Superior Mesenteric Artery Occlusion Research Articles

Staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection: a series of 10 cases

Objective: To examine the efficacy and experience of staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection (TIAD). Methods: This study was a retrospective case series. The clinic data of 10 patients with acute TIAD who were admitted to the Department of Cardiac Surgery, Second Hospital of Lanzhou University or the First People's Hospital of Lanzhou, between January 2016 and August 2022, were retrospectively studied. Ten patients underwent hybrid surgeries in two hospitalizations (stages), including 7 males and 3 females with an age of (60±7) years (range: 49 to 71 years). In stage 1, the first type Ⅱ hybrid arch repair was performed to treat the ascending, total arch, and descending thoracic aorta for acute TIAD without circulatory arrest. In stage 2, the second hybrid surgery including infrarenal abdominal aorta replacement, visceral arteries bypass and endovascular thoracoabdominal aortic repair was performed to treat residual thoracoabdominal aortic dissection after the first hybrid operation (segmented). Basic data, preoperative concomitant diseases, high-risk factors, surgical approaches and postoperative complications of all important organs, as well as CT imaging were analyzed. Results: There was no death in the 20 hybrid surgical procedures. In stage 1 type Ⅱ hybrid surgery, 4 cases underwent reconstruction of the aortic sinutubular junction, while Bentall and David surgery was performed for 3 cases, respectively. A patient received coronary artery bypass grafting. Then all patients were sequentially treated with arch debranching and thoracic aortic endovascular repair. Postoperative complications included renal insufficiency (4/10), hemofiltration (1/10), hypoxemia (4/10), neurologic event (1/10) and type Ⅱ endoleak (1/10). Complete false lumen thrombosis occurred in 9/10 of the patients. All complications recovered successfully at discharge and the average hospital stay was (21±4) days (range: 16 to 28 days) in the first hospitalization. At stage 2, the second hybrid surgery was successfully performed in all patients. No paraplegia, hepatic or renal insufficiency, or endoleak occurred. However, branch graft embolism of the left renal artery was found in one patient 3 days after laparotomy, as well as of superior mesenteric artery in another. Superior mesenteric artery occlusion was successfully treated by endovascular recanalization. Complete false lumen thrombosis occurred in all patients. Although all patients had different degrees of intestinal dysfunction, they were gradually relieved at discharge, and the average hospital stay was (19±2)days (range:16 to 21 days) in the second hospitalization. During follow-up, CT angiography showed aortic remodeling in all patients. Conclusion: Staged and segmented two hybrid surgeries are safe and feasible for total repair of Debakey type Ⅰ aortic dissection and are associated with acceptable early and midterm outcomes.

Safety, Efficacy and Outcome of Rotational Thrombectomy assisted Endovascular Revascularisation of the Superior Mesenteric Artery in Acute Thromboembolic Mesenteric Ischaemia.

To evaluate the efficacy and safety of percutaneous rotational thrombectomy-assisted endovascular revascularization of acute thromboembolic superior mesenteric artery occlusions in acute mesenteric ischemia. Fifteen cases of percutaneous rotational thrombectomy- assisted (Rotarex S, BD, USA) revascularization were retrospectively analyzed. The etiology was embolic in 40 % of cases and thrombotic in 60 %. A "Thrombectomy in Visceral Ischemia" (TIVI) 5-point score determined vessel patency at presentation, after percutaneous rotational thrombectomy, and after adjunctive technologies. TIVI 3 indicated nearly complete revascularization (minimal residual side branch thrombus). TIVI 4 indicated complete revascularization. Technical success was defined as successful device application and a final TIVI score of 3/4 after adjunctive technologies. Safety and outcome were also analyzed. Device application via femoral access was feasible in 100 % of cases and improved flow in 86.7 % of cases (1 × TIVI 0→1, 11 × TIVI 0→2, 1 × TIVI 1→2). There was no change in 13.3 % of cases (2 × TIVI 2→2). Additional devices resulted in further flow improvement in 93.3 % of cases (8 × TIVI 3, 6 × TIVI 4). One recanalization failed (TIVI 2→2→2). After adjunctive technologies (10 × manual aspiration, 11 × angioplasty, 9 × stenting), the technical success rate was 93.3 %. The mean procedure time was 40.5(± 14) minutes for embolism and 72.1(± 20) minutes for thrombosis. There was one device-related major complication (catheter tip fracture) resulting in a device-related safety rate of 93.3 %. The overall major complication rate was 20 %. Surgical exploration (13 ×), bowel resection (9 ×) and Fogarty embolectomy/bypass (3 ×) were also performed. The 30-day mortality rate was 40 %. Percutaneous rotational thrombectomy is an effective adjunct for rapid endovascular recanalization of acute thromboembolic superior mesenteric artery occlusions with an acceptable rate of major procedural complications. · Percutaneous rotational thrombectomy-assisted superior mesenteric artery revascularization in acute occlusive mesenteric ischemia is feasible and effective.. · Percutaneous rotational thrombectomy facilitates rapid flow restoration in native and stented superior mesenteric artery segments.. · Brachial access should be considered in the case of steep take-off angles of the superior mesenteric artery..

Prostaglandin E-major urinary metabolites as a new biomarker for acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) is an emergent vascular disease caused by cessation of the blood supply to the small intestine. Despite advances in the diagnosis, intervention, and surgical procedures, AMI remains a life-threatening condition. Prostaglandin E2 major urinary metabolite (PGE-MUM), the urinary metabolite of prostaglandin E2, is known to be stable in urine and has been suggested to be a valuable biomarker for intestinal mucosal inflammation, such as ulcerative colitis. We therefore investigated whether or not PGE-MUM levels reflect the degree of ischemia in an intestinal ischemia-reperfusion model. Male rats were used to establish a superior mesenteric artery occlusion (SMAO) group, in which the superior mesenteric artery was clamped, and a sham group. The clamping times in the SMAO group were either 30 minutes or 60 minutes, and reperfusion times were either 3 hours or 6 hours, after which PGE-MUM values were measured. The histological injury score of the SMAO (30-minute ischemia and 6-hour reperfusion group, 1.8 ± 0.4; 60-minute ischemia and 6-hour reperfusion group, 4.7 ± 0.5) and were significantly greater than that of the sham group (0.4 ± 0.7, p < 0.05). The PGE-MUM levels in the SMAO group (30-minutes ischemia and 6-hour reperfusion group, 483 ± 256; 60-minutes ischemia and 6-hour reperfusion group, 889 ± 402 ng/mL) were significantly higher than in the sham group (30-minute and 6-hour observation group, 51 ± 20; 60-minute and 6-hour observation group, 73 ± 32 ng/mL; p < 0.05). Furthermore, the PGE-MUM value was corrected by the concentration of urinary creatinine (Cr). The PGE-MUM/urinary Cr levels in the SMAO group were also significantly higher than in the sham group ( p < 0.05). We found that intestinal ischemia-reperfusion increased urinary PGE-MUM levels depending on the ischemic time. This suggests the potential utility of PGE-MUM as a noninvasive marker of intestinal ischemia.

Oral post-treatment supplementation with a combination of glutamine, citrulline, and antioxidant vitamins additively mitigates jejunal damage, oxidative stress, and inflammation in rats with intestinal ischemia and reperfusion.

Intestinal ischemia and reperfusion (IIR) injury is closely associated with oxidative stress. Evidence shows that oral supplementation with glutamine and citrulline alleviates IIR-induced jejunal damage. We investigated the effects of a combination of glutamine, citrulline, and antioxidant vitamins on IIR-induced jejunal damage, oxidative stress, and inflammation. Male Wistar rats that underwent 60 min of superior mesenteric artery occlusion were orally administered glutamine plus citrulline (GC), vitamin C plus E (CE), or a combination of GC and CE 15 min before and 3, 9, and 21 h after reperfusion. Healthy rats without IIR were used as controls. After reperfusion for 24 h, rats with IIR showed lower levels of red blood cells, hemoglobin, serum glucose, and jejunal DNA and increased white blood cell counts compared to controls (1-way ANOVA with the least significant difference, P < 0.05). The IIR-induced decrease in serum albumin and increase in plasma interleukin-6 and jejunal thiobarbituric acid-reactive substances (TBARS) were significantly reversed by GC and/or CE. The results of the 2-way ANOVA indicated that GC was the main factor that increased jejunal villus height and muscularis DNA, and CE was the main factor that increased jejunal muscularis protein and decreased jejunal proinflammatory cytokine levels and myeloperoxidase activity. In addition, GC and CE are the main factors that decrease plasma proinflammatory cytokine levels and the jejunal apoptotic index. Oral post-treatment supplementation with glutamine and citrulline, combined with vitamins C and E, may alleviate IIR-induced oxidative stress, inflammation, and jejunal damage.

Polysaccharide Isolated from Agaricus blazei Murill Alleviates Intestinal Ischemia/Reperfusion Injury through Regulating Gut Microbiota and Mitigating Inflammation in Mice.

Intestinal ischemia-reperfusion (I/R) injury is a serious disease in medical settings, and gut dysbiosis is a major contributor to its development. Polysaccharides from Agaricus blazei Murill (ABM) showed a range of pharmacological activities, yet no studies assessed the potential of ABM polysaccharides for alleviating intestinal I/R injury. Here, we purified a major polysaccharide (ABP1) from an ABM fruit body and subsequently tested its potential to mitigate intestinal I/R injury in a mouse model of temporary superior mesenteric artery occlusion. The results reveal that ABP1 pretreatment enhances gut barrier function via upregulation of the expression of tight junction proteins such as ZO-1 and occludin. Additionally, ABP1 intervention reduces the recruitment of neutrophils and the polarization of M1 macrophages and limits inflammation by blocking the assembly of the NLRP3 inflammasome. Moreover, the role of ABP1 in regulating the gut microbiota was confirmed via antibiotic treatment. The omics data reveals that ABP1 reprograms gut microbiota compositions, characterized by a decrease of Proteobacteria and an increase of Lachnospiraceae and Lactobacillaceae, especially the SCFA-producing genera such as Ligilactobacillus and Blautia. Overall, this work highlights the therapeutic potential of ABP1 against intestinal I/R injury, which mainly exhibits its effects via regulating the gut microbiota and suppressing the overactivated inflammation response.

Reperfusion Injury—Post-Endovascular Recanalization in Chronic Mesenteric Ischemia: A Rare Clinical Case Scenario

AbstractRegardless of the number of vessels involved endovascular recanalization of mesenteric vessels is the treatment of choice for chronic mesenteric ischemia. Reperfusion injury post-endovascular recanalization in chronic mesenteric ischemia is a rare clinical scenario as it is mostly encountered in cases of acute mesenteric ischemia. Here in, we describe a case with characteristic clinical and imaging findings of reperfusion syndrome, post-endovascular recanalization of chronically occluded superior mesenteric artery and severely stenosed celiac trunk in a patient with chronic mesenteric ischemia.

Trends in population-based incidence, diagnostics, and mortality of acute superior mesenteric artery occlusion.

Acute occlusion of the superior mesenteric artery (SMA) results in lethal intestinal ischemia. Results from two previous population-based studies in Malmö, Sweden, suggest a decreasing incidence of acute SMA occlusion. This study aimed to evaluate trends in the epidemiology of acute SMA occlusion in Malmö. The report was a retrospective population-based study conducted from 2014 to 2019 on patients with acute SMA occlusion residing in Malmö municipality. Patient data were retrieved from Skåne University Hospital and postmortem examinations. Epidemiological data were compared to those of the two earlier studies, in particular to the one conducted from 2000 to 2006. Sixteen patients with acute SMA occlusion resided in Malmö municipality. The incidence of acute SMA occlusion significantly decreased from 5.4/100,000 person-years to 0.8/100,000 person-years. The ratio of acute SMA occlusion to non-occlusive mesenteric ischemia (NOMI) decreased from 12.5:1 to 0.9:1 (p < 0.0001), the proportion of inhabitants aged 80 years or above in the population decreased from 6.0% to 4.3% (p < 0.0001), and the autopsy rate decreased from 25% to 14% (p < 0.0001). The in-hospital mortality rate decreased from 63% to 44% (p = 0.14). The incidence of acute SMA occlusion seems to have decreased significantly in Malmö, probably due to high-resolution computed tomography angiographies being available around the clock to distinguish acute SMA occlusion from NOMI, a reduced proportion of elderly individuals, improved control of medical risk factors, and a decrease in autopsy rates.

The mechanism of intestinal stem cells differentiation after ischemia-reperfusion injury in a rat model.

Notch and Wnt/β-catenin signaling are responsible for regulation of intestinal stem cells (ISCs) proliferation and differentiation. The purpose of the study was to evaluate Wnt/β-catenin and Notch signaling roles in regulation of ISC differentiation following ischemia-reperfusion (IR) injury in a rat. Rats were assigned into two groups: Sham rats underwent laparotomy without vascular intervention and IR rats underwent occlusion of SMA and portal vein for 20min followed by 48h of reperfusion. Wnt/β-catenin and Notch-related gene expression were determined using Real-Time PCR. Enterocyte proliferation, differentiation and Wnt-related proteins were determined by immunohistochemistry. IR rats demonstrated a significant decrease in β-catenin gene expression, a decrease in cyclin D1 and β-catenin positive cells in jejunum and ileum compared to Sham rats. IR rats demonstrated a significant increase in Notch-related gene expression in jejunum and ileum compared to Sham rats. The number of secretory cells was higher mainly in the jejunum and number of absorptive cells was significantly lower in jejunum and lower in ileum in IR rats compared to Sham rats. Intestinal stem-cell differentiation is toward secretory cells 48h after IR injury; however, Wnt/β-catenin pathway inhibition and Notch-related gene expression stimulation suggest crosstalk between pathways.

Curcumin suppresses the Wnt/β-catenin signaling pathway by inhibiting NKD2 methylation to ameliorate intestinal ischemia/reperfusion injury.

Intestinal ischemia/reperfusion (I/R) injury is a life-threatening condition with no effective treatment currently available. Curcumin (CCM), a polyphenol compound in Curcuma Longa, reportedly has positive effects against intestinal I/R injury. However, the mechanism underlying the protective effect of CCM against intestinal I/R injury has not been fully clarified. To determine whether the protective effect of CCM was mediated by epigenetic effects on Wnt/β-catenin signaling, the effect of CCM was examined in vivo and in vitro. An intestinal I/R model was established in Sprague-Dawley (SD) rats with superior mesenteric artery occlusion, and Caco-2 cells were subjected to hypoxia/reoxygenation (H/R) for in vivo simulation of I/R. The results showed that CCM significantly reduced inflammatory, cell apoptosis, and oxidative stress induced by I/R insult in vivo and in vitro. Western blot analysis showed that CCM preconditioning reduced the protein levels of β-catenin, p-GSK3β, and cyclin-D1 and increased the protein level of GSK3β compared with the I/R group. Overexpressing β-catenin aggravated H/R injury, and knocking down β-catenin relieved H/R injury by improving intestinal permeability and reducing the cell apoptosis. Moreover, Naked cuticle homolog 2(NKD2) mRNA and protein levels were upregulated in the CCM-pretreated group. 5-aza-2'-deoxycytidine (5-AZA) treatment improved intestinal epithelial barrier impairment induced by H/R. Besides, the protein levels of total β-catenin, phosphor-β-catenin and cyclin-D1 were reduced after overexpressing NKD2 in Caco-2 cells following H/R insult. In conclusion, Our study suggests that CCM could attenuate intestinal I/R injury in vitro and in vivo by suppressing the Wnt/β-catenin signaling pathway via inhibition of NKD2 methylation.

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

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

Abstract 12186: A Challenging Case of Acute Superior Mesenteric Artery Embolism Diagnosed by Gastroscopy

Introduction: Acute superior mesenteric artery (SMA) occlusion is one of the most lethal causes of acute abdomen that we often experience but mistake for gastrointestinal diseases. The golden time for revascularization in cases of SMA main trunk occlusion is within 5 hours of onset, requiring prompt diagnosis and treatment. We describe a challenging case of acute SMA embolism diagnosed by gastroscopy. Case Summary: A 66-year-old man with a history of hypertension presented to the emergency department for marked epigastric pain after eating raw seafoods. On arrival, electrocardiogram showed atrial flutter with no significant ST-segment changes. Despite the elevation of white blood cell count and lactate dehydrogenase in blood exam, computed tomography (CT) indicated no findings to cause his symptoms. Emergency gastroscopy performed on suspicion of anisakiasis demonstrated pallor findings with hematologic material in the duodenum, suggesting intestinal ischemia (Figure A). Since contrast-enhanced CT revealed an occlusion of SMA (Figure B), we diagnosed acute SMA embolism based on the finding of atrial flutter without anticoagulation. After discussion among cardiologists and gastroenterology surgeons, we selected to perform endovascular treatment. The epigastric pain was improved after reperfusion using a self-expandable stent, but flared up as oral intake progressed. Follow-up CT suggested ischemic enteritis of the proximal jejunum, leading to conduct laparoscopic partial jejunectomy. He was discharged 18 days after the operation with the ability to eat a normal diet. Conclusions: This case highlights that we should keep in mind SMA embolism when examining acute abdomen patients with atrial fibrillation or flutter without anticoagulation.

A gastroduodenal artery aneurysm with superior mesenteric artery occlusion repaired by incomplete aneurysmectomy for mesenteric collateral vasculature protection

A gastroduodenal artery aneurysm with superior mesenteric artery occlusion repaired by incomplete aneurysmectomy for mesenteric collateral vasculature protection

How to improve the description of superior mesenteric artery occlusions in acute mesenteric ischemia: A new computed tomography anatomic segmentation

How to improve the description of superior mesenteric artery occlusions in acute mesenteric ischemia: A new computed tomography anatomic segmentation

445 Endovascular treatment of acute mesenteric ischemia: An option to consider in patients unfit for major surgery

Abstract Introduction The number of embolectomies for superior mesenteric arterial occlusion has increased over the years. Endovascular embolectomies in acute mesenteric ischemia continue to be performed only in a smaller proportion of cases despite multiple studies reporting promising results. Case description An 85-year-old lady presented to the emergency surgical unit with an acute onset of severe abdominal pain and vomiting. She has a background of atrial fibrillation and hypertension and has been a chronic smoker for the past 50 years. One month before her presentation, she stopped taking her anticoagulation due to intermittent per-rectal bleeding attributed to diverticular disease. Initial CT demonstrated an SMA embolus extending from the first bifurcation approximately 4.5cm distally. In addition, there were features of bowel ischaemia with abnormal thickening of the small bowel loops in that vascular territory. She was deemed too frail for a laparotomy by the surgical and anaesthetic team, and the patient preferred to explore a non-operative approach. Despite treatment dose anticoagulation, her clinical condition deteriorated, with a rise in inflammatory markers, intolerance of food, and worsening abdominal pain. Unfortunately, thrombolysis was not an option because of the large size of the embolus and PR bleeding. She underwent an endovascular vacuum-assisted thrombectomy. The procedure achieved near-complete revascularisation, and the patient sustained a good recovery and was discharged on day 8 of admission. Discussion Available literature has shown promising results with endovascular treatment of acute mesenteric ischemia. The successful revascularisation, in this case, confirms that endovascular techniques are a viable option to consider in acute mesenteric ischemia.

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification

ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique): A New Technical Option for Recanalization of Complete Superior Mesenteric Artery Occlusion in Chronic Mesenteric Ischemia.

To report our experience with a new technique for recanalization of the superior mesenteric artery (SMA)/celiac trunk (CT) with complete occlusion at the origin. We describe our ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique) for recanalization of the CT and SMA in cases of complete occlusion of these arteries with a short or inexistent stump, which usually corresponds to chronic lesions with important calcification of the ostium. The ABS-SMART is an alternative for the recanalization of visceral arteries in cases where other conventional techniques have failed. It is particularly useful in scenarios characterized by a short occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin. Catheterization and recanalization of visceral stenoses may pose a challenge in some cases, as for example in the presence of a very narrow angle between the root or origin of the vessel and the aorta, as well as in the case of long and calcified stenoses, or when arteriography is unable to visualize the origin of the vessel. The present study describes our experience with the endovascular revascularization of visceral vessels using an aortic balloon-supported recanalization technique not previously described in the literature, that may be an effective alternative for the treatment of lesions of difficult access, such as total occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin of the SMA and CT, by improving the chances for technical success.

Extracellular RNAs/TLR3 signaling contributes to acute intestinal injury induced by intestinal ischemia reperfusion in mice

Toll-like receptor 3 (TLR3), one pattern recognition receptor activated by viral and endogenous RNA, has been recently reported to regulate ischemia/reperfusion (I/R) injury in various organs. However, the role of TLR3 in the development of intestinal I/R injury remains unclear. The aim of this study is to evaluate the effects of extracellular RNAs/TLR3 signaling in intestinal I/R injury. An intestinal I/R injury model was established with superior mesenteric artery occlusion both in wild-type and TLR3 knockout (KO, −/−) mice, and MODE-K cells were subjected to hypoxia/reoxygenation (H/R) to mimic the I/R model in vivo. Extracellular RNAs (exRNAs), especially double-stranded RNAs (dsRNAs) co-localized with TLR3, were significantly increased both in vitro and in vivo. Compared with wild-type mice, TLR3 knockout obviously attenuated intestinal I/R injury. Both TLR3/dsRNA complex inhibitor and TLR3 siRNA administration reduced TLR3 expressions and subsequently inhibited intestinal inflammatory cytokine production and apoptosis. In conclusion, exRNAs/TLR3 signaling is a key mechanism that regulates intestinal I/R injury in adult mice, and the TLR3/dsRNA complex inhibitor can be an effective approach for attenuating intestinal I/R-induced inflammatory response and apoptosis.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion.

Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion. We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN. The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor. III.

Trapdoor Endarterectomy for Coral Reef Plaque of the Paravisceral Aorta in the Modern Era

Coral reef atherosclerosis (CRA) of the paravisceral aorta is a rare disease whose description is largely confined prior to contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with CRA treated with trapdoor endarterectomy (TEA) at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients were identified who underwent TEA for symptomatic CRA. Data on patient demographics, operative details, hospital course, and outpatient follow-up were obtained via retrospective chart review. Patients were predominantly female (71%) with a median age of 65 years (interquartile range [IQR], 63-70) and had traditional vascular risk factors. Over 85% had previously diagnosed carotid stenosis; two patients (14%) had prior aortofemoral reconstruction, and one (7%) had prior axillobifemoral bypass. The most common presenting symptoms were claudication (64%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Eight patients (57%) received isolated TEA and six (43%) received concomitant aortobifemoral bypass (Table I). Thirteen patients (93%) required a supraceliac aortic clamp position with a median clamp time of 26 minutes (IQR, 20-30 minutes). Median estimated blood loss was 1650 mL (IQR, 1025-3750 mL). Cell saver was used in 13 procedures (93%) with median transfusion of 563 mL (IQR, 231-900 mL). Median operative time was 341 minutes (IQR, 315-316 minutes). Eight patients (57%) had acute kidney injury in the postoperative period with peak creatinine of 2.02 (IQR, 1.58-2.95) (Table II). Length of stay was 13 days (IQR, 7-16 days) with an intensive care unit stay of 4 days (IQR, 2-7 days). Two patients (14%) required reoperations in the immediate perioperative period, one for retroperitoneal hematoma and one for target vessel (superior mesenteric artery) occlusion. Postoperative ankle-brachial indices were increased from a median of 0.52 bilaterally in the preoperative period to >1 postoperatively. Eight patients (57%) had follow-up over 2 years after TEA, with five patients (36%) having follow-up over 3 years. Three major adverse cardiac events were reported at last follow-up. Just one patient reported persistent symptoms of chronic mesenteric ischemia at 11 years after TEA. Symptomatic CRA of the paravisceral aorta is a complex disease rarely encountered even at a high-volume quaternary referral center. These patients can be expected to experience short-term postoperative complications and require intensive care. Despite these challenges, trapdoor transaortic endarterectomy is a safe, effective procedure for CRA and most patients achieve dramatic symptomatic improvement with durable results.Table IGeneral operative characteristics (n = 14)VariablesMedian [IQR] or No. (%)Procedure types Trapdoor endarterectomy8 (57) Trapdoor endarterectomy with aortobifemoral bypass6 (43)Starting clamp position Supraceliac13 (93) Supramesenteric1 (7)Subsequent clamp position Infrarenal10 (71) None4 (29)Aortic closure Primary closure12 (86) Bovine patch angioplasty1 (7) Dacron patch angioplasty1 (7)Revascularized vessels Celiac3 (21)Eversion endarterectomy3 (100) Superior mesenteric artery5 (36)Eversion endarterectomy4 (80)Catheter embolectomy1 (20) Left renal5 (36)Eversion endarterectomy4 (80)Bypass graft1 (20) Right renal3 (21)Eversion endarterectomy3 (100) Bilateral renals3 (21)Eversion endarterectomy3 (100) IMA1 (7)Eversion endarterectomy1 (100)Cold renal perfusion8 (57)Estimated blood loss, mL1650 [1025-3750]Intraoperative transfusion, units2 [1-4]Cell saver13 (93) Volume transfused, mL563 [231-900]Suprarenal clamp time, minutes (n = 13)26 [20-30]Operative time, minutes341 [315-416]IQR, Interquartile range. Open table in a new tab Table IIPostoperative course, (n = 14)VariableMedian [IQR] or No. (%)Inpatient complications Anemia14 (100) Acute kidney injury8 (57)Creatinine (peak)2.02 [1.58-2.95]Dialysis1 (7) Cardiopulmonary complications5 (36) Reoperation2 (14)Retroperitoneal hematoma1 (7)Secondary intervention1 (7) Ileus2 (14) Colitis2 (14) Deep vein thrombosis1 (7) Myocardial infarction1 (7) Infection1 (7) Death1 (7)Intensive care unit admission14 (100) Length of stay, days4 [2-7]Total length of stay, days13 [7-16]Laboratory tests Blood urea nitrogen (preoperative)14 [10-16] Creatinine (preoperative)1.01 [0.91-1.31] Creatinine (discharge)1.06 [0.70-1.35]Hemodynamics Right ABI (preoperative), n = 100.52 [0.34-0.90] Left ABI (preoperative), n = 100.52 [0.38-0.81] Right ABI (postoperative op), n = 91.12 [1.06-1.16] Left ABI (postoperative), n = 91.10 [1.09-1.15]Readmission within 30 days3 (21)Duration of follow-up, years2 [0.5-3.0]Outpatient complications, time postoperative3 (21) Ureteral stricture, 2 months1 (7) Loss of primary patency, 18 months1 (7) New chronic mesenteric ischemia, 8 years1 (7)Amputation0 (0)Persistent symptomatology at last follow-up (n = 13)1 (7) Claudication or rest pain0 (0) Mesenteric angina1 (7)Major adverse cardiac events at last follow-up3 (21) Death2 (14) Myocardial infarction1 (7)IQR, Interquartile range. 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Acute mesenterial ischaemia: a contemporary view

During the COVID-19 pandemic, the incidence of acute mesenteric ischemia (AMI) increased to 10.9 per 100 000 population. Here we discuss causes, symptoms, current diagnosis and treatment of AMI.Frequently, such patients suffer from stenosis or occlusion of superior mesenteric artery accompanied by coronary artery disease, chronic heart failure, or chronic brain ischaemia. The main clinical symptom is constant abdominal pain which is sharp in case of mesenteric artery thrombosis or dull if thrombosis is restricted to the branch of superior or inferior mesenteric veins. Conventionally, the diagnosis of AMI is verified by multislice computed tomography angiography and contrast-enhanced multislice computed tomography. Timely diagnosis with emergency surgery reduces mortality from 90% to 30-50%. The best treatment outcomes are observed after early revascularizations and minimally invasive endovascular interventions.