Superior Mesenteric Artery Stenosis Research Articles

A clinical approach to acute mesenteric ischemia.

To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management. A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved. Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI.

Natural history of the asymptomatic stenoses of the superior mesenteric artery

The preventive treatment of the severe stenoses of the superior mesenteric artery (SMA) is debated. According to the Mikkelson’s rule, described in 1957 and relying on the study of four cases, at least two digestive arteries must be occluded to develop intestinal symptoms. The aim of this study was to compare the incidence of acute (AMI) and chronic (CMI) mesenteric ischemia in patients presenting an isolated >70% SMA stenosis compared to those presenting a SMA stenosis associated with a >70% stenosis of the lower mesenteric artery (IMA) and/or the coeliac trunk (CT).

The impact of endovascular treatment on clinical outcomes of stable symptomatic patients with spontaneous superior mesenteric artery dissection

ObjectiveTo evaluate the efficacy and clinical outcomes of endovascular treatment for superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with medical management alone after successful initial medical management. MethodsIn this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs, a composite of dissection-related death, the recurrence of mesenteric ischemia symptoms, and a requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA. ResultsA total of 94 patients with SMAD who underwent successful initial medical management (91 males; mean age, 50.4 ± 6.3 years) were enrolled in the study. Fifty-seven (60.6%) received medical management alone, and 37 (39.4%) underwent endovascular repair after initial medical management. In the endovascular group, the technical success rate was 86.5% (32 of 37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain, and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1, 3, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log rank P = .046). ConclusionsEndovascular treatment and medical management alone result in similar MAE-free survival for patients with SMAD after successful initial medical management. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.

Risk factors of geriatrics index of comorbidity and MDCT findings for predicting mortality in patients with acute mesenteric ischemia due to superior mesenteric artery thromboembolism.

To identify risk factors of geriatrics index of comorbidity (GIC) and multidetector CT (MDCT) findings for predicting mortality in patients with acute mesenteric ischemia (AMI) due to superior mesenteric artery (SMA) thromboembolism. 33 patients with AMI due to SMA thromboembolism underwent abdominal MDCT and angiography. Patients' comorbidities and MDCT findings of ischemic bowel/mesenteric injuries, regions of SMA involved by thromboembolism, and degrees of SMA stenosis were retrospectively reviewed. The comorbidities were classified into 1-4 levels according to GIC. The association of MDCT signs and GIC classification with mortality were analyzed. Diagnostic performances of risk factors associated with mortality were evaluated by receiver operating characteristic (ROC) curve analyses. Eighteen patients (54.5%) died during hospitalization or follow-up, including one patient with class 1, two patients with class 2, eight patients with class 3, and seven patients with class 4 according to GIC. Three risk factors significantly associated with mortality were identified, including pneumatosis and/or portomesenteric venous gas (PPMVG) (p = 0.017), four regions of SMA involved by thromboembolism (region I + II + III + IV) (p = 0.036), and class 3 + 4 of comorbidities (p = 0.001). The sensitivity and specificity of PPMVG, region I + II + III + IV, class 3 + 4 of comorbidities, and the three risk factors combined for diagnosing mortality were 33.3 and 100%, 27.8 and 100%, 83.3 and 73.3%, and 88.9 and 73.3%, respectively. The areas under the ROC curve (AUC) of the three risk factors combined (0.88) and class 3 + 4 of comorbidities (0.78) were larger than that of PPMVG (0.67) and region I + II + III + IV (0.64). The mortality rate rose from 15.4% in patients without risk factor to 66.7%, 100%, and 100% in patients with one, two, and three factors, respectively. Three risk factors for mortality were identified in patients with AMI due to SMA thromboembolism, including PPMVG and four regions of SMA involved by thromboembolism on MDCT images, and class 3 + 4 of comorbidities. Close monitoring of these risk factors could possibly lower the mortality. Risk factors based on GIC and MDCT findings may be used to predict mortality in patients with AMI. Close monitoring of these risk factors could possibly lower the mortality.

Effects of preoperative visceral artery stenosis on target artery outcomes after fenestrated/branched endovascular aortic aneurysm repair

ObjectiveTarget artery stenosis might affect the outcomes of fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The aim of the present study was to assess the effects of preoperative stenosis of the celiac artery (CA) and superior mesenteric artery (SMA) on the target artery outcomes after F-BEVAR. MethodsDuring a 4-year period, 287 consecutive patients, 204 men (71%) and 83 women (29%), had undergone F-BEVAR using fenestrated (83%), fenestrated-branched (4.5%), branched (3.5%), and off-the-shelf t-Branch (9%) devices (Cook Medical Inc, Bloomington, Ind). Preoperative SMA and CA significant stenosis was defined as a computed tomography angiography-based intraluminal diameter reduction >50%. The primary endpoints included primary patency, freedom from target vessel instability, and patient survival. ResultsThe median patient age was 71 years (interquartile range, 67-77 years). Suprarenal (36%), juxtarenal (25%), and thoracoabdominal (39%) aortic aneurysms were treated. The technical success rate was 99%. The 30-day survival was 97%. Among 981 stented vessels, 179 (18%) were CAs and 270 (27.5%) were SMAs. Significant preoperative CA stenosis was identified in 39 patients (22%) and SMA stenosis in 24 (9%). The median follow-up was 29.9 months. The primary patency rates at 12, 36, and 60 months were 98%, 92%, and 92% for the CA and 99%, 98%, and 98% for the SMA, respectively. Primary patency was significantly lower in the patients with previous significant CA stenosis than in those without stenosis (83%, 83%, and 76% vs 100%, 100%, and 97% at 12, 36, and 60 months, respectively; P < .01). Freedom from celiac branch instability was also significantly lower among patients with significant stenosis (84%, 84%, and 76% vs 100%, 93%, and 93% at 12, 36, and 60 months; P < .01). The presence of significant SMA stenosis did not affect either primary patency or freedom from target vessel instability. The survival rates at 12, 36, and 60 months were significantly lower for the patients with CA stenosis than for those without stenosis (67%, 61%, and 55% vs 90%, 84%, and 82%, respectively; P < .01). Similarly, lower survival rates were observed for patients with significant SMA stenosis (70%, 60%, and 60% vs 87%, 79%, and 78% at 12, 36, and 60 months, respectively; P = .04). ConclusionsF-BEVAR was associated with overall primary patency rates >90% for the CA and SMA. Preoperative CA stenosis was associated with lower primary patency and freedom from target vessel instability. In contrast, neither SMA branch primary patency nor freedom from target vessel instability were affected by preoperative SMA stenosis. We found visceral artery stenosis was a marker of atherosclerosis burden associated with reduced mid- and long-term patient survival.

Reconstruction of superior mesenteric artery by prostheses placement in a case of chronic mesenteric ischemia: A case report and literature review.

Although superior mesenteric artery stenosis is a relatively common situation, it is rarely symptomatic due to the fact that in a significant number of cases an adequate collateral circulation exists. The aim of this study is to report a case in which arterial reconstruction was needed due to the absence of such a patent collateral circulation. The 47-year-old patient was investigated for chronic postprandial pain and was diagnosed with superior mesenteric artery stenosis. Percutaneous treatment was the initial option of choice but the patient rapidly became symptomatic again. Therefore surgery was performed, the segment of arterial stenosis was resected and the arterial continuity was re-established by using a synthetic prosthesis. The postoperative outcome was uneventful, the patient was discharged in the seventh postoperative day under anticoagulant therapy. In conclusion, superior mesenteric artery reconstruction by using a synthetic prosthesis can be useful in cases presenting chronic mesenteric ischemia and failure of percutaneous treatment.

The Incidence of Chronic Mesenteric Ischemia in the Well-Defined Region of a Dutch Mesenteric Ischemia Expert Center.

INTRODUCTION:This study aimed to determine the incidence of chronic mesenteric ischemia (CMI) and to examine the influence of the etiological cause, location, and severity of a mesenteric artery stenosis on the probability of having CMI.METHODS:A prospective database, containing the details of all patients with suspected CMI referred to a renowned CMI expert center, was used. Patients residing within the expert centers' well-defined region, between January 2014 and October 2019, were included. CMI was diagnosed when patients experienced sustained symptom improvement after treatment.RESULTS:This study included 358 patients, 75 had a ≥50% atherosclerotic stenosis of 1 vessel (CMI 16%), 96 of 2 or 3 vessels (CMI 81%), 81 celiac artery compression (CMI 25%), and 84 no stenosis (CMI 12%). In total, 138 patients were diagnosed with CMI, rendering a mean incidence of 9.2 (95% confidence interval [CI] 6.2–13.7) per 100,000 inhabitants. Atherosclerotic CMI was most common, with a mean incidence of 7.2 (95% CI 4.6–11.3), followed by median arcuate ligament syndrome 1.3 (95% CI 0.5–3.6) and chronic nonocclusive mesenteric ischemia 0.6 (95% CI 0.2–2.6). The incidence of CMI was highest in female patients (female patients 12.0 [95% CI 7.3–19.6] vs male patients 6.5 [95% CI 3.4–12.5]) and increased with age. CMI was more prevalent in the presence of a ≥70% atherosclerotic single-vessel stenosis of the superior mesenteric artery (40.6%) than the celiac artery (5.6%).DISCUSSION:The incidence of CMI is higher than previously believed and increases with age. Probability of CMI seems highest in suspected CMI patients with multivessel disease or a ≥70% atherosclerotic single-vessel superior mesenteric artery stenosis.

The Impact of Endovascular Treatment on Clinical Outcomes of Spontaneous Superior Mesenteric Artery Dissection After Successful Initial Conservative Therapy

The objective was to evaluate the efficacy and clinical outcomes of endovascular treatment of superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with conservative treatment alone after successful initial conservative treatment. In this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs; a composite of dissection-related death, recurrence of mesenteric ischemia symptoms, and requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA. A total of 94 SMAD patients who underwent successful initial conservative treatment (91 male; mean age, 50.4 ± 6.3 years) were enrolled in the study; 57 (60.6%) received conservative treatment alone, and 37 (39.4%) underwent endovascular repair after initial conservative treatment. In the endovascular group, the technical success rate was 86.5% (32/37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1 year, 3 years, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log-rank, P = .046). Endovascular treatment and conservative treatment alone result in similar MAE-free survival for SMAD patients after successful initial conservative therapy. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.Fig 2Kaplan-Meier curve of patients with spontaneous superior mesenteric artery (SMA) dissections (SMADs). A, Cumulative freedom from major adverse events (MAEs); B, freedom from MAEs stratified by group; C, freedom from SMA stenosis or occlusion stratified by group; D, freedom from SMAD rupture or aneurysm stratified by group. The blue line indicates the conservative group; the green line, endovascular group.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endovascular Pressure Measurements to Assess the Functional Severity of Mesenteric Arterial Stenoses.

To assess the ability of pressure measurements to discriminate clinically significant celiac artery (CA) or superior mesenteric artery (SMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). Single-center, retrospective cohort study of 41 intra-arterial pressure measurements during mesenteric angiography with intended revascularization, performed in 37 patients (mean age 67.7 ± 10.8 years, 62% female) between April 2015 and May 2017. Simultaneous prestenotic and poststenotic pressure measurements had been obtained before and after intra-arterial administration of nitroglycerin. Revascularization was performed in 38 of 41 procedures. Definitive diagnosis of CMI was defined as patient-reported symptom relief or improvement after successful revascularization. Pressure gradients obtained after vasodilator administration were significantly higher in CAs and SMAs with ≥50% stenosis. Pressure ratios (pressure distal [Pd]/pressure aorta [Pa]) obtained after vasodilator administration were significantly higher in CAs with ≥50% stenosis. Subgroup analysis of 22 patients with a ≥50% stenosis of either CA or SMA showed significantly higher pressure gradients and Pd/Pa ratios after vasodilator administration in CMI patients (median pressure gradient: CMI [interquartile ratio] 36 [21-40] mm Hg versus no-CMI 20 [9-21] mm Hg, P= 0.041; Pd/Pa: CMI 0.703 [0.598-0.769] versus no-CMI 0.827 [0.818-0.906], P= .009). A ≤0.8 Pd/Pa cutoff value after administration of a vasodilator best identified a clinically relevant stenosis, with 86% sensitivity and 83% specificity. Complications related to the pressure measurements were not observed. Intra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis.

Endovascular surgery for acute mesenteric ischemia

To demonstrate the results of endovascular treatment of 15 patients with acute mesenteric ischemia. There were 15 patients with acute mesenteric ischemia who underwent surgery (9 men and 6 women). Mean age was 77±11 years. Acute intestinal ischemia was caused by thromboembolism of superior mesenteric artery (9 patients), thrombosis of superior mesenteric artery (5 patients) and critical stenosis of the ostia of superior mesenteric artery and celiac trunk (1 patient). Mean time from clinical manifestation of disease to admission to the hospital was 13 hours (range 2-72 hours). In-hospital development of acute mesenteric ischemia was noted in 2 patients. Indications for endovascular intervention and techniques of endovascular revascularization of superior mesenteric artery are described in the article. Blood flow restoration in superior mesenteric artery was achieved in 14 (93%) out of 15 patients. Laparotomy was required in 4 (27%) patients for extensive resection of necrotic intestine (n=1, 6.7%), local resection of small bowel (n=2, 13%). In another (6.7%) patient, intestine was recognized as viable after laparotomy. A bulk of intestine was preserved in most patients (n=14, 93%). In-hospital mortality rate was 47% (7 patients died). The main cause of nosocomial death (6 cases) was reperfusion syndrome followed by respiratory distress syndrome and multiple organ failure. New methods of prevention and treatment of reperfusion syndrome can improve the results of treatment of acute mesenteric ischemia.

Can Moyamoya Disease Susceptibility Gene Affect Extracranial Systemic Artery Stenosis?

Diseases associated with the RNF213 gene include moyamoya disease, with the p.R4810K (c.14429G>A, rs112735431) homozygous variant thought to be the most pathogenic and significantly associated with severe manifestation such as early onset or cerebral infarction at onset. We report a case of a unique Japanese pedigree associated with RNF213. A 53-year-old woman with no arteriosclerotic risk factors experienced coronary artery disease, followed by coronary artery bypass surgery. In 8 years, she suffered sudden abdominal pain. Her abdominal contrast computed tomography revealed stenosis of abdominal artery and superior mesenteric artery. Though her 2 children and uncle had a typical moyamoya disease with RNF213 p.R4810K heterozygous variant, she has had no clinical and radiological evidence of moyamoya disease. Due to a family history of moyamoya disease, a genetic investigation was performed and revealed RNF213 p.R4810K homozygous variant. A possible role of RNF213 influencing systemic artery stenosis can be further be understood from this rare case harboring the homozygous variant carrier.

1450 Acute Ischemic Pancreatitis Secondary to Superior Mesenteric Artery Stenosis: A Common Diagnosis Due to an Uncommon Etiology

INTRODUCTION: Pancreatic ischemia is a rare cause for acute pancreatitis which is poorly defined without specific radiological appearance. CASE DESCRIPTION/METHODS: We present a case of 57-year-female with 2-week history of abdominal pain. Her history included CHF, carotid stenosis, hypertension, COPD, and invasive Aspergillosis. She underwent cardiac catheterization 6 years ago which showed heavy atherosclerosis without obstruction. Her post procedure course was complicated by cholesterol embolization to left lower extremity. She was a heavy smoker with 1-2 PPD smoking but denied alcohol use. She was diagnosed with invasive Aspergillosis 2 months ago and initially treated with Voriconazole. It was switched to isavuconazole 1 month ago after developing blurring of vision. Patient reported decreased appetite since then with poor oral intake. She presented with 2 week h/o severe abdominal pain, associated with intense nausea and multiple episodes of vomiting. Her initial work up showed leukocytosis and elevated lipase &gt;4000. CT abdomen showed diffuse, homogenous pancreatic enlargement with prominent aortic atherosclerosis and distal aortic aneurysm measuring 3.1 cm. Initially, the antifungal agent, isavuconazole was thought to be the culprit, causing pancreatitis but literature review was negative. IGg4 levels and lipid profile were unrevealing. Pancreatic ischemia was considered as the likely etiology. An abdominal duplex showed superior mesenteric artery stenosis. However, given h/o cholesterol embolization following cardiac catheterization, she was considered high risk for endo-vascular procedure. High intensity statin therapy was prescribed and she was discharged home with close outpatient follow up. Patient was strongly encouraged to quit smoking, as this would likely decrease her risk of major adverse cardiac event. DISCUSSION: Three well-identified causes of acute ischemic pancreatitis include hemorrhage, hypotension, &amp; mesenteric vessel occlusion. Pancreatic ischemia leads to appearance of oxygen-derived free radicals which cause endothelial dysfunction, resulting in increased permeability and localized inflammatory response. Our patient had heavy calcified atherosclerosis. She was an active smoker. Dehydration also played a role in the development of ischemic pancreatitis, as the patient endorsed poor oral intake, confounded by nausea, vomiting and diarrhea. Treatment of acute ischemic pancreatitis consists of supportive care with IV fluids and pain control and restoration of pancreatic perfusion.

Endovascular treatment of chronic mesenteric ischemia

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

Results from a prospective multicenter feasibility study of Zenith p-Branch stent graft

ObjectiveTo evaluate the Cook Zenith p-Branch stent graft (William A. Cook Australia, Brisbane, Queensland, Australia) for the treatment of patients with asymptomatic juxtarenal or pararenal abdominal aortic aneurysms in a prospective, nonrandomized, multicenter, feasibility study conducted in the United States. MethodsThe off-the-shelf p-Branch endograft incorporates a celiac scallop, superior mesenteric artery (SMA) fenestration, and two conical-shaped pivot renal fenestrations. Patients were eligible if the aneurysm did not extend above the distal margin of the SMA and the anatomy of renal and visceral arteries were compatible with one of the two p-Branch configurations (configuration A, renal fenestrations at the same longitudinal position; configuration B, offset renal fenestration). ResultsA total of 30 patients (93% men; mean age, 73 years; mean aneurysm diameter, 64.7 ± 11.4 mm) were enrolled from January 2013 to June 2015. The mean follow-up period was 28.7 ± 12.5 months (as of October 2017). The technical success rate was 93% (28/30), with technical failure occurring in the first two study cases (device deliberately repositioned below the renal arteries because of difficulty in cannulating the renal arteries in one and an inability to place a renal stent in the other; both patients survived the procedure and withdrew from the study before the 12-month follow-up visit). No additional technical failures occurred after these first two cases, when an updated physician training and proctoring program was implemented. No 30-day mortality occurred. Of the remaining 28 patients, three died during the follow-up period; none within 30 days and none related to the device or procedure as determined by Clinical Events Committee adjudication. No treated aneurysm ruptures, conversion, or core laboratory-reported migration, or stent fracture were reported. The primary renal artery patency (interval to occlusion or reintervention for stenosis) rate was 88.6% ± 4.4% at 1 and 2 years. Two patients (7%) developed renal insufficiency secondary to a right renal artery stenosis in one patient and progression of chronic renal insufficiency in one patient. No patient required dialysis or developed mesenteric ischemia. Of the 28 patients, nine (32%) had undergone 13 secondary interventions for renal artery occlusion (n = 2), SMA occlusion (n = 1), renal or SMA stenosis (5 interventions in 4 patients), renal stent kinking (n = 1), lower extremity claudication (n = 2 in the same patient), type III endoleak between the p-Branch and renal stent (n = 1), and type II endoleak (n = 1). ConclusionsThese early and intermediate results, which incorporated physician learning curves, support the safety and feasibility of the off-the-shelf Zenith p-Branch device. Follow-up examinations through 5 years will continue to assess the long-term results.

Neoaortoiliac system buttressed with tensor fascia lata for treatment of juxtarenal mycotic aortic aneurysm

A 50-year-old man presented with abdominal pain and high-grade fever for 3 months and was diagnosed to have juxtarenal saccular abdominal aortic aneurysm and superior mesenteric artery stenosis on imaging (A). He was diabetic and a chronic smoker. Blood and urine culture specimens had grown group D Salmonella. Open repair of the mycotic aneurysm was done with a neoaortoiliac system using bilateral superficial femoral veins and autologous tensor fascia lata to reinforce the proximal anastomotic line (B and C). The patient was also prescribed long-term antibiotic therapy. The postoperative period was uneventful except for mild lymphorrhea from bilateral thigh wounds that subsided by 1 week. He was discharged on postoperative day 11 with normal pedal pulses and preserved renal function. On 3-month follow-up, the patient is doing well and is asymptomatic. Follow-up computed tomography showed intact anastomoses with good flow through the vein graft (D/Cover). The patient gave informed consent for publication of images and details of the case. Femoropopliteal vein conduit to reconstruct the aortoiliac vasculature has excellent long-term durability and is resistant to infection, which makes it a useful treatment option in cases of mycotic aneurysm.1Bernatchez J. Gauvin V. Gilbert N. Rhéaume P. Long-term results of the neoaortoiliac system procedure for aortic graft infections and mycotic aneurysms: a single-center experience.J Vasc Surg. 2016; 64: 1544Abstract Full Text Full Text PDF Google Scholar Autologous tensor fascia lata was used to buttress the proximal anastomotic line as the posterior aortic wall at the anastomosis was diseased; it will also minimize the risk of infection compared with synthetic felt pledget. Salmonella is associated with persistent and extended infection, and the virulence of the organism involved is to be considered in planning endovascular aneurysm repair. Endovascular management with fenestrated endovascular aneurysm repair should be considered only in select critically ill patients with complex mycotic aneurysms in whom surgical management is too risky, considering the high risk of persistent infection and associated complications after the procedure.2Sörelius K. Mani K. Björck M. Nyman R. Wanhainen A. Endovascular repair of mycotic aortic aneurysms.J Vasc Surg. 2009; 50: 269-274Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Because our patient was young and otherwise healthy, we opted for open repair of the aneurysm. Limiting the extent of femoral vein harvest to the adductor canal, as in this case, will help in reducing the risk for development of compartment syndrome in the postoperative period as it will preserve the profunda vein and popliteal genicular draining veins.

Prospective Study on Diagnostic Performance of Color Doppler Ultrasound Using Trans-stenotic Mean Arterial Pressure Gradient as a Reference in Stented Superior Mesenteric Artery

The aim of this study was to evaluate the diagnostic performance of color Doppler ultrasound (CDU) after stenting of superior mesenteric artery (SMA) stenosis using mean arterial pressure (MAP) gradients as a reference method. This is a prospective study. Thirty-one patients underwent 51 paired measurements of MAP gradients and CDU after endovascular intervention with endoprosthesis in the SMA for mesenteric atherosclerotic disease between March 2009 and July2016. Peak systolic velocities (PSVs; r=0.44, P=0.001) and end-diastolic velocities (EDVs; r=0.59, P<0.001) correlated with MAP gradients. The area under the receiver-operating characteristics curve for diagnosis of significant in-stent stenosis for different threshold values of PSV and EDV using MAP gradient of ≥10mm Hg as reference was 0.75 and 0.80, respectively. Sensitivity and specificity for PSV >3.3m/s were 43.5% (95% confidence interval [CI] 23.2-63.7) and 92.9% (95% CI 83.3-100.0), respectively. Sensitivity and specificity for EDV >0.50m/s were 63.6% (95% CI 43.5-83.7) and 92.3% (95% CI 82.1-100.0), respectively. Specificity and positive predictive value were both 100% for combined PSV >3.0m/s and EDV >0.5m/s. PSV and EDV were equally useful in evaluation of significant SMA stent stenosis, when using trans-stenotic MAP gradient as reference. Finding of a significant stenosis on CDU should be considered as a true significant SMA stent stenosis.

Active Overt Obscured Gastrointestinal Bleeding Due to Ectasia of the Anterior Inferior Pancreaticoduodenal Artery and Its Endovascular Management in a Treated Case of Superior Mesenteric Artery Stenosis

Active Overt Obscured Gastrointestinal Bleeding Due to Ectasia of the Anterior Inferior Pancreaticoduodenal Artery and Its Endovascular Management in a Treated Case of Superior Mesenteric Artery Stenosis

Isolated caecal necrosis-a case study.

A patient with right iliac fossa pain underwent CT angiography which demonstrated isolated caecal necrosis with associated superior mesenteric artery (SMA) stenosis. This was supported by colonoscopic findings and histopathological analysis. Isolated caecal necrosis is a rare presentation of ischaemic colitis.. Clinical and imaging findings of ischaemic colitis may mimic other pathologies. To improve diagnostic accuracy both referrers and radiologists should be aware of risk factors associated with ischaemic colitis. Isolated bowel wall thickening and pneumatosis of a colonic segment on CT are suggestive of focal bowel ischaemia, in the right clinical context.

GW29-e1877 Superior mesenteric artery and celiac artery stenosis caused by Takayasu arteritis: a case report and review of the literatures

Takayasu arteritis(TA) induced superior mesenteric artery(SMA) and celiac artery(CA) stenosis is rare.This article presents a case of TA invaded SMA and CA,and review the management strategies. A 22-year-old female patient was admitted to our hospital with symptoms of headache and dizziness for

Continuous infusion of lipo-prostaglandin E1 for Takayasu\u2019s arteritis with heart failure in an 11-month-old baby: a case report

BackgroundTakayasu’s arteritis is extremely rare in children aged below 6 years. At the onset of Takayasu’s arteritis in children, symptoms are varied but differ from those in adults. Corticosteroids are the mainstay of treatment for preventing irreversible vascular damage but there is no standard treatment for progressive vascular stenosis.Case presentationA Japanese 11-month-old baby boy presented with Takayasu’s arteritis and heart failure, possibly due to afterload mismatch caused by high blood pressure. Computed tomography was performed and revealed thoracic and abdominal aortic aneurysms. It also revealed severe celiac artery stenosis and bilateral renal artery stenosis. Prednisolone was initiated as first-line therapy. The fever resolved, and C-reactive protein levels returned to normal. Although his general condition improved, deterioration of vascular lesions was evident. Celiac artery occlusion, severe right renal artery stenosis, and new superior mesenteric artery stenosis were observed. We decided to use a continuous infusion of lipo-prostaglandin E1 for prevention of branch stenosis of his abdominal aorta. The progression of vascular stenosis was stopped and our patient’s cardiac function gradually improved.ConclusionsA differential diagnosis of heart failure with high blood pressure should be considered in babies. The progression of vascular stenosis may be suppressed by lipo-prostaglandin E1.