Treatment strategy for acute type A aortic dissection; how to manage mesenteric ischemia

Mesenteric ischemia is a dreaded complication of acute type A aortic dissection. From January 1994 to December 2004, 134 patients with acute type A aortic dissection were operated. Eleven patients showed postoperative mesenteric ischemia. Mortality of such patients was much higher than that without mesenteric ischemia (81.8 vs. 10.6% , p < 0.0001). Preoperative mesenteric and/or lower extremity ischemia were revealed to be the risk factors of postoperative mesenteric ischemia. Our strategy to manage these patients is as follows; patients who are suffering mesenteric and/or lower extremity ischemia preoperatively, or those whose computed tomography (CT) shows stenosis, obstruction, or dissection of the superior mesenteric artery, should be recognized as high-risk patients of postoperative mesenteric ischemia. Their mesenteric circulation should be examined directly with laparotomy after the central repair. If the mesenteric circulation seems to be suboptimal, iliac artery-superior mesenteric artery bypass should be performed.     

急性肠系膜上动脉闭塞的诊断与治疗

目的 探讨急性肠系膜上动脉闭塞的诊断与治疗.方法 对2000-2007年收治的15例急性肠系膜上动脉闭塞患者的临床资料进行回顾性分析.结果 本组15例患者中肠系膜上动脉栓塞11例,肠系膜上动脉血栓形成4例.入院后均行急诊剖腹探查术,其中2例行肠系膜上动脉取栓术,11例行肠系膜上动脉取栓加坏死肠管切除术,2例放弃手术.术后均行肝素等抗凝治疗.4例死亡,总病死率为27%.结论 对于有器质性心脏病的患者,如突然出现腹部疼痛,应警惕肠系膜上动脉闭塞的可能.早期诊断、早期行肠系膜上动脉取栓术是提高治愈率的关键.     

Open staged repair of splenic and extensive superior mesenteric artery aneurysms

A 31-year-old man with a history of multiple strokes of unknown etiology presented with multiple asymptomatic visceral artery aneurysms including a 3.3-cm bilobed splenic artery aneurysm and a 3.1-cm fusiform superior mesenteric artery aneurysm. He had no family history of aneurysms, and there was no evidence of collagen disease. He underwent open splenic artery aneurysm resection without splenectomy and had an uneventful recovery. Seven months later, he had open repair of his 14.6-cm-long fusiform superior mesenteric artery aneurysm with a 15-cm-long collagen-coated polyester interposition graft with multiple visceral branch reimplantations into the graft. The postoperative course was uneventful, and computed tomography confirmed patent graft and side branches. Two years later, the patient remained free of abdominal symptoms, although he suffered another episode of a mild stroke.     

自发性孤立性肠系膜上动脉夹层16例诊治分析

目的:探讨自发性孤立性肠系膜上动脉夹层(SISMAD)的临床特点及诊治路径。方法:回顾性分析2012年9月—2017年10月中南大学湘雅医院收治的16例SISMAD患者的临床资料。其中男12例,女4例;年龄47~70岁,中位数年龄56.5岁;其中14例表现为急性上腹痛或脐周痛,另外2例分别因肾结石及胸腺癌复查CT时发现SISMAD。所有患者均经过CTA扫描检查明确诊断。治疗方法包括保守治疗、腔内血管重建术及开放手术治疗。结果:保守治疗成功10例,腔内血管重建术治疗成功5例,1例保守治疗中出现血压下降,怀疑夹层破裂出血急诊行开放动脉修补术,成功重建肠系膜上动脉血运。16例患者全部获得随访,随访时间4~60个月,平均(28±13)个月,在随访期内无腹痛复发及肠道缺血症状。随访CT显示,保守治疗的患者无夹层瘤样扩张,腔内治疗成功的患者支架均通畅。结论:对于SISMAD,当诊断明确、肠系膜血运没有受到夹层严重影响、无腹膜炎征象时,应先给予保守治疗;没有缺血性肠坏死或腹膜炎征象、经保守治疗腹痛症状没有明显缓解时,应考虑采取腔内修复术;若出现夹层破裂出血、肠坏死或腹膜炎征象则应积极采取开放手术治疗。     

Superficial femoral artery transposition repair for isolated superior mesenteric artery dissection

Isolated dissection of the superior mesenteric artery is an uncommon event, but many new cases have been reported recently, reflecting the progress of imaging and suggesting that this pathology is not as rare as previously thought. Here we report a case of superior mesenteric artery dissection where we performed, after failure of conservative medical management, an original surgical technique for mesenteric revascularization using a superficial femoral artery transposition. To the best of our knowledge, this is the first report of the use of this technique for complex mesenteric revascularization.     

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??Treatment of isolated superior mesenteric artery dissection GUO Wei, XIONG Jiang. Department of Vascular Surgery??Vascular Center of Military??Chinese PLA General Hospital??Beijing100853??China
Corresponding author: GUO Wei, E-mail: pla301dml@vip.sina.com
Abstract Isolated superior mesenteric artery dissection (ISMAD) is a clinically rare disease. The harmfulness of ISMAD mainly includes acute catastrophic bowel ischemia or aneurismal superior mesenteric artery (SMA) rupture. Though a variety of treatment options including conservative management??anticoagulation??open surgical repair and endovascular stenting (ES) have been used for ISMAD??there is no consensus as to an appropriate treatment strategy.     

Open surgical repair using a reimplantation technique for a large celiac artery aneurysm anomalously arising from the celiomesenteric trunk

Celiac artery aneurysms anomalously arising from the celiomesenteric trunk (hepatosplenomesenteric trunk) are rare, with only four patients reported thus far. Surgical intervention for this condition is challenging, particularly when the aneurysm is large and in a retropancreatic location. We report an open repair surgery in a 54-year-old asymptomatic man who presented with a saccular calcified aneurysm (diameter, 4.0 cm) of the celiac artery originating from the celiomesenteric trunk. Our technique involved minimal dissection of the surrounding vessels and complete aneurysm resection, along with revascularization of the hepatic, splenic, and superior mesenteric arteries with a single anastomosis.     

Right colectomy with simultaneous vascular reconstruction for celiac and superior mesenteric arterial occlusion

INTRODUCTIONIdentification of the primary feeding vessel and its removal with corresponding lymphatics is crucial for oncologic bowel resection for colon cancer. However, this notion would be challenged if we encountered abnormal mesenteric vascular anatomy. We report a case of colon cancer with abnormal mesenteric circulation, for whom we performed oncologic colectomy with vascular reconstruction.PRESENTATION OF CASEA 61-year-old man presented with obstructing transverse colon cancer. A contrast-enhanced computed tomography (CT) scan showed complete occlusion at the root of the superior mesenteric artery (SMA) and the celiac artery (CA), with evidently dilated marginal artery (MA). An X-ray angiography revealed retrograde arterial blood flow originating from the inferior mesenteric artery (IMA) via the MA, the SMA, and to the CA.At laparotomy, we found remarkably dilated MA with the mid-transverse colon cancer. There were no other communicating vessels between the IMA and the SMA. Right colectomy with proper lymph node dissection was completed, following vascular anastomosis between the MA to the SMA. His postoperative course was uneventful. A postoperative CT angiography showed revascularization of the areas where the SMA and the CA supplied.DISCUSSIONIn this patient, if the abberant mesenteric circulation remained unrecognized at the time of surgery, and the MA were divided without vascular reconstruction, severe ischemia and subsequent gangrene of large part of the visceral organs would have occurred.CONCLUSIONThis case illustrates the fundamental importance of assessment for vascular anatomy in patients undergoing oncologic abdominal surgery which associates with division of major mesenteric arteries.     

Endovascular exclusion of superior mesenteric artery pseudoaneurysms: an alternative to open laparotomy in high-risk patients

Superior mesenteric artery (SMA) aneurysms are rare. However, patients are frequently symptomatic on presentation and require urgent repair. SMA aneurysms have the potential for severe complications, including thrombosis or rupture, resulting in acute mesenteric ischemia and death. In patients with adhesions secondary to prior abdominal surgery, traditional open exposure of the aneurysm neck via dissection at the base of the transverse colon mesentery may be technically difficult. Endovascular exclusion of visceral artery aneurysms using covered stent grafts presents a reasonable alternative to the morbidity associated with laparotomy. We report an interesting case of a patient with a large SMA aneurysm and multiple prior laparotomies treated percutaneously with a combined expanded polytetrafluoroethylene/nitinol self-expanding stent-graft allowing maintenance of end-organ perfusion and bowel viability.     

源自肠系膜上动脉的变异肝动脉在胃癌D2根治术中的应用

目的 对源自肠系膜上动脉的变异肝动脉走行情况进行分型,并检测变异肝动脉旁淋巴组织是否有转移,从而指导胃癌D2根治术.方法 对2008年1月至2010年6月间由同一术者进行胃癌D2根治术的86例胃癌患者的临床资料进行研究.患者术前均通过多层螺旋CT血管造影(MSCTA)对存在源自肠系膜上动脉变异肝动脉的走行情况进行分型,并经术中验证,术后将变异肝动脉旁淋巴组织行重组人细胞角蛋白20(CK20)、癌胚抗原(CEA)免疫组化作对照,从而判断异常动脉旁是否有淋巴结转移的发生.结果 本组源自肠系膜上动脉变异肝动脉14例,其中男12例、女2例,平均62岁,其中变异肝总动脉3例,变异肝右动脉11例,总变异率为16.3%,其中走行于胰腺前方的1例、胰腺后方的13例,术中清扫此变异肝动脉,尤其胰后型其难度较大,易损伤异常血管及胰腺,并且手术时间较正常肝动脉者明显延长[(218.8±23.9)min比(179.6±18.5)min],术前可通过MSCTA了解变异肝动脉的走行情况,从而指导术中的操作;胰前、后型异常血管旁淋巴组织的CK20、CEA免疫组化未发现淋巴结转移.结论 源自肠系膜上动脉的变异肝动脉走行分为胰前型和胰后型;建议在D2胃癌根治术中若发现此变异肝动脉存在时,可不做此血管周围组织清扫.

Abstract：

Objectives To classify the courses of the abnormal hepatic arteries originated from superior mesenteric artery in patients with gastric cancer, and to define its application in the D2 radical gastrectomy in those patients. Methods Eighty-six patients with gastric cancer who had received D2 radical gastrectomy by the same surgeon between January 2008 and June 2010 were included in this study. All patients received the preoperative multislice spiral computed tomoangiography (MSCTA) to classify the abnormal hepatic artery originated from the superior mesenteric artery, which was verified during the surgery. Postoperative immunohistochemistry of the lymphoid tissues around the abnormal hepatic artery was performed by recombinant human cytokeratin 20 (CK20) and carcino-embryonic antigen (CEA) to verify the micrometastasis. Results In this group, the abnormal hepatic artery originated from the superior mesenteric artery were found with MSCTA and verified by operation in 14 patients, including 12 men and 2women. The mean age was 62 years. Of the 14 cases with abnormal hepatic artery, 3 cases were found with abnormal common hepatic artery and 11 cases with abnormal right hepatic artery. The total mutation rate is 16. 3%. In those patients, the hepatic artery ran in front of the pancreas in 1 case and behind the pancreas in 13 cases. It was difficult to dissect the abnormal hepatic artery, especially for the post-pancreas type in D2lymphadenectomy, for fear of damaging the abnormal blood vessel and pancreas. The operation time in cases with abnormal hepatic artery was significantly longer than that in patients with normal hepatic artery [(218.8±23.9) min vs. (179. 6 ± 18. 5 ) min]. Immunohistochemical analysis revealed no metastasis in the lymphoid tissues surrounding the abnormal artery. Conclusions Abnormal hepatic arteries originated from the superior mesenteric artery can be classified into pre-pancreas type and post-pancreas type. The dissection of the abnormal hepatic artery is not advocated in D2 radical gastrectomy for no lymph node metastasis is found around the abnornal hepatic artery in this study.     

Hybrid management of ruptured isolated superior mesenteric artery dissecting aneurysm

A 70-year-old woman, with history of asymptomatic isolated superior mesenteric artery (SMA) dissection was admitted for acute abdominal pain. Computed tomography showed ruptured isolated SMA dissection. Endovascular treatment was chosen over surgical repair because of prior abdominal surgeries. Because an angulated SMA trunk and compressed true lumen by the dilated false lumen prevented the insertion of a guidewire into the SMA via the transfemoral artery, transmesenteric approach under laparotomy was selected. After creating a pull-through condition from the SMA to the left brachial artery, a successful stent graft placement with adequate hemostasis was achieved. The aneurysm shrunk remarkably, with no complication at follow-up.     

Superior Mesenteric Artery Syndrome: An Uncommon Complication of Abdominal Aortic Aneurysm Repair

The superior mesenteric artery syndrome (SMAS) is an uncommon finding, especially when occurring after open abdominal aortic aneurysm (AAA) repair. Very few cases have been previously reported in the literature. The underlying anatomic mechanism as well as a better way to manage this complication remains controversial. We report a case of well-documented duodenum obstruction occurring after an elective, uneventful open AAA repair in an 83-year-old white male. The patient was initially discharged from hospital on the fifth postoperative (PO) day but was readmitted on the seventh PO day with suspicion of intestinal obstruction caused either by adhesions or extrinsic pressure by a retroperitoneal hematoma. A laparotomy carried out on the 10th PO day was unremarkable and the patient continued vomiting until a left lateral decubitus positioning was assumed. The patient was discharged home on the 19th PO day and has remained well since.     

Mesenteric Paraganglioma: Report of a Case

We report a rare case of a solitary primary paraganglioma arising in the mesentery, found in a 72-year-old woman who presented with abdominal pain and a palpable abdominal mass. This extra-abdominal paraganglioma developed from paraganglionic cells that travelled by vertebral migration from the root of the superior mesenteric artery. Extra-adrenal paraganglia extend anywhere from the neck down to the base of the pelvis. Ultrasonography, computed tomography (CT), and angiography showed a solid and cystic heterogeneously enhanced mass, which was fed by the superior mesenteric artery, without distant metastasis. Exploratory laparotomy revealed a large, dark, brownish-red mass in the mesentery of the ileum, which was distinct from the ileum. The mass consisted of peripherally solid areas with central hemorrhage and cystic degeneration. It was diagnosed as a paraganglioma histologically. The patient is free from recurrence of paraganglioma after 1 year of follow up. To our knowledge, this represents only the seventh case of a paraganglioma arising in the mesentery.     

Thrombolysis via an Operatively Placed Mesenteric Catheter for Portal and Superior Mesenteric Vein Thrombosis: Report of a Case

Mesenteric venous thrombosis (MVT) is a catastrophic form of mesenteric vascular occlusion. In the absence of peritoneal signs, anticoagulation therapy should be started immediately. For selected patients, thrombolysis through the superior mesenteric artery (SMA), jugular vein, or portal vein via a transhepatic route might be successful; however, exploratory laparotomy is mandatory when peritoneal signs develop. We report a case of acute MVT associated with protein C and S deficiency, treated successfully by limited bowel resection and simultaneous thrombolytic infusion, given via an operatively placed mesenteric vein catheter.     

Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection.

Isolated dissection of a peripheral artery is a rare event. Only 11 reports exist in the literature of dissection of the superior mesenteric artery, most of which have been fatal. This is the first documented case of the successful treatment of an acute ischemic event caused by a superior mesenteric artery dissection. In addition, the new technique of right gastroepiploic artery-to-superior mesenteric artery bypass is introduced as a satisfactory method of revascularization.     

Three isolated superior mesenteric artery dissections: update of previous case reports, diagnostics, and treatment options

Isolated superior mesenteric artery dissection is a relatively rare vascular pathology. However, the number of recent case reports has shown an increasing incidence with the widespread use of computed tomography imaging for abdominal pain. Here we report three cases of isolated superior mesenteric artery dissection. The unique surgical option of small bowel transplantation along with successful medical management is described. A treatment algorithm for isolated superior mesenteric artery dissection is also proposed.     

经腹小切口超声引导系膜穿刺逆向开通治疗肠系膜上动脉开口全堵病变

背景与目的：对于肠系膜上动脉（SMA）闭塞患者,尤其是存在开口处动脉粥样硬化性无残端病变,开腹逆行肠系膜动脉支架置入术（ROMS）是一种有效的治疗方法,但该手术创伤较大,一些身体条件差的患者并不适合。笔者通过报告1例SMA全堵病变病例的治疗过程介绍一种改良的微创ROMS技术,以期为临床治疗方法的选择提供参考。 方法：回顾复旦大学附属中山医院厦门医院血管外科2019年10月收治的1例SMA全堵病变患者的临床资料。患者为64岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血,行杂交手术再通SMA。 结果：患者SMA开口处为无残端完全闭塞病变且无侧支血管与腹腔干动脉及脾动脉沟通,顺行或逆行血管腔内开通均无法进行。因患者全身条件较差,难以耐受开放血运重建手术和传统的ROMS。遂做腹部做小切口,超声引导下经系膜穿刺SMA远端建立通路,导丝顺利逆向通过SMA闭塞处进入降主动脉;右侧肱动脉入路导管和逆向导丝对接后顺利正向通过病变,完成球囊扩张和支架置入术。术后患者恢复良好,症状消失,3个月后随访CTA示,支架形态、位置良好,血流通畅。 结论：对于血管腔内治疗失败且全身条件较差的SMA闭塞患者,通过经腹小切口超声引导系膜穿刺逆向开通SMA是可行的。     

Early superior mesenteric artery revascularization for acute type A aortic dissection with cardiac tamponade and mesenteric malperfusion

We report herein the successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man with back and abdominal pain and in shock, who was transported to our hospital 2 h after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.     

A ruptured thoracoabdominal aortic aneurysm managed endovascularly using the telescoping chimney technique

Extending the proximal landing zone to facilitate endovascular repair of aortic aneurysms with short proximal necks using the chimney, top-fenestration, or snorkel technique has been previously reported. In addition, extending the distal landing zone using the periscope technique has also been recently described. In this study, we used an extended chimney technique, the "telescoping technique," to successfully treat a ruptured Crawford type III thoracoabdominal aortic aneurysm in a patient with pre-existing renal failure and an occluded superior mesenteric artery.     

Temporary perfusion for mesenteric ischemia with acute type A aortic dissection

We report advantages of a temporary mesenteric perfusion method for bowel ischemia with acute type A aortic dissection. The perfusion catheter was inserted from the branch of the superior mesenteric artery. This technique was found to be useful in certain cases that require prompt visceral organ perfusion and proximal aortic repair, which enabled a simultaneous treatment for both lesions and a blood pressure evaluation.