内脏动脉狭窄闭塞侧支循环的多层螺旋CT血管成像

目的:探讨腹腔动脉(CA)、肠系膜上动脉(SMA)、肠系膜下动脉(IMA)狭窄闭塞侧支循环在多层螺旋CT血管造影(MSCTA)中的表现.方法:搜集CA、SMA、IMA慢性狭窄闭塞行MSCTA检查的患者80例,采用容积再现(VR)血管添加技术(AV)对侧支血管进行选择性重建.结果:80例慢性期内脏动脉狭窄闭塞患者中SMA...     

肠系膜上动脉病变 MSCTA 诊断价值

目的：探讨多层螺旋 CT 血管成像(MSCTA)诊断肠系膜上动脉(SMA)病变临床价值。方法回顾性分析40例 SMA病变患者 MSCTA 图像特点,运用容积再现(VR)、多平面重组(MPR)、曲面重组(CPR)及最大密度投影(MIP)等多种后处理重建技术。结果SMA 缺血16例,包括 SMA 急性闭塞8例,其中并发小肠缺血性坏死1例并行坏死小肠切除术。SMA 慢性闭塞8例;孤立性 SMA 夹层10例;SMA 真性动脉瘤7例,感染性心内膜炎相关假性动脉瘤1例;SMA 溃疡3例,其中1例合并肠系膜下动脉(IMA)重度狭窄;腹腔干重度狭窄2例;IMA 闭塞1例。本组40例患者可见 SMA 疾病相关侧支循环13例,4例见于 SMA 慢性闭塞,3例见于 SMA 急性闭塞,1例见于孤立性 SMA 夹层,1例见于 SMA 假性动脉瘤,2例分别见于 IMA 狭窄和闭塞。2例见于腹腔干重度狭窄。其中包括胰十二指肠前、后动脉弓3例,胰背动脉侧支2例、Riolan 弓10例。结论MSCTA 可以清晰观察SMA 各类病变、侧支循环开通情况以及评估肠腔缺血状态。     

Gadolinium-enhanced MR angiography of visceral arteries in patients with suspected chronic mesenteric ischemia

The purpose of this study was to evaluate accuracy of dynamic gadolinium-enhanced MR angiography (MRA) of the celiac, superior, and inferior mesenteric arteries in patients with suspected mesenteric ischemia compared with catheter angiography or surgery. Sixty-five patients with suspected mesenteric ischemia underwent three-dimensional spoiled gradient-recalled acquisition in the steady state (GRASS) gadolinium-enhanced MRA. Correlative studies were performed on 14 patients, catheter angiography alone was performed on 12 patients, and surgery alone was performed on two patients. Six patients had mesenteric ischemia. In all patients, the celiac artery (CA) and superior mesenteric artery (SMA) were seen well enough to evaluate; however, the inferior mesenteric artery (IMA) could be evaluated in only 9 of the 14 patients. MRA showed severe stenosis (>75%) or occlusion of the celiac axis in seven patients, of the SMA in six patients, and of the IMA in four patients. The overall sensitivity and specificity were 100% and 95%, respectively, compared with catheter angiography and surgery. The two errors were caused by overgrading the severity of IMA disease. Three-dimensional gadolinium-enhanced MRA can accurately demonstrate the origins of the CA and SMA and is useful in evaluation of patients with suspected mesenteric ischemia.     

Interobserver Variability in the Evaluation of Chronic Mesenteric Ischemia with Gadolinium-enhanced MR Angiography

RATIONALE AND OBJECTIVES: The purpose of this study was to assess interobserver variability in the interpretation of gadolinium-enhanced magnetic resonance (MR) angiograms of splanchnic vessels in patients suspected of having chronic mesenteric ischemia (CMI). MATERIALS AND METHODS: Two readers blinded to the initial interpretation retrospectively reviewed gadolinium-enhanced MR angiograms obtained for suspected CMI in 26 patients (20 women and six men; age range, 23-77 years; mean age, 61 years) who also underwent conventional angiography. Each reader graded the degree of stenosis based on the percentage diameter reduction of the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) by using a five-point ordinal scale: 0, no stenosis: 1, mild stenosis (<50%); 2, moderate stenosis (50%-75%); 3, severe stenosis (>75%); 4, occluded artery. Using the conventional angiogram as a reference standard, authors determined sensitivity and specificity for each observer, assigning two thresholds (grades 2 and 3) as significant stenoses. A kappa statistic (kappa) measured interobserver agreement. RESULTS: With grade 2 stenosis used as a threshold, cumulative accuracies for detecting significant stenosis were 0.95 (95% confidence interval, 0.86-0.99) for reader A and 0.97 (0.88-1.0) for reader B. Interobserver agreement for grading proximal splanchnic stenosis was 0.90 for CA, 0.92 for SMA, and 0.48 for IMA. CONCLUSION: Gadolinium-enhanced MR angiography is reproducibly accurate for detection of proximal splanchnic artery stenosis, with good to excellent interobserver agreement.     

CT血管造影在消化道疾病诊断中的应用

目的 探讨多层螺旋CT血管造影在消化道疾病诊断中的应用. 资料与方法 对27例经临床或病理证实的消化道疾病患者的中小血管CTA表现进行分析. 结果 5例小肠缺血中3例CTA表现为肠系膜上动脉闭塞,2例表现为肠系膜上动脉狭窄.7例小肠Crohn病CTA均表现为肠管的动脉远端分支迂曲扩张,6例出现"梳样征";肠系膜上动脉压迫综合症CTA表现为肠系膜上动脉与腹主动脉的夹角变小;11例消化道肿瘤的CTA可显示肿瘤的供血动脉及肿瘤与血管的关系. 结论 CT血管造影能直观显示消化道疾病患者的血管情况.     

Percutaneous Retrograde Recanalization of the Celiac Artery by Way of the Superior Mesenteric Artery for Chronic Mesenteric Ischemia

A 52-year-old man presented with recurrent postprandial abdominal pain, sitophobia, and progressive weight loss. Chronic mesenteric ischemia (CMI) due to subtotal occlusion of the superior mesenteric artery (SMA) and flush occlusion of the celiac artery (CA) was diagnosed. Retrograde recanalization of the CA by way of a collateral channel from the SMA was performed using contemporary recanalization equipment. The CA and SMA were then stented, resulting in sustained resolution of CMI-related symptoms.     

Chronic mesenteric ischaemia: 28-year experience of endovascular treatment

Objective

To report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI).

Methods

A retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed.

Results

In 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014).

Conclusion

Technical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates.

Key Points

• Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms.

• Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting

• Although technical success rates are improved with the use of stents.

• Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.

     

Endovascular Repair of a Type III Thoracoabdominal Aortic Aneurysm in a Patient with Occlusion of Visceral Arteries

The successful endovascular repair of a type III thoracoabdominal aortic aneurysm (TAAA) with the use of a tube endograft is reported. A 56-year-old male with a 6.4-cm type III TAAA, a 4.2-cm infrarenal abdominal aortic aneurysm, and chronic renal insufficiency presented with flank pain, nausea, acute anuria, and serum creatinine of 6.1 mg/dl. Acute occlusion of the left solitary renal artery was diagnosed and emergent recanalization with percutaneus transluminal angioplasty and stenting was performed successfully, with reversal of the serum creatinine level at 1.6 mg/dl. Further imaging studies for TAAA management revealed ostial occlusion of both the celiac artery (CA) and the superior mesenteric artery (SMA) but a hypertrophic inferior mesenteric artery (IMA) providing retrograde flow to the aforementioned vessels. This rare anatomic serendipity allowed us to repair the TAAA simply by using a two-component tube endograft without fenestrations (Zenith; William Cook, Bjaeverskov, Denmark) that covered the entire length of the aneurysm, including the CA and SMA origins, since a natural arterial bypass from the IMA to the CA and SMA already existed, affording protection from gastrointestinal ischemic complications. The patient had a fast and uneventful recovery and is currently doing well 6 months after the procedure. To our knowledge, this is the first report in the English literature of successful endovascular repair of a TAAA involving visceral arteries with the simple use of a tube endograft.     

Noninvasive evaluation of the celiac trunk and superior mesenteric artery with multislice CT in patients with chronic mesenteric ischaemia

Purpose

This study sought to assess the role of multislice computed tomography (MSCT) in patients with suspected chronic mesenteric ischaemia (CMI).

Materials and methods

Forty-five patients (29 men; mean age 68) underwent MSCT angiography of the abdomen for suspected CMI (main clinical finding: postprandial abdominal pain). The scan protocol was detectors/collimation 16/0.75 mm; feed 36 mm/s; rotation time 500 ms; increment 0.4 mm; 120–150 mAs and 120 kVp. A volume of 80 ml of contrast material was administered through an antecubital vein (rate 4 ml/s), followed by 40 ml of saline (rate 4 ml/s). Images were analysed on the workstation with different algorithms (axial image scrolling, multiplanar reconstructions, maximum intensity projection, volume rendering). Targeted central lumen-line reconstructions (curved reconstructions) were obtained along the celiac trunk (CeT) and superior mesenteric artery (SMA). Vessel occlusions and significant (>50%) stenosis were recorded.

Results

Image generation and interpretation required 25 min. Stenosis and/or occlusions were detected in 29 (65%) cases on the CeT and in 32 (71%) on the SMA. Of those lesions (n=61), 44 (49%) were classified as not significant. In 16 (35%) cases, there was a simultaneous stenosis and/or occlusion of the CeT and SMA (confirmed by conventional angiography). In six (13%) cases, there were no lesions affecting the CeT, SMA or their branches (confirmed by clinical follow-up).

Conclusions

MSCT angiography can play a major role in the detection of stenosis of the abdominal arteries in patients with suspected CMI.     

Percutaneous recanalization and stent placement in chronic proximal superior mesenteric artery occlusion

Atherosclerotic stenosis involving the proximal portion of at least two visceral arteries usually causes symptoms of intestinal ischemia and can lead to massive bowel infarction and death. This report describes a case of chronic proximal occlusion of the superior mesenteric artery (SMA) in a 51-year-old man, successfully treated by local catheter-directed thrombolytic therapy, followed by balloon dilatation and stent placement of the residual atherosclerotic stenosis. At 3 months follow-up, the patient was free of symptoms. This case shows that local thrombolytic therapy, percutaneous transluminal angioplasty and stent placement can be useful in the treatment of chronic atherosclerotic occlusion of the proximal SMA. Received 5 November 1996; Revision received 5 February 1997; Accepted 27 March 1997     

Splanchnic arterial stenosis or occlusion: diagnosis at Doppler US

PURPOSE: To determine the diagnostic accuracy of Doppler ultrasonography (US) in the detection of high-grade stenosis or occlusion of the celiac artery (CA) and superior mesenteric artery (SMA) and validate the previously reported Doppler US criteria. MATERIALS AND METHODS: During a recent 36-month period, 82 patients were prospectively examined with Doppler US of the splanchnic arteries and with lateral abdominal aortography, regardless of their abdominal symptoms. The previously reported diagnostic criteria with the fasting peak systolic velocity measurement were prospectively used in all patients. The results of Doppler US were compared with those of lateral aortography. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Doppler US for the detection of 70% or greater CA stenosis or occlusion were 100%, 87%, 57%, 100%, and 89%, respectively; for 70% or greater SMA stenosis or occlusion, these values were 100%, 98%, 93%, 100%, and 99%, respectively. CONCLUSION: Owing to its high accuracy in the diagnosis of high-grade splanchnic arterial stenosis or occlusion, Doppler US can be used as a screening method to help detect CA or SMA stenosis or occlusion and can reduce the use of unnecessary, invasive angiography.     

Riolan动脉弓MSCT血管成像及临床意义

目的:探讨Riolan动脉弓扩张的MSCTA表现和临床意义。方法:回顾性分析626例患者的腹部CTA及临床资料,将其中的47例Riolan动脉弓扩张患者作为研究组,另抽取47例无扩张者为对照组,测量Riolan动脉弓平均直径,由两位有经验放射科医师独立分析Riolan动脉弓扩张与临床资料的关系。结果:对照组及肠系膜上动脉(SMA)闭塞、SMA狭窄、肠系膜下动脉(IMA)闭塞、IMA狭窄、结肠癌、活动性溃疡性结肠炎组Riolan动脉弓平均直径分别为(1.2±0.1)、(4.6±0.7)、(2.5±0.2)、(2.3±0.3)、(1.9±0.2)、(2.5±0.3)和(2.0±0.3)mm,研究组Riolan动脉弓直径大于对照组(Z=-8.403,P<0.01),SMA闭塞后Riolan动脉弓扩张最为显著(F=20.064,P<0.01)。血流上行组与血流下行或双向血流组Riolan动脉弓直径差异存在统计学意义(P<0.01)。结论:Riolan动脉弓扩张常提示有肠道供血动脉或肠道病变,MSCTA不仅可以清晰地显示Riolan动脉弓,而且可以很好显示相关血管狭窄及闭塞的情况,对临床诊疗方案选择有重要指导意义。     

Microballoon Occlusion Test to Predict Colonic Ischemia After Transcatheter Embolization of a Ruptured Aneurysm of the Middle Colic Artery

A 76-year-old woman presented with sudden massive melena, and superior mesenteric arteriography showed an aneurysm in the middle colic artery (MCA). Because she had a history of right hemicolectomy and ligation of the inferior mesenteric artery (IMA) during open abdominal aortic aneurysm repair, embolization of the MCA aneurysm was considered to pose a risk comparable to that of colonic ischemia. A microballoon occlusion test during occlusion of the MCA confirmed retrograde visualization of the IMA branches through the collateral arteries by way of the left internal iliac artery, and embolization was successfully performed using microcoils. No colonic ischemia or aneurysm rupture occurred after embolization.     

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

PurposeTo 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).Materials and MethodsSingle-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.ResultsPressure 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.ConclusionsIntra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis.     

Spontaneous Dissection of Superior Mesenteric Artery: Long-Term Outcome of Stent Placement

Stent placement was performed in 10 patients with symptomatic spontaneous dissection of the superior mesenteric artery (SMA). A stent was placed as first-line treatment in 7 patients and as second-line treatment in 3 patients in whom conservative treatment had failed. Abdominal pain completely resolved within 2 days after stent placement, and follow-up (median 53 months; range, 11–99 months) CT angiography revealed complete obliteration of the false lumen and good stent patency in 9 patients. One patient showed asymptomatic stent occlusion at 99-month follow-up. Long-term patency of stent placement in patients with symptomatic SMA dissection seems to be acceptable.     

Successful intraarterial recombinant tissue plasminogen activator therapy for acute embolic occlusion of the superior mesenteric artery

While there have been multiple reports of catheter-directed thrombolysis with streptokinase or urokinase for thromboembolic occlusion of the superior mesenteric artery (SMA), there has been only one previous report describing SMA thrombolysis using tissue plasminogen activator (rt-PA). We present a case of acute embolic occlusion of the SMA initially diagnosed by CT and then successfully treated with selective infusion of rt-PA.     

Recanalization of Chronic Total Occlusions of the Superior Mesenteric Artery in Patients with Chronic Mesenteric Ischemia: Technical and Clinical Outcomes

PurposeTo evaluate the safety and outcomes of endovascular recanalization of chronic total occlusions (CTOs) of the superior mesenteric artery (SMA) in patients with chronic mesenteric ischemia (CMI).Materials and MethodsA single-institution retrospective review was performed of 47 consecutive patients (18 male, 29 female) who underwent endovascular stent placement for CTOs of the SMA between February 2006 and November 2012. All patients had symptoms of CMI. Procedural and follow-up data were collected for assessment of technical success, safety, and outcome.ResultsTechnical success was achieved in 41 of 47 patients (87%). Forty-two of the 47 procedures were performed from a femoral approach. Fifteen patients underwent concurrent revascularization of the celiac artery. All patients who underwent successful recanalization reported symptomatic improvement. Kaplan–Meier analysis revealed primary freedom from symptomatic recurrence of 95% at 12 months and 78% at 24 months. Symptomatic recurrence was observed in seven patients, all of whom underwent successful assisted or secondary endovascular procedures. Secondary freedom from symptomatic recurrence rates were 100% at 12 months and 88% 24 months. There were three (7%) minor access-related complications and no major complications.ConclusionsEndovascular stent-assisted recanalization of chronic SMA occlusions is safe and effective, with an acceptable rate of technical success and excellent midterm clinical outcomes.     

Penetrating atherosclerotic ulcer of the abdominal aorta involving the celiac trunk origin and superior mesenteric artery occlusion: endovascular treatment

We describe a case of endovascular treatment in a 64-year-old woman affected by a penetrating atherosclerotic ulcer (PAU) of the abdominal aorta with a 26-mm pseudoaneurysm involving the celiac trunk (CT) origin and with superior mesenteric artery (SMA) occlusion in the first 30 mm. The patient underwent stenting to treat the SMA occlusion and subsequent deployment of a custom-designed fenestrated endovascular stent-graft to treat the PAU involving the CT origin. Follow-up at 6 months after device placement demonstrated no complications, and there was complete thrombosis of the PAU and patency of the two branch vessels.     

Tumor tissue characterization evaluating the luciferase activity under the control of a hsp70 promoter and MR imaging in three tumor cell lines

Severe stenosis/occlusion of the proximal celiac trunk due to median arcuate ligament compression (MALC), arteriosclerosis, pancreatitis, tumor invasion, and celiac axis agenesis has been reported. However, clinically significant ischemic bowel disease attributable to celiac axis stenosis/occlusion appears to be rare because the superior mesenteric artery (SMA) provides for rich collateral circulation. In patients with celiac axis stenosis/occlusion, the most important and frequently encountered collateral vessels from the SMA are the pancreaticoduodenal arcades. Patients with celiac artery stenosis/occlusion are treated by interventional radiology (IR) via dilation of the pancreaticoduodenal arcade. In patients with dilation of the pancreaticoduodenal arcade on SMA angiograms, IR through this artery may be successful. Here we provide several tips on surmounting these difficulties in IR including transcatheter arterial chemoembolization for hepatocellular carcinoma, an implantable port system for hepatic arterial infusion chemotherapy to treat metastatic liver tumors, coil embolization of pancreaticoduodenal artery aneurysms, and arterial stimulation test with venous sampling for insulinomas.     

胰腺癌侵犯胰周主要血管的CT表现分析

目 的分析多层螺旋CT(MSCT)胰腺检查，胰腺癌侵及胰周主要动、静脉的不同CT表现特征。方法 MSCT诊断胰腺癌68例患者中，33例行手术治疗(其中12例行胰十二指肠切除术，21例剖腹探查发现不可切除)，病理结果均证实为胰腺导管细胞癌。术中由手术者仔细探查胰周主要血管[肠系膜上动脉(SMA)、腹腔干(CA)、肝动脉(HA)、肠系膜上静脉(SMV)及门静脉主干(PV)]。结果 165支受检血管中，手术探查发现103支血管未受侵犯，其余62支血管受侵，MSCT术前检查，8．1％(5／62)受侵血管误判为未受侵犯(假阴性)。其余受侵的胰周主要动、静脉(57支)具有不同的CT表现特征：胰周主要动脉受侵时，均被肿瘤包绕大于管周的1／2或完全包埋于肿瘤中。胰周主要静脉受侵时，部分静脉血管被肿瘤包绕小于管周的1／2：SMV为4支(4／17)，PV为2支(2／13)，但同时均出现管壁受浸润或管腔狭窄或管腔形态改变；胰周静脉受侵犯时出现管腔狭窄或闭塞的机会较胰周动脉大：SMV为11支(11／17)，PV为12支(12／13)，而CA为3支(3／8)，HA为4支(4／7)，SMA为4支(4／12)；胰周静脉受侵犯时管壁呈浸润性改变的比例较胰周动脉高：SMV为11支(11／17)，PV为7支(7／13)，而CA为3支(3／8)，HA为2支(2／7)，SMA为6支(6／12)。结论 胰周动、静脉受侵及时，其CT表现具有不同特征。