Suprarenal Artery Research Articles

Laparoscopic Dissection of Lymph Node Station 16-Why and How?

Dissection of para-aortic lymph nodes (Station 16) provides an important prognosticator for patients with gastrointestinal, colorectal, and hepatobiliary cancers.1-4 For example, a positive Station 16 lymph node has been shown to lead to 2-year survival of 3% in patients with pancreas adenocarcinoma, akin to stage IV disease.5,6 Thereby, Station 16 involvement can help with the risk/benefit stratification of the decision to move forward with radical surgery.7-9 Furthermore, it has been shown for gallbladder cancer that involvement of Station 16 cannot necessarily be predicted from the dissection of the hepatoduodenal ligament lymph nodes only.10,11 TECHNIQUE: With the patient in the French position, a complete Kocherization and a Cattel-Braasch maneuver is performed, allowing for visualization of LN station 16b. Station 16b is the inferior border of the station 16 compartment. The left renal vein (LRV) serves as an important landmark to identify the superior border of the dissection comprised by Stations 16a2 and 16b1. Station 16a2 dissection may be associated with a traction injury of the left renal vein or damage of right renal or suprarenal arteries and is dissected if there are specific concerns regarding involvement. While station 16 provides important prognostic information for risk stratification, a strategic and stepwise approach is needed for a safe sampling. This is accomplished by wide mobilization of the duodenum, implementation of thermal fusion to minimize chyle leak, and careful dissection below the left renal vein.

THU619 Atypical Clinical Presentation Of Adrenal Hemorrhage

Abstract Disclosure: T.L. Madsen-Barbosa: None. F.H. Antoni: None. A. Ghazi: None. Introduction: Adrenal hemorrhage (AH) is an uncommon condition that is challenging to diagnose due to its nonspecific findings. We illustrate a case of AH that presented with acute clinical deterioration and had catecholamine overproduction. Case: A 58-year-old woman with a history of migraine headaches and prediabetes presented to the emergency department for “the worst headache of her life” and palpitations of 4 hours duration. On admission, her blood pressure was 224/139 mmHg and heart rate was 102 bpm. Her physical examination was significant for diaphoresis and active vomiting. Initial laboratory tests showed hyperglycemia and leukocytosis. Her ECG, non-contrast CT scan of the head and CT angiography of the head and neck were unremarkable. Her hospital course was complicated by recurrent hypertensive episodes, arrhythmias including Torsades de pointes, and left flank pain. A CT chest, abdomen, and pelvis revealed a large left retroperitoneal hemorrhagic collection which seemed to arise from the inferior aspect of the left adrenal gland. She subsequently underwent successful IR embolization of the left inferior suprarenal artery. Further workup showed elevated urinary fractionated metanephrine and normetanephrine levels, as well as elevated levels of plasma free metanephrine and normetanephrine. Given concern for pheochromocytoma, phenoxybenzamine was started. A repeat CT abdomen after six days demonstrated shrinkage in hematoma and a 7 mm hypoattenuating nodule arising from the medial limb of the left adrenal gland. Outpatient follow-up CT abdomen showed left adrenal thickening with a 2.3 cm nodular area with 78.9 Hounsfield units and absolute washout of 60.9% suggestive of adenoma. After one month, repeat catecholamine levels normalized. Discussion: The clinical manifestation of AH varies widely. Acute adrenal insufficiency is seen if bilateral glands and 90% of the cortices are compromised. However, unilateral AH is most often asymptomatic - found incidentally on imaging. Having elevated catecholamines is described in 30% of patients in one case series. Differentiating spontaneous AH from hemorrhagic adrenal tumors is also a dilemma. Among the hemorrhagic adrenal masses, pheochromocytoma is the most common. Conclusion: This case highlights that clinicians should be aware of clinical manifestations of catecholamine excess when evaluating patients with AH. A catecholamine producing adrenal mass (pheochromocytoma) should also be ruled out in these situations. Reference:1- Elhassan YS, Ronchi C, Wijewickrama P, Balvedeweg SE. Approach to the patient with adrenal hemorrhage. J Clin Endocrinol Metab. 2023, 108 (4):995-1006.2- Karwacka IM, Obolonczyk L, Sworczak K. Adrenal hemorrhage: a single center experience and literature review. Adv Clin Exp Med. 2018; 27 (5): 681-687. Presentation: Thursday, June 15, 2023

Anomalous origin of the left suprarenal, inferior phrenic arteries and left ovarian artery in a human cadaver.

This report addresses three variants identified within a female cadaver. Specifically, these were an anomalous origin of the right suprarenal artery, an abnormal bilateral ovarian vein branch, and a arterial tortuosity of the left ovarian artery. Indeed, the cadaver evinced abnormal origins in the case of the middle suprarenal artery (MSA), right inferior phrenic artery (IPA), and the renal capsule artery (emanating from the right renal artery). The MSA and IPA shared a common trunk with the inferior suprarenal artery. It was additionally observed that the right ovarian vein anastomoses the branches from the right kidney posterior inferior along with those to the renal fat capsule. Abnormal origin was evident in the case of the left ovarian artery, and arterial tortuosity was apparent in the lower region of the vessels. This report addresses both the clinical import of these variations and their likely causes. In the subdiaphragmatic region, surgical success and prognosis may be impacted by such anomalies; accordingly surgeons must be aware of anatomical variants of the ovarian and suprarenal arteries.

The safety and efficacy of oxaliplatin-loaded drug-eluting beads transarterial chemoembolization for the treatment of unresectable or advanced lung cancer.

Aim: Drug-eluting beads are usually applied for the treatment of advanced hepatocellular carcinoma. Oxaliplatin was suggested as first-line therapy for advanced non-small-cell lung cancer. However, there has been little investigation about the application of drug-eluting beads transarterial chemoembolization (DEB-TACE) with oxaliplatin-loaded CalliSpheres beads (CB) for the treatment of unresectable or advanced lung cancer. We aimed to investigate the safety and efficacy of oxaliplatin-loaded DEB-TACE for the treatment of unresectable or advanced lung cancer. Methods: From January 2019 to December 2021, all patients with primary unresectable or advanced lung cancer who underwent DEB-TACE with oxaliplatin-loaded CB were retrospectively enrolled. This study defined overall survival and objective response rate (ORR) as the primary endpoints, disease control rate (DCR) and progression-free survival (PFS) as the secondary endpoints. Results: A total of 33 sessions of DEB-TACE were performed in 20 patients, with a mean of 1.7 ± 1.0 sessions. A total of 55 arteries were emoblized by CB, including 40 bronchial arteries, 13 intercostal arteries, one suprarenal artery and one inferior phrenical artery. No procedural-related mortality or severe complications were observed. The median tumor diameter was 49.0 [Interquartile range (IQR) 37.8-66.8] mm before DEB-TACE, and decreased to 38.8 (IQR 27.7-56.9), 26.1 (IQR 19.1-48.8), and 20.5 (IQR 13.1-49.7) mm at 1, 3 and 6months later (p = 0.04). The ORR and DCR at 1, 3, and 6months after DEB-TACE were 28.6% and 92.9%, 38.5% and 84.6%, 30.8% and 61.5%, respectively. The median PFS and median overall survival was 9.9 and 29.6months, respectively. Conclusion: DEB-TACE with oxaliplatin-loaded CB is suggested as a safe, effective and well-tolerated treatment for patients with unresectable or advanced lung cancer.

PSAT029 Acute Presentations of 4 Patients with Spontaneous Adrenal Hemorrhage

Abstract Case 1 A 19 year old primigravida, 35 weeks gestation, presented with acute severe right flank pain and vomiting. She underwent a MR cholangiopancreatography following advice from the gastroenterologists. This revealed a right adrenal gland haemorrhage 46×24×40 mm. CRP was raised at 151mg/l. Random cortisol, potassium and plasma metanephrines (pMET) were normal. She was delivered by Caesarian Section at term with 100 mg IV hydrocortisone cover and with no complications to either mother or baby. CT adrenals performed 8 weeks postpartum was entirely normal with no evidence of residual haemorrhage or adrenal mass. Case 2 A 63 man with hypertension presented with acute severe left flank pain. CT renal and CT angiogram showed a large left adrenal and perinephric haemorrhage. This was treated with coil embolization of the left suprarenal artery. Initial biochemistry showed mildly raised plasma normetanephines at 2211 pmol/l which subsequently normalised. Overnight dexamethasone suppression test (ONDST) and aldosterone/plasma renin activity were normal. Serial CT scan showed gradual resolution of the adrenal haemorrhage with no underlying adrenal lesion. Case 3 A 56 year old man presented with a 3 day history of epigastric and left sided abdominal pain with nausea and fever. CT scan of the abdomen revealed a 5 cm adrenal haemorrhage which was contained within the gland. ONDST, pMET and aldosterone/plasma renin activity were normal. Serial scans showed resolution of the adrenal haemorrhage and a residual 14×13 mm adrenal nodule with a density of 20 Hounsfield Units but which remained unchanged in size. Case 4 A 72 year old man with generalised abdominal pain a week after hip replacement surgery. He developed a fever and his inflammatory markers were raised. CT abdomen showed non-enhancing bilateral adrenal lesions consistent with adrenal haemorrhage. He was taking Apixaban for thromboprophylaxis following hip replacement. A short synacthen test performed to rule out adrenal insufficiency showed a suboptimal cortisol response and treatment with hydrocortisone was commenced. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Prevalence and clinical relevance of the anatomical variations of suprarenal arteries: a review.

Prevalence and clinical relevance of the anatomical variations of suprarenal arteries: a review.

Abstract 130: Thymidine Phosphorylase Enhances Abdominal Aortic Aneurysm Formation In Mice

Abdominal aortic aneurysm (AAA) is affected by multiple factors, including vessel wall cells, extracellular matrix, genetic disorders, etc.; however, the pathophysiology of AAA remains unclear. We recently found that thymidine phosphorylase (TYMP) is a signaling protein, and an increase of TYMP inhibits the proliferation of VSMCs, the major cell population that affects AAA progression. TYMP enhances platelet activity, thrombosis, and inflammation. These data suggest that TYMP may play a role in AAA formation. By using human AAA samples, we found that TYMP expression was significantly increased in AAA vessel walls than in healthy aortas. We thus further examined the role of TYMP in AAA formation using a mouse model. WT C57BL/6J and Tymp -/- mice were fed a western diet (TD.88137), started at 4 weeks (wks) old for 8 wks, and then received implantation of Ang II mini pump, which delivers Ang II to mice at a dose of 1 μg/kg/min for 4 wks. By echography, we found that Ang II perfusion dramatically increased inner aorta diameter at the diastolic phase in WT, but not Tymp -/- mice. Mice were sacrificed 4 wks after Ang II perfusion. AAA was confirmed in 3 of the 12 WT mice, but no AAA was found in all 11 Tymp -/- mice used. The AAA was mainly formed at the suprarenal artery level. Histological examination confirmed the presence of freshly formed or fibrotic hematoma. By using TYMP overexpressing rat VSMC cell line, C2, and its control cells, PC, we found that TYMP increased MMP2 production, secretion, and activation, which was diminished by tipiracil, a selective TYMP inhibitor. Ang II did not affect extracellular MMP2 activity in both PC and C2. TYMP facilitated TNF-α induced MMP2 activation. TYMP induced constitutive AKT phosphorylation, which was further enhanced by TNF-α. TYMP increased expression of active TGFβ1. Consequently, TYMP significantly enhanced thrombospondin-1 type 1 repeat domain (TSR) stimulated TGFβ1 signaling activation and expression of CTGF, which is correlated with severe fibrotic disorders and AAA. In summary, our study, for the first time, demonstrated that TYMP, a pyrimidine salvage pathway enzyme, plays an important role in regulating vascular biology, especially, VSMC function. TYMP-mediated microenvironment changes enhance the development of AAA.

Prevalence and clinical relevance of the anatomical variations of suprarenal arteries: a review.

The suprarenal arteries are arising from three sources: superior suprarenal artery, middle suprarenal artery, and inferior suprarenal artery. Variations in the arterial supply of the suprarenal glands in respect to origin and number are quite common and very frequently reported. The most common variation noted is in the inferior suprarenal artery followed by the middle suprarenal artery and the least common variations were observed in the superior suprarenal artery. Arteriogram of the inferior suprarenal artery is crucial in suprarenal tumour diagnosis but variation in the branching pattern and multiplicity of these arteries can cause hindrance in arteriography. The absence of middle suprarenal artery was seen to be associated with increased number of the inferior suprarenal artery. Variation in the multiplicity of arteries was observed more frequently in the inferior suprarenal artery and middle suprarenal artery which was more on the right side in most of the studies. Also, the variation in suprarenal arteries was often correlated to variations in inferior phrenic and gonadal arteries. The variations were observed to be more common on the left side therefore right adrenalectomy should be preferred over the left one. The loop formed by the inferior suprarenal artery around the right renal vein can cause venous obstruction. These variations of suprarenal vasculature are explained on the developmental basis, and prior knowledge of such variants is crucial for nephrologists to ensure minimum blood loss while performing laparoscopic adrenalectomy especially for large adrenal tumours and pheochromocytoma where the duration of surgery exceeds the usual.

Celiac Trunk Quadrification, Replaced Common Hepatic Artery, and Double Cystic Arteries

Understanding the gastrointestinal system's anatomical variants is vital for surgeons, anatomists, and those who deal with referred abdominal pain, such as physical therapists. Direct access physical therapists must diligently diagnose symptoms to determine the cause of either real musculoskeletal pain or insidious symptoms masquerading as an ischemic insult. Variants of the celiac trunk and common hepatic artery were found in an 80-year-old cadaver-donor during an educational student dissection. The objective of this study was to classify and evaluate this variant in comparison to previous literature. The celiac trunk typically (95%) branches into the left gastric, splenic, and common hepatic arteries to supply the foregut, while the superior mesenteric artery (SMA) branches supply the midgut. In place of the celiac trunk, a gastrosplenic trunk (Uflacker Type V), a common inferior phrenic trunk, and a middle suprarenal artery emerged during dissection. Additionally, a replaced common hepatic artery (RCHA) originated from the superior mesenteric artery (Michels Type IX) – the presence of the CHA as a hepatomesenteric trunk is rare, a 0.07-6% prevalence. The combination of the Uflacker Type V and the Michels Type IX has a prevalence of 0.4-4.37%, while an inferior phrenic trunk originating from the celiac trunk has a reported prevalence of 7.69-13.6%. Many reports state that the RCHA variant courses posterior to the hepatic portal vein. In this case, the RCHA and associated branches were anteromedial for most of its course. The right hepatic artery took a tortuous path posterior to the common bile duct and did not enter the hepatobiliary (Calot's) triangle. Inferior to the gallbladder, double cystic arteries emerged from the right hepatic artery, previously reported with a 2-18% prevalence. Knowledge of arterial branching patterns and the variants – both common and rare – is vital for anatomists and surgeons performing dissections or operations within the abdominal area to ensure success and maximal safety. The combination of variants reported in this case is rare and has not been reported previously. This case may provide additional evidence for future studies on the morphologic and embryologic basis of vascular development. Specifically, studies that aim to evaluate a temporal relationship of combined vascular anomalies during embryologic development.

An accessory aberrant testicular artery branching from the inferior suprarenal artery: embryologic and genetic consideration

During routine educational dissection of a cadaver (61-year-old, male, white descent), multiple aberrant right testicular artery and veins were discovered. Detailed analysis of the abdominal vascular pattern showed that the accessory aberrant testicular artery branched off the right inferior suprarenal artery. It crossed the anterior pararenal space, gave several branches to the soft tissues of the posterior pararenal space, and descended towards the deep inguinal ring. The accessory aberrant testicular vein accompanied the aberrant artery and was drained by the right inferior suprarenal vein into the renal one. Two other testicular veins followed a typical course and opened into the inferior vena cava. The anatomical variability reported in this paper requires attention of the related specialists, as it may significantly complicate surgical and minimally invasive procedures on the organs of the retroperitoneal space and inguinal region. Thorough preoperative investigation regarding the variability of the vascular pattern should be conducted in patients considered for intervention on the adrenal gland, kidney, or testis.

Bilateral variant origin of the inferior phrenic artery

The inferior phrenic arteries (IPA) arise from aorta, just above the level of celiac artery. Although descriptions of the right and left phrenic arteries are typically brief, the inferior phrenic arteries have received attention in recent years because of its involvement in treating unresectable hepatocellular carcinoma (HCC) by using transcatheter embolization. Since IPA contributes to the arterial supply of adrenal glands, they are important in angiographic examination of adrenal lesions. During routine dissection for MBBS students, bilateral variant origin of inferior phrenic arteries was observed. In this case, coeliac artery was tortuous and it measured 2 cm in length and 0.6 cm in diameter. The right IPA originated from the coeliac artery as a common trunk. This common trunk divided into two. One branch formed the right IPA and the other branch formed the superior suprarenal artery. On the left side, a common trunk originated from coeliac artery which divided into two branches. One branch joined the splenic artery and the other branch again formed a common trunk which further divided into two i.e superior suprarenal artery and left IPA. In patients with left suprarenal mass or oesophgo- gastric junction hemorrhage, certain interventional procedures such as selective IPA angiography is necessary. Due to variable anatomy of its origin, cannulation of IPA can be challenging. Therefore, the knowledge of this type of variations should be kept in mind by the surgeons and care should be taken to avoid unintentional sectioning of small caliber arteries.

Aberrant inferior suprarenal vessels crossing posterior pararenal space: a case report

During routine educational dissection of a cadaver (63-year-old, male, USA), an atypical course of the left inferior suprarenal vessels via the posterior pararenal space was discovered. Detailed analysis of the abdominal vascular pattern showed that the atypical inferior suprarenal artery represented a terminal branch of the left inferior phrenic artery. The last one branched off from the very beginning of the left renal artery, ascended between the fibers of the left crus of the diaphragm, then ran laterally giving off muscular branches and, finally, descended along the costal part of the diaphragm to the left posterior pararenal space. The terminal branch of the inferior phrenic artery pierced the retrorenal fascia and entered the perirenal space as an atypical left inferior suprarenal artery. It ran upward and medially crossing the anterior surface of the kidney to reach and supply the lower pole of the left suprarenal gland. The left inferior phrenic vein accompanied the artery taking a similar course. It received numerous tributaries passing via the posterior pararenal space, drained the inferior suprarenal vein, and opened into the left renal vein. Such anomalous pararenal vascular pattern is a challenge for surgeons performing open procedures on retroperitoneal organs, not to mention specialists employing minimally invasive laparoscopic techniques. The anatomical variation reported in this paper requires urgent attention of the related specialists.

A8234 Role of GRK4 in the regulation of renal ETB receptor in hypertension

Objectives: To study the role of G protein-coupled receptor kinase 4 (GRK4) in the regulation of endothelin receptor B (ETBR) in hypertension. Methods: Male anaesthetic spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto (WKY) rats were used to test ETBR-mediated natriuresis and diuresis. The ETBR agonist, BQ-3020 (0.1, 0.5, 1.0Ymg/kg/min) were infused via supra-renal artery at a rate of 0.04Yml/min for 40Ymin. The same experiments were conducted in GRK4 A142 V transgenic mice to confirm the relationship between GRK4 and ETBR hyper-phosphorylation. Co-immunoprecipitation and confocal microscopy were conducted to test interaction between GRK4 and ETBR. Results: Activation of ETBR induced natriuresis and diuresis in WKY rats, which was impaired in SHRs. ETBR phosphorylation was higher in SHRs as compared with WKY rats, although ETBR expression had no difference in kidneys from WKY and SHRs. Activation of ETBR induced natriuresis in wild-type mice, however, in GRK4 transgenic mice, the ETBR-mediated natriuresis and diuresis was lost, accompanied with higher ETBR hyper-phosphorylation. There were co-localization and co-immunoprecipitation between ETBR and GRK4 in RPT cells both from WKY and SHRs, the ETBR/GRK4 linkage was higher in SHR cells than in WKY cells. Down-regulation of GRK4 with siRNA recovered ETBR function, which is pathophysiological significance, because down-regulation of renal GRK4 expression via ultrasound-targeted microbubble destruction restored ETBR-mediated natriuresis and diuresis in SHRs, accompanied with lowered ETBR phosphorylation. Conclusion: This study provides a mechanism by which GRK4, via regulation of renal ETBR function, participates in the pathogenesis of hypertension.

Rare combined variations of renal, suprarenal, phrenic and accessory hepatic arteries

Knowledge of the morphological variations within the abdominal cavity is significant for all medical practitioners planning surgery. This report presents the rare origin of a common trunk for the right inferior phrenic artery, and superior and inferior suprarenal artery from the right renal artery. An accessory hepatic artery was found, which served as a branch of the right inferior phrenic artery. The diameter of the common trunk was 3.95 mm, and the diameters of the inferior and superior suprarenal arteries were 1.84 and 1.36 mm, respectively. The diameter of the right inferior phrenic artery was 2.55 mm. Both the embryological background and the potential clinical significance of this morphological variation are discussed. Knowledge of this common trunk and the occurrence of the accessory right hepatic artery may be of significance in diagnostic and surgical procedures.

Anatomical variations of testicular artery: a review

The testicular arteries (TAs) also known as internal spermatic arteries are long and slender arteries usually arising from the anterolateral aspect of the abdominal aorta, 2.5 cm to 5 cm caudal to the renal arteries. The variation in TAs may be found with respect to their origin, number or course. They can originate from the abdominal aorta itself at an abnormal level. If not arising from abdominal aorta the TA variants may arise from renal artery, suprarenal artery or any one of the lumbar arteries. Rarely it can arise from common or internal iliac artery, or from the superior epigastric artery. The most common variation with respect to origin of TA was found in association with renal vessels. In regard to their number, double TA was found to be most common and with respect to course most common variation was arched TA over ipsilateral renal vein. The arched TA at times on right side had a retrocaval course. Occurrence of TA variants is explained with embryology and the knowledge of its clinical significance is essential for future surgeons for designing vascular surgeries. Four studies had attempted to classify TA variants regarding their origin, number and course but they could not accommodate recently found TA variants. This led to our new proposed classification.

Angiotensin II infusion into ApoE-/- mice: a model for aortic dissection rather than abdominal aortic aneurysm?

Angiotensin II-infused ApoE-/- mice are a popular mouse model for preclinical aneurysm research. Here, we provide insight in the often-reported but seldom-explained variability in shape of dissecting aneurysms in these mice. N = 45 excised aortas were scanned ex vivo with phase-contrast X-ray tomographic microscopy. Micro-ruptures were detected near the ostium of celiac and mesenteric arteries in 8/11 mice that were sacrificed after 3 days of angiotensin II-infusion. At later time points (after 10, 18, and 28 days) the variability in shape of thoraco-abdominal lesions (occurring in 31/34 mice) was classified into 7 different categories based on the presence or absence of a medial tear (31/31), an intramural hematoma (23/31) or a false channel (11/23). Medial tears were detected both in the thoracic and the abdominal aorta and were most prevalent at the left and ventral aspects of celiac and mesenteric arteries. The axial length of the hematoma strongly correlated to the total number of ruptured branch ostia (r2 = 0.78) and in 22/23 mice with a hematoma the ostium of the left suprarenal artery had ruptured. Supraceliac diameters at baseline were significantly lower for mice that did not develop an intramural hematoma, and the formation of a false channel within that intramural hematoma depended on the location, rather than the length, of the medial tear. Based on our observations we propose an elaborate hypothesis that explains how aortic side branches (i) affect the initiation and propagation of medial tears and the subsequent adventitial dissection and (ii) affect the variability in shape of dissecting aneurysms. This hypothesis was partially validated through the live visualization of a dissecting aneurysm that formed during micro-CT imaging, and led us to the conclusion that angiotensin II-infused mice are more clinically relevant for the study of aortic dissections than for the study of abdominal aortic aneurysms.

Abstract 473: Dissecting Aortic Aneurym in Angiotensin II - Infused Mice: The Mechanisms Behind Lesion Variability

Angiotensin II-infused mice develop dissecting aneurysms, characterized by intramural rather than intraluminal thrombus, suprarenal rather than infrarenal lesions, medial dissections rather than circumferential elastin degradation and a variability in lesion shape that remained as yet unexplained. In order to provide insight into these intriguing lesions we scanned murine aortas at baseline and after 10, 18 and 29 days of Angiotensin II infusion, both in vivo (ultrasound, micro-CT) and ex vivo (phase-contrast X-ray tomographic microscopy). Dissecting aneurysms of varying severity occurred in 31/34 mice. All of these were characterized by a medial tear near the ostium of thoracic and abdominal aortic side branches, with a predilection for the left and ventral aspects of the ostium of the celiac artery. In 25/31 animals an intramural hematoma was formed. Fully ruptured branch ostia occurred significantly more often in the supraceliac aorta, affecting in particular the left suprarenal artery (the first branch cranial to the celiac artery, 23/25). Animals with a thoracic tear (6/31) had significantly larger intramural hematoma than animals with an abdominal tear (p<0.05), and the length of the hematoma correlated to the number of ruptured side branches (r 2 =0.78). In 11 mice a parallel false channel was formed. The volume of free-flowing intramural blood in the false channel was significantly larger for left than for ventral tears, but was not related to the length of the tear. Our data suggest that (i) medial tears are the primary event in dissecting AAA formation, (ii) an intramural hematoma is formed if the adventitia covering the medial tear dissects and leads to the accumulation of intramural blood from ruptured side branches, (iii) adventitial dissection and hematoma formation progress in the direction of least resistance/smallest side branches (i.e. cranial of the celiac artery) and (iv) a false channel is formed if the radial expansion of the adventitia due to blood flowing out of the medial tear acts in the same (leftward) direction as the expansion due to a ruptured left suprarenal artery. We conclude that Ang II-infused mice can be a valuable model to study the under-researched role of side branches in the formation and progression of aortic dissections.

A Detailed Study of Multiple Vascular Variations in the Upper Part of Abdomen.

Introduction:Knowledge of vascular variations near the kidney is of importance to many clinical disciplines such as nephrologists, radiologists, gastroenterologists, and general surgeons. Variant branches of the abdominal aorta and renal arteries are the victims of iatrogenic bleeding during surgery. We found multiple vascular variations in the upper part of the abdomen during our dissection classes.Methods:During the dissection classes of the abdomen for undergraduate medical students, we observed multiple vascular variations in the abdomen of an adult male cadaver. The vessels and surrounding viscera were cleaned using dissection instruments. Variations observed were photographed.Results:The right kidney had its hilum directed posteriorly. There were two right renal veins and a partially doubled left renal vein (LRV). The left suprarenal and gonadal veins drained into the upper LRV. There were two right renal arteries. Upper right renal artery gave origin to the right inferior phrenic and middle suprarenal arteries. There were two renal arteries on the left side also. The left upper renal artery gave a polar branch to the left kidney and divided into two branches before entering the kidney. The left inferior phrenic artery (IPA) gave two gastric branches to the fundus of the stomach.Conclusions:The variations noted by us are of tremendous surgical application. The variant vessels might get damaged during surgical procedures if the surgeons are not aware of these variations. The most important among the variations reported here is the gastric branch of the IPA, which has not been reported yet.

Risk factors for long-term result of endovascular treatment for auto-immune disease related abdominal aorta pseudo-aneurysm

Objective: To summarize results of endovascular treatment for auto-immune disease related abdominal aorta pseudo-aneurysm(AIPA), and to analysis clinical predictors of long term major adverse clinical events(MACE). Methods: Retrospectively collected endovascular treatment for AIPA cases in Peking Union Medical College Hospital within 2000 to 2015. Twenty-nine cases with AIPA treated by endovascular therapy were enrolled in this study. Twenty five cases were male, range from 23 to 67 years old, mean age was (39.3±11.4) years old.Demographic characters, locations of aneurysms, type to auto-immune disease, immuno medical therapy, operation strategy and long term follow-up data were reported. Statistical analysis was made to verify clinical predictors of long-term MACE. Results: Among the 29 cases, 22 cases with bechet's disease, 4 cases with Takayasu's arteritis, 2 cases with systemic lupus erythematosus, 1 cases with polyarteritis nodosa. Eight cases had ruptured or pending ruptured pesudo-aneurysms, the rest 21 cases had dull pain or no overt symptome. Twenty-four cases had infra-renal artery aneurysms, two were para-and supra-renal artery, two were supra-celiac artery, and the rest one had multiple aneurysms involved thoracic and abdominal aorta.All the cases received regular immune medical therapy except the three emergency cases. All the operations were under general anaesthesia. Nineteen cases underwent classical Endovascular aortic aneurysm repair (EVAR), 5 cases underwent fenestration EVAR, the rest 5 cases underwent hybrid procedure. All the 29 operations were successful, without conversion to open surgery. Major peri-operation complication included 3 incision infection, 3 pulmonary infection. No death occurred. All the cases received regular follow-up from 1 to 120 months. There were five recurrence of pseudo-aneurysm, 1 case suffered from iliac limb occlusion. 5 cases received re-intervention procedure. No occlusion of revascularizal visceral artery was found during follow-up. There were 3 deaths during follow-up, with 1 aneurysm related death, the rest died due to other reasons. Single factors logical regressions analysis showed discontinuing immune medicine therapy and age no less than 40 years significantly related long-term MACE(P<0.05). Meanwhile, type of original auto-immune disease, none classical EVAR were not significant related to MACE. Conclusions: Endovascular therapy is safe and effective for AIPA. Regular peri-operation and long-term immunotherapy is key to success.

A cadaveric study of the testicular artery and its clinical significance.

BackgroundKnowledge of testicular artery variations is vital to ensure that they are not neglected during a variety of different operative techniques, since damage can cause testicular atrophy.ObjectivesThe present study was therefore intended to identify variants in the origin and course of the testicular arteries. An attempt was made to classify the arteries based on their various origins.MethodsThis study examined 42 formalin-fixed cadavers of 40 to 70-year-old adult males. Variant origins of the testicular artery were identified and classified. Variations in the origin and course of the artery were colored, photographed, and documented. The distances between the origins of the testicular arteries and the mid-points of the origins of the renal arteries were measured.ResultsTesticular arteries were classified into four categories on the basis of origin. This variability was defined in relation to the renal and inferior mesenteric arteries. The mean distance between the origin of the testicular artery and the mid-point of the origin of the renal artery were 3.08 and 3.47 cm, on the right and left sides respectively. Variations were almost exclusively found on the left side. The variations observed included multiple arterial twigs forming the testicular artery, suprarenal arteries arising from the testicular artery, and testicular artery duplication.ConclusionThis study provides an insight into variations in the testicular artery and proposes a classification which could help surgeons during a variety of procedures on the male abdomen and pelvis.