human applications.

Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study

Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving human patients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.

Temporary intravascular shunts as a damage control adjunct to maintain intestine perfusion after superior mesenteric artery injury in a swine model

Temporary intravascular shunts as a damage control adjunct to maintain intestine perfusion after superior mesenteric artery injury in a swine model